Interprofessional collaboration in telemedicine for long-term care: An exploratory qualitative study.

BACKGROUND: Widespread and sustained adoption of telemedicine in long-term residential care is emerging. Nursing home (NH) nurses play a key role in collaborating with remote physicians to manage residents' medical conditions through videoconferencing. Therefore, understanding of interprofessional collaboration and effective communication between nurses and physicians is critical to ensure quality of care and safety during teleconsultations. AIMS: To explore NH nurses' and physicians' experiences of interprofessional collaboration and communication during teleconsultations. METHODS: A qualitative descriptive design was adopted. Purposive sampling was conducted to recruit 22 physicians and nurses involved in NH teleconsultations. Semi-structured online interviews were conducted, and data were thematically analyzed. RESULTS: Three themes were identified: (1) Manner of communication in telemedicine, (2) sociocultural influences in collaborative practice, and (3) role expectations in telemedicine. Both nurses and physicians recognized the importance of building and maintaining trust as physicians heavily depended on nurses for provision of objective information for clinical decision-making. However, practice differences were observed between nurses and physicians during teleconsultations. Sociocultural influences such as power relations and language barriers also affected the nurse-physician relationship and interpersonal communication. Additionally, different performance expectations were identified between nurses and physicians. CONCLUSION: Interprofessional collaboration in teleconsultations is challenging because of lack of in-person assessment and dependence on nurses for clinical information. In addition, expectations and communication styles differ among healthcare professionals. This study called for interprofessional telemedicine training with incorporation of shared mental models to improve role clarity and communication. Given the international-dominated healthcare workforce in long-term care, the development of cultural competency could also be considered in telemedicine training to enhance nurse-physician collaborative practice. CLINICAL RELEVANCE: Telemedicine is increasingly adopted in long-term care settings, where multidisciplinary healthcare professionals from different health institutions are involved in resident care. Interprofessional collaboration should be incorporated into telehealth education for enhanced clinical practice in this care delivery model.

Enablers and barriers to nurse-facilitated geriatric teleconsultations in nursing homes: a qualitative descriptive multi-site study.

BACKGROUND: Nurses play a major role in facilitating teleconsultations in nursing homes with remote physicians. Currently, evidence explicating their role in teleconsultations is lacking. As telemedicine usage grows, understanding the factors that enable or impede nurses' role in teleconsultations allows for more support in the provision of patient care through this modality. OBJECTIVE: This study sought to explore enablers and barriers nurses faced in facilitating geriatric teleconsultations in nursing homes. METHODS: A qualitative descriptive study using semi-structured interviews was conducted in Singapore, from July to November 2021. Purposive sampling of nursing home nurses was undertaken. Data were inductively analysed using Braun and Clarke's thematic analysis approach. RESULTS: Twenty-two nursing home nurses participated in the study. Six key themes were identified as enablers and barriers in nurse-facilitated geriatrics teleconsultations. Enablers included nurses' acknowledgement of teleconsultations as needs-orientated service, close partnership with the hospital-based geriatric service for training and workflow support and nurses' sense of empowerment in teleconsultation involvement. Barriers that existed were the nurses' lack of confidence in physical assessment and communication competencies, role conflict due to nurses' perceived inability to meet physicians' expectations and limited scope of practice in performing teleconsultation-related tasks and the presence of technology-related challenges. CONCLUSION: The identification of enablers and barriers in teleconsultations for nursing home residents provides insights for future research and development in telemedicine-related implementation and educational interventions in long-term care. Developing strong partnerships between telemedicine providers and nursing homes, further enhancement of nurses' telemedicine competencies and optimising digital infrastructure are warranted.

The development of empathy in the healthcare setting: a qualitative approach.

BACKGROUND: Healthcare professionals' empathetic behaviors have been known to lead to higher satisfaction levels and produce better health outcomes for patients. However, empathy could decrease over time especially during training and clinical practice. This study explored factors that contributed to the development of empathy in the healthcare setting. Findings could be used to improve the effectiveness and sustainability of empathy training. METHOD: A qualitative approach, informed by aspects of grounded theory, was utilized to identify factors that enabled the development of empathy from the perspectives of doctors, nurses, allied healthcare workers and students. Twelve sessions of focus group discussions were conducted with 60 participants from two hospitals, a medical school, and a nursing school. Data was analyzed independently by three investigators who later corroborated to refine the codes, subthemes, and themes. Factors which influence the development of empathy were identified and categorized. This formed the basis of the creation of a tentative theory of empathy development for the healthcare setting. RESULTS: The authors identified various personal (e.g. inherent characteristics, physiological and mental states, professional identity) and external (e.g. work environment, life experience, situational stressors) factors that affected the development of empathy. These could be further categorized into three groups based on the stability of their impact on the individuals' empathy state, contributed by high, medium, or low stability factors. Findings suggest empathy is more trait-like and stable in nature but is also susceptible to fluctuation depending on the circumstances faced by healthcare professionals. Interventions targeting medium and low stability factors could potentially promote the development of empathy in the clinical setting. CONCLUSIONS: Understanding factors that impact the development of empathy allows us to develop measures that could be implemented during training or at the workplace leading to improve the quality of care and higher clinical work satisfaction.

Adapting ENABLE for patients with advanced cancer and their family caregivers in Singapore: a qualitative formative evaluation.

BACKGROUND: ENABLE (Educate, Nurture, Advise, Before Life Ends) is a nurse coach-led, early palliative care model for patients with advanced cancer and their family caregivers. Content covered includes problem-solving, advance care planning, symptom management and self-care. The aim was to evaluate the cultural acceptability of ENABLE among patients with advanced cancer and their caregivers in Singapore and identify modifications for an adapted ENABLE-SG model. METHODS: Qualitative formative evaluation with a thematic analysis approach in two hospitals in Singapore, involving patients (n = 10), family caregivers (n = 11) and healthcare professionals (n = 10) who care for patients with advanced cancer. Semi-structured interviews were conducted to explore (i) the main needs and challenges facing individuals with advanced cancer and their family caregivers; (ii) patient involvement in healthcare decision making; and (iii) content and delivery of ENABLE. RESULTS: While physical needs were largely well met, participants expressed that psychosocial care was delivered too late in the illness trajectory. Healthcare decision making approaches varied from a patient-centred shared decision-making model to a family-centred model where patients may not know their cancer diagnosis and prognosis. The content was considered to be relevant, comprehensive and practical; financial assistance, adjustment to body image, and evaluation of complementary therapy were also recommended. Face-to-face rather than telephone sessions were preferred to facilitate rapport building. CONCLUSIONS: ENABLE was broadly acceptable with some modifications, including adjusting the content to ensure it can be delivered even if the patient is not fully aware of cancer diagnosis and delivering the first session face-to-face with flexibility for subsequent sessions.

Attitudes towards the dying and death anxiety in acute care nurses - can a workshop make any difference? A mixed-methods evaluation.

OBJECTIVES: In Singapore, the core curriculum for end-of-life (EOL) care used in nurse training courses is limited. Only 45% of nurses indicated familiarity with inpatient palliative care. Nurses who lack skills in palliative care may develop anxiety and negative attitudes towards caring for dying patients. We explored whether a two-day, multimodal EOL care workshop could reduce nurses' death anxiety and improve nurses' skills, knowledge, and attitude towards palliative care. METHODS: Forty-five nurses participated in the workshop. At baseline before and at six weeks after, a 20-item knowledge-based questionnaire and the Death Attitude Profile-Revised (DAP-R) were administered. Six weeks post-workshop, in-depth interviews were conducted. We employed descriptive statistics, student paired samples t-test and inductive thematic analysis. RESULTS: There was a significant improvement in nurses' knowledge score (p < 0.01) and reduction in their death anxiety score (p < 0.01). Fear of Death (p = 0.025) and Death Avoidance (p = 0.047) sub-scores decreased significantly. However, the remaining domains such as Neutral Acceptance, Approach Acceptance, and Escape Acceptance did not show any significant difference, although Escape Acceptance showed a trend towards a reduced score (p = 0.063). After the workshop, more nurses adopted the Neutral Acceptance stance (76.2%), and none of them fell into the Fear of Death subdomain. Most nurses interviewed reported a positive change in their knowledge, attitudes, and practice even after the workshop. SIGNIFICANCE OF RESULTS: The multimodal palliative care workshop was useful in improving nurses' EOL knowledge and reducing their anxiety towards death. The positive change in nurses' attitudes and practices were noted to be sustained for at least six weeks after the intervention.

Sensitivity and Specificity Analysis: Use of Emoticon for Screening of Depression in Elderly in Singapore.

BACKGROUND: The current screening tools for depression can be tedious to administer, especially in the elderly population with hearing impairment and/or limited proficiency in English language. OBJECTIVES: To look at the feasibility of using emoticon as a screening and assessment tool for depression in the elderly. DESIGN: Cross-sectional study. METHOD: A total of 77 elderly patients completed the study from June 2014 to August 2015 in a general geriatric outpatient clinic of an acute care hospital in Singapore. Patients rated their mood using an emoticon scale, which ranges from 1 ( most happy face) to 7 ( most sad face). Depression was assessed using the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) criteria as the gold standard. Sensitivity and specificity for depression were calculated for the cutoff scores from 1 to 7 on the emoticon scale. RESULTS: The sensitivity percentages were low across all cutoff scores. The specificity was more than 90% for the cutoff score of 5 and above on the emoticon scale. However, all the patients who had depression diagnosed using the DSM-IV criteria did not have emoticon scores of 5 and above. CONCLUSIONS: The emoticon scale was easy to use, but its effectiveness in the screening of depression in the elderly needs to be explored further. The inability to use the emoticon scale as a tool may be the lack of measurements in the other domains of the DSM-IV criteria (sleep, energy, appetite, etc.), rather than failure of the emoticon scale to assess mood.

Video training of nursing home healthcare workers in palliative care.

OBJECTIVES: The provision of palliative care in nursing homes (NHs) is of paramount importance, a realism underscored by the frailty and medical complexity of the residents. However, palliative care (PC) education tends to be resource-intensive both for educators and healthcare workers (HCWs). The aim of this study was to investigate how PowerFacts, a video animation series that taught basic PC to NH HCWs in Singapore impacted their knowledge, attitudes and confidence. METHODS: A cohort study design was adopted for the study. A total of 264 NH HCWs across 12 NHs in Singapore participated in the study from January 2021 to October 2022. Participants were assessed using a 20-summative multiple-choice question assessment, a 30-item Frommelt Attitude Toward Care of the Dying Scale (FATCOD) and four questions on their confidence level before and after the PowerFacts course. RESULTS: Paired t-test was performed. Significant changes were noted in the knowledge and confidence score post-intervention. The knowledge score improved significantly from preintervention (12.2±3.5) to post-intervention (15.8±3.4; p<0.01). The confidence score increased significantly from 14.7±2.7 to 16.7±2.2 (p<0.01). However, the FATCOD score did not reveal any significant changes between preintervention and post-intervention results (p>0.05). CONCLUSIONS: PowerFacts has demonstrated its potential as a valuable addition to the array of teaching methods available to NH HCWs. Future studies are required to evaluate the impact of animation on patient care and clinical practice.

Facts to Snacks. Evaluating the Effectiveness of Bite-Sized Animations in Teaching Palliative Care to Medical Students.

BACKGROUND: Current palliative care training in medical school is inadequate in preparing doctors to provide quality palliative care. Little attention is paid to determining effective methods of training. OBJECTIVE: To assess the use of bite-sized animations in improving the confidence, knowledge and attitudes of medical students towards palliative care. METHODS: A mixed methods cohort study was adopted for the study. 50 medical students without prior palliative training completed questionnaires before and after watching a 12-part animated palliative care video series called PowerFacts. Of these participants, 18 underwent semi-structured interviews. RESULTS: The quantitative results showed that animations are effective in improving the confidence (P < .001) and knowledge (P < .001), but not the attitudes (P = .183) of medical students. Confidence, knowledge and attitudes were not correlated. Analysis of follow-up interviews of a convenience sample of participants showed that animations can be effective in teaching knowledge and does fill some gaps in palliative education for medical undergraduates. However, the content delivered as a sole learning tool is inadequate in preparing medical students for clinical practice. CONCLUSION: All participants achieved level 1 (reaction), some achieved level 2 (learning) but most did not achieve level 3 (behaviour) of the Kirkpatrick's model. There is a need for a multimodal approach in the comprehensive teaching of palliative care in undergraduate medical training to achieve all four levels of the Kirkpatrick Model.

Telemedicine entrustable professional activities for nurses in long-term care: A modified Delphi study.

BACKGROUND: As the use of telemedicine proliferates in community care, it is essential to ensure practice recommendations and guidelines are available to assist healthcare providers in providing telemedicine-based care. This study aimed to develop entrustable professional activities (EPAs) for nursing home nurses involved in telemedicine consultations. AIM: To develop entrustable professional activities (EPAs) for nursing home nurses involved in telemedicine consultations. DESIGN: Modified Delphi study. METHODS: The study was conducted in two stages. First, content analysis of 28 healthcare provider interviews and literature review on telemedicine competencies was conducted to develop an initial list of EPAs. An expert workgroup comprising of an international panel of academics and clinicians reviewed the activities. In the second stage, a three-round e-Delphi technique was used to develop telemedicine EPAs for nurses in long-term care. Descriptive statistics and qualitative feedback were distributed to participants after each round. Agreement within survey rounds was computed. RESULTS: Six core telemedicine EPAs with 28 descriptors were developed, from preparing the resident for the teleconsultation encounter to follow-up care post-teleconsultation. Agreement coefficients were high across all Delphi rounds. CONCLUSION: This study identifies the core functions that long-term care nurses' are expected to perform in telemedicine consultations. The internationally relevant EPAs are sufficiently broad to be adapted to design telemedicine training and workplace-based assessment for nurses. Organisations may utilise the EPAs as a resource during the implementation process of telemedicine services in long-term care in designing nursing workflow and complement the learning and development of nurses for telemedicine services. Equipping long-term care nurses with this resource can ensure consistency, patient safety and quality of teleconsultations delivered to nursing home residents. However, further work is required to expand the EPAs for application to practice.

Risk Factors for All-Cause Mortality in Patients Diagnosed with Advanced Heart Failure: A Scoping Review.

Introduction: Identifying the evolving needs of patients with advanced heart failure (AdHF) and triaging those at high risk of death can facilitate timely referrals to palliative care and advance patient-centered individualized care. There are limited models specific for patients with end-stage HF. We aim to identify risk factors associated with up to three-year all-cause mortality (ACM) and describe prognostic models developed or validated in AdHF populations. Methods: Frameworks proposed by Arksey, O'Malley, and Levac were adopted for this scoping review. We searched the Medline, EMBASE, PubMed, CINAHL, Cochrane library, Web of Science and gray literature databases for articles published between January 2010 and September 2020. Primary studies that included adults aged ≥ 18 years, diagnosed with AdHF defined as New York Heart Association class III/IV, American Heart Association/American College of Cardiology Stage D, end-stage HF, and assessed for risk factors associated with up to three-year ACM using multivariate analysis were included. Studies were appraised using the Quality of Prognostic Studies tool. Data were analyzed using a narrative synthesis approach. Results: We reviewed 167 risk factors that were associated with up to three-year ACM and prognostic models specific to AdHF patients across 65 articles with low-to-moderate bias. Studies were mostly based in Western and/or European cohorts (n = 60), in the acute care setting (n = 56), and derived from clinical trials (n = 40). Risk factors were grouped into six domains. Variables related to cardiovascular and overall health were frequently assessed. Ten prognostic models developed/validated on AdHF patients displayed acceptable model performance [area under the curve (AUC) range: 0.71-0.81]. Among the ten models, the model for end-stage-liver disease (MELD-XI) and acute decompensated HF with N-terminal pro b-type natriuretic peptide (ADHF/proBNP) model attained the highest discriminatory performance against short-term ACM (AUC: 0.81). Conclusions: To enable timely referrals to palliative care interventions, further research is required to develop or validate prognostic models that consider the evolving landscape of AdHF management.

Educational needs of nursing home staff: does a needs-based palliative care course make a difference?

OBJECTIVE: In Singapore, more elderly are living in nursing homes (NHs), with a resultant increase in deaths occurring in NHs. However, palliative care training is limited in Singapore's core nursing curriculum, and many NHs rely on foreign-trained staff who may not have previous palliative care training. Our study aimed to evaluate whether a needs-based course can improve the palliative care knowledge and attitudes of NH nurses in Singapore. METHODS: Twenty-five nurses participated in the study. The intervention was an 8-week palliative care course developed based on needs assessment and led by a multidisciplinary faculty. A 50-item knowledge test was administered at baseline and 0 day and 3 and 6 months postcourse. Semistructured interviews were conducted at 3 months to assess for changes in attitudes and nursing practices. RESULTS: The mean knowledge score increased significantly from 31.4 (±4.4) precourse to 35.1 (±5.1) at 3 months. Knowledge scores in end-of-life care increased up to 6 months, and scores for pain and symptom management increased significantly at 3 months. Participants reported a positive change with improved communication skills and increased compassion. There was a lack of opportunities to apply some new knowledge and skills due to regulations and perceived residents' preferences to engage more local senior staff. CONCLUSION: The multidisciplinary needs-based palliative care course using various teaching modalities with follow-up knowledge tests helped to increase knowledge and improve communication skills and attitudes of NH nurses towards palliative care. The increase in knowledge and positive change in attitudes was noted to be sustained for at least 3 months postcourse.

A Phenomenological Investigation Into the Meaning of Food in Palliative Care Patients With Anorexia.

Little has been published on the meaning of food to palliative care patients with anorexia. Our study aims to investigate the meaning of food in palliative patients with anorexia. Fifteen patients with anorexia were recruited from the Palliative Care Unit of an acute hospital in Singapore from August 2018 to August 2021. A phenomenological methodology was employed to study the lived experience of anorexia and the meaning of food to palliative care patients. Our study findings revealed that food has social, physical, and emotional meaning in palliative care patients with anorexia. The social meaning of food was the predominant theme. Food was viewed as an important tool to bond and connect with their loved ones. It was perceived to be more important than the food itself and the taste of food was enhanced through social interactions. Food intake was related to physical strength and health status. Patients regarded eating as a way to improve their health status. Emotionally, eating was associated with positive feelings like enjoyment and freedom. Half of our participants felt that anorexia contributed to their low mood. Therefore, unlike the traditional focus of modifying the taste and quality of food in patients with anorexia, the authors recommended a focused assessment and management of the social aspect of anorexia on individual. This is important to mitigate the negative impact of anorexia, thus improving the quality of life and increasing their dignity towards the end of their lives.

Advance care planning: comparing the views of residents and healthcare professionals in nursing homes in Singapore.

BACKGROUND: With more frail elderly living and likely to die in nursing homes, advance care planning (ACP) is critical in overall efforts to provide good palliative care. However, it is unclear how willing older, vulnerable residents in nursing homes are to take on an active role in care decisions. AIM: The objective of this pilot study was to examine nursing homes' healthcare professionals' and residents' views on ACP and the extent of similarities and differences in their views. METHODS: Our sample of 24 healthcare professionals and 24 residents were identified and recruited through contacts established from existing collaborations with the nursing homes. Surveys were administered to the participants by a trained research assistant between April 2015 and August 2015. RESULTS: Almost all the healthcare professionals (95.8%) would like to make an ACP for themselves in the future, while residents were divided in their choices (P<<0.01). Most residents (79.1%) felt that the most important guide for their surrogate in making decisions for them when they lose decision-making capacity should be based on their best interests. However, most healthcare professionals (75.0%) felt that it should be based on the resident's wishes and values. CONCLUSIONS: Healthcare professionals tended to overestimate the importance of patient autonomy compared to the residents. This study demonstrates that as much as advocacy and awareness are ongoing, nursing home residents' motivation to participate in ACP is lacking. The lack of motivation in ACP participation could be due to medical paternalism and familial determination, which have been a cultural norm for older Singaporeans. This study demonstrates there is a lack of cultural sensitivity in this group of healthcare professionals in approaching nursing home residents' end-of-life care decision-making.

Does an Integrated Palliative Care Program Reduce Emergency Department Transfers for Nursing Home Palliative Residents?

Background: Nursing homes (NHs) are faced with a myriad of challenges to provide quality palliative care to residents who are at their end of life. Objectives: To describe and examine the impact of the GeriCare Palliative Care Program, which comprises telemedicine, on-site clinical preceptorship, palliative care education program, and Advance Care Planning (ACP) advocacy in reducing emergency department (ED) transfers from NHs. Design: Retrospective cohort study. Setting/Subjects: A total of 217 telemedicine consults were conducted for 187 unique NH residents across 5 NHs in Singapore over a 27-month period from April 2018 to June 2020. Measurement: Records of all enrolled palliative care residents who were triaged by telemedicine consultations were examined. Results: Our findings revealed that 82% of our urgent telemedicine consultations have successfully averted ED transfers. Gender and completion of ACP were statistically significant between ED transfer group and non-ED transfer group. Among those who completed their ACP, 78.3% of the ED transfer group chose limited intervention as their main goals of care compared with 30% in the non-ED transfer group. Conclusions: The GeriCare Palliative Care Program is a novel program, which is developed to improve the quality of palliative care in NHs. The comprehensive GeriCare model comprises a systematic framework, an integration of clinical support, ACP advocacy, and education program. Our findings demonstrated that these interventions synergistically led to a reduction in ED transfers while optimizing the residents' quality of care. By carrying out the targeted initiatives to support NHs, the residents could age-in-place comfortably.

Telemedicine experiences and perspectives of healthcare providers in long-term care: A scoping review.

OBJECTIVE: To consolidate existing evidence on experiences and perspectives of healthcare providers involved in telemedicine services in long-term residential care. METHODS: A scoping review was conducted. A systematic search for articles published in 2000-2021 was performed in CINAHL, Web of Science, PubMed, EMBASE and Scopus; further, relevant journals and grey literature websites were hand searched. Key search terms included 'telemedicine', 'telehealth' and 'nursing homes'. RESULTS: Twenty-six articles were included. A narrative synthesis of evidence was conducted. The review identified four themes: (1) Presence of multidisciplinary care, (2) perceived usefulness of telemedicine, (3) perceived ease of use and (4) expanded role of nursing home staff. The presence of multidisciplinary care providers provided a wide range of telemedicine services to residents and promoted interprofessional collaboration between acute and long-term care. Telemedicine was perceived to increase timely onsite management by remote specialists, which enabled care quality improvement. However, technical problems associated with equipment usage reduced the ease of use of telemedicine. Concerns emerged from the expanded role of nursing home staff, which could negatively affect clinical decision-making and create medico-legal risks. CONCLUSION AND IMPLICATIONS: Telemedicine is valuable in distance-based care, especially in the current 2019 coronavirus pandemic, for supporting continuity of care to nursing home residents. This review provided evidence from multiple healthcare providers' perspectives. Further research can elucidate their specific roles and responsibilities in telemedicine and challenges in work processes, which will facilitate developing evidence-based competencies and improving technical infrastructure, thus contributing to personal and organisational readiness for telemedicine integration.

Understanding Quality of Life for Palliative Patients With Dysphagia Using the Swallowing Quality of Life (SWAL-QOL) Questionnaire.

OBJECTIVE: There are few studies concerning the differences in quality-of-life (QOL) between palliative care patients with and without dysphagia to date. We aimed to compare the QOL and symptoms in palliative patients with and without dysphagia using Swallowing Quality of Life (SWAL-QOL). METHODS: Eighty-one palliative patients with and without dysphagia underwent the SWAL-QOL questionnaire. A series of Mann Whitney U tests were performed between non-dysphagic and dysphagic groups for the total SWAL-QOL score and the 11 SWAL-QOL domains. RESULTS: Dysphagia significantly impacted patients' QOL in the dysphagic group (mean, 69.5; SD 21.9) than non-dysphagic group (mean, 83.2; SD 14.8) (P = 0.006). Significant differences were observed between both groups for the domains of burden, eating desire, eating duration, symptoms, food selection, communication and mental health. The results also showed that the dysphagic group had lower symptom score across all symptoms, suggesting higher symptom burdens. CONCLUSIONS: This study is the first to examine QOL and swallow symptoms in palliative care patients with and without dysphagia. Dysphagia causes significantly worse QOL in palliative care patients. Screening for dysphagia and managing its impact on symptoms and QOL domains is important in palliative care.

Defining clinical empathy: a grounded theory approach from the perspective of healthcare workers and patients in a multicultural setting.

OBJECTIVE: To define clinical empathy from the perspective of healthcare workers and patients from a multicultural setting. DESIGN: Grounded theory approach using focus group discussions. SETTING: A health cluster in Singapore consisting of an acute hospital, a community hospital, ambulatory care teams, a medical school and a nursing school. PARTICIPANTS: 69 participants including doctors, nurses, medical students, nursing students, patients and allied health workers. MAIN OUTCOME MEASURES: A robust definition of clinical empathy. RESULTS: The construct of clinical empathy is consistent across doctors, nurses, students, allied health and students. Medical empathy consists of an inner sense of empathy (imaginative, affective and cognitive), empathy behaviour (genuine concern and empathic communication) and a sense of connection (trust and rapport). This construct of clinical empathy is similar to definitions by neuroscientists but challenges a common definition of clinical empathy as a cognitive process with emotional detachment. CONCLUSIONS: This paper has defined clinical empathy as 'a sense of connection between the healthcare worker and the patient as a result of perspective taking arising from imaginative, affective and cognitive processes, which are expressed through behaviours and good communication skills that convey genuine concern'. A clear and multidimensional definition of clinical empathy will improve future education and research efforts in the application and impact of clinical empathy.

Prognostication in Home-Dwelling Patients with Advanced Dementia: The Palliative Support DEMentia Model (PalS-DEM).

OBJECTIVE: Difficulties with prognostication prevent more patients with advanced dementia from receiving timely palliative support. The aim of this study is to develop and validate a prognostic model for 6-month and 1-year mortality in home-dwelling patients with advanced dementia. DESIGN: Prospective cohort study. SETTING AND PARTICIPANTS: The data set of 555 home-dwelling patients with dementia at Functional Assessment Staging Test stage 7 was split into derivation (n = 275) and validation (n = 280) cohorts. METHODS: Cox proportional hazards regression modeled survival in the derivation cohort using prognostic variables identified in univariate analysis. The model was validated internally and using 10-fold cross-validation. Area under the receiver operating characteristic curve measured the accuracy of the final model. RESULTS: Four hundred nineteen (75.5%) patients died with a median follow-up of 47 days [interquartile range (IQR) 161]. Prognostic variables in the multivariate model included serum albumin level, dementia etiology, number of homecare admission criteria fulfilled, presence of moderate to severe chronic kidney disease, peripheral vascular disease, quality of life in late-stage dementia scores, housing type, and the Australian National Sub-Acute and Non-Acute Patient palliative care phase. The model was refined into a parsimonious 6-variable model [Palliative Support DEMentia Model (PalS-DEM)] consisting of age, dementia etiology, Functional Assessment Staging Test stage, Charlson Comorbidity Index scores, Australian National Sub-Acute and Non-Acute Patient palliative care phase, and 30-day readmission frequency for the prediction of 1-year mortality. The area under the receiver operating characteristic curve was 0.65 (95% confidence interval 0.59-0.70). Risk scores categorized patients into 3 prognostic groups, with a median survival of 175 days (IQR 365), 104 days (IQR 246), and 19 days (IQR 88) for the low-risk (0‒1 points), moderate-risk (2‒4), and high-risk (≥5) groups, respectively. CONCLUSIONS AND IMPLICATIONS: The PalS-DEM identifies patients at high risk of death in the next 1 year. The model produced consistent survival results across the derivation, validation, and cross-validation cohorts and will help healthcare providers identify patients with advanced dementia earlier for palliative care.

The Nuts and Bolts of Utilizing Telemedicine in Nursing Homes - The GeriCare@North Experience.

OBJECTIVES: We examined the demographics and the clinical profile of teleconsultations conducted between an acute geriatric medicine department and 8 nursing homes over a period of 6.5 years. DESIGN: This is a prospective, descriptive study. SETTING AND PARTICIPANTS: This study was conducted in 8 nursing homes of Singapore. All nursing home patients referred to the program for teleconsultation between December 2010 and May 2017 were enrolled in the study. MEASURES: The unit observed and studied was the individual telemedicine consultation. Each unique patient contributed 1 or more observation points. The data collected included consultation dates, patient demographics, background medical comorbidities, reasons for referral, physical examination findings, primary diagnoses, and general management plans recommended by the doctors. RESULTS: There were 1673 teleconsultations conducted with 850 unique patients. Most of these patients were categorized as having moderate to severe disability. Ninety-five percent of the consultations were scheduled. The main reasons for referral were for medication review (47.6%) and behavioral problems (22.1%). The 4 commonest comorbidities were hypertension (57.0%), dementia (40.0%), diabetes (39.0%), and hyperlipidemia (38%). The most common primary diagnosis was dementia (21.6%), of which 227 of those diagnosed (62.8%) were referred for behavioral and psychological symptoms of dementia. CONCLUSIONS AND IMPLICATIONS: A telemedicine service for older patients is feasible and could be of a high quality, especially if made available in places where a high density of the latter reside, such as in the care homes and other nursing and rehabilitation facilities.