Marcus Sellars

Advance care planning in palliative care: a national survey of health professionals and service managers

OBJECTIVE To identify the attitudes, knowledge and practices regarding advance care planning (ACP) in palliative care. METHODS A nationwide online survey was distributed to Australian palliative care services associated with the Palliative Care Outcomes Collaboration (n=105). Seventy-three health professionals (HPs) and 59 service managers completed the survey. RESULTS Regarding ACP, 51% of service managers reported relevant policies and procedures were in place in their service and 44% included ACP in job descriptions. Most HPs were confident in undertaking ACP, including initiating discussions with patients and complying with documents; however, only 44% reported receiving ACP specific training. Although 58% of HPs reported having conversations about ACP with more than 11 patients in the past 6 months, only 44% of managers report that it is offered to most patients. Thirty per cent of HPs were aware of others not adhering to patient wishes in the past 6 months and only 43% of HPs (and 37% of managers) believed ACP is done well within their service. CONCLUSIONS This first national survey examining ACP in palliative care services demonstrates there is a need to improve systems to support ACP and to understand circumstances in which ACP wishes are not followed.

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.

Australian Psychiatrists' Support for Psychiatric Advance Directives: Responses to a Hypothetical Vignette

This study examines whether Australian psychiatrists would support requests in a psychiatric advance directive (PAD) and the reasons underlying their decisions in response to a hypothetical vignette. An online survey was completed by 143 psychiatrists. Fewer than 3 out of 10 psychiatrists supported the patient to create a PAD which requested cessation of pharmacotherapy (27%) or remaining out of hospital and not being subject to an involuntary treatment order (24%) should their depression condition deteriorate. A thematic analysis showed that patient autonomy was the strongest theme among those who supported the patient to create a PAD, whereas the clinical profile of and risk to the patient and the professional or ethical imperative of the psychiatrist were strongest among those who were unsure about supporting the patient or who did not support the patient. These findings provide a challenge about how to fulfil obligations under the United Nations Convention on the Rights of Persons with Disabilities (2006).

Prospective comparative effectiveness cohort study comparing two models of advance care planning provision for Australian community aged care clients

Objectives Conduct a prospective comparative effectiveness cohort study comparing two models of advance care planning (ACP) provision in community aged care: ACP conducted by the client’s case manager (CM) (‘Facilitator’) and ACP conducted by an external ACP service (‘Referral’) over a 6-month period. Methods This Australian study involved CMs and their clients. Eligible CM were English speaking, ≥18 years, had expected availability for the trial and worked ≥3 days per week. CMs were recruited via their organisations, sequentially allocated to a group and received education based on the group allocation. They were expected to initiate ACP with all clients and to facilitate ACP or refer for ACP. Outcomes were quantity of new ACP conversations and quantity and quality of new advance care directives (ACDs). Results 30 CMs (16 Facilitator, 14 Referral) completed the study; all 784 client’s files (427 Facilitator, 357 Referral) were audited. ACP was initiated with 508 (65%) clients (293 Facilitator, 215 Referral; p<0.05); 89 (18%) of these (53 Facilitator, 36 Referral) and 41 (46%) (13 Facilitator, 28 Referral; p<0.005) completed ACDs. Most ACDs (71%) were of poor quality/not valid. A further 167 clients (facilitator 124; referral 43; p<0.005) reported ACP was in progress at study completion. Conclusions While there were some differences, overall, models achieved similar outcomes. ACP was initiated with 65% of clients. However, fewer clients completed ACP, there was low numbers of ACDs and document quality was generally poor. The findings raise questions for future implementation and research into community ACP provision.

A case-control study of end-of-life treatment preferences and costs following advance care planning for adults with end stage kidney disease: Advance care planning in ESKD

The aim of the present study was to examine the efficacy of advance care planning (ACP) to improve the likelihood that end‐stage kidney disease (ESKD) patient’s preferences will be known and adhered to at end‐of‐life.

An economic model of advance care planning in Australia: a cost-effective way to respect patient choice.

BackgroundAdvance care planning (ACP) is a process of planning for future health and personal care. A person’s values and preferences are made known so that they can guide decision making at a future time when that person cannot make or communicate his or her decisions. This is particularly relevant for people with dementia because their ability to make decisions progressively deteriorates over time. This study aims to evaluate the cost-effectiveness of delivering a nationwide ACP program within the Australian primary care setting.MethodsA decision analytic model was developed to identify the costs and outcomes of an ACP program for people aged 65+ years who were at risk of developing dementia. Inputs for the model was sourced and estimated from the literature. The reliability of the results was thoroughly tested in sensitivity analyses.ResultsThe results showed that, compared to usual care, a nationwide ACP program for people aged 65+ years who were at risk of dementia would be cost-effective. However, the results only hold if ACP completion is higher than 50% and adherence to ACP wishes is above 75%.ConclusionsA nationwide ACP program in the primary care setting is a cost-effective or cost-saving intervention compared to usual care in a population at-risk of developing dementia. Cost savings are generated from providing treatment and care that is consistent with patient preferences, resulting in fewer hospitalisations and less-intensive care at end-of-life.

P-1 Implementation of advance care planning for home care package clients

Background The Australian Government funds personal and clinical support to the frail/unwell elderly to support them to live at home. These Home Care Package (HCP) clients have a case manager (CM) who, with the client and family, coordinates the client’s support services. Advance Care Planning (ACP) is important to these clients. The CMs can either assist the client with ACP (“Facilitator Model”) or refer the client to a separate ACP service (“Referral Model”). Aim To test the Referral and Facilitator models in a Randomised Controlled Trial (RCT). Methods CMs, who were randomised to the Referral or Facilitator models, were trained for their model and implemented to their 25 clients. The trial evaluation included: Assessing CM knowledge, attitudes and practice regarding ACP Auditing client’s files to measure ACP documentation quantity/quality. Interviews/focus groups with CMs to explore perspectives/experiences/attitudes re ACP. Result Randomisation of 35 CMs, representing 800 clients. Training improved confidence (17 CMs pre, 32 CMs post felt confident) and comfort (22 pre, 33 post felt comfortable) in discussing ACP and improved knowledge (31% pre to 80% post got 6 or 7/7 correct answers). Barriers to ACP completion include insufficient time, CM confidence and experience, client ability to access services, and engagement with GPs. Full audit data analysis will be completed by April 2015 and presented at the ACPEL conference. Discussion The CM knowledge of the client/family/GP/context supports the Facilitator model, whereas the expertise of the ACP service supports the Referral model. To be discussed in full at conference.

O-93 Current practice and barriers to advance care planning in the australian and New Zealand nephrology setting: A national survey

Background Recent guidelines emphasise the need to improve advance care planning (ACP) for patients with chronic kidney disease (CKD). Little is known about current ACP practice in the Australian/New Zealand nephrology setting. Aim To describe current practice and barriers to ACP from the perspective of Australian/New Zealand nephrology health professionals. Methods A cross-sectional survey was administered online to nephrology nurses, nephrologists and social workers. Invitations were circulated via peak bodies, national conferences and the research team’s networks. Results 417 renal clinicians participated from >135 renal units; 57% indicated that ACP was done in their workplace on an ad-hoc basis, 21% that there was a formal program, 14% that ACP hardly ever occurred, and 6% were unsure. Sixty-one percent reported that ACP was done poorly, 32% well, and 7% were unsure. Perceived barriers to ACP most commonly included patient/family discomfort, difficulty involving families and lack of clinician expertise (83% each), lack of clinician time (82%), health professional discomfort (72%), cultural/language barriers (65%), environmental problems such as lack of space (61%) and lack of policy/procedures (60%). Whilst discouragement from colleagues or managers was identified as a barrier in only 20% of cases, comments emphasised the gate-keeping role played by nephrologists. Discussion ACP in Australian/New Zealand nephrology may be limited due to health system, provider and patient related barriers. Given the volunteer effect associated with online surveys, our study probably underestimates the need for ACP support in this setting. Conclusion Targeted interventions are needed to improve ACP in Australian/New Zealand nephrology settings.

O-60 Preferences for end-of-life care and advance care planning in the event of dementia: A nationwide survey of older Australians

Background Advanced dementia (AD) is an incurable disease of the brain in which people are not able to communicate with others; however the literature shows there’s low uptake of advance care planning (ACP) among people with dementia. Aim To conduct a national survey on older Australian’s preferences for treatment and ACP in a state of AD. Methods A survey was distributed through an online panel (n = 1,003) to examine the above. Results Most respondents showed a preference for comfort care (75%) or limited care (20%) rather than life-prolonging care (5%) if they required medical treatment in a state of AD. Furthermore, overall preferences for care changed significantly after reading a description of AD (p < 0.001), with preference for comfort care increasing (79%) and limited care decreasing (16%). Similarly, although <10% of respondents had previously documented ACP wishes; most wanted to in a state of AD and this preference increased significantly after reading a description of AD (p < 0.001). Preference for a written plan increased (72% pre vs. 77% post) and preferences for making an oral plan only (13% vs. 10%) and leaving all medical decisions to the family or doctor decreased (16% vs. 12%). Discussion Older Australians prefer comfort or limited care and to have documented ACP wishes if they become seriously ill and require medical treatment in a state of AD. Conclusion The opportunity for older Australians to complete ACP will assist to communicate their wishes in the event they become seriously ill and require medical treatment in a state of AD.