Justin Sanders

Factors Impacting Advance Care Planning among African Americans: Results of a Systematic Integrated Review

BACKGROUND African Americans (AA) are more likely to receive worse end-of-life (EOL) care and are less likely to participate in advance care planning (ACP) than white Americans. OBJECTIVE Our goal was to understand factors impacting ACP among AA and explore their interactions, in order to guide further research and intervention development. METHODS We systematically identified, using Medline, Embase, and World of Science databases, the quantitative and qualitative ACP literature in which AA were included. We assessed the quality of these studies and evaluated the literature in an iterative and integrative fashion, using themes developed from the qualitative literature to understand and categorize findings from the quantitative literature. RESULTS Thirty-eight mostly moderate and low quality quantitative studies focused largely on advance directive (AD) completion. Whereas most conclude that AA, when compared with white Americans, prefer more aggressive care, participate less in ACP, and are more likely to informally discuss EOL care than to formally document wishes, study findings were contradictory in a number of domains. Fourteen qualitative studies revealed a number of themes that informed the development of an empirically derived model to explain the relationship of factors impacting ACP for AA along historical and structural axes. CONCLUSIONS The multiple factors that impact ACP for AA are inter-related and may result in part from historical realities that shape contemporary experience. We know little from the data about how best to improve ACP in AA. That AA appear to prefer informal discussions about ACP to formal documentation of preferences suggests that future research should focus on improving ACP conversations among clinicians, patients, and their families in order to improve the receipt of goal-concordant care at EOL.

Finding the Right Words at the Right Time — High-Value Advance Care Planning

Ms. C died in the ICU after an unsuccessful resuscitation attempt — probably not what she would have wanted, though nobody knew for certain. Advance care planning discussions are difficult, and evidence suggests that targeting everyone for them might dilute our efforts.

Meaning and methadone: patient perceptions of methadone dose and a model to promote adherence to maintenance treatment.

Objectives:Methadone maintenance treatment (MMT) effectively reduces illicit opioid use and its negative consequences when patients participate in and adhere to treatment. Patients’ participation and adherence may relate to their perceptions about methadone doses and dose adjustments and the meanings that patients associate with treatment. This study assessed patient perceptions about methadone dosing and the meanings associated with methadone treatment to better support patient adherence to and success in MMT. Methods:We conducted semistructured interviews with 19 patients in an urban MMT program. Interviews were transcribed verbatim and analyzed through an iterative process. Results:Participants’ expressed perceptions about methadone doses related to ideas of “comfort” and “function,” suggesting a model for determining dose appropriateness and “ideal” methadone dose based on various factors both intrinsic and extrinsic to MMT. Intrinsic factors included those exerting downward pressure on “ideal” methadone dose such as lack of control in treatment, disdain for getting “high,” concerns about methadone dependence, and desire to avoid adverse effects; those exerting upward pressure such as concern about withdrawal; and those exerting mixed pressures such as methadone formulations. Extrinsic factors included those exerting downward pressure such as shame about and stigma around MMT; those exerting upward pressure such as medical conditions and medication interactions; and those exerting mixed pressures such as family and peer relationships. Conclusions:Participants held perceptions about methadone dosing that included considerations beyond typical medical parameters used by physicians and other MMT providers to determine appropriate methadone doses. The model that emerged from our data could help inform MMT providers to support greater patient comfort with methadone doses and dose changes, as well as adherence to and success in MMT.

Resident Physician Interactions with Surrogate Decision-Makers: The Resident Experience

This study explored interactions between medical residents and patient surrogates in order to clarify resident understanding of roles and relationships, resident emotional experience, and resident learning processes. Qualitative analysis of in‐depth interviews were used involving three family medicine residency programs serving culturally diverse, urban, underserved patient populations. Eighteen second‐ and third‐year trainees described a memorable interaction with a surrogate and then were prompted to discuss their learning experience and their role in the interaction. Interviews were transcribed verbatim and analyzed through an iterative process. Residents experienced significant emotional burden during interactions yet continued to value their relationships with surrogates. Despite their reservations about giving recommendations, residents adopted a variety of roles with surrogates as they gave support, information, and advice. Although residents reported little formal education about surrogate decision‐making, they relied on passive role modeling and their own previous experiences to help surrogates make decisions. Residents have complex and emotionally significant interactions with surrogates despite minimal formal education about surrogate decision‐making. Educational efforts should seek to help residents understand their own emotions and the ethical beliefs that underlie the roles they adopt with surrogates. This will help residents to facilitate value‐based conversations with surrogates and better support surrogates in the decision‐making process.

Can we improve the quality of documented end-of-life conversations using a structured, multicomponent intervention?

49 Background: Conversations about serious illness care goals are often inadequate and fail to address key elements of high-quality discussions. METHODS As part of a cluster-randomized trial of a multi-component communication intervention, we conducted a retrospective chart review of 147 deceased oncology patients to assess frequency and timing of documentation of end-of-life (EOL) conversations; charts of a subset of 20 intervention and 20 matched control patients underwent detailed review to assess quality. A systematically developed abstraction tool was used by two blinded researchers. The tool contained 25 elements reflecting four EOL conversation domains: goals/values, illness understanding/prognosis, EOL care planning, life-sustaining treatments. RESULTS Of 153 intervention patients, 44.4% died (n = 68); of 161 controls, 49.1% died (n = 79). Significantly more intervention patients than controls (92.7% vs 74.7%, p = 0.006) had at least 1 documented EOL discussion before death; intervention conversations occurred 3 months earlier (median 147 days vs 62 days, p = 0.003). 59.4% of intervention conversations were documented in a retrievable EHR location compared to 10.2% of controls (p = 0.001). In the detailed review, 85% (n = 17) of intervention and 40% (n = 8) of controls had at least 1 documented discussion about values/goals (p = 0.0001), with an average of 3.6 of 8 elements (0.7 of 8 for controls) (p = 0.0003). 85% percent (n = 17) of intervention and 30% (n = 6) of controls had at least 1 documented discussion about prognosis (p = 0.0014), with an average of 2.5 of 7 elements (0.5 of 7 for controls) (p = 0.001). 85% of intervention (n = 17) and 55% of controls (n = 11) had at least 1 documented discussion about EOL planning (p = 0.009). 55% of intervention and 30% of controls had at least 1 documented discussion about life-sustaining treatments (p = 0.20). CONCLUSIONS The intervention resulted in more, earlier and better documentation of serious illness care goals. Across 3 of 4 domains of quality, intervention patients had more detailed information about their EOL care preferences, demonstrating that the intervention results in more patient-centered, comprehensive discussions. CLINICAL TRIAL INFORMATION NCT01786811.