Nurses' perceptions and experiences of caring for patients who die in the emergency department setting.

INTRODUCTION: The number of people dying in emergency departments (EDs) is increasing. However, EDs are not well designed or resourced for safe and effective End-Of-Life (EOL) care encounters, and there is little evidence regarding clinicians' perceptions and experiences of providing such care when the death is sudden and unexpected. AIM: This study explored nurses' perceptions and experiences of caring for patients who die suddenly and unexpectedly in the ED. METHODS: Open-end responses were collected as part of a larger descriptive survey design. The qualitative data were analysed thematically. RESULTS: 211 ED nurse completed the online survey. Within the qualitative data, five themes were identified during analysis: 1) key elements of EOL care, 2) systemic and environmental barriers, 3) educational deficits, 4) role ambiguity, and 5) emotional impact. Participants identified communication, a standardised approach, and better educational preparedness as the most important elements of EOL care when the death was sudden and unexpected. CONCLUSIONS: ED nurses want to provide high quality care to dying patients and their families. However, their efforts are hampered by systemic and environmental barriers outside their control. There is a need for a culture shift to overcome the barriers that currently obstruct ED nurses from providing meaningful and effective EOL care in the ED.

How do clients in Australia experience Consumer Directed Care?

BACKGROUND: Our study explored client experience of Australian Consumer Directed Care. This evolving funding model enables consumer autonomy and choice, allowing older people to remain in their community as they age and need support through the creation of a personalised support service. Consumer Directed Care focuses on providing services that the consumer self-determines to meeting their needs including identifying their types of services, from whom, when and how these services are delivered. METHODS: Semi-structured in-depth interviews were conducted in two Australian states between August 2015 and April 2016 with 14 participants, preferably in receipt of CDC services for at least the previous 12 months. Questions explored how the participant first learned about this service; the types of services they received; whether services met their needs; and any additional support services they personally purchased. Interviews were transcribed, coded and thematically analysed. RESULTS: Four main themes related to consumer experience emerged. Knowledge: Unsure what Consumer Directed Care Means. Acceptance: Happily taking any prescriptive service that is offered. Compliance: Unhappily acceding to the prescriptive service that is offered. External Influences: Previous aged care service experience, financial position, and cultural differences. CONCLUSION: Our results suggest that the anticipated outcomes of Consumer Directed Care providing a better service experience were limited by existing client knowledge of these services, how best to utilise their funding allocation, and their acceptance or compliance with what was offered, even if this was not personalised or sufficient. External influences, such as service experience, finances, cultural difference, impacted the way clients managed their allocation. Our study identified that ongoing engagement and discussion with the client is required to ensure that services are specific, directly relevant and effective to achieving a consumer directed care service.

Which online format is most effective for assisting Baby Boomers to complete advance directives? A randomised controlled trial of email prompting versus online education module.

BACKGROUND: Completion of Advance Directives (ADs), being financial and healthcare proxy or instructional documents, is relatively uncommon in Australia. Efforts to increase completion rates include online education and prompting which past literature suggests may be effective. The aim of this randomized controlled trial was to assess computer-based online AD information and email prompting for facilitating completion of ADs by Australian Baby Boomers (b.1946-1965) as well as factors which may impede or assist completion of these documents by this generation when using the online environment. METHODS: Two hundred eighty-two men and women aged 49-68 years at the time of the trial were randomly assigned to one of 3 intervention groups: education module only; email prompt only; email prompt and education module; and a control group with no education module and no email prompt. The randomized controlled trial was undertaken in participants' location of choice. Randomization and allocation to trial group were carried out by a central computer system. The primary analysis was based on a final total of 189 participants who completed the trial (n = 52 education module only; n = 44 email prompt only; n = 46 email prompt and education module; and n = 47 control). The primary outcome was the number of individuals in any group completing any of the 4 legal ADs in South Australia within 12 months or less from entry into the trial. Frequency analysis was conducted on secondary outcomes such as reasons for non-completion. RESULTS: Mean follow-up post-intervention at 12 months showed that 7% of overall participants completed one or more of the 4 legal ADs but without significant difference between groups (delta = 1%, p = .48 Prompt/Non-Prompt groups, delta = 5%, p = .44 education/non-education groups). Reasons offered for non-completion were too busy (26%) and/or it wasn't the right time (21%). CONCLUSION: Our results suggest that neither email prompting nor provision of additional educational material online were sufficient to significantly impact AD completion rates for this generational cohort. Research with this cohort over longer periods of time exploring online preferences for engagement with ADs as they age may provide better insight into using this environment for ADs with this group. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12616000425493 .

Costs and advance directives at the end of life: a case of the 'Coaching Older Adults and Carers to have their preferences Heard (COACH)' trial.

BACKGROUND: Total costs associated with care for older people nearing the end of life and the cost variations related with end of life care decisions are not well documented in the literature. Healthcare utilisation and associated health care costs for a group of older Australians who entered Transition Care following an acute hospital admission were calculated. Costs were differentiated according to a number of health care decisions and outcomes including advance directives (ADs). METHODS: Study participants were drawn from the Coaching Older Adults and Carers to have their preferences Heard (COACH) trial funded by the Australian National Health and Medical Research Council. Data collected included total health care costs, the type of (and when) ADs were completed and the place of death. Two-step endogenous treatment-regression models were employed to test the relationship between costs and a number of variables including completion of ADs. RESULTS: The trial recruited 230 older adults with mean age 84 years. At the end of the trial, 53 had died and 80 had completed ADs. Total healthcare costs were higher for younger participants and those who had died. No statistically significant association was found between costs and completion of ADs. CONCLUSION: For our frail study population, the completion of ADs did not have an effect on health care utilisation and costs. Further research is needed to substantiate these findings in larger and more diverse clinical cohorts of older people. TRIAL REGISTRATION: This study was registered on 13/12/2007 with the Australian New Zealand Clinical Trial Registry ( ACTRN12607000638437 ).

Use of advance directives by South Australians: results from the Health Omnibus Survey Spring 2012.

OBJECTIVE: To determine the prevalence of completion of advance directives (ADs) and wills by South Australians aged 15 years and over. DESIGN, SETTING AND PARTICIPANTS: Statewide population-based survey of a single member (aged 15 years and over) of 3055 South Australian households between 4 September and 12 December 2012. MAIN OUTCOME MEASURES: Prevalence and sociodemographic determinants of completion of the four recognised legal ADs in South Australia (enduring power of attorney [EPA] for finance, enduring power of guardianship [EPG] for health care/lifestyle, medical power of attorney [MPA] for medical treatment and anticipatory direction for end-of-life care) and wills. RESULTS: Nearly half the 3055 survey participants had not completed any AD document or will. Financial documents were more likely to be completed than health care documents. In multivariate analysis, the odds of not having completed any AD was higher among those aged 15-24 years compared with those aged over 65 years (odds ratio [OR], 55.3; 95% CI, 31.3-97.7) and 25-44 years (OR, 24.9; 95% CI, 17.3-36.1). Similarly, the odds were higher for those born in another country (OR, 2.0; 95% CI, 1.6-2.4); those never married (OR, 3.1; 95% CI, 2.3-4.2) or in de facto relationships (OR, 2.8; 95% CI, 2.1-3.8) or separated/divorced (OR, 1.8; 85% CI, 1.3-2.4) compared with those married; those who left school in Year 12 or before (OR, 1.5; 95% CI, 1.1-1.9) or with a bachelor degree (OR, 1.5; 95% CI, 1.1-2.0) compared with those who had completed a trade/apprenticeship, certificate/diploma; and those in blue collar occupations (OR 1.6; 95% CI, 1.3-2.2) or not employed (OR, 2.2; 95% CI, 1.4-3.6) versus professionals. The odds of not having completed any AD were lower for those living in rural or regional areas (OR, 0.8, 95% CI, 0.6-1.0) compared with the metropolitan area, and for those in the highest income bracket earning more than $80 000 (OR, 0.6; 95% CI, 0.5-0.8) compared with those in the middle bracket earning $40 000-$80 000. CONCLUSION: Completion rates of ADs among South Australians remain low, with financial instruments more likely to be completed than health care and lifestyle instruments. The odds of not completing ADs were associated with age and socioeconomic characteristics. General practitioners are in a good position to target advance care planning towards relevant patient groups, which would likely improve rates of decision making in future health care.

Systematic review of the types of methods and approaches used to assess the effectiveness of healthcare information websites.

The aim of this systematic review was to identify types of approaches and methods used to evaluate the effectiveness of healthcare information websites. Simple usage data may not be sufficient to assess whether desired healthcare outcomes were achieved or to determine the relative effectiveness of different web resources on the same health topic. To establish the state of the knowledge base on assessment methods used to determine the effectiveness of healthcare websites, a structured search of the literature was conducted in Ovid Medline, resulting in the retrieval of 1611 articles, of which 240 met the inclusion criteria for the present review. The present review found that diverse evaluation methods were used to measure the effectiveness of healthcare websites. These evaluation methods were used during development, before release and after release. Economic assessment was rare and most evaluations looked at content issues, such as readability scores. Several studies did try to assess the usefulness of websites, but few studies looked at behaviour change or knowledge transfer following engagement with the designated health website. To assess the effectiveness of the knowledge transfer of healthcare information through the online environment, multiple methods may need to be used to evaluate healthcare websites and may need to be undertaken at all stages of the website development process.