Gender and couple status differences in advance care planning: a cross-sectional study.

Background: Past studies have shown mixed results on how gender and living with a spouse or partner impact advance care planning (ACP). Few if any have tested for the interaction between these two variables. Objective: We examined how gender and couple status interact to impact the use of ACP practices including written instructions, designating a durable power of attorney for healthcare (DPOAHC), and discussing one's decisions with others. Design: We used cross-sectional data taken from the Health and Retirement Study, a longitudinal study of adults over the age of 50 in the United States. Methods: Data are from 632 respondents who died between the 2016 core survey and the 2018 exit survey. Participants had completed the 2016 survey and had a proxy informant complete the 2018 exit survey after their death. Generalized linear mixed models were used to test for main effects and interactions. Results: Women were more likely than men to designate a DPOAHC and to discuss their wishes with others. Women living without a partner were more likely than men living without a partner and coupled households to discuss their wishes with family or others. Conclusion: Both gender and couple status are important variables associated with ACP practices. Healthcare providers may want to reach out to women living within a coupled household and men living without a partner to ensure that they know the benefits of ACP.

Are men and women living with a partner less likely to make plans for the type of medical treatment they prefer at the end of life? Why was the study done? To see if men and women living alone or with a partner were more likely to make plans for the type of medical treatment they preferred at the end of life. We examined whether they had written plans, designated someone to make decisions for them, or discussed their wishes with other family members or healthcare providers before they died. What did the researchers do? The research team used survey data from the Health and Retirement Study in the United States on 632 people who had completed a survey in 2016 and died within two years. A family member or friend completed a survey after the person's death reporting on their preferences for end-of-life medical care. What did the researchers find? Women were more likely than men to designate another person to make medical decisions for them and to discuss their wishes with others. Single women were more likely than single men and people living with a partner to discuss their wishes with family or others. What do the findings mean? Women living alone may be more likely to see the benefits of making their end-of-life medical care wishes known to others. Men living alone were the least likely to make their wishes known. Healthcare providers may want to keep these differences in mind when reaching out to patients to explain the benefits of making plans for medical treatments in the future.

[The Experiences of Healthy Adults Participating in Advance Care Planning].

BACKGROUND: After enactment of the Patient Right to Autonomy Act in Taiwan, most of the individuals participating in advance care planning (ACP) and signing advance decisions (AD) have been healthy adults. This demographic is inadequately covered in the literature, in which related studies focus primarily on individuals with major illnesses. PURPOSE: This study was implemented to understand the experiences of healthy adults participating in ACP. METHODS: A qualitative approach was taken and participants were recruited from ACP outpatient clinics in three hospitals in northern, central, and southern Taiwan. All of the participants were healthy adults who had completed the ACP process, did not have a major illness, had no psychiatric diagnoses, and could express themselves clearly. Data were collected via semi-structured interviews and analyzed using content analysis. RESULTS: A total of 15 participants were interviewed, generating three major themes: "Establishing the foundations of ACP", "Preserving dignity in end-of-life care", and "Key elements for successful ACP". Their motivation to engage in ACP and sign the AD form was influenced by past experiences and a desire to maintain dignity and physical autonomy through the aging process. Their decision-making processes were influenced by family opinions, sociocultural factors, and systemic dynamics. CONCLUSIONS / IMPLICATIONS FOR PRACTICE: During the ACP and AD signing process, the consulting team not only helps healthy adults successfully provide informed consent but also, by fostering a supportive communication environment, ensures medical preferences and expectations are accurately reflected, thus promoting mutual care, support, and understanding among all parties.

Effects of intervention by trained care managers on advance care planning engagement among long-term care service users in Japan: a pre- and post-pilot comparative study across multiple institutions.

Background: A majority of Japanese care managers lack medical qualifications, feel uncomfortable discussing future medical choices and believe that it is not their responsibility. Objectives: As there is a paucity of care manager intervention studies, this study aimed to measure changes in advance care planning engagement among long-term care service users before and after intervention by care managers with communication training. Design: A multi-institutional pre- and post-pilot comparative study. Methods: A multi-institutional pre- and post-trial study was performed from August 2022 to January 2023 (trial ID: 000048573). Nine trained care managers communicated with 30 long-term care service users regarding advance care planning, and the pre- and post-trial advance care planning engagement scores were compared. Additionally, the post-trial impact of events score was investigated. Results: All 30 long-term care service users completed the trial. The advance care planning engagement score increased after the trial. The sample size was considered adequate for future trials. Years of experience as a care manager, impact of events score, and having a clinical frailty scale of ⩾5 were significant explanatory variables that affected the objective variable of the difference between pre- and post-trial advance care planning engagement score. Conclusion: This study on the impact of advance care planning communication interventions by trained care managers offers insights into determining appropriate sample sizes and identifying factors influencing future research outcomes. Advance care planning engagement of long-term care service users might change before and after intervention by care managers through advance care planning communication. Trial registration: University Hospital Medical Information (UMIN) Network Trial ID: 000048573.

Physicians' Perceived Barriers and Willingness to Initiate Advance Care Planning with Young Adults Living with Cardiometabolic Diseases.

Objectives: The current global practice is to plan for the end-of-life period of persons already terminally ill with chronic diseases. However, affected persons should not have to wait till the stage of terminal illness to begin making plans for future healthcare preferences. This pilot study explored perceived barriers to and willingness of physicians to initiate discussions on advance care planning (ACP) with young adults living with cardiometabolic diseases. Materials and Methods: The study was the pilot phase of descriptive cross-sectional research conducted among primary care physicians practising in Kuwait. Pilot data was collected with an electronic version of the modified DECIDE questionnaire (adapted from the "DECIsion-making about goals of care for hospitalized ElDErly patients" study) from February to April 2023. Data were analysed with Google Sheets. Results: Nine out of 22 participants exited the study early on grounds of non-familiarity with the concept of ACP. Thirteen responses were analysed and reported herein. The mean age of the participants was 44.2 (±7.9) years; eight were male and five were female; five were Hindu, 7 Muslim, and 2 Christian. Perceived barriers to initiating ACP discussions included lack of knowledge about ACP and its relationship to ACP and goals of care discussions (8), lack of knowledge about the legal status of ACP documents in Kuwait (11), religious disapproval (12), lack of knowledge about how to elicit values, beliefs, preferences related to end-of-life care (13) and fear that these conversations will diminish hope in patients with serious illness (12), among others. Twelve participants were willing to initiate discussions and exchange information with young adult patients. Twelve participants indicated that they were confident about initiating discussions and exchanging ACP information, had all not taken any extra training or certification in ACP, but, respectively, described their current level of skill in having ACP discussions and supporting patients in the finalisation of their advance care plans as limited (2), fair (3), average (4), very good (3) and expert (1). Conclusion: Despite the low level of awareness and other factors perceived as barriers, the primary care physicians who participated in the study were confident and willing to initiate ACP discussions with young adults living with cardiometabolic diseases. With the generally reported lack of previous training in ACP, there might be a need for coordinated efforts in training or up-skilling on knowledge and practice of ACP among primary care physicians.

Management of Rarest Type of Talus Fracture: A Case Report.

This is a case of the rarest type of talus fracture in a 28-year-old male who presented with pain in his right ankle and foot following a road traffic accident. He was unable to bear weight or walk after the injury. Imaging studies indicated fractures in the head and neck of the talus, as well as the talar dome, with a fracture line extending into the subtalar joint. The patient underwent open reduction and internal fixation using mini fragment plating and Herbert screw fixation for the osteochondral fragment. Both the intraoperative and postoperative periods were without complications. The patient was placed in plaster of Paris (POP) slab immobilization for four weeks and was advised to avoid weight-bearing while using a walker for eight weeks, after which physiotherapy commenced. Follow-up assessments showed satisfactory fracture union, good range of motion in the ankle, an excellent American Orthopedic Foot and Ankle Society (AOFAS) score, an excellent 17-Italian Foot Function Index (FFI) score, and a good Hawkins score.

Rice HUSK silica: A review from conventional uses to new catalysts for advanced oxidation processes.

The rice industry is of great importance worldwide and within the cereal industrialization process, rice husk is obtained as waste, a by-product with various alternative uses, among others, the obtaining of amorphous silica, a covalent oxide with chemical, structural and textural properties suitable for use as catalytic support. This review shows the potential of rice husk silica in the synthesis of heterogeneous catalysts with transition metals for the oxidation of different polluting molecules present in water, as well as the limitations of the catalytic system and the way to overcome them through new synthesis routes, to obtain single atom catalysts - SACs. The main preparation strategies applied for aqueous phase systems are summarized, as well as the studies of single atom catalysts in oxidation reactions of recalcitrant compounds using silica as support and, finally, the perspectives and opportunities regarding this novel topic.

Acknowledgement and use of advance care directives and goals of care by emergency department staff: a mixed method post intervention study.

INTRODUCTION: Advance Care Planning (ACP) refers to a process that includes Advance Care Directives (ACD) and Goals of Care (GOC), a practice widely used for over three decades. Following the findings of an audit and a cross-sectional study in 2019 and 2021 respectively, we implemented several educational and other interventional strategies aimed at enhancing staff awareness and emphasizing the importance of recognizing and documenting of ACD/GOC. The aim of this study was to evaluate the acknowledgement and use of ACD and GOC by Emergency Department (ED) staff following these interventions. METHOD: We used a mixed methods approach, incorporating both observational and cross-sectional designs with reflexive thematic analysis. Data extraction for the observational study took place between 1st April and 30th June 2023 focusing on a target population of randomly sampled adults aged ≥ 65 years. Demographics and other ACD and GOC related patients' clinical data were collected. Data collection for the cross-sectional study occurred between 19th July and 13th September 2023 targeting all ED staff. Information gathered included demographics, awareness about ACD and GOC, including storage location and implementation, as well as knowledge of Medical Treatment decision Makers (MTDM), a jurisdictional term identifying a person legally appointed to make healthcare decisions on behalf of someone who lacks decision-making capacity and other Victorian State legislative requirements were collected. RESULTS: In the observational period, 22,335 patients attended the ED and 19% (n = 6546) qualified for inclusion from which a sample of 308 patients were randomly extracted. We found ACD documents were noted in the medical records of 6.5% of the sample, fewer than 8% identified in our previous study. There was no correlation between ACD record availability and age (p = 0.054; CI ranging from - 0.065 to 7.768). The response rate for the cross-sectional survey was 12% (n = 340) in contrast to earlier study with 28% (n = 476) respondents. Staff knowledge and familiarity with ACD was 25% and GOC 45%. CONCLUSION: After implementing interventions in staff education and ACP awareness, we found that ACD documentation did not improve. However, GOC documentation increased in the context of heightened institutional awareness and integration into the Electronic Medical Records (EMR).

Do China's ecological civilization advance demonstration zones inhibit fisheries' carbon emission intensity? A quasi-natural experiment using double machine learning and spatial difference-in-differences.

China's National Ecological Civilization Demonstration Zone (NECDZ) policy has a significant role in ensuring national ecological security, and it is essential to investigate how the NECDZ policy affects the carbon emissions intensity of fisheries (CEIF) to advance China's commitment to reducing carbon emissions. This study evaluates the CEIF in 30 Chinese provinces from 2007 to 2021 using ecological civilization demonstration areas as a quasi-natural experiment and double machine learning (DML)to examine the impact and internal mechanisms of NECDZ implementation on the CEIF. We also explore spatial spillover effects using a spatial difference-in-differences approach. The results reveal that NECDZ implementation has a significantly negative impact on the CEIF and this effect continues over time. NECDZ policy potentially affects the CEIF through technology development, industrial structure improvement, and reduced energy consumption. Further investigation reveals that NECDZ implementation has spillover effects and inhibits the CEIF in surrounding regions. Therefore, it is essential to focus on developing the NECDZ policy to enhance fisheries' industrial structure, encourage low-carbon innovation in fishery technologies, and increase energy consumption efficiency. This could be supported by facilitating exchanges and cooperation with other areas, considering regional disparities, and assigning common but distinct responsibility for reducing the CEIF.

Embracing ambivalence and hesitation: a Ricoeurian perspective on anticipatory choice processes at the end of life.

Especially older adults are increasingly stimulated to think about, talk about and record their preferences with regard to future (health)care decisions, preferably in a pro-active manner. In this paper, I analyse these anticipatory choice processes. My goal is twofold: Firstly, to provide a deeper understanding of what it actually means to decide in advance about end-of-life treatments or options. Secondly, to make a theoretical contribution to bioethics and ACP-theories by rethinking the concept of end-of-life choices from a phenomenological viewpoint. To achieve this, I start by presenting a case narrative that elucidates how these anticipatory choices are lived. Secondly, I map out a theoretical framework about choice based on the phenomenology of the will of Paul Ricoeur. Finally, guided by this Ricoeurian framework, I investigate the potential meaning of choice in the context of contemporary advance care planning trajectories. The analysis demonstrates that choice and agency always imply notions of passivity and uncontrollability. It also indicates the significant value of hesitation and ambivalence. Moreover, it highlights the importance of the notion of co-responsibility in the context of anticipated end-of-life choices, and the relevant distinction between a (willed) choice and a wish. To improve care and support regarding end-of-life trajectories and to promote meaningful conversations, it is imperative to integrate these underrated elements more substantially in our theories, language and practical approaches. I conclude by suggesting that, in order to do justice to the real-life complexities, we might even need to revise the notion of advance 'directives'.

Understanding non-pharmacological palliative care for people with serious COPD: the individual and organizational perspective.

TOPIC IMPORTANCE: This narrative review emphasizes the growing interest in palliative care for people with serious lung diseases, such as COPD. It reflects upon recent publications from the American Thoracic Society (ATS), the World Health Organization (WHO) and European Respiratory Society (ERS) with a focus on non-pharmacological palliative care for people with COPD, from both the healthcare professional and the organizational perspective. REVIEW FINDINGS: The concept of palliative care has changed over time and is now seen as applicable throughout the whole disease trajectory according to need, in conjunction with any disease-modifying therapies. Palliative care should pay attention to the needs of the person with COPD as well as the informal caregiver. Timely integration of palliative care with disease-modifying treatment requires assessment of needs at the individual level as well as organizational changes. High-quality communication, including advance care planning is a cornerstone of palliative care. SUMMARY: Therefore, services should be based on the understanding that palliative care is not just specific standardized actions and treatments, but a holistic approach that includes compassionate communication and treatment and care addressing the patient, informal and formal caregivers. Living with and dying from COPD is much more than objective measurements. It is the sum of relationships with others and the experience of living in the best possible harmony with one's own values and hopes despite having a serious illness.

Feasibility of Using Simulation to Evaluate Implementation Fidelity in an Advance Care Planning Pragmatic Trial.

Background and Objectives: Traditional methods of fidelity monitoring are not possible in pragmatic trials in real-world clinical settings. We describe our approach to monitoring and reinforcing the fidelity to ACP conversations for a hard-to-reach subpopulation by using standardized patients in a pragmatic trial. Research Design and Methods: We developed standardized patient scenarios grounded in the Respecting Choices First Steps™ Advance Care Planning curriculum to provide an opportunity to reinforce and assess ACP facilitator competency. Scenarios represented one-on-one encounters. The first case was a standardized patient with cognitive impairment and the second case involved a standardized patient with dementia and their care partner. A previously validated fidelity checklist was used to score skills and behaviors observed during simulations including encounter set-up, ACP topics, and general communication. Simulations involved voice teleconferencing to align primary modality of ACP in the pragmatic trial. Results: Six facilitators completed two standardized patient cases each. Overall fidelity scores were moderately high (78.8% ± 11.7; 63.4 - 95.6) for the case with cognitive impairment and for the case with the patient with dementia and care partner (76.2% ± 13.0; 54.4 - 91.5). Discussion and Implications: Simulation using standardized patients supported fidelity monitoring and provided coachable feedback to support facilitator competency. Our study can help inform future research and training related to advance care planning in older adults living with Alzheimer's disease and related disorders.

Multi-class plant hormone HILIC-MS/MS analysis coupled with high-throughput phenotyping to investigate plant-environment interactions.

Plant hormones are chemical signals governing almost every aspect of a plant's life cycle and responses to environmental cues. They are enmeshed within complex signaling networks that can only be deciphered by using broad-scale analytical methods to capture information about several plant hormone classes simultaneously. Methods used for this purpose are all based on reversed-phase (RP) liquid chromatography and mass spectrometric detection. Hydrophilic interaction chromatography (HILIC) is an alternative chromatographic method that performs well in analyses of biological samples. We therefore developed and validated a HILIC method for broad-scale plant hormone analysis including a rapid sample preparation procedure; moreover, derivatization or fractionation is not required. The method enables plant hormone screening focused on polar and moderately polar analytes including cytokinins, auxins, jasmonates, abscisic acid and its metabolites, salicylates, indoleamines (melatonin), and 1-aminocyclopropane-1-carboxylic acid (ACC), for a total of 45 analytes. Importantly, the major pitfalls of ACC analysis have been addressed. Furthermore, HILIC provides orthogonal selectivity to conventional RP methods and displays greater sensitivity, resulting in lower limits of quantification. However, it is less robust, so procedures to increase its reproducibility were established. The method's potential is demonstrated in a case study by employing an approach combining hormonal analysis with phenomics to examine responses of three Arabidopsis ecotypes toward three abiotic stress treatments: salinity, low nutrient availability, and their combination. The case study showcases the value of the simultaneous determination of several plant hormone classes coupled with phenomics data when unraveling processes involving complex cross-talk under diverse plant-environment interactions.

Family perspectives on and experiences with advance care planning in nursing homes: A thematic synthesis.

OBJECTIVES: To synthesize family members' experiences and perspectives on advance care planning (ACP) in nursing homes. METHODS: The thematic synthesis is reported following the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement. A systematic search of the APA PsycINFO, CINAHL Plus, Embase and PubMed databases is initially conducted in October 2022, and the search is updated in January 2024. Qualitative studies that presented family members' quotes regarding advance care planning in nursing homes published in a peer-reviewed journal were included. Screening and data extraction were independently performed by two reviewers, and any discrepancies were resolved with the assistance of the third author. RESULTS: A total of 1027 articles were identified, and 23 articles were included in the full-text review. Subsequently, a total of 17 studies were ultimately included, and 127 quotes were extracted and analysed. The main findings were categorized into three themes: (1) invitation to conversation and care, (2) the resident's surrogate and (3) nurses. Considering the importance of family members' roles in ACP conversations in a nursing home setting, this study provided an in-depth understanding of family members' perceptions and experiences of ACP by synthesizing qualitative studies. Family members' lack of knowledge regarding the timing and pursuits of ACP was also identified. CONCLUSION: The findings of this study provide synthesized qualitative evidence of family members' perspectives on ACP, which can inform care and treatment in nursing homes. As this study synthesizes the experiences of family members in nursing homes about ACP, the findings of this study contribute to reflecting family members' experiences and providing evidence for nursing home healthcare professionals. PATIENT OR PUBLIC CONTRIBUTION: This study reports the experiences of family members in ACP nursing homes. The findings of this study contribute to reflecting family members' experiences and building evidence for nursing home healthcare professionals.

Oncology Nurses' Communication Practices and Challenges Towards Advance Care Planning: A Sequential Explanatory Mixed-Method Study.

AIMS: This study aims to explore the practice of advance care planning (ACP) among Chinese oncology nurses and identify challenges influencing care provision. DESIGN: A sequential explanatory mixed-method design was employed, comprising a quantitative phase to assess communication practices, followed by a qualitative phase to explore the challenges faced in ACP. METHODS: The study employed convenience sampling, including 532 oncology nurses from seven hospitals in northern China. Quantitative data were collected through a cross-sectional survey and the ACP communication index from December 2021 to January 2022. The qualitative phase consisted of 19 interviews conducted between May and July 2022, which were thematically analysed to elucidate the challenges in ACP practices. RESULTS: Quantitative findings revealed a low frequency of ACP communication among Chinese oncology nurses. Qualitative analysis identified four themes: lack of optimal timing, passive engagement of patients or families, reluctance of healthcare professionals and unsupported policies. CONCLUSION: The study concluded that identified challenges compromise the effectiveness of ACP practices among Chinese oncology nurses. Inadequate communication, limited interdisciplinary collaboration and policy gaps contribute to nonstandardised ACP processes. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: The findings underscore the need for targeted interventions to enhance nurses' communication skills, foster interdisciplinary collaboration and provide policy support. Such interventions are pivotal to optimising end-of-life care in oncology settings and facilitating the integration of ACP into routine nursing practices. REPORTING METHODS: This study adhered to the Mixed Methods Article Reporting Standards. PATIENT OR PUBLIC CONTRIBUTION: No contributions from patients or the public were involved in this study.

Psychometric properties of lift and carry test in assessing people with stroke.

Objective: To investigate the psychometric properties of the Lift and Carry Test (LCT) time in people with stroke. Design: Cross-sectional design. Setting: University based neurorehabilitation laboratory. Participants: Twenty-four people with stroke and 24 healthy controls. Outcome measures: Lift and Carry Test (LCT), Fugl-Meyer Assessment of upper extremity and lower extremity, ankle dorsiflexor and plantarflexor muscle strength, Berg Balance Scale (BBS), Timed Up and Go (TUG) and Community Integration Measure. Results: The mean LCT time (29.70s) in people with stroke was more than double of that in healthy controls (13.70s). The LCT showed excellent intra-rater, inter-rater and test-retest reliability [intraclass correlation coefficient (ICC) = 0.943-1.000]. The LCT times demonstrated a significant negative correlation with the BBS score (rs = -0.771) and significant positive correlations with the TUG times (rs = 0.933). There was no significant correlation between LCT times and FMA score (p > 0.05). An optimal cut-off LCT time of 15.48 s (sensitivity = 95.8%, specificity = 87.5%) was identified to differentiate between people with stroke and healthy controls (area under the curve = 0.957). Conclusion: LCT is an excellent clinical test for examining advanced functional ability in people with stroke and distinguishing people with stroke from healthy controls.

Communication processes in an advance care planning initiative: A socio-ecological perspective for service evaluation.

BACKGROUND: Advance care planning initiatives are becoming more widespread, increasing expectations for providers to engage in goals of care conversations. However, less is known about how providers communicate advance care planning within and throughout a health care system. AIM: To explore perspectives of communication processes in the rollout of an advance care planning initiative. DESIGN: Theoretically informed secondary analysis of 31 semi-structured interviews. SETTING/PARTICIPANTS: Key partners in a Veterans Health Administration goals of care initiative. RESULTS: Using the constant comparative approach followed by qualitative mapping of themes to the layers of the Socio-Ecological Model, four themes and corresponding Socio-Ecological layers were identified: Goals of Care Communication Training (Policy, Community, and Institutional) requires more resources across sites and better messaging to reduce provider misconceptions and promote an institutional culture invested in advance care planning; Interprofessional Communication (Interpersonal) suggests care team coordination is needed to facilitate continuity in goals of care messaging; Communication in Documentation (Institutional, Interpersonal, and Intrapersonal) highlights the need for capturing the context for goals of care preferences; and Patient/Family Communication (Interpersonal and Intrapersonal) encourages offering materials and informational resources early to facilitate rapport building and readiness to determine goals of care. CONCLUSIONS: Findings support the need for initiatives to incorporate an evaluation of how goals of care are discussed beyond the interpersonal exchange between patient and provider and signal opportunities for applying the Socio-Ecological Model to better understand goals of care communication processes, including opportunities to improve initiation and documentation of goals of care.

Paying for advance care planning in medicare: Impacts on care and spending near end of life.

Spending at end of life (EOL) accounts for a large and growing share of healthcare expenditures in the US, and often reflects aggressive care with questionable value for dying patients. Using a novel instrumental variables approach, we conduct the first study on the causal effect of Medicare reimbursement for advance care planning (ACP)-the process of discussing and recording patient preferences for goals of care-on care utilization, spending, and mortality outcomes for critically ill Medicare patients. We find that billed ACP services substantially increase hospice use and hospice spending within a year, accompanied by corresponding increase in one-year mortality. The impacts of ACP services on hospice use and spending are especially prominent among patients with dementia and those of lower socioeconomic status. Among decedents, death is significantly less likely to occur in the hospital, and total and inpatient spending within the last 30 days of life fall significantly. Our findings suggest that paying for ACP services can be effective in improving hospice use for critically ill Medicare patients, with the (possibly intended) consequence of increased one-year mortality.