Karen Detering

The impact of advance care planning on end of life care in elderly patients: randomised controlled trial

Objective To investigate the impact of advance care planning on end of life care in elderly patients. Design Prospective randomised controlled trial. Setting Single centre study in a university hospital in Melbourne, Australia. Participants 309 legally competent medical inpatients aged 80 or more and followed for six months or until death. Interventions Participants were randomised to receive usual care or usual care plus facilitated advance care planning. Advance care planning aimed to assist patients to reflect on their goals, values, and beliefs; to consider future medical treatment preferences; to appoint a surrogate; and to document their wishes. Main outcome measures The primary outcome was whether a patient’s end of life wishes were known and respected. Other outcomes included patient and family satisfaction with hospital stay and levels of stress, anxiety, and depression in relatives of patients who died. Results 154 of the 309 patients were randomised to advance care planning, 125 (81%) received advance care planning, and 108 (84%) expressed wishes or appointed a surrogate, or both. Of the 56 patients who died by six months, end of life wishes were much more likely to be known and followed in the intervention group (25/29, 86%) compared with the control group (8/27, 30%; P<0.001). In the intervention group, family members of patients who died had significantly less stress (intervention 5, control 15; P<0.001), anxiety (intervention 0, control 3; P=0.02), and depression (intervention 0, control 5; P=0.002) than those of the control patients. Patient and family satisfaction was higher in the intervention group. Conclusions Advance care planning improves end of life care and patient and family satisfaction and reduces stress, anxiety, and depression in surviving relatives. Trial registration Australian New Zealand clinical trials registry ACTRN12608000539336.

Teaching general practitioners and doctors-in-training to discuss advance care planning: evaluation of a brief multimodality education programme

Objective To develop and evaluate an interactive advance care planning (ACP) educational programme for general practitioners and doctors-in-training. Design Development of training materials was overseen by a committee; informed by literature and previous teaching experience. The evaluation assessed participant confidence, knowledge and attitude toward ACP before and after training. Setting Training provided to metropolitan and rural settings in Victoria, Australia. Participants 148 doctors participated in training. The majority were aged at least 40 years with more than 10 years work experience; 63% had not trained in Australia. Intervention The programme included prereading, a DVD, interactive patient e-simulation workshop and a training manual. All educational materials followed an evidence-based stepwise approach to ACP: Introducing the topic, exploring concepts, introducing solutions and summarising the conversation. Main outcome measures The primary outcome was the change in doctors’ self-reported confidence to undertake ACP conversations. Secondary measures included pretest/post-test scores in patient ACP e-simulation, change in ACP knowledge and attitude, and satisfaction with programme materials. Results 69 participants completed the preworkshop and postworkshop evaluation. Following education, there was a significant change in self-reported confidence in six of eight items (p=0.008 –0.08). There was a significant improvement (p<0.001) in median scores on the e-simulation (pre 7/80, post 60/80). There were no significant differences observed in ACP knowledge following training, and most participants were supportive of patient autonomy and ACP pretraining. Educational materials were rated highly. Conclusions A short multimodal interactive education programme improves doctors’ confidence with ACP and performance on an ACP patient e-simulation.

A retrospective analysis of sleep quality and survival with domiciliary ventilatory support in motor neuron disease.

Previous studies have demonstrated that domiciliary ventilatory support improves survival, quality of life and cognitive function in motor neuron disease (MND). These benefits are partly attributed to better sleep quality and less hypoxia. In a retrospective analysis we compared the effect of non‐invasive (NPPV, n = 52), tracheostomy (TPPV, n = 23) and no ventilation (n = 43) on sleep and survival in MND patients over a seven‐year period. The TPPV and NPPV groups had more sleep arousals (AI, p = 0.024), more respiratory events (p = 0.001) and more time asleep with an oxygen saturation less than 90% (%TST with SpO2<90%, p = 0.01), than those who were not ventilated. After treatment with TPPV or NPPV, the percentage of rapid eye movement sleep increased (p<0.001) and the %TST with Sp02<90% (p = 0.006) and AI (p = 0.001) decreased. Improvements were larger and more consistent with NPPV. The median survival of those who used TPPV was 41 months, NPPV 32 months and of those not ventilated was 25 months, significantly different four years (p = 0.0497) after symptom onset. In this retrospective cohort of MND patients, ventilation, particularly NPPV, markedly improved sleep and conferred a modest survival advantage.

Inpatient and long-term outcomes of individuals admitted for weaning from mechanical ventilation at a specialized ventilation weaning unit

Background:  Weaning from invasive mechanical ventilation (IMV) in specialized weaning units has been demonstrated to be safe and cost‐effective. Success rates and outcomes vary widely, probably relating to patient factors and unit expertise.

Advance directives, perioperative care and end-of-life planning.

It is ethically and legally important, when providing care to our patients, to respect their autonomy and dignity, to act in their best interests and avoid doing harm. Advance care planning is essential to achieving this by giving patients the opportunity to tell us what they would want us to do if they became seriously unwell and could no longer communicate their wishes. Whereas earlier attempts at advance care planning focussed on the completion of forms, the more recent, successful focus has been on the patient-centred discussion, involving family, appointment of substitute decision makers and identification of what the patient would see as an acceptable outcome from any proposed treatment. Advance care planning is successful in caring for the elderly, including in the perioperative setting. There is an increasing focus on improving end-of-life care, including the prevention of suffering, making earlier and wiser end-of-life decisions about the appropriateness of treatment and improving communication with patients and families. New awareness of the poor outcomes from cardiopulmonary resuscitation (CPR) is catalysing reassessment of the appropriateness of this intervention.

Advance care planning in Australia: what does the law say?

Advance care planning (ACP) assists people to plan for their future health and personal care. ACP encourages a person to legally appoint a substitute decision maker (SDM) and to document any specific wishes regarding their future health care in an advance care directive (ACD). Formal documentation of wishes increases the chances that a persons wishes will be known and followed. However, one of the biggest impediments for doctors following the persons wishes is uncertainty surrounding the law, which is complicated and varies between the states and territories of Australia. SDM legislation varies regarding who can be appointed, how they are appointed, the powers that an SDM can be given and the decision-making principles that the SDM needs to follow. In circumstances where an SDM has not been appointed, the hierarchy for determining the default SDM for a person also varies between states. Although many states have legislated ACD forms allowing for documentation of a persons health care wishes, these forms allow for different things to be documented and have different requirements to be valid. The Australian population is mobile, with patients frequently moving between states. The status of ACP documentation created in a state other than the state in which a patient requires treatment also varies, with some states recognising interstate ACDs whereas others do not. This article outlines the legal status of ACDs, within Australian jurisdictions, including the legal validity of interstate ACDs, and argues that uniform laws and documents would assist with awareness and understanding of, and compliance with, ACDs.

Advance care planning in chronic kidney disease: A survey of current practice in Australia

Advance care planning (ACP) in nephrology is widely advocated but not always implemented. The aims of this study were to describe current ACP practice and identify barriers/facilitators and perceived need for health professional education and chronic kidney disease (CKD)‐specific approaches.

Feasibility and acceptability of advance care planning in elderly Italian and Greek speaking patients as compared to English-speaking patients: an Australian cross-sectional study.

Objectives To assess the feasibility and acceptability of facilitated advance care planning (ACP) discussions in elderly Italian and Greek-speaking inpatients compared to English-speaking inpatients. Design, setting and participants This cross-sectional study with convenience sampling was conducted in Melbourne, Australia, and recruited hospital inpatients with medical decision-making capacity, aged 65 years or above, who spoke Greek (25 patients), Italian (24 patients) or English (63 patients). Intervention Facilitated ACP was offered, aiming to assists patients to consider and discuss their goals, values, beliefs and future treatment wishes with their family and doctor; to help them consider how they would like healthcare decisions made in the future if they become unable to do this for themselves; and to complete advance care directives. Main outcome measures The completion of ACP discussions, their duration, advance care directive completion and utilisation of interpreters. Results Of 112 patients, 109 (97%) had at least one discussion, 63 (54%) completed advance care directives, either nominating a substitute decision-maker, documenting their wishes or both, and 76 (68%) included family in discussions. The median duration of discussions for all patients was slightly more than 1 h, over two visits. There were no differences between the Greek-speaking and the Italian-speaking patients, or between the Non-English speaking and the English-speaking patients in any of these measures. Only 14 non-English speaking patients, (30%) utilised interpreters, but when utilised, patients were much more likely (p<0.005) to complete advance care directives. Conclusions Facilitated ACP in elderly Italian and Greek-speaking patients is feasible, acceptable and is similar to that for English-speaking patients.

The epidemiology of respiratory arrests in a teaching hospital

AIMS We aimed to characterise antecedent causes and outcomes of respiratory arrests occurring within a metropolitan tertiary teaching hospital in Melbourne, Australia. METHODS We conducted a retrospective audit of respiratory arrests within our hospital over a 6-year period. Data were collected regarding patient characteristics, preceding clinical state, presumed causes and outcomes of arrests. We also compared outcomes of respiratory arrests to that of cardiac arrests occurring over the same period. RESULTS We identified 82 respiratory arrests, occurring at a rate of 0.57/1000 inpatient admissions. Pre-existing respiratory, neurologic and cardiac disease was common, as was multi-morbidity. Preceding clinical instability was evident in 39% of arrests, most commonly elevated respiratory rate or progressive hypoxia. Pulmonary oedema was the most common cause of respiratory arrest followed by aspiration, neurologic events, medication side-effects, and tracheostomy-tube complications. In-hospital mortality for respiratory arrests was 25.1%, compared with 74.9% for cardiac arrests (p<0.001) over the same time period. CONCLUSIONS Although rare, respiratory arrests are associated with significantly lower in-hospital mortality than cardiac arrests. Further studies are needed to better predict respiratory arrests and identify interventions to reduce incidence and improve outcomes.

Protocol for a national prevalence study of advance care planning documentation and self-reported uptake in Australia

Introduction Advance care planning (ACP) is a process between a person, their family/carer(s) and healthcare providers that supports adults at any age or stage of health in understanding and sharing their personal values, life goals and preferences regarding future medical care. The Australian government funds a number of national initiatives aimed at increasing ACP uptake; however, there is currently no standardised Australian data on formal ACP documentation or self-reported uptake. This makes it difficult to evaluate the impact of ACP initiatives. This study aims to determine the Australian national prevalence of ACP and completion of Advance Care Directives (ACDs) in hospitals, aged care facilities and general practices. It will also explore people’s self-reported use of ACP and views about the process. Methods and analysis Researchers will conduct a national multicentre cross-sectional prevalence study, consisting of a record audit and surveys of people aged 65 years or more in three sectors. From 49 participating Australian organisations, 50 records will be audited (total of 2450 records). People whose records were audited, who speak English and have a decision-making capacity will also be invited to complete a survey. The primary outcome measure will be the number of people who have formal or informal ACP documentation that can be located in records within 15 min. Other outcomes will include demographics, measure of illness and functional capacity, details of ACP documentation (including type of document), location of documentation in the person’s records and whether current clinical care plans are consistent with ACP documentation. People will be surveyed, to measure self-reported interest, uptake and use of ACP/ACDs, and self-reported quality of life. Ethics and dissemination This protocol has been approved by the Austin Health Human Research Ethics Committee (reference HREC/17/Austin/83). Results will be submitted to international peer-reviewed journals and presented at international conferences. Trial registration number ACTRN12617000743369