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2.
Jpn J Clin Oncol ; 50(9): 976-989, 2020 Sep 05.
Artigo em Inglês | MEDLINE | ID: mdl-32761078

RESUMO

Ageing has been recognized as one of the most critically important health-care issues worldwide. It is relevant to Asia, where the increasing number of older populations has drawn attention to the paramount need for health-care investment, particularly in end-of-life care. The advocacy of advance care planning is a mean to honor patient autonomy. Since most East Asian countries are influenced by Confucianism and the concept of 'filial piety,' patient autonomy is consequently subordinate to family values and physician authority. The dominance from family members and physicians during a patient's end-of-life decision-making is recognized as a cultural feature in Asia. Physicians often disclose the patient's poor prognosis and corresponding treatment options to the male, family member rather to the patient him/herself. In order to address this ethical and practical dilemma, the concept of 'relational autonomy' and the collectivism paradigm might be ideally used to assist Asian people, especially older adults, to share their preferences on future care and decision-making on certain clinical situations with their families and important others. In this review article, we invited experts in end-of-life care from Hong Kong, Indonesia, Japan, South Korea, Singapore and Taiwan to briefly report the current status of advance care planning in each country from policy, legal and clinical perspectives. According to the Asian experiences, we have seen different models of advance care planning implementation. The Asian Delphi Taskforce for advance care planning is currently undertaken by six Asian countries and a more detailed, culturally sensitive whitepaper will be published in the near future.


Assuntos
Planejamento Antecipado de Cuidados/normas , Assistência Terminal/normas , Idoso , Envelhecimento , Grupo com Ancestrais do Continente Asiático , Feminino , Humanos , Masculino
3.
Med Clin North Am ; 104(3): 375-389, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32312404

RESUMO

Clinicians working with seriously ill patients need the skills to effectively communicate with patients and their families throughout the trajectory of illness. Common communication tasks that arise in the care of seriously ill patients include advance care planning, delivering serious news, discussing prognosis, eliciting values, and medical decision making. Clinicians often use goals of care conversations to facilitate these tasks. Similar to other procedures, goals of care conversations require a systematic, evidence-based approach to ensure quality and value. This article provides a framework that clinicians can follow to effectively communicate with seriously ill patients and families and promote patient-centered care.


Assuntos
Planejamento Antecipado de Cuidados/normas , Competência Clínica/normas , Planejamento de Assistência ao Paciente/normas , Assistência Centrada no Paciente/métodos , Tomada de Decisão Clínica , Comunicação , Estado Terminal , Prática Clínica Baseada em Evidências/normas , Humanos , Prognóstico
4.
J Clin Nurs ; 29(13-14): 2663-2674, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32301187

RESUMO

AIMS AND OBJECTIVES: To explore wishes and needs, such as existing and preferred communication processes, of residents and relatives regarding medical and nursing planning at the end of life. BACKGROUND: Nursing home residents are a relevant target group for advance care planning (ACP) due to their high age and multimorbidity. Their relatives seem to be important partners in terms of communication and their documentation of wishes and needs. DESIGN: A qualitative descriptive design was used. METHODS: Thirty-two guideline-based interviews with nursing home residents (n = 24) and relatives (n = 8) were conducted in nursing homes in Germany (n = 7). All interviews were analysed by content-structured content analysis. The COREQ checklist was used to document reporting of the study. RESULTS: Residents particularly express wishes and needs regarding their health, like the desire to maintain or improve one's current state of health and to be active and mobile and also regarding their social situation, for example the well-being of relatives and beloved ones. A limited group of people was identified with whom residents spoke about issues such as preparedness and self-determination. These were mainly their relatives. Relatives themselves have a need for more communication. Various communication barriers could be identified. CONCLUSION: Residents express diverse and partly explicit wishes and needs. Although many of the respondents had already drafted advanced directives, the demand for offers of communication to plan ahead for the end of life remains clear. The results indicate the unconditional participation of relatives and people close to the residents, if they are available. RELEVANCE TO CLINICAL PRACTICE: Derivations for a target group-related ACP concept in the study region are identified. Besides the involvement of relatives, nurses could also be involved in the communication and decision-making process of residents in nursing homes under certain conditions.


Assuntos
Planejamento Antecipado de Cuidados/normas , Diretivas Antecipadas/psicologia , Tomada de Decisões , Família/psicologia , Assistência Terminal/psicologia , Idoso , Idoso de 80 Anos ou mais , Feminino , Alemanha , Instituição de Longa Permanência para Idosos , Humanos , Relações Interpessoais , Masculino , Pessoa de Meia-Idade , Casas de Saúde , Pesquisa Qualitativa
6.
J Med Internet Res ; 22(3): e15578, 2020 03 17.
Artigo em Inglês | MEDLINE | ID: mdl-32181750

RESUMO

BACKGROUND: Advance care planning (ACP) is a process with the overall aim to enhance care in concordance with patients' preferences. Key elements of ACP are to enable persons to define goals and preferences for future medical treatment and care, to discuss these with family and health care professionals, and to document and review these if appropriate. ACP is usually conducted through personal conversations between a health care professional, a patient, and-if appropriate-family members. Although Web-based ACP programs have the potential to support patients in ACP, their effectiveness is unknown. OBJECTIVE: This study aimed to assess the feasibility and effectiveness of Web-based, interactive, and person-centered ACP programs. METHODS: We systematically searched for quantitative and qualitative studies evaluating Web-based, interactive, and person-centered ACP programs in seven databases including EMBASE, Web of Science, Cochrane Central and Google Scholar. Data on the characteristics of the ACP programs' content (using a predefined list of 10 key elements of ACP), feasibility, and effectiveness were extracted using a predesigned form. RESULTS: Of 3434 titles and abstracts, 27 studies met the inclusion criteria, evaluating 11 Web-based ACP programs-10 were developed in the United States and one in Ireland. Studied populations ranged from healthy adults to patients with serious conditions. Programs typically contained the exploration of goals and values (8 programs), exploration of preferences for treatment and care (11 programs), guidance for communication about these preferences with health care professionals or relatives (10 programs), and the possibility to generate a document in which preferences can be recorded (8 programs). Reportedly, participants were satisfied with the ACP programs (11/11 studies), considering them as easy to use (8/8 studies) and not burdensome (7/8 studies). Designs of 13 studies allowed evaluating the effectiveness of five programs. They showed that ACP programs significantly increased ACP knowledge (8/8 studies), improved communication between patients and their relatives or health care professionals (6/6 studies), increased ACP documentation (6/6 studies), and improved concordance between care as preferred by the patients and the decisions of clinicians and health care representatives (2/3 studies). CONCLUSIONS: Web-based, interactive, and person-centered ACP programs were mainly developed and evaluated in the United States. They contained the key elements of ACP, such as discussing and documenting goals and preferences for future care. As participants considered programs as easy to use and not burdensome, they appeared to be feasible. Among the 13 studies that measured the effectiveness of programs, improvement in ACP knowledge, communication, and documentation was reported. The concordance between preferred and received care is yet understudied. Studies with high-quality study designs in different health care settings are warranted to further establish the feasibility and effectiveness of Web-based ACP programs.


Assuntos
Planejamento Antecipado de Cuidados/normas , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pesquisa Qualitativa
7.
J Clin Oncol ; 38(9): 852-865, 2020 03 20.
Artigo em Inglês | MEDLINE | ID: mdl-32023157

RESUMO

Palliative care has evolved over the past five decades as an interprofessional specialty to improve quality of life and quality of care for patients with cancer and their families. Existing evidence supports that timely involvement of specialist palliative care teams can enhance the care delivered by oncology teams. This review provides a state-of-the-science synopsis of the literature that supports each of the five clinical models of specialist palliative care delivery, including outpatient clinics, inpatient consultation teams, acute palliative care units, community-based palliative care, and hospice care. The roles of embedded clinics, nurse-led models, telehealth interventions, and primary palliative care also will be discussed. Outpatient clinics represent the key point of entry for timely access to palliative care. In this setting, patient care can be enhanced longitudinally through impeccable symptom management, monitoring, education, and advance care planning. Inpatient consultation teams provide expert symptom management and facilitate discharge planning for acutely symptomatic hospitalized patients. Patients with the highest level of distress and complexity may benefit from an admission to acute palliative care units. In contrast, community-based palliative care and hospice care are more appropriate for patients with a poor performance status and low to moderate symptom burden. Each of these five models of specialist palliative care serve a different patient population along the disease continuum and complement one another to provide comprehensive supportive care. Additional research is needed to define the standards for palliative care interventions and to refine the models to further improve access to quality palliative care.


Assuntos
Planejamento Antecipado de Cuidados/normas , Prestação Integrada de Cuidados de Saúde/organização & administração , Modelos Organizacionais , Neoplasias/terapia , Cuidados Paliativos/normas , Equipe de Assistência ao Paciente/normas , Qualidade da Assistência à Saúde/normas , Gerenciamento Clínico , Humanos
8.
J Clin Oncol ; 38(9): 885-904, 2020 03 20.
Artigo em Inglês | MEDLINE | ID: mdl-32023159

RESUMO

A growing body of research demonstrates the feasibility and efficacy of psychological interventions for adult patients with advanced cancer. Findings from quantitative studies of psychotherapeutic interventions with primary psychological outcomes for such patients are reviewed here and recommendations for best practice are made. We consider these interventions according to three broad phases in which they are most commonly applied: soon after diagnosis of advanced cancer, when living with the disease, and at or near the end of life. Cumulative evidence from well-designed studies demonstrates the efficacy of psychosocial interventions for patients with advanced disease to relieve and prevent depression, anxiety, and distress related to dying and death, as well as to enhance the sense of meaning and preparation for end of life. Individual and couple-based interventions have been proven to be most feasible, and the development and use of tailored and validated measures has enhanced the rigor of research and clinical care. Palliative care nurses and physicians can be trained to deliver many such interventions, but a core of psychosocial clinicians, including social workers, psychologists, and psychiatrists, is usually required to train other health professionals in their delivery and to ensure their quality. Few of the interventions for which there is evidence of effectiveness have been routinely incorporated into oncology or palliative care. Advocacy on the basis of this evidence is required to build psychosocial resources in cancer treatment settings and to ensure that psychological care receives the same priority as other aspects of palliative care in oncology.


Assuntos
Planejamento Antecipado de Cuidados/normas , Assistência à Saúde/normas , Neoplasias/psicologia , Neoplasias/terapia , Cuidados Paliativos/normas , Estresse Psicológico/terapia , Adulto , Humanos , Qualidade de Vida
9.
J Clin Oncol ; 38(9): 987-994, 2020 03 20.
Artigo em Inglês | MEDLINE | ID: mdl-32023165

RESUMO

Although robust evidence demonstrates that specialty palliative care integrated into oncology care improves patient and health system outcomes, few clinicians are familiar with the standards, guidelines, and quality measures related to integration. These types of guidance outline principles of best practice and provide a framework for assessing the fidelity of their implementation. Significant advances in the understanding of effective methods and procedures to guide integration of specialty palliative care into oncology have led to a proliferation of guidance documents around the world, with several areas of commonality but also some key differences. Commonalities originate from a shared vision for integration; differences arise from diverse roles of palliative care specialists within cancer care globally. In this review we discuss three of the most cited standards/guidelines, as well as quality measures related to integrated palliative and oncology care. We also recommend changes to the quality measurement framework for palliative care and a new way to match palliative care services to patients with advanced cancer on the basis of care complexity and patient needs, irrespective of prognosis.


Assuntos
Planejamento Antecipado de Cuidados/normas , Prestação Integrada de Cuidados de Saúde/organização & administração , Modelos Organizacionais , Neoplasias/terapia , Cuidados Paliativos/normas , Guias de Prática Clínica como Assunto/normas , Qualidade da Assistência à Saúde/normas , Gerenciamento Clínico , Humanos
10.
PLoS One ; 15(2): e0228553, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32023311

RESUMO

IMPORTANCE: Medicare beneficiaries with high medical needs can benefit from Advance Care Planning (ACP). Medicare reimburses clinical providers for ACP discussions, but it is unknown whether high-need beneficiaries are receiving this service. OBJECTIVE: To compare rates of billed ACP discussions among a cohort of high-need Medicare beneficiaries with the non-high-needs Medicare population. DESIGN: Retrospective analysis of Medicare Fee-for-Service (FFS) claims in 2017 comparing high-need beneficiaries (seriously ill, frail, ESRD, and disabled) with non-high need beneficiaries. SETTING: Nationally representative FFS Medicare 20% sample. PARTICIPANTS: Medicare beneficiaries were assigned to one of the following classifications: seriously ill (65+), frail (65+), seriously ill & frail (65+); non-high need (65+); end stage renal disease (ESRD) or disabled (<65). All participants had data available for years 2016-2017. EXPOSURE: Receipt of a billed ACP discussion, CPT codes 99497 or 99498. MAIN OUTCOME AND MEASURE: Rates of billed ACP visits were compared between high-need patients and non-high-need patients. Rates were adjusted for the 65+ population for sex, age, race/ethnicity, Charlson comorbidity index, Medicare/Medicaid dual eligibility status, and Hospital Referral Region. RESULTS: Among the 65+ groups, those most likely to have a billed ACP discussion included seriously ill & frail (5.2%), seriously ill (4.2%), and frail (3.3%). Rates remained consistent after adjusting (4.5%, 4.0%, 3.1%, respectively). Each subgroup differed significantly (p < .05) from non-high need beneficiaries (2.3%) in both unadjusted and adjusted analyses. Among the <65 high need groups, the rates were 2.7% for ESRD and 1.3% for the disabled (the latter p < .05 compared with non-high needs). CONCLUSIONS AND RELEVANCE: While rates of billed ACP discussions varied among patient groups with high medical needs, overall they were relatively low, even among a cohort of patients for whom ACP may be especially relevant.


Assuntos
Planejamento Antecipado de Cuidados/estatística & dados numéricos , Planejamento Antecipado de Cuidados/normas , Current Procedural Terminology , Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Gastos em Saúde/estatística & dados numéricos , Medicare/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Estudos Retrospectivos , Estados Unidos
11.
Support Care Cancer ; 28(10): 4667-4675, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31955277

RESUMO

PURPOSE: Patients with advanced cancer often receive suboptimal end-of-life (EOL) care. Particularly males with advanced cancer are more likely to receive EOL care that is more aggressive, even if death is imminent. Critical factors determining EOL care are EOL conversations or advance care planning. However, information about gender-related factors influencing EOL conversations is lacking. Therefore, the current study investigates gender differences concerning the content, the desired time point, and the mode of initiation of EOL conversations in cancer patients. METHODS: In a cross-sectional study, 186 female and male cancer patients were asked about their preferences for EOL discussions using a semi-structured interview, focusing on (a) the importance of six different topics (medical and nursing care, organizational, emotional, social, and spiritual/religious aspects), (b) the desired time point, and (c) the mode of discussion initiation. RESULTS: The importance of EOL topics differs significantly regarding issue (p = 0.002, η2 = 0.02) and gender (p < 0.001, η2 = 0.11). Males wish to avoid the engagement in discussions about death and dying particularly if they are anxious about their end-of-life period. They wish to be addressed regarding the "hard facts" nursing and medical care only. In contrast, females prefer to speak more about "soft facts" and to be addressed about each EOL topic. Independent of gender, the majority of patients prefer to talk rather late: when the disease is getting worse (58%), at the end of their therapy, or when loosing self-sufficiency (27.5%). CONCLUSION: The tendency of patients to talk late about EOL issues increases the risk of delayed or missed EOL conversations, which may be due to a knowledge gap regarding the possibility of disease-associated incapability. Furthermore, there are significant gender differences influencing the access to EOL conversations. Therefore, for daily clinical routine, we suggest an early two-step, gender-sensitive approach to end-of-life conversations.


Assuntos
Planejamento Antecipado de Cuidados/normas , Neoplasias/psicologia , Assistência Terminal/psicologia , Estudos Transversais , Feminino , Identidade de Gênero , Humanos , Masculino
12.
Cardiovasc Res ; 116(1): 12-27, 2020 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-31386104

RESUMO

Contrary to common perception, modern palliative care (PC) is applicable to all people with an incurable disease, not only cancer. PC is appropriate at every stage of disease progression, when PC needs emerge. These needs can be of physical, emotional, social, or spiritual nature. This document encourages the use of validated assessment tools to recognize such needs and ascertain efficacy of management. PC interventions should be provided alongside cardiologic management. Treating breathlessness is more effective, when cardiologic management is supported by PC interventions. Treating other symptoms like pain or depression requires predominantly PC interventions. Advance Care Planning aims to ensure that the future treatment and care the person receives is concordant with their personal values and goals, even after losing decision-making capacity. It should include also disease specific aspects, such as modification of implantable device activity at the end of life. The Whole Person Care concept describes the inseparability of the physical, emotional, and spiritual dimensions of the human being. Addressing psychological and spiritual needs, together with medical treatment, maintains personal integrity and promotes emotional healing. Most PC concerns can be addressed by the usual care team, supported by a PC specialist if needed. During dying, the persons' needs may change dynamically and intensive PC is often required. Following the death of a person, bereavement services benefit loved ones. The authors conclude that the inclusion of PC within the regular clinical framework for people with heart failure results in a substantial improvement in quality of life as well as comfort and dignity whilst dying.


Assuntos
Planejamento Antecipado de Cuidados/normas , Insuficiência Cardíaca/terapia , Cuidados Paliativos/normas , Planejamento Antecipado de Cuidados/ética , Atitude Frente a Morte , Consenso , Efeitos Psicossociais da Doença , Europa (Continente) , Nível de Saúde , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/psicologia , Humanos , Saúde Mental , Cuidados Paliativos/ética , Equipe de Assistência ao Paciente , Qualidade de Vida , Resultado do Tratamento
13.
Am J Hosp Palliat Care ; 37(1): 5-11, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31030524

RESUMO

OBJECTIVE: Quality communication is an important aspect of advance care planning (ACP). This study evaluates a certification program that trains lay people in communication skills to support community-based ACP conversations. METHODS: The program was developed with an emphasis on communication skills training. The testing of the program included ACP Guides and conversation partners, who were hospice volunteers, to assess the use of communication skills in ACP conversations. The evaluation used direct observations of conversations between trained ACP Guides and conversation partners as well as semi-structured interviews with those trained to become ACP Guides and those participating in the conversation. RESULTS: Twenty-two ACP Guides participated in the testing phase with a retention rate of 100% completing all 4 sessions. The RELATE model of communication emerged during program development and testing. Evaluation of 15 ACP Guides having ACP conversations found that trained ACP Guides could use the RELATE model of communication to support ACP conversations. CONCLUSION: A community-academic partnership developed an ACP Community Guides Program that trained individuals to have community-based ACP conversations. Next steps include additional testing of the program and RELATE in small numbers, especially among minority populations, to evaluate acceptability and usability of this approach. PRACTICE IMPLICATIONS: Laypersons with concrete communication skills can facilitate effective peer-to-peer ACP conversations.


Assuntos
Planejamento Antecipado de Cuidados/organização & administração , Comunicação , Cuidados Paliativos na Terminalidade da Vida/organização & administração , Voluntários/educação , Adulto , Planejamento Antecipado de Cuidados/normas , Idoso , Relações Comunidade-Instituição , Feminino , Cuidados Paliativos na Terminalidade da Vida/normas , Humanos , Masculino , Pessoa de Meia-Idade , Grupo Associado , Desenvolvimento de Programas , Universidades
14.
Support Care Cancer ; 28(3): 1315-1324, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31243585

RESUMO

BACKGROUND: It is unknown if the implementation of an advance care planning (ACP) program is feasible in daily clinical practice for glioblastoma patients. We aimed to develop an ACP program and assess the preferred content, the best time to introduce such a program in the disease trajectory, and possible barriers and facilitators for participation and implementation. METHODS: A focus group with health care professionals (HCPs) and individual semi-structured interviews with patients and proxies (of both living and deceased patients) were conducted. RESULTS: All predefined topics were considered relevant by participants, including the current situation, worries/fears, (supportive) treatment options, and preferred place of care/death. Although HCPs and proxies of deceased patients indicated that the program should be implemented relatively early in the disease trajectory, patient-proxy dyads were more ambiguous. Several patient-proxy dyads indicated that the program should be initiated later in the disease trajectory. If introduced early, topics about the end of life should be postponed. A frequently mentioned barrier for participation was that the program would be too confronting, while a facilitator was adequate access to information. CONCLUSION: This study resulted in an ACP program specifically for glioblastoma patients. Although participants agreed on the program content, the optimal timing of introducing such a program was a matter of debate. Our solution is to offer the program shortly after diagnosis but let patients and proxies decide which topics they want to discuss and when. The impact of the program on several patient- and care-related outcomes will be evaluated in the next step.


Assuntos
Planejamento Antecipado de Cuidados , Neoplasias Encefálicas/terapia , Glioblastoma/terapia , Adulto , Planejamento Antecipado de Cuidados/organização & administração , Planejamento Antecipado de Cuidados/normas , Diretivas Antecipadas/estatística & dados numéricos , Idoso , Neoplasias Encefálicas/patologia , Tomada de Decisões , Feminino , Grupos Focais , Glioblastoma/patologia , Pessoal de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Procurador , Assistência Terminal/organização & administração , Assistência Terminal/normas
15.
BMC Palliat Care ; 18(1): 99, 2019 Nov 11.
Artigo em Inglês | MEDLINE | ID: mdl-31711482

RESUMO

BACKGROUND: Despite the documented and well known patient benefits of ACP, the completion of ACP, only a minority of patients, during the advanced or EOL stage of their illnesses, receive such care. The misconceptions about ACP for healthcare providers, such as nurses, might become potential barriers to the effective implication of ACP. Also, from the transcultural perspective, it is evident essential to explore Taiwanese nurses' attitudes, knowledge, and actions of ACP. The purposes of this study were to explore the implication of ACP or hospice care for nurses caring for non-cancer chronic illness patients at a regional teaching hospital in Taiwan; and, to identify predictors of those nurses' knowledge, attitudes, and actions toward ACP. METHODS: This cross-sectional study with a purposive sample of 218 nurses was conducted at a teaching hospital in southern Taiwan. Structured questionnaires were employed and data were analyzed with descriptive statistics, t-test, one-way ANOVAs, Pearson's correlation and multiple regressions. RESULTS: 16.1% of Taiwanese physicians actively initiated ACP issues or conversations with patients or their family members. Nurses' attitudes toward ACP were fairly positive but their knowledge about ACP was insufficient and actions of ACP were not positively executed. The predictors of ACP-Knowledge (ACP-K) included position title, education hours and lacking of educational training. The predictors of ACP-Attitude (ACP-A) included ACP-K and "fear of patient or family member not accepting", whereas ACP-A, position title, "patients do not feel necessary" and "not sure physician's concern" were the predictors of ACP-Act. CONCLUSION: Continuous education and training for nurses regarding ACP needs to be improved by taking those predictors found in this current study into account, and more studies on the nurse's role in ACP also should be further examined. TRIAL REGISTRATION: KAFGH 106-012. Date of registration 1 May 2017.


Assuntos
Planejamento Antecipado de Cuidados/organização & administração , Atitude do Pessoal de Saúde , Conhecimentos, Atitudes e Prática em Saúde , Cuidados Paliativos na Terminalidade da Vida/organização & administração , Adulto , Planejamento Antecipado de Cuidados/normas , Estudos Transversais , Cuidados Paliativos na Terminalidade da Vida/normas , Hospitais de Ensino , Humanos , Pessoa de Meia-Idade , Médicos/organização & administração , Fatores Socioeconômicos , Taiwan , Adulto Jovem
16.
BMC Palliat Care ; 18(1): 95, 2019 Nov 05.
Artigo em Inglês | MEDLINE | ID: mdl-31690289

RESUMO

BACKGROUND: Research in Taiwan has indicated that advance care planning is rarely undertaken in long-term care facilities. The purpose of this study was to develop an advance care planning interview guideline and care model to facilitate the process of advance care planning for residents and their families in long-term care facilities. METHODS: This study follows an action research design. Cycles of planning, action, observation, and reflection were planned and modified based on the results of interviews with residents and their families as well as meetings with staff. To establish the interview guideline and care model through this action research study, residents and their families were interviewed separately. The researcher subsequently held meetings with staff members to evaluate the results and identify problems during each advance care planning process. This information was synthesised and used to modify the care model for implementation with the next resident-family pair. This process was performed a total of ten times. RESULTS: This study included residents (N = 10), their families (N = 20), and medical staff (N = 4) at a long-term care facility. The interviews and meetings were audio recorded, transcribed, and subjected to a simple thematic analysis together with the field notes and reflection logs. Four themes emerged from the data related to: opening the conversation with the interview guidelines about the life story of residents; continuing life stories to the quality of remaining years of the residents; gradually changing the topic to the end-of-life care issues; and concluding the conversation by explaining the content of advance directives and hospice care. CONCLUSIONS: The advance care planning care model was implemented following logical thinking from a Chinese perspective. This consisted of opening, developing, changing, and concluding through the views of Confucianism, Buddhism, and Taoism. The research findings indicate that the model successfully facilitated the process of advance care planning for residents and their families.


Assuntos
Planejamento Antecipado de Cuidados/organização & administração , Diretivas Antecipadas/etnologia , Assistência de Longa Duração/organização & administração , Casas de Saúde/organização & administração , Planejamento Antecipado de Cuidados/normas , China , Família/etnologia , Guias como Assunto , Pessoal de Saúde , Pesquisa sobre Serviços de Saúde , Humanos , Taiwan , Assistência Terminal/organização & administração
17.
Int J Palliat Nurs ; 25(10): 494-502, 2019 Oct 02.
Artigo em Inglês | MEDLINE | ID: mdl-31755842

RESUMO

BACKGROUND: Advance care planning (ACP) is recommended as part of the management of patients with heart failure (HF). AIMS: To develop and validate ACP support tools for patients with HF. METHODS: An ACP support tool was developed based on a systematic literature review. A multi-center, prospective before and after study was conducted to evaluate the usefulness of the support tool. This study included 21 patients with HF, 11 patients formed the control group and 10 patients were part of the intervention group who received ACP from medical staff using the ACP support tools developed for this study. Participants of the study were surveyed about their experience of ACP using a 6-point Likert scale. FINDINGS: All of the healthcare professionals (n=9) involved in the study found the ACP tool useful and about 90% of patients considered the support tool useful. The score for 'the patient did not feel anxious about the future after receiving ACP discussion' was significantly higher (3.5 [3.0, 4.0] vs 2.0 [1.0, 3.0]; P=0.04) in the intervention group that used the ACP tool. CONCLUSION: ACP support tools are useful to manage patients with HF and could enable effective ACP without increasing patient anxiety.


Assuntos
Planejamento Antecipado de Cuidados/normas , Diretivas Antecipadas/psicologia , Doença Crônica/enfermagem , Técnicas de Apoio para a Decisão , Insuficiência Cardíaca/enfermagem , Enfermagem de Cuidados Paliativos na Terminalidade da Vida/normas , Guias de Prática Clínica como Assunto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reprodutibilidade dos Testes , Inquéritos e Questionários
18.
J Hosp Palliat Nurs ; 21(6): 518-523, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31568108

RESUMO

The purpose of this article is to synthesize the evidence on advance care planning (ACP), determine what is applicable to the home health (HH) setting, and find where gaps in knowledge may exist. An integrative review methodology was chosen. Although there is ample literature on the topic of ACP, most research has been conducted in the acute care, outpatient, and general community settings. There is limited literature regarding ACP with patients living with chronic cardiovascular and pulmonary illnesses, who comprise the majority of the HH population. Some literature has been published regarding the interprofessional team's role in ACP in the HH setting. A gap in knowledge exists regarding ACP in HH, and recommendations for future research are provided.


Assuntos
Planejamento Antecipado de Cuidados/normas , Agências de Assistência Domiciliar/tendências , Planejamento Antecipado de Cuidados/tendências , Agências de Assistência Domiciliar/organização & administração , Humanos
19.
J Oncol Pract ; 15(11): e942-e947, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31509484

RESUMO

PURPOSE: Patients make treatment decisions based not only on what they want, but what they think their families want. Discordance in such perceived preferences may therefore pose challenges for advance care planning. This study examines discordance in preference for life-extending care versus comfort-focused care and its association with do-not-resuscitate (DNR) order placement. METHODS: One hundred eighty-nine patients with advanced cancers refractory to at least one chemotherapy regimen were enrolled in a multisite observational study. In structured interviews, patients reported their preference for treatment maximizing either life extension or comfort; patients also indicated their perception of their families' preference. DNR placement was reported by patients and verified using medical records. RESULTS: Approximately 23% of patients (n = 43) perceived discordance between their preference and their families' preference. Patients who perceived discordance were less likely to have completed a DNR compared with those who perceived concordance, even after controlling for relevant confounds (odds ratio = .35; P = .02). Subgroups of discordance and concordance showed varying DNR placement rates (χ2, 19.95; P < .001). DNR placement rate was lowest among discordant subgroups, where there was either a personal (26.7%; four of 15) or family preference for comfort care (28.6%; eight of 28), followed by patients who perceived concordance for wanting life-extending care (34.5%; 29 of 84) and by patients who perceived concordance in wanting comfort-focused care (66.1%; 41 of 62). CONCLUSION: Many patients may perceive discordance between personal and family treatment preferences, posing impediments to advance care planning. Such patients may benefit from additional decision support.


Assuntos
Planejamento Antecipado de Cuidados/normas , Comportamento de Escolha , Tomada de Decisões , Pacientes Internados/psicologia , Neoplasias/terapia , Ordens quanto à Conduta (Ética Médica)/psicologia , Assistência Terminal/psicologia , Feminino , Seguimentos , Humanos , Pacientes Internados/educação , Masculino , Pessoa de Meia-Idade , Neoplasias/psicologia , Conforto do Paciente , Preferência do Paciente , Prognóstico
20.
J Am Coll Cardiol ; 74(13): 1682-1692, 2019 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-31558252

RESUMO

BACKGROUND: Although implantable cardioverter-defibrillators (ICDs) reduce sudden death, these patients die of heart failure (HF) or other diseases. To prevent shocks at the end of life, clinicians should discuss deactivating the defibrillation function. OBJECTIVES: The purpose of this study was to determine if a clinician-centered teaching intervention and automatic reminders increased ICD deactivation discussions and increased device deactivation. METHODS: In this 6-center, single-blinded, cluster-randomized, controlled trial, primary outcomes were proportion of patients: 1) having ICD deactivation discussions; and 2) having the shocking function deactivated. Secondary outcomes included goals of care conversations and advance directive completion. RESULTS: A total of 525 subjects were included with advanced HF who had an ICD: 301 intervention and 224 control. At baseline, 52% (n = 272) were not candidates for advanced therapies (i.e., cardiac transplant or mechanical circulatory support). There were no differences in discussions (41 [14%] vs. 26 [12%]) or deactivation (33 [11%] vs. 26 [12%]). In pre-specified subgroup analyses of patients who were not candidates for advanced therapies, the intervention increased deactivation discussions (32 [25%] vs. 16 [11%]; odds ratio: 2.90; p = 0.003). Overall, 99 patients died; there were no differences in conversations or deactivations among decedents. SECONDARY OUTCOMES: Among all participants, there was an increase in goals of care conversations (47% intervention vs. 38% control; odds ratio: 1.53; p = 0.04). There were no differences in completion of advance directives. CONCLUSIONS: The intervention increased conversations about ICD deactivation and goals of care. HF clinicians were able to apply new communication techniques based on patients' severity of illness. (An Intervention to Improve Implantable Cardioverter-Defibrillator Deactivation Conversations [WISDOM]; NCT01459744).


Assuntos
Desfibriladores Implantáveis/psicologia , Cardioversão Elétrica/psicologia , Insuficiência Cardíaca/psicologia , Assistência ao Paciente/psicologia , Papel do Médico/psicologia , Relações Médico-Paciente , Planejamento Antecipado de Cuidados/normas , Idoso , Comunicação , Desfibriladores Implantáveis/efeitos adversos , Desfibriladores Implantáveis/normas , Cardioversão Elétrica/normas , Feminino , Insuficiência Cardíaca/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Assistência ao Paciente/normas , Método Simples-Cego
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