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Australian Health Review Australian Health Review Society
Journal of the Australian Healthcare & Hospitals Association
RESEARCH ARTICLE

Normalising advance care planning in a general medicine service of a tertiary hospital: an exploratory study

Ian A. Scott A B E , Nalaka Rajakaruna A , Darshan Shah A , Leyton Miller C , Elizabeth Reymond C and Michael Daly D
+ Author Affiliations
- Author Affiliations

A Department of Internal Medicine and Clinical Epidemiology, Level 5A, Princess Alexandra Hospital, Ipswich Road, Brisbane, Qld 4102, Australia.

B Associate Professor of Medicine, School of Medicine, University of Queensland, St Lucia, Brisbane, Qld 4072, Australia.

C Metro South Palliative Care Service, Metro South Hospital and Health Service, 2 Clara Street, Corinda, Qld 4075, Australia. Email: leyton.miller@health.qld.gov.au; elizabeth.reymond@health.qld.gov.au

D Metro South Clinical Governance Unit, Metro South Hospital and Health Service, Level 3, Building 15, Princess Alexandra Hospital, Ipswich Road, Brisbane, Qld 4102, Australia. Email: michael.daly@health.qld.gov.au

E Corresponding author. Email: ian.scott@health.qld.gov.au

Australian Health Review 40(4) 391-398 https://doi.org/10.1071/AH15068
Submitted: 17 April 2015  Accepted: 28 August 2015   Published: 5 November 2015

Abstract

Objective The aim of the present study was to develop, implement and explore the effects of a program in advance care planning (ACP) within a tertiary hospital general medicine service.

Methods Before–after exploratory mixed-methods analysis was conducted of an ACP program comprising seven components designed to overcome well-documented barriers to ACP in clinical practice. The results of pre-ACP program audits performed in June 2014 were compared with those of post-ACP audits performed over 5 months from July to November 2014. The main outcome measure was the number of advance care plans completed in patients considered eligible for ACP based on a life expectancy of 12 months or less as assessed by two prognostication instruments. Questionnaire surveys ascertained staff perceptions of ACP and the usefulness of training and resources in ACP.

Results Pre-ACP program analysis of 166 consecutive patients deemed eligible for ACP revealed that only 1% had a documented advance care plan. Following ACP implementation, 115 of 215 (53%) potentially eligible patients were considered able to participate in ACP discussions and were approached to do so before discharge, of whom 89 (77.4%) completed an advance care plan, whereas 26 (23.6%) declined. This equated to an overall completion rate for all potentially eligible patients of 41% compared to 1% pre-ACP (P < 0.001). Major barriers to ACP perceived by at least 30% of questionnaire respondents included the reluctance of patients and family to discuss ACP, insufficient time to initiate or complete ACP, patient and/or family factors that rendered ACP impractical, inadequate communication skills around end-of-life issues, confusion about who was primarily responsible for conducting ACP and difficulty using ACP documentation forms. Enabling factors included dedicated ACP workshops, facilitator and resource packages for staff, and ACP brochures for patients and family.

Conclusion A multifaceted ACP program in a general medicine service led to completion of an advance care plan in more than three of four patients considered eligible for, and who participated in, ACP. However, although program components were tailored to overcome known barriers to ACP, staff indicated ongoing difficulties, with less than half of ACP-eligible patients completing advance care plans.

What is known about this topic? Advance care planning is increasingly recognised as an important part of hospital care for older patients with advanced chronic disease. However, research indicates that ACP discussions are rare in hospital settings because of various barriers that are not adequately addressed in the design of ACP programs.

What does this paper add? The present exploratory study of the development, implementation and evaluation of an ACP program in a tertiary hospital general medicine service shows that program components designed to overcome specific barriers to ACP discussions was associated with a >75% completion rate of advance care plans among ACP-eligible patients who participated in ACP discussions. Dedicated staff training and resources in ACP, employment of an ACP facilitator and ready access to ACP documentation forms were important enabling strategies.

What are the implications for practitioners? Hospital units caring for significant numbers of older patients with limited life expectancy can implement ACP programs that help normalise ACP discussions within routine clinical care.


References

[1]  Scott IA, Mitchell GK, Reymond EJ, Daly MP. Difficult but necessary conversations: the case for advance care planning. Med J Aust 2013; 199 662–6.
Difficult but necessary conversations: the case for advance care planning.Crossref | GoogleScholarGoogle Scholar | 24237095PubMed |

[2]  Fried TR, Bullock K, Iannone L, O’Leary JR. Understanding advance care planning as a process of health behaviour change. J Am Geriatr Soc 2009; 57 1547–55.
Understanding advance care planning as a process of health behaviour change.Crossref | GoogleScholarGoogle Scholar | 19682120PubMed |

[3]  Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ 2010; 340 c1345
The impact of advance care planning on end of life care in elderly patients: randomised controlled trial.Crossref | GoogleScholarGoogle Scholar | 20332506PubMed |

[4]  Wright AA, Zhang B, Ray A, Mack JW, Trice E, Balboni T, Mitchell SL, Jackson VA, Block SD, Maciejewski PK, Prigerson HG. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA 2008; 300 1665–73.
Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BD1cXht1ejsrjI&md5=8cdf54ba7bc166971e8b0e03b700bc5cCAS | 18840840PubMed |

[5]  Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, Dahlin CM, Blinderman GD, Jacobsen J, Pirl WF, Billings JA, Lynch TJ. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010; 363 733–42.
Early palliative care for patients with metastatic non-small-cell lung cancer.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BC3cXhtVCrt7nP&md5=57465210dabd235919d256cafc15891aCAS | 20818875PubMed |

[6]  Fromme EK, Zive D, Schmidt TA, Cook JNB, Tolle SW. Association between physician orders for life-sustaining treatment for scope of treatment and in-hospital death in Oregon. J Am Geriatr Soc 2014; 62 1246–51.
Association between physician orders for life-sustaining treatment for scope of treatment and in-hospital death in Oregon.Crossref | GoogleScholarGoogle Scholar | 24913043PubMed |

[7]  Houben CHM, Spruit MA, Groenen MTJ, Wouters EFM, Janssen DJA. Efficacy of advance care planning: a systematic review and meta-analysis. J Am Med Dir Assoc 2014; 15 477–89.
Efficacy of advance care planning: a systematic review and meta-analysis.Crossref | GoogleScholarGoogle Scholar |

[8]  Bischoff KE, Sudore R, Miao Y, Boscardin WJ, Smith AK. Advance care planning and the quality of end-of-life care in older adults. J Am Geriatr Soc 2013; 61 209–14.
Advance care planning and the quality of end-of-life care in older adults.Crossref | GoogleScholarGoogle Scholar | 23350921PubMed |

[9]  Nicholas LH, langa KM, Iwashyna TJ, Weir DR. Regional variation in the association between advance care directives and end-of-life Medicare expenditures. JAMA 2011; 306 1447–53.
Regional variation in the association between advance care directives and end-of-life Medicare expenditures.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BC3MXhtlSkurbK&md5=15417ed2c2abe7f014ff107ceacbb91bCAS | 21972306PubMed |

[10]  Ache K, Harrold J, Harris P, Dougherty M, Casarett D. Are advance directives associated with better hospice care? J Am Geriatr Soc 2014; 62 1091–6.
Are advance directives associated with better hospice care?Crossref | GoogleScholarGoogle Scholar | 24852308PubMed |

[11]  Molloy DW, Guyatt GH, Russo R, Goeree R, O’Brien BJ, Bedard M, Willan A, Watson J, Patterson C, Harrison C, Standish T, Strang D, Darzins PJ, Smith S, Dubois S. Systematic implementation of an advance directive program in nursing homes: a randomized controlled trial. JAMA 2000; 283 1437–44.
Systematic implementation of an advance directive program in nursing homes: a randomized controlled trial.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3c7psFSksw%3D%3D&md5=edda83d8cfd3a9d5f32ac1ad673b2b82CAS | 10732933PubMed |

[12]  Heyland DK, Dodek P, Rocker G, Groll D, Gafni A, Pichora D, Shortt S, Tranmer J, Lazar N, Kutsogiannis J, Lam M. What matters most on end-of-life care: perceptions of seriously ill patients and their family members. CMAJ 2006; 174 627–33.
What matters most on end-of-life care: perceptions of seriously ill patients and their family members.Crossref | GoogleScholarGoogle Scholar | 16505458PubMed |

[13]  Rhee JJ, Zwar NA, Kemp LA. Uptake and implementation of advance care planning in Australia: findings of key informant interviews. Aust Health Rev 2012; 36 98–104.
Uptake and implementation of advance care planning in Australia: findings of key informant interviews.Crossref | GoogleScholarGoogle Scholar | 22513028PubMed |

[14]  Samsi K, Manthorpe J. ‘I live for today’: a qualitative study investigating older people’s attitudes to advance care planning. Health Soc Care Community 2011; 19 52–9.
‘I live for today’: a qualitative study investigating older people’s attitudes to advance care planning.Crossref | GoogleScholarGoogle Scholar | 20846274PubMed |

[15]  Heyland DK, Barwich D, Pichora D, Dodek P, Lamontagne F, You JJ, Tayler C, Porterfield P, Sinuff T, Simon J. Failure to engage hospitalized elderly patients and their families in advance care planning. JAMA Intern Med 2013; 173 778–87.
| 23545563PubMed |

[16]  Silveira MJ, Wiitala W, Piette J. Advance directive completion by elderly Americans: a decade of change. J Am Geriatr Soc 2014; 62 706–10.
Advance directive completion by elderly Americans: a decade of change.Crossref | GoogleScholarGoogle Scholar | 24697553PubMed |

[17]  Gott M, Ingleton C, Bennett MI, Gardiner C. Transitions to palliative care in acute hospitals in England: qualitative study. BMJ 2011; 342 d1773
| 21447572PubMed |

[18]  Walling AM, Asch SM, Lorenz KA, Roth CP, Barry T, Kahn KL, Wenger NS. The quality of care provided to hospitalised patients at the end of life. Arch Intern Med 2010; 170 1057–63.
The quality of care provided to hospitalised patients at the end of life.Crossref | GoogleScholarGoogle Scholar | 20585072PubMed |

[19]  Sellars M, Silvester W, Masso M, Johnson CE. Advance care planning in palliative care: a national survey of health professionals and service managers. Aust Health Rev 2015; 39 146–53.
Advance care planning in palliative care: a national survey of health professionals and service managers.Crossref | GoogleScholarGoogle Scholar | 25607322PubMed |

[20]  Lund S, Richardson A, May C. Barriers to advance care planning at the end of life: an explanatory systematic review of implementation studies. PLoS One 2015; 10 e0116629
Barriers to advance care planning at the end of life: an explanatory systematic review of implementation studies.Crossref | GoogleScholarGoogle Scholar | 25679395PubMed |

[21]  Ahluwalia SC, Bekelman DB, Huynh AK, Prendergast TJ, Shreve S, Lorenz KA. Barriers and strategies to an iterative model of advance care planning communication. Am J Hosp Palliat Care 2014;
Barriers and strategies to an iterative model of advance care planning communication.Crossref | GoogleScholarGoogle Scholar | 24988894PubMed |

[22]  You JJ, Downar J, Fowler RA, Lamontagne F, Ma IW, Jayaraman D, Kryworuchko J, Strachan PH, Ilan R, Nijjar AP, Neary J, Shik J, Brazil K, Patel A, Wiebe K, Albert M, Palepu A, Nouvet E, des Ordons AR, Sharma N, Abdul-Razzak A, Jiang X, Day A, Heyland DK. Barriers to goals of care discussions with seriously ill hospitalised patients and their families. A multicentre survey of clinicians. JAMA Intern Med 2015; 175 549–56.
| 25642797PubMed |

[23]  Baker R, Camosso-Stefinovic J, Gillies C, Shaw EJ, Cheater F, Flottorp S, Robertson N. Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2010; 3 CD005470
| 20238340PubMed |

[24]  Boyd K, Murray SA. Recognising and managing key transitions in end of life care. BMJ 2010; 341 c4863
Recognising and managing key transitions in end of life care.Crossref | GoogleScholarGoogle Scholar | 20847023PubMed |

[25]  Moss AH, Lunney JR, Culp S, Auber M, Kurian S, Rogers J, Dower J, Abraham J. Prognostic significance of the ‘surprise’ question in cancer patients. J Palliat Med 2010; 13 837–40.
Prognostic significance of the ‘surprise’ question in cancer patients.Crossref | GoogleScholarGoogle Scholar | 20636154PubMed |

[26]  Murray E, Treweek S, Pope C, MacFarlane A, Ballini L, Dowrick C, Finch T, Kennedy A, Mair F, O’Donnell C, Ong BN, Rapley T, Rogers A, May C. Normalisation process theory: a framework for developing, evaluating and implementing complex interventions. BMC Med 2010; 8 63–9.
| 20961442PubMed |

[27]  Heppenstall CP, Broad JB, Boyd M, Gott M, Connolly MJ. Progress towards predicting 1-year mortality in older people living in residential long-term care. Age Ageing 2015; 44 497–501.
| 25652076PubMed |

[28]  Scott IA. Physicians need to take the lead in advance care planning. Intern Med J 2014; 44 937–9.
Physicians need to take the lead in advance care planning.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BC2M7psFeksA%3D%3D&md5=79856572301f8c1dec503c2347406eacCAS |

[29]  Fagerlin A, Schneider CE. Enough. The failure of the living will. Hastings Cent Rep 2004; 34 30–42.
Enough. The failure of the living will.Crossref | GoogleScholarGoogle Scholar | 15156835PubMed |

[30]  Robins-Browne K, Palmer V, Komesaroff P.. An unequivocal good? Acknowledging the complexities of advance care planning. Intern Med J 2014; 957–60.
An unequivocal good? Acknowledging the complexities of advance care planning.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BC2M7psFektg%3D%3D&md5=79d072cca047a15ad71967c5219078fbCAS | 25302719PubMed |

[31]  Auriemma CL, Nguyen CA, Bronheim R, Kent S, Nadiger S, Pardo D, Halpern SD. Stability of end-of-life preferences: a systematic review of the evidence. JAMA Intern Med 2014; 174 1085–92.
| 24861560PubMed |