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Documentation of advance care planning (ACP) in the electronic health record (EHR) is a quality measure promoted by both the Centers for Medicare and Medicaid Services (CMS) and the Department of Veterans Affairs (VA). There is no best practice model for promotion of ACP in primary care. Clinic prompts reminders from staff, and provision of forms and handouts modestly increase ACP completion. Targeted advance care planning and goals of care discussions for high-risk high-need older patients may help promote ACP in primary care.
High-risk, high-need geriatric patients were identified by the clinical assessment of need (CAN) risk calculator for a telehealth intervention by an advanced practice nurse trained in palliative care and embedded in the geriatric patient-aligned care team (Geri-PACT) and provided telehealth outreach for ACP and goals of care discussions.
At baseline the Geri-PACT panel had a 54% prevalence of ACP in the EHR. Completion of a life-sustaining treatment note (LST) increased from 39% to 74% following the telehealth intervention producing a total of 89% ACP documents in the EHR. Additionally, 9% of patients received goals of care discussions and a need for additional home and community-based services was identified for 12% of patients contacted. Outreach to three practices in an established physician referral and patient visit network which included 10 providers indicated that primary care providers desired to approach their own patients for ACP. These providers were educated and provided tools and information about CMS and VA ACP quality improvement directives.
A focused telehealth intervention performed by a nurse trained in palliative care and embedded in a geriatric patient-centered medical home was able to significantly increase ACP documentation in the EHR for elderly patients in the practice. Primary care providers place core importance on the value of the patient-clinician relationship and prefer to approach their own patients rather than rely on consultation for ACP. Education for primary care providers and provision of resources to perform ACP and goals of care discussions for their patients may be a worthwhile strategy to improve ACP completion and documentation in the EHR.
Advance directives; Primary care; Telehealth.
This paper examines the link between non-pharmacological care tools carried out by volunteers in a hospice and the development of the perception of dignity in people with end-of-life terminal illnesses.
Materials and Methods
We interviewed volunteers from a hospice institution in Argentina, who carried out non-pharmacological care activities aimed at people at the end-of-life. The results of these interviews were analyzed with the Atlas Ti software, using the grounded theory as a form of qualitative codification.
From the codification of the interviews, we obtained the following analysis categories: 1. Caring after the caregivers (mentioned 14 times), 2. Care taking into account the temporal needs of others (mentioned 7 times), 3. Active listening (mentioned 11 times), 4. Environmental aesthetic factors (mentioned 18 times) and 5. Enhancement of autonomy and selfhood (mentioned 22 times).
We examined ways in which volunteers associated with the care of people with end-of-life terminal illnesses understand their work from the explanation of the non-pharmacological care activities developed within the institution, as well as the link that these have with the different dimensions of the human sense.
The non-pharmacological care tools, as they alleviate existential/spiritual suffering, impact positively in the possibility of a terminal person’s capacity to perceive herself/himself as worthy.
Hospice; Non-pharmacological care; Dignity.
Music therapy (MT) is part of the care plan in many end-of-life (EOL) settings, though several authors remain cautious about its effectiveness to improve EOL symptoms and patient well-being.
Our primary goal was to design and test the feasibility of a clinical trial protocol that would address the main critiques of MT trials previously reported in the literature.
We conducted a literature review guided by the questions: (1) What is the set of indicators and tools that can be used to measure effectiveness of MT for seniors in palliative care and EOL settings? (2) What are the characteristics of a well-designed clinical trial protocol that can measure effectiveness of MT in palliative care and EOL settings and can be used for a future large scale study? Based on best practices from the review, we developed a clinical trial protocol and tested its feasibility.
Ten participants were accrued. Approximately 25% of eligible participants chose to participate. The consent rate was 55% with 70% of participants completing all MT sessions. All participants completed more than 60% of questionnaires.
Although our protocol could not be considered feasible based on the parameters we originally set, we argue that our study provides enough data to make adjustments to our original trial protocol, which could lead to the collection of reliable evidence related to the effectiveness of MT for seniors at EOL. We recommend future studies to use block randomization and allocation concealment, focus on one primary outcome and conduct intention-to-treat analysis.
Music Therapy (MT); End-of-Life (EOL); Seniors; Clinical trial; Palliative Performance Scale (PPS); Standardized Mini-Mental State Examination (SMMSE); Positive Affect and Negative Affect Schedule (PANAS); Spiritual Health Assessment (SHA).
Cachexia is a syndrome which is a common feature in more than 80% of patients with advanced cancer and globally accounts for over two million deaths per annum. At present there are no standard treatment guidelines for cancer cachexia management. Previous research conducted with the United Kingdom and Australia has highlighted different understanding and treatment practices of health care professionals in cachexia management, however, no study has elucidated the understanding and current practices of health care professionals in the United States.
The aim of this research was to explore the understanding and current practices of health care professionals in the United States when providing care to an individual with advanced cancer who has cachexia.
This is a qualitative study underpinned by symbolic interactionism. Face-to-face semi-structured interviews were conducted (n=17) with multi-disciplinary oncology staff and thematically analysed. Health care professionals were recruited from one large health care facility in the United States, until data saturation was reached. NVivo was used for data management. Criteria for upholding rigor (credibility, dependability, confirmability, transferability) were adhered to within this qualitative study. Full ethical approval was obtained prior to data collection commencing.
Analysis determined four main themes related to (1) recognizingthe signs and symptoms of cachexia; (2) the multidimensional impact of cachexia on both patients and families; (3) complexities when treating cachexia; and (4) future direction of care delivery for patients with advanced cancer who have cachexia.
Participants within this study recognized the multi-factorial pathophysiology of cachexia and its holistic impact which spanned biological, psychological and social domains. Additionally, they recognized the impact of cachexia on not only patients but also their family carers. In particular the feelings of helplessness family carers experience in trying to stop the progressive and involuntary weight loss associated with cachexia. Further research is required to examine how to best support the needs of patients with advanced cancer who have cachexia and their family carers and equip staff to optimize delivery of this.
Qualitative research; Cancer cachexia; Symbolic interactionism; Multi professional care; Patients and carers.
Middle East Cancer Consortium
P.O. Box 7495
Haifa 31074, Israel
Associate Professor of Nursing
Department of Nursing
Morehead State University
150 University Blvd
Morehead, KY 40351, USA
Yong Loo Lin School of Medicine
National University of Singapore
Level 2, Clinical Research Centre, Block MD11
10 Medical Drive 117597
Palliative Care Physician
Aga Khan University
P.O. Box 4614-00200, Nairobi, Kenya