Study protocol to investigate the efficacy of normalisation of Advance Care Planning (ACP) for people with chronic diseases in acute and community settings: a quasi-experimental design (original) (raw)
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BMJ Open Respiratory Research, 2020
Background and aimsAdvance care planning (ACP) is communication about wishes and preferences for end-of-life care. ACP is not routinely used in any Norwegian hospitals. We performed a pilot study (2014–2017) introducing ACP on a thoracic medicine ward in Norway. The aims of this study were to explore which topics patients discussed during ACP conversations and to assess how patients, relatives and clinicians experienced the acceptability and feasibility of performing ACP.MethodsConversations were led by a study nurse or physician using a semistructured guide, encouraging patients to talk freely. Each conversation was summarised in a report in the patient’s medical record. At the end of the pilot period, clinicians discussed their experiences in focus group interviews. Reports and transcribed interviews were analysed using systematic text condensation.ResultsFifty-one patients participated in ACP conversations (41–86 years; 9 COPD, 41 lung cancer, 1 lung fibrosis; 11 women); 18 were accompanied by a relative. Four themes emerged: (1) disturbing symptoms, (2) existential topics, (3) care planning and (4) important relationships. All participants appreciated the conversations. Clinicians (1 physician and 7 nurses) participated in two focus group interviews. Reports from ACP conversations revealed patient values previously unknown to clinicians; important information was passed on to primary care. Fearing they would deprive patients of hope, clinicians acted as gatekeepers for recruitment. Although they reported barriers during recruitment, many clinicians saw ACP as pertinent and called for time and skills to integrate it into their daily clinical practice.ConclusionsPatients, relatives and clinicians showed a positive attitude towards ACP. Focusing on present and future symptom control may be an acceptable way to introduce ACP. Important aspects for implementing ACP in this patient group are management support, education, training, feasible routines and allocated time to perform the conversations.
Journal of Research in Nursing, 2018
Background Advance Care Planning (ACP) communication is difficult to implement in hospital. Possibly this has to do with the fact that the concept is not well tuned to the needs of hospital professionals or that they experience implementation barriers in practice. Aims The aim of this study was to investigate what is valued in having ACP conversations by hospital professionals (physicians, nurses, psychologists and social workers) and what they experience as barriers and facilitating factors for having ACP conversations with patients. Methods A Delphi study consisting of two rounds with respectively 21 and 19 multidisciplinary experts from seven European countries was organised. Data were analysed using content analysis and descriptive statistics. Results Participants agreed that ACP is valued mostly because it is seen to improve transmural continuation of care, emotional processing of the loss of a patient, and serenity at the end of life. Reported barriers are patient characterist...
2020
Background: Advance Care Planning (ACP) enables healthcare professionals to embrace the important process where patients think about their values in life and goals for health care, and discuss their future health care preferences with family members for a time when they are not able to make health care decisions. Despite the promotion of ACP last two decades, and well-known benefits of ACP and a written Advance Care Directive (ACD), they are still underutilised in Australia and across the world. Previous studies have provided some insights, however, an uptake of ACP and prevalence of ACDs in community setting is rarely reported.Methods: The aim of this study was to determine the uptake of ACP and prevalence of ACDs among people with chronic diseases in hospital and community settings. A retrospective medical record audit of eligible patients looking for evidence of ACP was conducted in 16 research sites (eight intervention and eight control) in hospital and community care settings. ...
PLOS ONE
To examine the use of Normalisation Process Theory (NPT) to establish if, and in what ways, the AMBER care bundle can be successfully normalised into acute hospital practice, and to identify necessary modifications to optimise its implementation. Method Multi-method process evaluation embedded within a mixed-method feasibility cluster randomised controlled trial in two district general hospitals in England. Data were collected using (i) focus groups with health professionals (HPs), (ii) semi-structured interviews with patients and/or carers, (iii) non-participant observations of multidisciplinary team meetings and (iv) patient clinical note review. Thematic analysis and descriptive statistics, with interpretation guided by NPT components (coherence; cognitive participation; collective action; reflexive monitoring). Data triangulated across sources. Results Two focus groups (26 HPs), nine non-participant observations, 12 interviews (two patients, 10 relatives), 29 clinical note reviews were conducted. While coherence was evident, with HPs recognising the value of the AMBER care bundle, cognitive participation and collective action presented challenges. Specifically: (1) HPs were unable and unwilling to
Integrative Clinical Medicine, 2017
Background: Advance Care Planning (ACP) can be defined as an ongoing process of communication between patients and (in-) formal caregivers to help an individual identify, reflect upon, discuss, and express her or his values, beliefs, goals, and priorities to guide individual care and treatment decision making when nearing end of life. Studies suggest ACP is not well implemented in the hospital setting. This contrast sharply to the necessity of those conversations in hospitals: treatment decisions are made which potentially have a big impact on the patient's and families quality of life. AIMS: In order to facilitate the implementation of the ACP decision making process in hospital, it might be interesting to know what helps hospital professionals to overcome challenges. Methods: 24 semi-structured interviews were taken from hospital physicians, nurses, psychologists and social workers and analyzed using content analysis based upon grounded theory principles. Results: Participants reported that finding consensus about treatment and care was difficult. Furthermore, finding consensus on when to start decision making conversations with patients was difficult. Helping factors are multidisciplinary cooperation and strategies to convince one another, like the use of rhetoric's. Also, working closely together is also seen to be advantageous, because opinions can be checked and one can learn from more experienced colleagues. Conclusion: This study gives an insight in how ACP is conducted in hospital practice and what is experienced as helping to overcome obstacles. Results can be used to facilitate implementation, for example by educating professionals.
Journal of General Internal Medicine
BACKGROUND: Goals of care (GOC) is a communication and decision-making process that occurs between a clinician and a patient (or surrogate decision-maker) during an episode of care to facilitate a plan of care that is consistent with the patient's preferences and values. Little is known about patients' experiences of these discussions. OBJECTIVE: This study explored patients' perspectives of the GOC discussion in the hospital setting. DESIGN: An explorative qualitative design was used within a social constructionist framework. PARTICIPANTS: Adult patients were recruited from six Australian hospitals across two states. Eligible patients had had a GOC discussion and they were identified by the senior nurse or their doctor for informed consent and interview. APPROACH: Semi-structured individual or dyadic interviews (with the carer/family member present) were conducted at the bedside or at the patient's home (for recently discharged patients). Interviews were audio-recorded and transcribed verbatim. Data were analysed for themes. KEY RESULTS: Thirty-eight patient interviews were completed. The key themes identified were (1) values and expectations, and (2) communication (sub-themes: (i) facilitators of the conversation, (ii) barriers to the conversation, and (iii) influence of the environment). Most
Advance care planning in rehabilitation: An implementation study
Journal of Rehabilitation Medicine
Advance care planning (ACP) is the process of planning for future healthcare and life-prolonging treatment preferences to guide clinical decision-making when one is unable to communicate decisions due to lack of capacity. We evaluated the effectiveness of an ACP programme in an inpatient rehabilitation setting in Australia with patients with chronic illnesses. This programme identified barriers and enablers, with implementation of ACP strategies in this setting, resulting in an increase in ACP conversations between rehabilitation staff and patients. The programme is feasible, but needs longer-term follow-up to assess the impact of outcomes on improved care quality. Objective: To identify implementation and process issues that influence the implementation of an advance care planning (ACP) programme in rehabilitation settings. Methods: An ACP programme was established in an inpatient tertiary rehabilitation setting in Victoria, Australia. Rehabilitation patients with chronic illnesses were recruited and the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework used. Pre-implementation measures included: patient medical record audit of ACP discussions; and barriers and facilitators analyses. Implementation interventions were staff group educational sessions and clinical process changes. Further medical record audit was carried out to review the number of ACP conversations performed and re-evaluate ACP barriers. Results: A total of 180 consecutive inpatients were recruited for pre-(n = 90) and post-(n = 90) implementation groups. The majority of the pre-implementation cohort were female (51%), mean age 64.2 years (standard deviation 16.4 years) and had low rates of ACP discussions (n = 9, 10%). Major ACP barriers included: lack of staff education programme, and insufficient knowledge to conduct ACP. There was a significant increase in ACP conversations performed (n = 21, 23.3%) between both groups; however, staff reported limited time and skills to perform discussions. Conclusion: This ACP programme is feasible, but needs robust process evaluation and longer term follow-up to assess the impact of outcomes in public hospital settings on care quality.
Implementing advance care planning: a qualitative study of community nurses' views and experiences
Background: Advance care planning (ACP) is a process of discussion about goals of care and a means of setting on record preferences for care of patients who may lose capacity or communication ability in the future. Implementation of ACP is widely promoted by policy makers. This study examined how community palliative care nurses in England understand ACP and their roles within ACP. It sought to identify factors surrounding community nurses' implementation of ACP and nurses' educational needs. Methods: An action research strategy was employed. 23 community nurses from two cancer networks in England were recruited to 6 focus group discussions and three follow up workshops. Data were analysed using a constant comparison approach.
Provider Tools for Advance Care Planning and Goals of Care Discussions: A Systematic Review
The American journal of hospice & palliative care, 2018
Advance care planning and goals of care discussions involve the exploration of what is most important to a person, including their values and beliefs in preparation for health-care decision-making. Advance care planning conversations focus on planning for future health care, ensuring that an incapable person's wishes are known and can guide the person's substitute decision maker for future decision-making. Goals of care discussions focus on preparing for current decision-making by ensuring the person's goals guide this process. To provide evidence regarding tools and/or practices available for use by health-care providers to effectively facilitate advance care planning conversations and/or goals of care discussions. A systematic review was conducted focusing on guidelines, randomized trials, comparative studies, and noncomparative studies. Databases searched included MEDLINE, EMBASE, and the proceedings of the International Advance Care Planning Conference and the Americ...