Advance Care Planning Affects End-of-Life Treatment Preferences Among Patients With Heart Failure: A Randomized Controlled Trial.

This study explored the effects of advance care planning interventions on end-of-life treatment decisions among patients with heart failure. The study design was a randomized controlled trial. An intervention involving a motivational video, a cartoon version educational brochure, and a guided discussion was implemented. A total of 82 hospitalized patients with heart failure were recruited. Half of the participants received the intervention, and the other half received routine care. The Life Support Preferences Questionnaire was the primary measurement instrument. Before the advance care planning intervention, a significant difference between the experimental and control groups was observed in the cardiopulmonary resuscitation score but not the total, antibiotics, surgery, and artificial nutrition and hydration scores. In the experimental group but not in the control group, significant differences were observed between pretest and posttest total, antibiotics, cardiopulmonary resuscitation, surgery, and artificial nutrition and hydration scores. Significant differences in mean score changes were observed in total and each treatment score between the experimental and control groups. The advance care planning intervention led participants to select fewer medical treatments. This intervention may be suitable for societies where people are unfamiliar with advance care planning and may feel uncomfortable discussing death.

Taiwanese Older Adults Prefer to Use Antibiotics and Intravenous Infusion at the End of Life based on a Cartoon Version of the Life Support Preferences Questionnaire.

Asians believe discussing death-related topics is inauspicious and may bring bad luck. It is critical to explore the end-of-life care preferences of the Asian elderly with less-threatening tools. The study examined older adults' preferences regarding end-of-life treatments by applying a cartoon version of the Life Support Preferences Questionnaire (LSPQ). A cross-sectional survey was conducted to understand older adults' preferences for end-of-life treatments. A total of 342 older adults participated in the study, comprising 268 elderly patients from a veterans hospital located in northern Taiwan and 74 elderly family members of the patients. Regardless of scenario, cardiopulmonary resuscitation (CPR) had the lowest score, indicating that older adults considered it a less desirable medical treatment. By contrast, antibiotics and intravenous infusions had the highest scores, indicating that older adults tended to prefer them. End-of-life care preferences were significantly different in genders. CPR and surgical preferences of older adults differed significantly with education level. Different demographic characteristics had different end-of-life treatment preferences, and future research may develop advance care planning programs for different attributes. This cartoon version of the LSPQ can help healthcare professionals to understand older adults' preferences for end-of-life care and warrants further empirical research.

Older Adults' Behavioral Intentions Toward Advance Care Planning Based on Theory of Reasoned Action.

This study aimed to explore the factors affecting the behavioral intentions of older adults toward advance care planning (ACP). A questionnaire survey was conducted at 2 medical wards and a senior activity center in northern Taiwan. Four hundred one participants were older adults aged over 65 years, comprising hospitalized patients, their caregivers, and members of a senior activity center. The regression model revealed that participant type (patient, caregiver, or community resident); financial support; discussion of ACP with family; and knowledge, attitudes, and subjective norms accounted for 46.3% of the variance in behavioral intentions. The behavioral intention of caregivers was higher than that of patients. The behavioral intention of participants who were financially dependent on the family was lower than that of pensioners. Regarding discussing ACP with family, older adults in the contemplation and preparation stages score higher on behavioral intention than those in the precontemplation stage. This study supports the theory of reasoned action. Older adults' ACP knowledge and attitudes need to be enhanced through education. Caregivers' behavioral intentions tend to perform ACP. Sharing their caring experiences may be a strategy for promoting ACP. Older adults' financial status affects their behavioral intentions. Therefore, financial planning should be performed early and should incorporate ACP.

Knowledge, attitudes, and behavioral intentions of elderly individuals regarding advance care planning: Questionnaire development and testing.

BACKGROUND: Studies have indicated that the advance care planning knowledge and attitudes of elderly individuals strongly affect their implementation of advance care planning. A measurement with a theoretical base for evaluating elderly individuals' knowledge, attitudes, and behavioral intentions regarding advance care planning is lacking. OBJECTIVES: To develop a questionnaire and understand elderly individuals' knowledge, attitudes, and behavioral intentions regarding implementing advance care planning. METHODS: A cross-sectional questionnaire survey was conducted. The content validity index, and statistical methods, including discrimination, factor, and reliability analysis, were adopted for psychometric testing. Descriptive statistics mainly presented data analysis. RESULTS: 401 elderly individuals were recruited from a medical center and one senior activity center. The content validity index was approximately 0.71-0.92 for the developed questionnaires, the Kuder-Richardson formula 20 was 0.84 for advance care planning knowledge, and the Cronbach's alpha was 0.86, 0.94, 0.76, and 0.92 for attitudes, behavioral intentions, influencing factors, and subjective norms, respectively. The average score for advance care planning knowledge for elderly individuals was 4.42, with a correct answer rate of 49.1%. They lacked knowledge of advance care planning-related legislation. The mean score for attitudes and behavioral intentions was 14.32 and 3.48, respectively. Elderly individuals agreed that advance care planning has benefits but were worried about the emotional distress caused by advance care planning discussions. Elderly individuals with positive behavioral intentions tend to implement advance care planning. Spouses, children, doctors, and nurses are significant reference people for elderly individuals. CONCLUSIONS: The developed questionnaire exhibits good validity and reliability for understanding elderly individuals' knowledge, attitudes, and behavioral intentions concerning advance care planning. Advance care planning materials or decision aids suitable for elderly individuals must be developed to increase their understanding of advance care planning. Additionally, the role of nurses is indispensable in promoting advance care planning among elderly individuals.

Factors Influencing Older Adults' End-of-Life Care Preferences.

The objective of this study was to explore factors influencing Taiwanese older adults' end-of-life (EOL) care preferences. A cross-sectional questionnaire survey was conducted in 2 geriatric wards of a veterans' hospital. Fifty-five older adults aged 65 years or older were included. Structured questionnaires were used to collect data regarding demographic characteristics, EOL care preferences, stages of change for advance care planning behaviors, and reluctance to burden others. The study revealed that nearly 60% of the participants preferred to let their spouses, adult children, or health care professionals make the decisions. Furthermore, 83.6% of the participants lived with their family members and were moderately to severely disabled with a certain degree of dependence on their family members. Sex, independence, discussion of advance care planning with family members, and completion of advance directives were significantly correlated with EOL care preferences. The regression model showed that the participants' discussion of advance care planning with their family members influenced their EOL care preferences. The results demonstrate that family is an essential consideration for older adults choosing EOL care. Accordingly, because Chinese culture focuses on family harmony, improving communication between older adults and their family members is crucial for promoting advance care planning.

The Differences and Perspectives Between Elderly Individuals and Their Surrogates Regarding End-of-Life Care: A Mixed Methods Study.

Background: Family members often take the place of decision-making for elderly individuals. Previous studies showed that family members could not predict elderly individuals' thoughts about end-of-life care. Objectives: The aims are to understand the differences and perspectives between elderly individuals and surrogates regarding end-of-life care. Design: A mixed methods study comprising a cross-sectional survey and field notes analysis. Setting: Two geriatric wards in a veterans hospital located in northern Taiwan. Subjects: Fifty-five pairs of elderly individuals and their surrogates. Measurements: Life support preferences questionnaire and field notes. Results: The quantitative data showed that the elderly individuals and their surrogates had proper consistency in cardiopulmonary resuscitation and surgery. However, their consistency was poor in antibiotics and nasogastric tube feeding. Four themes were identified in qualitative data: recognizing old age, struggling with hope and peace, worries and concerns, and control of life. Recognizing old age for both elderly individuals and their surrogates was critical. Elderly individuals and their surrogates may seek a ray of hope among aggressive treatments and struggle with hope and peace. A lot of worries and concerns were mentioned, including contextual concerns. Elderly individuals need to depend on their ability to control their life. Conclusions: The study highlights elderly individuals' and their surrogates' considerations for antibiotics and nasogastric tube feeding. Furthermore, elderly individuals expressed that it is different for making decisions for themselves or others; thus, future studies can further explore whether elderly individuals allow their surrogates leeway from their wishes.

A quasi-experimental evaluation of advance care planning improves consistency between elderly individuals and their surrogates regarding end-of-life care preferences: Development and application of a decision aid with cartoon pictures.

OBJECTIVE: This study sought to develop a decision aid with cartoon pictures and evaluate its effectiveness in increasing consistency between elderly individuals and their surrogates regarding end-of-life care. METHODS: A pre-post quasi-experimental design was adopted using the Life Support Preferences Questionnaire. The intervention had two components: (1) increasing participants' knowledge of medical treatments related to end-of-life care, and (2) sharing their end-of-life wishes. The experimental group received an intervention, whereas the control group received usual care. RESULTS: A total of 110 participants in 55 pairs of elderly individuals with average aged 86.4 and their surrogates (27 in the experimental group, 28 in the control group) were recruited from a veterans hospital in northern Taiwan. Nearly 90 % of elderly individuals were male. The multiple linear regression showed that the inconsistent gap between elderly individuals and their surrogates in the experimental group decreased 12 points than the control group after controlling the covariances (B = -12.116, p = 0.032). CONCLUSION: The intervention improved the consistency between elderly individuals and their surrogates regarding end-of-life care. PRACTICE IMPLICATIONS: A decision aid with cartoon pictures may support the discussion of end-of-life care in older Asian populations.

Advance Care Planning to Improve End-of-Life Decision-Making Consistency between Older People and Their Surrogates in Taiwan.

Background: Surrogates often do not accurately predict older people's preferences about end-of-life (EOL) care. Few studies have examined the impact of advance care planning (ACP) on EOL decision-making consistency between older people and their surrogates, and these studies have yielded conflicting results. Objectives: To evaluate the effectiveness of ACP in improving EOL decision-making consistency between older people and their surrogates. Design: The intervention in this pre-post quasi-experimental design included an informative video, a brochure about ACP, and a guided discussion about EOL wishes. Setting: Two geriatric wards in a medical center in northern Taiwan. Subjects: One hundred eight participants, as 54 pairs of older people and their surrogates, were randomly assigned to either the experimental or control group. The experimental group received an intervention, while the control group received usual care. Measurements: Life-Support Preferences Questionnaire. Results: The intervention did not improve decision-making consistency between older people and their surrogates. This was the first time that most pairs discussed specific EOL decisions, so additional preparation may improve comfort with this topic. This study also found that some older people had difficulty concentrating on the educational brochure or understanding the related terms. Conclusions: Preparation for ACP discussion is needed for older people and their surrogates. Longer-term effects of ACP should be monitored because ACP interventions may have enhanced empathy between older people and their surrogates. Additionally, a culturally sensitive illustrated questionnaire that explains life-support preferences and ACP topics may improve communication between older people and their surrogates.

Experiences and perspectives of older people regarding advance care planning: A meta-synthesis of qualitative studies.

BACKGROUND: Studies have indicated that family members or health professionals may not know or predict their older relatives' or patients' health preferences. Although advance care planning is encouraged for older people to prepare end-of-life care, it is still challenging. AIM: To understand the experiences and perspectives of older people regarding advance care planning. DESIGN: A systematic review of qualitative studies and meta-synthesis was conducted. DATA SOURCES: CINAHL, MEDLINE, EMBASE, and PsycINFO databases were searched. RESULTS: A total of 50 articles were critically appraised and a thematic synthesis was undertaken. Four themes were identified: life versus death, internal versus external, benefits versus burdens, and controlling versus being controlled. The view of life and death influenced older people's willingness to discuss their future. The characteristics, experiences, health status, family relationship, and available resources also affected their plans of advance care planning. Older people needed to balance the benefits and burdens of advance care planning, and then judge their own ability to make decisions about end-of-life care. CONCLUSION: Older people's perspectives and experiences of advance care planning were varied and often conflicted; cultural differences amplified variances among older people. Truthful information, available resources, and family support are needed to enable older people to maintain dignity at the end of life. The views of life and death for older people from different cultures should be compared to assist health professionals to understand older people's attitudes toward advance care planning, and thus to develop appropriate strategies to promote advance care planning in different cultures.

Ethical and methodological issues in qualitative health research involving children: A systematic review.

BACKGROUND: The right of children to have their voice heard has been accepted by researchers, and there are increasing numbers of qualitative health studies involving children. The ethical and methodological issues of including children in research have caused worldwide concerns, and many researchers have published articles sharing their own experiences. OBJECTIVES: To systematically review and synthesise experts' opinions and experiences about ethical and methodological issues of including children in research, as well as related solution strategies. RESEARCH DESIGN: The research design was a systematic review of opinion-based evidence, based on the guidelines by Joanna Briggs Institute. METHODS: A search of five computerised databases has been conducted in April 2014 and 2271 articles were found. After screening the titles, abstracts, full texts and appraising the quality, 30 articles were finally included in the review. A meta-aggregative approach was applied in the data analysis and synthesis process. ETHICAL CONSIDERATIONS: Ethical approval is not needed as it is a systematic review of published literature. RESULTS: Six themes were identified, including evaluating potential risks and benefits, gaining access, obtaining informed consent/assent, protecting confidentiality and privacy, building rapport and collecting rich data. The similarities and differences between research involving children and that involving adults were indicated. CONCLUSION: All potential incentives should be justified when designing the study. Further studies need to research how to evaluate individual capacity of children and how to balance protecting children's right to participate and their interests in the research. Cultural differences related to researching children in different regions should also be studied.

Nurses' views regarding implementing advance care planning for older people: a systematic review and synthesis of qualitative studies.

AIMS AND OBJECTIVES: To explore nurses' views regarding implementing advance care planning for older people. BACKGROUND: Advance care planning is recommended as a way for older people to discuss their future care with family members and health professionals. Nurses play key roles in the process of advance care planning, including ensuring that patients are informed of their rights and that decisions are known to, and respected by, the health care team. Thus, understanding of nurses' experiences and perspectives regarding implementing advance care planning for older people is a significant topic for review. DESIGN: Qualitative meta-synthesis. METHODS: Four databases including CINAHL plus, Medline [EBSCOhost], EMBASE, and PsycINFO were searched, and 1844 articles were initially screened. Finally, 18 articles were critically appraised and a thematic synthesis was undertaken. RESULTS: Four themes were identified regarding implementation of advance care planning: perceived disadvantages and advantages of advance directives; nurses' responsibility and roles; facilitators and barriers; and nurses' needs and recommendations. Nurses felt that advance directives provided more advantages than disadvantages. Nurses generally believed that they were well positioned to engage in advance care planning conversations. Nurses perceived barriers relating to older people, families, environment, time, culture, cost, language and knowledge of health care teams with regard to advance care planning. In nurses' needs, education and support were highlighted. CONCLUSIONS: This study provides useful knowledge for implementing advance care planning through illustrating nurses' experiences and perspectives. The results showed that nurses were more concerned about barriers in relation to working environment, teamwork, time and knowledge of health care team members than older people's characteristics, when implementing advance care planning. RELEVANCE TO CLINICAL PRACTICE: The findings provide nurses and administrators with information to develop related policies and education. Additionally, the appointment of nurses to formal roles related to advance care planning is appropriate and warranted.

[Frailty in the elderly: a concept analysis].

Frailty is a term frequently used in geriatric medicine and gerontology. Even though this term appeared some three decades ago, the concept it embodies is still inconsistently defined and multi-dimensional. It is also relatively new to the nursing discipline. The author analyzed the concept of frailty using the concept analysis approach of Walker and Avant (2005). The result indicated that frailty must meet at least three of Fried et al. (2001)'s five attributes of frailty, i.e., shrinking, weakness, poor endurance, slowness, and low activity. Frailty in the elderly must further involve multiple factors, dependency, dynamic processes, and vulnerability. The author hopes this paper helps clinical nursing staffs better understand the concept of frailty in the elderly. A clearly defined definition for frailty in the elderly can help nurses apply this important concept in clinical practice and develop related nursing implications to improve elderly health.

Effects of educational intervention on nurses' knowledge, attitudes, and behavioral intentions toward supplying artificial nutrition and hydration to terminal cancer patients.

INTRODUCTION: This study aimed to investigate the effects of educational intervention on nurses' knowledge, attitudes, and behavioral intentions regarding supplying artificial nutrition and hydration (ANH) to terminal cancer patients. MATERIALS AND METHODS: A quasi-experimental design was adopted. A structured questionnaire evaluated the effects of educational intervention. From April to June 2005, 88 nurses were enrolled in the gastroenterology, general surgery, and intensive care unit of Taipei Veterans General Hospital in Taiwan. The nurses were randomly assigned into experimental and control groups in equal numbers (44 nurses in each group). After the experimental and control groups completed the pretest, the experimental group participated in a 50-min lecture. Both groups received a post-test 2 weeks after the lecture. RESULTS: This study showed that prior to educational intervention, nurses have possessed experiences of ANH use in routine caring for terminal cancer patients. However, due to the lack of knowledge about supplying ANH to terminal cancer patients, the nurses trended toward the negative behavioral intention, although they realized the burdens of ANH in these patients. After educational intervention, mean scores of knowledge, attitudes and behavioral intentions of the experimental group increased significantly (z = -5.255, p < 0.001; t = -5.191, p < 0.001; z = -3.274, p <== 0.001). Mean score changes of knowledge and attitude between these two groups reached significant differences (t = -7.306, p < 0.001; t = -4.165, p < 0.001), but no significant difference was observed in the mean score change of behavioral intention (z = -1.943, p > 0.05). CONCLUSION: The educational intervention remarkably improved nurses' knowledge and attitudes regarding supplying terminal cancer patients with ANH. As for the changes in the behavioral intentions, it requires long-term moral and ethical training and communication. The results of this research emphasized the importance of educational interventions, which should be considered seriously in future reference nursing education program.

Knowledge, attitudes, and behavioral intentions of nurses toward providing artificial nutrition and hydration for terminal cancer patients in Taiwan.

The aim of this study was to understand present knowledge, attitudes, and behavioral intentions of clinical nurses providing artificial nutrition and hydration (ANH) for terminal cancer patients. Study subjects were composed of 197 nurses from the gastroenterology, general surgery, and intensive care units of Taipei Veterans General Hospital in Taiwan. Subjects were surveyed between April and June 2005 via self-developed structural questionnaires. Collected data were descriptively analyzed with SPSS 11.0 software. Nurses' knowledge about palliative care was high (accurate-answer rate, 96.75%); knowledge about providing ANH for terminal cancer patients was lower (accurate-answer rate, 53.67%). Although nurses' attitudes about providing ANH for terminal cancer patients viewed ANH as having more burdens (mean [SD], 14.12 [3.62]) than benefits (6.35 [2.19]), nurses' behavioral intentions still favored providing ANH (3.21 [0.95]). In subjective norms, "attending physicians and/or superiors" (45.3%) and, secondarily, "patients" (38.4%) were important influencing persons on nurses' support for ANH. Other influencing factors were communication difficulties with patients and/or family members (3.40 [0.83]), staff disagreements (3.01 [0.78]), and fear of medical dispute (3.42 [0.95]). Study results suggest that reinforcing in-service education to enhance nurses' knowledge of providing ANH for terminal cancer patients and building up positive attitudes and behavioral intentions may strengthen nurses' efforts to actively communicate and cooperate with physicians in assisting patients and families to make the most appropriate medical decisions.