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.

Corrigendum: Knowledge and thresholds for palliative care and surgery among healthcare providers caring for adults with serious illness.

[This corrects the article DOI: 10.3389/fmed.2024.1351864.].

Transforming Communication on Serious Illness and Frailty: A Comprehensive Approach to Empowering Informed Decision-Making.

Health care professionals can enhance conversations about serious illness and medical decision-making by adopting a transparent, standardized approach. This article critiques established communication strategies, which often emphasize patient values and goals without providing the necessary medical information to align these goals with a shared understanding of prognosis. We propose an alternate strategy that (1) provides detailed explanations of medical conditions at the beginning of the conversation, (2) includes support persons in discussions, (3) considers capacity, and (4) offers tailored advice by clinicians. The proposed framework aims to provide patients (or their delegates) with the information they need to integrate their values in pursuit of well-informed medical decisions. This strategy builds trust by providing honest information about medical conditions and their trajectories. It empowers decision makers to consider realistic outcomes, allowing them to accept or reject treatments in accordance with their preferences. This article presents a thorough step-by-step guide on how to conduct a serious illness conversation and facilitate medical decision-making, including a supplement that provides example phrases for use in clinical practice.

Validation of a checklist to facilitate serious illness conversations in adult emergency in China: a single-centre pilot study.

BACKGROUND: Advances in emergency and critical care have improved outcomes, but gaps in communication and decision-making persist, especially in the emergency department (ED), prompting the development of a checklist to aid in serious illness conversations (SIC) in China. METHODS: This was a single-centre prospective interventional study on the quality improvement of SIC for life-sustaining treatment (LST). The study recruited patients consecutively for both its observational baseline and interventional stages until its conclusion. Eligible participants were adults over 18 years old admitted to the Emergency Intensive Care Unit (EICU) of a tertiary teaching hospital, possessing full decisional capacity or having a legal proxy. Exclusions were made for pregnant women, patients deceased upon arrival, those who refused participation, and individuals with incomplete data for analysis. First, a two-round Delphi process was organized to identify major elements and generate a standard process through a checklist. Subsequently, the efficacy of SIC in adult patients admitted to the EICU was compared using the Decisional Conflict Scale (DCS) score before (baseline group) and after (intervention group) implementing the checklist. RESULTS: The study participants presented with the most common comorbidities, such as diabetes, myocardial infarction, cerebrovascular disease, moderate-to-severe renal disease, congestive heart failure, and chronic pulmonary disease. The median Charlson Index did not differ between the baseline and intervention cohorts. The median length of hospital stay was 11.0 days, and 82.9% of patients survived until hospital discharge. The total DCS score was lower in the intervention group than in the baseline group. Three subscales, including the informed, values clarity, and support subscales, demonstrated significant differences between the intervention and baseline groups. Fewer intervention group patients agreed with and changed their minds about cardiopulmonary resuscitation (CPR) compared to the baseline group. CONCLUSION: The use of a SIC checklist in the EICU reduced the DCS score by increasing medical information disclosure, patient value awareness, and decision-making support.

Multidisciplinary oncology clinicians' experiences delivering spiritual care to patients with cancer and their care partners.

PURPOSE: To understand multidisciplinary healthcare clinicians' meaningful and challenging experiences providing spiritual care to patients with cancer and their care partners. METHODS: Multidisciplinary clinicians who participated in a communication training program supported by the National Cancer Institute or a palliative care training for nurses (N = 257) responded to two, open-ended questions about meaningful and challenging experiences of providing spiritual care. A thematic analysis of responses using an iterative, inductive approach was conducted until saturation was reached. RESULTS: Participants from nursing (68%), social work (22%), and chaplaincy (10%) responded to open-ended survey questions. Three themes related to meaningful experiences of providing spiritual care emerged: building authentic interpersonal connection with patients and care partners; creating intentional space for patients and care partners to inform spiritual care; and actively supporting patients and care partners in their processes with spirituality. Three themes related to challenging experiences of providing spiritual care emerged: contextual factors and clinical circumstances complicate provision of spiritual care; facing barriers to providing high-quality, patient-centered care; and navigating ethical and logistical issues that affect spiritual and other care. CONCLUSION: Clinicians derive meaning from a range of experiences throughout their provision of spiritual care to patients with cancer. However, they also face many challenges in delivering person-centered spiritual care in cancer settings, with some challenges reflecting significant gaps in spiritual care knowledge and training. Findings can guide future training and educational endeavors for multidisciplinary clinicians in the domain of spiritual care.

Palliative Care Consults for Clinician Distress: Part of the Job?

Clinician distress is common in serious illness care. Palliative specialists are often consulted for cases involving significant distress among primary teams. Consults involving clinician distress can be challenging to navigate when it feels like (1) palliative specialists do not have the right skills to be helpful or (2) palliative specialists are being asked to 'fix' difficult situations that would require changing other people's attitudes, beliefs, or behaviors, or healthcare systems writ large. This article uses three composite cases to illustrate types of clinician distress and examine the benefits and risks of palliative specialist involvement. We conclude with a discussion of potential impacts of palliative care consults for clinician distress on the field of palliative care and consider next steps in critically important efforts to support and sustain the entire workforce-both palliative specialists and non-specialists alike-when caring for patients with serious illness and their family caregivers.

Care conundrum in the emergency department: The gap between clinician awareness and patient expectations surrounding advance directives.

OBJECTIVES: Clinicians in the emergency department (ED) frequently encounter seriously ill patients at a time when advance directives may be pivotal in improved clinician decision-making. The objectives of this study were to identify the prevalence of advanced directives in ED patients, as well as patterns of advance care discussions between patients and providers. This study describes patients' perceptions and expectations of such serious illness discussions in an emergency care setting with the expectation of including patients as strategic members of the care team. METHODS: Trained research assistants in two emergency departments surveyed patients over age 65, or their caregivers, from July 2016 to August 2018. Patients were verbally administered a standard survey tool related to advance directives and advance care planning. RESULTS: 497 out of 877 patients completed surveys (59.4%). 50% of patients reported having an advance care planning document. The large majority (92%) of patients with an advance directive had not been asked about it during their ED visit. When questioned about their personal preferences, 79% of patients thought emergency physicians should be aware of their wishes regarding life-sustaining treatments and end-of-life care. Paradoxically, only 38% expressed a desire to discuss advance care plans with an ED clinician. CONCLUSIONS: Older patients expect emergency clinicians to be aware of their care preferences, yet most are not asked about these care preferences in the ED. The large gap between patient preference and reality suggests the need for more targeted discussion by ED clinicians and translation of patient perspectives into system healthcare improvements. Future studies should explore barriers to advance care planning in the ED as well as patient preferences for these conversations to support a true healthcare learning system.

Special considerations in managing pain and psychosocial distress in patients with opioid use disorder and cancer: the role of the supportive care and psycho-oncology interdisciplinary team.

People with a substance use disorder (SUD) have shortened lifespans due to complications from their substance use and challenges engaging with traditional health care settings and institutions. This impact on life expectancy is especially prominent in patients with co-occurring SUDs and cancer, and often has a much worse prognosis from the cancer than a similar patient without a SUD. Palliative care teams are experts in serious illness communication and symptom management and have become increasingly embedded in the routine care of patients with cancer. We argue that the skill set of palliative care teams is uniquely suited for addressing the needs of this oft marginalized group. We provide a comprehensive review of tools for addressing these needs, including medications that can both treat pain and opioid use disorder (OUD), and highlight psychosocial approaches to treating patients with OUD and cancer in a way that is respectful and effective. Using a trauma informed framework, we focus on the application of harm reduction principles from addiction medicine and the principles of clear communication, accompaniment, and emotional presence from palliative care to maximize support. We also focus on ways to reduce stigma in the delivery of care, by providing language that reduces barriers and increases patient engagement. Finally, we describe a clinic embedded within our institution's cancer center which aims to serve patients with cancer and SUDs, built on the framework of harm reduction, accompaniment and trauma informed care (TIC). Overall, we aim to provide context for addressing the common challenges that arise with patients with cancer and OUD, including the direct impact of psychosocial stress on substance use and cancer treatment, delays in disease directed treatment that can potentially impact further treatment options and outcomes, challenging pain management due to greater opioid debt, and potential loss of primary coping mechanism through substance use in the face of potential terminal diagnosis.

Medical Mistrust Among Black Patients with Serious Illness: A Mixed Methods Study.

BACKGROUND: Medical mistrust among Black patients has been used to explain the existence of well-documented racial inequities at the end of life that negatively impact this group. However, there are few studies that describe patient perspectives around the impact of racism and discriminatory experiences on mistrust within the context of serious illness. OBJECTIVE: To better characterize experiences of racism and discrimination among patients with serious illness and its association with medical mistrust. PARTICIPANTS: Seventy-two Black participants with serious illness hospitalized at an academic county hospital. APPROACH: This is a convergent mixed methods study using data from participant-completed surveys and existing semi-structured interviews eliciting participants' perspectives around their experiences with medical racism, communication, and decision-making. MAIN MEASURES: The experience of medical racism and its association with Group-Based Medical Mistrust (GBMM) scale scores, a validated measure of medical mistrust. KEY RESULTS: Of the 72 Black participants, 35% participated in interviews. Participants were mostly men who had significant socioeconomic disadvantage, including low levels of wealth, income, and educational attainment. There were reported high levels of race-based mistrust in the overall GBMM scale score (mean [SD], 36.6 [9.9]), as well as high scores within the suspicion (14.2 [5.0]), group disparities in healthcare (9.9 [2.8]), and lack of support (9.1 [2.7]) subscales. Three qualitative themes aligned with the GBMM subscales. Participants expressed skepticism of healthcare workers (HCWs) and modern medicine, recounted personal experiences of discrimination in the medical setting, and were frustrated with poor communication from HCWs. CONCLUSIONS: This study found high levels of mistrust among Black patients with serious illness. Suspicion of HCWs, disparities in healthcare by race, and a lack of support from HCWs were overarching themes that influenced medical mistrust. Critical, race-conscious approaches are needed to create strategies and frameworks to improve the trustworthiness of healthcare institutions and workers.

Transforming the discharge conversation through support and structure: A scoping review.

Background: System level demands and interpersonal barriers can disrupt nurse delivery of high-quality information at discharge, which can contribute to a lack of caregiver preparedness to manage care of the patient and ultimately affect patient health. Objective: To synthesize evidence on effective nurse communication with informal caregivers during hospital discharge of adult patients with cognitive decline or Alzheimer's disease and related dementia. Design: A scoping review of inpatient nurse communication with informal caregivers. Methods: Collected research (published between 2011 and 2023) from three databases (MEDLINE, PsycINFO, and CINAHL), along with a separate search for gray literature (N = 18), to extract and synthesize recommended communication practices evidenced to improve the nurse care experience and support caregiver activation and preparedness. Results: Extraction synthesis of strategies resulted in two themes with corresponding sub-themes: Support (Information exchange, Space and time to determine preparedness, and Positive reinforcement of caregiver efforts) and Structure (Setting shared expectations, Informational resources, and Standardization). Conclusions: We offer practical recommendations for both interpersonal and policy level facilitation of nurse delivery of high-quality information at discharge to caregivers of patients with serious illness.

Effectiveness of initiating advance care planning among older outpatients through intervention by physicians trained in a model discussion video: A randomized controlled trial.

AIM: This study aimed to assess the impact of a physician-led intervention on advance care planning (ACP) introduction among older outpatients using a model discussion video. METHODS: This prospective interventional study included Japanese general practice outpatients aged ≥65 years. All participants received an ACP leaflet. Co-researchers were trained using a model discussion video based on the "Serious Illness Conversation Guide," and provided ACP introduction explanations to the intervention group to ensure intervention content consistency. The control group received the ACP leaflet only, with no standardized explanations. The primary outcome was ACP discussion occurrence. Secondary outcomes included ACP engagement (assessed through the 4-item ACP Engagement Survey), engagement score for advance directives acquisition and score for surrogate decision-maker identification, and anxiety incidence (assessed through Generalized Anxiety Disorder-7). RESULTS: This study included 48 participants: 25 (52.1%) in the intervention group and 23 (47.9%) in the control group. Regarding primary outcome, the intervention group had significantly more ACP discussions compared with the control group (92.0% vs 26.1%, adjusted odds ratio 50.2, P = 0.0012). Regarding secondary outcomes, the intervention group showed greater readiness (mean scores for the 4-item Engagement Survey [P = 0.0001], engagement score for advance directives acquisition [P = 0.01] and score for surrogate decision-maker determination [P = 0.03]) than the control group, without increasing anxiety. CONCLUSIONS: This physician-led ACP introduction for older patients in a Japanese general practice setting enhanced ACP readiness and stimulated discussions, without increasing anxiety. The model discussion video for ACP introduction might effectively train physicians in general practice settings. Geriatr Gerontol Int 2024; ••: ••-••.

Targeting Community-Based Palliative and Serious Illness Care Resources: Challenges of More Stringent Diagnostic Criteria for Prospective Enrollment.

Background: For patients with serious illnesses, one aim of palliative care services is to reduce the frequency and severity of hospital-based episodes of care. Since hospital-alternative palliative care may consume costly resources, providers need to efficiently target high-intensity services toward those most at risk for such adverse episodes of care. Objective: Our objective was to investigate progressively more restrictive diagnosis-based indications of serious illness as used to prospectively identify patients with higher average rates of hospitalization. Design/Setting: We designed an observational cohort quality improvement study using historical Medicare claims records to evaluate diagnostic inclusion criteria for targeting palliative and serious illness care resources. We first isolated a Seriously Ill Population (SIP) and then defined More SIP and Most SIP subgroups. Measurements: Our primary outcome measure was the 2019 acute-care count of hospitalizations for patients in the SIP, More SIP, and Most SIP subgroups, respectively. Results: The More SIP and Most SIP subgroups exhibited higher hospitalization rates. However, they also excluded progressively more seriously ill patients who did experience hospitalizations. In addition, almost half of the Most SIP subgroup were not hospitalized at all, despite having an average hospitalization rate greater than one. Conclusion:Allocating resources (personnel and services) toward reducing hospitalizations when almost half of the targeted population never goes to the hospital could result in unnecessary expenditures and exclude patients that could potentially benefit. Engaging community-based services to detect changes in status could provide supplemental indications of when and for whom to target palliative care resources.

It Starts With a Story: A Four-Step Narrative-Based Framework for Serious Illness Conversations.

Background: As a key component of advance care planning, serious illness conversations form a core intervention in palliative care. To achieve effective serious illness conversations, acknowledgment and inclusion of patient sense of self and identity are critical. However, no framework exists to describe how goals, values, and choices relate to patient identity. This conceptual gap hinders the advancement of palliative care education and practice. Objective: This philosophical investigation aimed to explicate two items: first, a novel conceptual framework for serious illness conversations; second, a structured approach to optimize these conversations within the palliative care clinical context. Methods: A philosophical and theoretical analysis was performed within an interdisciplinary context, by scholars in palliative care, medical humanities, philosophy, and bioethics. Key literature in psychology, qualitative research on the experience of serious illness, medical ethics, and choice architecture in medical decision-making were reviewed, and a structured conceptual and narrative analysis was performed. Results: An original and innovative identity-centered conceptual framework for serious illness conversations was developed. The framework consists of a four-step, reproducible approach: (1) attend to patient narrative identity, (2) identify values, (3) cocreate goals, and (4) actively promote choices. In short: attend, identify, create, and promote (AICP). Discussion: By using this conceptual framework and four-step approach, clinicians can accomplish goal-concordant serious illness care and build rich clinical relationships that foster trust and goodwill.

Providing clarity: communicating the benefits of palliative care beyond end-of-life support.

Background: Palliative care affords numerous benefits, including improvements in symptom management, mental health, and quality of life, financial savings, and decreased mortality. Yet palliative care is poorly understood and often erroneously viewed as end-of-life care and hospice. Barriers for better education of the public about palliative care and its benefits include shortage of healthcare providers specializing in palliative care and generalist clinicians' lack of knowledge and confidence to discuss this topic and time constraints in busy clinical settings. Objectives: Explore and compare the knowledge, values, and practices of community-dwelling adults 19 years and older from Nebraska about serious illness and end-of-life healthcare options. Design: Secondary analysis of cross-sectional data collected in 2022 of 635 adults. We examined the fifth wave (2022) of a multiyear survey focusing on exploring Nebraskans' understanding of and preferences related to end-of-life care planning. Methods: Descriptive statistics and chi-square tests to compare results between groups. Univariable and multivariable logistic regression analyses examine associations of variables as to knowledge of hospice and palliative care. Results: While 50% of respondents had heard a little or a lot about palliative care, 64% either did not know or were not sure of the difference between palliative care and hospice. Those who reported being in poor health were not more likely to know the difference between palliative care and hospice compared to those reporting being in fair, good, or excellent health. Conclusion: This study offers insight into the knowledge and attitudes about palliative care among community-dwelling adults, 19 years and older living in Nebraska. More effort is needed to communicate what palliative care is, who can receive help from it, and why it is not only for people at end of life. Advance care planning discussions can be useful in offering clarity.

Promoting serious illness conversations in primary care through telehealth among persons living with cognitive impairment.

BACKGROUND: serious illness conversations (SIC), particularly for persons living with cognitive impairment (PLCI), inconsistently happen in primary care. Pragmatic, scalable strategies are needed to promote SIC for PLCI. DESIGN: Pragmatic, prospective single-arm pilot study that occurred between July 1, 2021 and May 30, 2022 across seven primary care practices in North Carolina. PARTICIPANTS: Community-dwelling patients aged 65 and older with known or probable mild cognitive impairment or dementia (with decision-making capacity) and their care partners (if available). INTERVENTION: SIC telehealth intervention (TeleVoice) via video or telephone to assist PLCI in discussing their current goals, values, and future medical preferences, while facilitating documentation within the EHR. MAIN OUTCOMES: Main feasibility outcomes included reach/enrollment, intervention completion, and adoption rates at the clinic and provider level. Primary effectiveness outcomes included SIC documentation and quality within the EHR and usage of advance care planning billing (ACP) codes. RESULTS: Of the 163 eligible PLCI approached, 107 (66%) enrolled (mean age 83.7 years, 68.2% female, 16.8% Black, 22% living in a geographic area of high socioeconomic disadvantage) and 81 (76%) completed the SIC telehealth intervention; 45 care partners agreed to participate (mean age 71.5 years, 80% female). Adoption at clinic level was 50%, while 75% of providers within these clinics participated. Among PLCI that completed the intervention, SIC documentation and usage of ACP billing codes was 100% and 96%, respectively, with 96% (n = 78) having high-quality SIC documentation. No significant differences were observed between telephone and video visits. CONCLUSION: These findings provide preliminary evidence to support the feasibility of conducting SICs through telehealth to specifically meet the needs of community-dwelling PLCI. Further investigation of the sustainability of the intervention and its long-term impact on patient and caregiver outcomes is needed.

Who, What, Where, and How? The State of Family Science in Pediatric Palliative Care.

CONTEXT: Families are vital providers and recipients of pediatric palliative care (PPC) services. Understanding the scope and nature of evidence at the intersection of family science and PPC research is necessary to develop family-focused interventions that enhance child and family health. OBJECTIVES: Explore and describe the family-level impact of pediatric serious illness. METHODS: We conducted a librarian-assisted scoping review using Arskey and O'Malley's approach. We searched PubMed, Scopus, CINAHL, and EMBASE databases for empirical publications from 2016 to 2021 that focused on families navigating serious pediatric illness published in English. Two reviewers assessed eligibility, with discrepancies resolved by a third. We used Covidence and REDCap for data management and extraction. RESULTS: We screened 10,983 abstracts; 309 abstracts were included in full text screening. The final group of 52 citations was analyzed by the entire team. Most research was conducted in Western Europe and North America. The perspectives of parents of children with cancer were most frequently described; voices of seriously ill youth and their siblings were less often presented. Most of the research was descriptive qualitative, followed by descriptive quantitative. Few studies were mixed methods, inferential, or interpretive. Studies most often described parent, youth, and family experience with illness and less often explored family processes and relationships. Irrespective of the approach (i.e., qualitative, quantitative), few studies focused on families as the analytic unit or used family-level analysis techniques. Study participants were usually from local dominant populations and less often from historically marginalized communities. CONCLUSION: The robust, descriptive, and individual-level evidence describing family impact of serious pediatric illness provides a solid foundation for future research priorities. Stronger integration of family techniques and diverse family voices in pediatric palliative care research can clarify family processes, illuminate structural barriers, and inform interventions that are responsive to family needs. These steps will enhance the education, policy, and clinical provision of PPC to all who would benefit, thereby advancing health equity for children living with serious illness and their families.

Increasing goals of care conversations in primary care: Study protocol for a cluster randomized, pragmatic, sequential multiple assignment randomized trial.

BACKGROUND: Goals of care conversations explore seriously ill patients' values to guide medical decision making and often inform decisions about life sustaining treatments. Ideally, conversations occur before a health crisis between patients and clinicians in the outpatient setting. In the United States Veterans Affairs (VA) healthcare system, most conversations still occur in the inpatient setting. Strategies are needed to improve implementation of outpatient, primary care goals of care conversations. METHODS: We plan a cluster randomized (clinician-level) sequential, multiple assignment randomized trial to evaluate the effectiveness of patient implementation strategies on the outcome of goals of care conversation documentation when delivered in combination with clinician implementation strategies. Across three VA healthcare system sites, we will enroll primary care clinicians with low rates of goals of care conversations and their patients with serious medical illness in the top 10th percentile of risk of hospitalization or death. We will compare the effectiveness of sequences of implementation strategies and explore how patient and site factors modify implementation strategy effects. Finally, we will conduct a mixed-methods evaluation to understand implementation strategy success or failure. The design includes two key innovations: (1) strategies that target both clinicians and patients and (2) sequential strategies with increased intensity for non-responders. CONCLUSION: This study aims to determine the effect of different sequences and combinations of implementation strategies on primary care documentation of goals of care conversations. Study partners, including the VA National Center for Ethics in Health Care and Office of Primary Care, can consider policies based on study findings.

Experiences with implementing advance care planning (ACP-GP) in Belgian general practice in the context of a cluster RCT: a process evaluation using the RE-AIM framework.

BACKGROUND: General practice is often recommended as an ideal setting to initiate advance care planning (ACP), but uptake of ACP in this setting is low. ACP-GP is a complex intervention to facilitate ACP for patients with chronic, life-limiting illness in Belgian general practice. It aims to increase patient ACP engagement and general practitioner (GP) ACP self-efficacy. In a cluster-randomized controlled trial, the intervention was not superior to control in increasing these outcomes. A parallel process evaluation aimed to enhance understanding of how the intervention was implemented, and which factors might have influenced trial results. METHODS: We conducted a mixed-methods process evaluation following the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. Data sources include recruitment and implementation monitoring, questionnaires for patients and GPs, and semi-structured (focus group) interviews with patients and GPs. Questionnaire data were analyzed descriptively. Qualitative data were first analyzed inductively; themes were then assigned deductively to RE-AIM dimensions. RESULTS: Thirty-five GPs and 95 patients were recruited to the trial; GP reach was low. Sixteen GPs and 46 patients provided questionnaire data at 3 months post-baseline; qualitative data were transcribed for 14 GPs and 11 patients. Adoption of intervention components was moderate to good, with the exception of the documentation template for GPs. Interviews revealed varying patient attitudes towards ACP, but patients nonetheless emphasized that conversations made them feel reassured. GPs especially valued a positive framing of ACP. When adopted, the intervention was well-implemented and participant satisfaction was high. However, intention for maintenance was moderate, with GPs raising questions of how to sustainably implement ACP conversations in the future. CONCLUSIONS: Implementing the complex ACP-GP intervention in general practice is feasible, and can be successful. However, the implementation process is challenging and the sustainability is suboptimal. Our findings will guide future research and recommendations for facilitating and implementing ACP in general practice. TRIAL REGISTRATION: ISRCTN12995230; prospectively registered on 19/06/2020.

Study on the policy implementation effect of serious Illness medical insurance in the ethnic minority autonomous area of Western China

Objective: To evaluate the implementation effect of serious illness medical insurance in Guang Xi Zhuang Autonomous Region of western China. Study design: Through the collection of 2017-2021 Guang Xi serious illness medical insurance specific policy making such as fund usage, serious illness compensation, medical expenses data, and data analysis of a serious illness medical insurance effect. Method: Literature research, Policy text analysis, quantitative data collection method, using Excel and SPSS 19.0 data descriptive statistical analysis and comparative analysis. Results: Serious illness medical insurance has had some effect, e.g., from 2017 to 2021, the utilization rate of serious illness medical insurance fund in Guang Xi was 109.49% and 103.87% respectively, the fund balance rate was -9.45% and -8.54% respectively, and the accumulated balance was -2.3871 million CNY and -70.7955 million CNY. Conclusion: The serious illness medical insurance has reduced the burden of large medical expenses of patients to a certain extent, but the fund is under too much pressure, and there is a payment deficit. The coverage and security of serious illness medical insurance need to be expanded and strengthened, and the cooperation mechanism with commercial insurance institutions should be gradually explored to improve the serious illness medical insurance.

Objetivo: evaluar el efecto de la implementación de seguros médicos para enfermedades graves en la Región Autónoma Guang Xi Zhuang, al oeste de China. Diseño del estudio: a través de la recopilación de pólizas de seguro médico específicas para enfermedades graves de la región de Guang Xi entre 2017-2021, como por ejemplo: uso de fondos, compensación por enfermedades graves, datos de gastos médicos y análisis de datos del efecto de seguros médicos para enfermedades graves. Método: investigación de literatura, análisis de textos de políticas públicas, metodología de recolección de datos cuantitativos utilizando Excel y SPSS 19.0, análisis estadístico descriptivo de datos y análisis comparativo. Resultados: el seguro médico para enfermedades graves ha demostrado tener efectos, tales como: entre 2017 y 2021, la tasa de utilización de fondos de seguros médicos para enfermedades graves en Guang Xi fue de 109,49 % y 103,87 % respectivamente, las tasas de saldo del fondo fue de -9,45 % y -8,54 % respectivamente y el saldo acumulado fue de -2,3871 millones de CNY y -70,7955 millones de CNY. Conclusión: El seguro médico para enfermedades graves ha reducido en cierta medida la carga de los grandes gastos médicos de los pacientes, pero al existir un déficit de pagos está bajo demasiada presión. Por ello, es necesario ampliar y fortalecer la cobertura y seguridad del seguro médico para enfermedades graves, y explorar gradualmente mecanismos de cooperación con instituciones de seguros comerciales.

Objetivo: Avaliar o efeito da implementação de seguro médico para doenças graves na Região Autônoma de Guang Xi Zhuang da China Ocidental. Desenho do Estudo: Através da coleta de políticas específicas de seguro médico para doenças graves de Guang Xi 2017-2021, uso de fundos, compensação por doenças graves, dados de despesas médicas e análise de dados de um efeito de seguro médico para doenças graves. Método: Pesquisa na literatura, análise do texto da política, método de coleta de dados quantitativos usando Excel e SPSS 19.0, análise estatística descritiva de dados e análise comparativa. Resultados: Seguro médico de doenças graves teve um certo efeito. Em 2017 e 2021, a taxa de utilização do fundo de seguro médico para doenças graves em Guang Xi foi 109,49% e 103,87% respectivamente, a taxa de saldo do fundo foi -9,45% e -8,54% respectivamente e o saldo acumulado foi -2,3871 milhões de yuans e -70,7955 milhões de yuans. Conclusão: O seguro médico para doenças graves reduziu o ônus de grandes despesas médicas dos pacientes até certo ponto mas o fundo está sob demasiada pressão e há um déficit de pagamentos. A cobertura e segurança do seguro médico de doenças graves necessitam ser expandidas e fortalecidas, e o mecanismo de cooperação com instituições de seguros comerciais deve ser gradualmente explorado para melhorar o seguro médico para doenças graves.

Clinicians' Perspectives on the Telehealth Serious Illness Care Program for Older Adults With Myeloid Malignancies: Single-Arm Pilot Study.

BACKGROUND: Serious illness conversations may help patients avoid unwanted treatments. We previously piloted the telehealth Serious Illness Care Program (SICP) for older adults with acute myeloid leukemia and myelodysplastic syndrome. OBJECTIVE: In this study, we aimed to understand the experience of the telehealth SICP from the clinician's perspective. METHODS: We studied 10 clinicians who delivered the telehealth SICP to 20 older adults with acute myeloid leukemia or myelodysplastic syndrome. Quantitative outcomes included confidence and acceptability. Confidence was measured using a 22-item survey (range 1-7; a higher score is better). Acceptability was measured using an 11-item survey (5-point Likert scale). Hypothesis testing was performed at α=.10 (2-tailed) due to the pilot nature and small sample size. Clinicians participated in audio-recorded qualitative interviews at the end of the study to discuss their experience. RESULTS: A total of 8 clinicians completed the confidence measure and 7 clinicians completed the acceptability measure. We found a statistically significant increase in overall confidence (mean increase of 0.5, SD 0.6; P=.03). The largest increase in confidence was in helping families with reconciliation and goodbye (mean 1.4, SD 1.5; P=.04). The majority of clinicians agreed that the format was simple (6/7, 86%) and easy to use (6/7, 86%). Clinicians felt that the telehealth SICP was effective in understanding their patients' values about end-of-life care (7/7, 100%). A total of three qualitative themes emerged: (1) the telehealth SICP deepened relationships and renewed trust; (2) each telehealth SICP visit felt unique and personal in a positive way; and (3) uninterrupted, unrushed time optimized the visit experience. CONCLUSIONS: The telehealth SICP increased confidence in having serious illness conversations while deepening patient-clinician relationships. TRIAL REGISTRATION: ClinicalTrials.gov NCT04745676; https://www.clinicaltrials.gov/study/NCT04745676.