Joel Rhee

Advance care planning and interpersonal relationships: a two-way street

BACKGROUND Advance care planning (ACP) has been gaining prominence for its perceived benefits for patients in enhancing patient autonomy and ensuring high-quality end-of-life-care. Moreover, it has been postulated that ACP has positive effects on families and health professionals and their relationship with the patient. However, there is a paucity of studies examining the views of GPs on this issue. OBJECTIVE To explore GP views on the impact that ACP has on interpersonal relationships among those involved in the patients care. METHOD Semi-structured, open-ended interviews of a purposive sample of 17 GPs. Interview transcripts were analysed using constructionist grounded theory methodology with QSR NVivo 9 software. RESULTS ACP was seen as having both positive and negative impacts on interpersonal relationships. It was thought to enhance family relationships, help resolve conflicts between families and health professionals and improve trust and understanding between patients and health professionals. Negatively, it could take the familys attention away from patient care. The link between ACP and interpersonal relationships was perceived to be bidirectional-the nature of interpersonal relationship that patients have with their families and health professionals has a profound impact on what form of ACP is likely to be useful. CONCLUSION Our study highlights the importance that GPs place on the link between ACP and the patients interpersonal context. This has implications on how ACP is conducted in primary care settings that are considerably different from other care settings in their emphasis on continuity of care and long-term nature of relationships.

How is advance care planning conceptualised in Australia? Findings from key informant interviews

OBJECTIVE Advance Care Planning (ACP) has been gaining prominence as an important component of good end-of-life care. This study explored how ACP is conceptualised by stakeholder organisations and clinicians involved in aged care and end-of-life care in Australia, in particular their views on the aim, appropriate context and settings for ACP, and how ACP should be facilitated. PARTICIPANTS Twenty-three participants including expert clinicians and representatives of government organisations, professional societies, consumer groups and other organisations involved in aged care and end-of-life care. DESIGN Qualitative descriptive analysis of semi-structured telephone interviews. RESULTS Most participants viewed ACP as an ongoing process aimed at enhancing an individuals autonomy and ensuring good end-of-life care. However, there were significant differences in how this process was conceptualised. Some viewed ACP as a process undertaken by patients to define and communicate their treatment preferences. Others viewed ACP as discussions undertaken by health professionals to gain a better understanding of the patients values and goals in order to provide good care. IMPLICATIONS Our findings highlight significant differences in how ACP is conceptualised in Australia. A shared conceptualisation and agreement on purpose is needed to ensure a successful implementation of ACP in Australia.

Medical practitioners' knowledge and self‐reported practices of substitute decision making and implementation of advance care plans

Advance care planning (ACP) provides patients with the ability to make their decisions known about how they would like to be treated if they lose capacity. Medical practitioners have a key role to play in providing information on ACP to their patients. This research explores their knowledge and attitudes to advance care planning and how this affects their practice.

A web-based personally controlled health management system increases sexually transmitted infection screening rates in young people: a randomized controlled trial.

OBJECTIVE To determine if a web-based personally controlled health management system (PCHMS) could increase the uptake of sexually transmitted infections (STI) screening among a young university population. METHODS A non-blinded parallel-group randomized controlled trial was conducted. Participants aged 18-29 years were recruited from a university environment between April and August 2013, and randomized 1:1 to either the intervention group (immediate online PCHMS access) or control group (no PCHMS access). The study outcome was self-reported STI testing, measured by an online follow-up survey in October 2013. RESULTS Of the 369 participants allocated to the PCHMS, 150 completed the follow-up survey, and of the 378 in the control group, 225 completed the follow-up survey. The proportion of the PCHMS group who underwent an STI test during the study period was 15.3% (23/150) compared with 7.6% (17/225) in the control group (P = .017). The difference in STI testing rates within the subgroup of sexually active participants (20.4% (23/113) of the PCHMS group compared with 9.6% (15/157) of the control group) was significantly higher (P = .027) than among non-sexually active participants. DISCUSSION Access to the PCHMS was associated with a significant increase in participants undergoing STI testing. This is also the first study to demonstrate efficacy of a PCHMS targeting a health concern where susceptibility is generally perceived as low and the majority of infections are asymptomatic. CONCLUSION PCHMS interventions may provide an effective means of increasing the demand for STI testing which, combined with increased opportunistic testing by clinicians, could reduce the high and sustained rates of STIs in young people.

Many people in Scotland now benefit from anticipatory care before they die: an after death analysis and interviews with general practitioners

Background Key Information Summaries (KIS) were introduced throughout Scotland in 2013 so that anticipatory care plans written by general practitioners (GPs) could be routinely shared electronically and updated in real time, between GPs and providers of unscheduled and secondary care. Aims We aimed to describe the current reach of anticipatory and palliative care, and to explore GPs’ views on using KIS. Methods We studied the primary care records of all patients who died in 2014 in 9 diverse Lothian practices. We identified if anticipatory or palliative care had been started, and if so how many weeks before death and which aspects of care had been documented. We interviewed 10 GPs to understand barriers and facilitating factors. Results Overall, 60% of patients were identified for a KIS, a median of 18 weeks before death. The numbers identified were highest for patients with cancer, with 75% identified compared with 66% of those dying with dementia/frailty and only 41% dying from organ failure. Patients were more likely to die outside hospital if they had a KIS. GPs identified professional, patient and societal challenges in identifying patients for palliative care, especially those with non-cancer diagnoses. Conclusions GPs are identifying patients for anticipatory and palliative care more equitably across the different disease trajectories and earlier in the disease process than they were previously identifying patients specifically for palliative care. However, many patients still lack care planning, particularly those dying with organ failure.

Why are advance care planning decisions not implemented? Insights from interviews with Australian General Practitioners

BACKGROUND Advance care planning (ACP) is thought to enhance patient autonomy and improve end-of-life care. However, there is evidence that when patients engage in ACP, the resultant plans are often not implemented. This has been attributed to either nonadherence by health professionals or inadequacies in ACP such as inaccessibility of the plans, plans providing ambiguous or conflicting instructions, and inappropriate focus on the completion of documents rather than communication. However, it is not known whether these postulated reasons are consistent with the experiences and views of health care professionals providing end-of-life care in the community. OBJECTIVE Our aim was to explore the perspectives of general practitioners (GPs) on factors influencing the implementation of ACPs. METHODS We conducted semi-structured, open-ended interviews of a purposive sample of 17 Australian GPs. Interview transcripts were analysed using constructionist grounded theory utilizing NVivo 9 software. RESULTS Factors that were considered to have an important influence on the implementation of ACPs include: ACP factors such as form, legal standing, accessibility, clarity, currency, and specificity; illness factors such as quality of life, function, diagnosis, prognosis, and prognostic certainty; family factors such as family attitudes to ACP and different conceptualizations on whether care is provided to individuals or to a family unit; and organizational and care setting factors such as health care facilitys attitudes and policies in relation to end-of-life care. CONCLUSIONS Problems in implementation of ACPs are multifactorial and not necessarily due to deliberate nonadherence by health professionals. Potential solutions to improve the clinical impact of ACP are discussed.

Using intuition or a formal palliative care needs assessment screening process in general practice to predict death within 12 months: A randomised controlled trial

Background: Population ageing will lead to more deaths with an uncertain trajectory. Identifying patients at risk of dying could facilitate more effective care planning. Aim: To determine whether screening for likely death within 12 months is more effective using screening tools or intuition. Design: Randomised controlled trial of screening tools (Surprise Question plus the Supportive and Palliative Care Indicators Tool for Surprise Question positive patients) to predict those at risk of death at 12 months compared with unguided intuition (clinical trials registry: ACTRN12613000266763). Setting/participants: Australian general practice. A total of 30 general practitioners (screening tool = 12, intuition = 18) screened all patients (n = 4365) aged ≥70 years seen at least once in the last 2 years. Results: There were 142 deaths (screening tool = 3.1%, intuition = 3.3%; p = 0.79). General practitioners identified more at risk of dying using Surprise Question (11.8%) than intuition (5.4%; p = 0.01), but no difference with Surprise Question positive then Supportive and Palliative Care Indicators Tool (5.1%; p = 0.87). Surprise Question positive predicted more deaths (53.2%, intuition = 33.7%; p = 0.001), but Surprise Question positive/Supportive and Palliative Care Indicators Tool predictions were similar (5.1%; p = 0.87 vs intuition). There was no difference in proportions correctly predicted to die (Surprise Question = 1.6%, intuition = 1.1%; p = 0.156 and Surprise Question positive/Supportive and Palliative Care Indicators Tool = 1.1%; p = 0.86 vs intuition). Screening tool had higher sensitivity and lower specificity than intuition, but no difference in positive or negative predictive value. Conclusion: Screening tool was better at predicting actual death than intuition, but with a higher false positive rate. Both were similarly effective at screening the whole cohort for death. Screening for possible death is not the best option for initiating end-of-life planning: recognising increased burden of illness might be a better trigger.

A self-reported survey on the confidence levels and motivation of New South Wales practice nurses on conducting advance-care planning (ACP) initiatives in the general-practice setting

Nurses are well positioned to initiate and conduct advance-care planning (ACP) conversations; however, there has been limited research on practice nurses performing this role in Australia. The aim of the present study was to understand the beliefs, attitudes, perceptions, confidence, training and educational needs of New South Wales practice nurses with regards to involvement in ACP. A cross-sectional online survey was conducted in August to October 2014. Nurses were recruited through nursing organisations and Medicare Locals. There were 147 completed surveys (n=147). Participants were mostly female registered nurses, with a median age of 50, and 6 years of practice-nurse experience. Practice nurses were generally positive towards their involvement in ACP and believed it would be beneficial for the community. Their confidence in initiating ACP increased as their familiarity with patients increased. They showed a high level of interest in participating in training and education in ACP. Barriers to their involvement in ACP included the lack of a good documentation system, limited patient-education resources and unclear source of remuneration. Nurses were also concerned over legalities of ACP, ethical considerations and their understanding of end-of-life care options. Nevertheless, they were highly receptive of integrating ACP discussions and were willing to enhance their skills. These findings uncover a need for further training and development of practice nurses for ACP discussions.

The ‘surprise’ question may improve the accuracy of GPs in identifying death in patients with advanced stage IV solid-cell cancer

Commentary on : Moroni M, Zocchi D, Bolognesi D, et al, .; on behalf of the SUQ-P group. The ‘surprise’ question in advanced cancer patients: a prospective study among general practitioners. Palliat Med 2014;28:,959–64.[OpenUrl][1][Abstract/FREE Full Text][2] The ‘surprise’ question has been developed in order to improve the ability of clinicians to identify patients who are at risk of dying in the near future. The question, ‘Would I be surprised if this patient died in the next year?’ shifts the focus away from precise identification of dying patients to identifying patients who might be dying.1 This may enable more patients to receive timely assessment and planning for their supportive care needs. This is a single-group prospective cohort study aimed at determining the accuracy of the ‘surprise’ question in identifying patients at risk of death. The population examined was patients with stage IV solid-cell cancers cared for by general practitioners (GPs). A random sample of 50 GPs from a local chapter of a GP organisation in Italy was invited to … [1]: {openurl}?query=rft.jtitle%253DPalliat%2BMed%26rft_id%253Dinfo%253Adoi%252F10.1177%252F0269216314526273%26rft_id%253Dinfo%253Apmid%252F24662237%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/ijlink?linkType=ABST&journalCode=sppmj&resid=28/7/959&atom=%2Febmed%2F20%2F2%2F71.atom

Systematic review of general practice end-of-life symptom control

Background End of life care (EoLC) is a fundamental role of general practice, which will become more important as the population ages. It is essential that general practice’s role and performance of at the end of life is understood in order to maximise the skills of the entire workforce. Objective To provide a comprehensive description of the role and performance of general practitioners (GPs) and general practice nurses (GPNs) in EoLC symptom control. Method Systematic literature review of papers from 2000 to 2017 were sought from Medline, PsycINFO, Embase, Joanna Briggs Institute and Cochrane databases. Results From 6209 journal articles, 46 papers reported GP performance in symptom management. There was no reference to the performance of GPNs in any paper identified. Most GPs expressed confidence in identifying EoLC symptoms. However, they reported lack of confidence in providing EoLC at the beginning of their careers, and improvements with time in practice. They perceived emotional support as being the most important aspect of EoLC that they provide, but there were barriers to its provision. GPs felt most comfortable treating pain, and least confident with dyspnoea and depression. Observed pain management was sometimes not optimal. More formal training, particularly in the use of opioids was considered important to improve management of both pain and dyspnoea. Conclusions It is essential that GPs receive regular education and training, and exposure to EoLC from an early stage in their careers to ensure skill and confidence. Research into the role of GPNs in symptom control needs to occur.