Advance care planning (ACP) is the process of ongoing communication among patients, family and health care professionals regarding what plans for future care are preferred in the event that patients ...become unable to make their own decisions. Clinicians play an important role in ACP as both initiators and decision coaches. However, lack of training for clinicians has frequently been reported as the reason for low involvement in ACP discussions - hence the present review evaluates the effectiveness of ACP training programs for healthcare professionals to guide the development of novel training programs for them in the future.
A literature search for intervention studies was conducted independently by two reviewers in July 2018. Participants included all healthcare professionals working with adult patients suffering from terminal illness. The primary outcomes were the professionals' knowledge of and attitudes towards ACP, and self-perceived competence in ACP conversations. The Effective Public Health Practice Project appraisal tool was used to examine the quality of the studies included.
A total of 4025 articles were identified, and ten eligible articles, covering 1081 participants, were included in the review. However, there is a lack of high quality randomized controlled trials of providing ACP training for nurses working in non-palliative care hospital settings. The overall quality of the intervention studies was moderate. All the studies included used instructional sessions in their interventions, while some contained group discussion, role-play and the use of advanced technology. The training programs increased the knowledge, attitudes towards shared decision-making, perceived communication skills, confidence, comfort and experiences concerned with discussing end-of-life (EOL) issues. Patient advocacy, job satisfaction and perceived level of adequate training for EOL care were improved. The use of 'decision aids' was rated as acceptable and clinically useful.
Training for healthcare professionals in ACP has positive effects on their knowledge, attitude and skills. The use of decision aids and advanced technology, instructional sessions with role play, training content focused on ACP communication skills and the needs and experience of patient in the ACP process, and a values-based ACP process are all those factors that made the ACP training programs effective.
Celotno besedilo
Dostopno za:
CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Background:
Studies have shown positive clinical outcomes of specialist palliative care for end-stage heart failure patients, but cost-effectiveness evaluation is lacking.
Aim:
To examine the ...cost-effectiveness of a transitional home-based palliative care program for patients with end-stage heart failure patients as compared to the customary palliative care service.
Design:
A cost-effectiveness analysis was conducted alongside a randomized controlled trial (Trial number: NCT02086305). The costs included pre-program training, intervention, and hospital use. Quality of life was measured using SF-6D.
Setting/participants:
The study took place in three hospitals in Hong Kong. The inclusion criteria were meeting clinical indicators for end-stage heart failure patients including clinician-judged last year of life, discharged to home within the service area, and palliative care referral accepted. A total of 84 subjects (study = 43, control = 41) were recruited.
Results:
When the study group was compared to the control group, the net incremental quality-adjusted life years gain was 0.0012 (28 days)/0.0077 (84 days) and the net incremental costs per case was −HK$7935 (28 days)/−HK$26,084 (84 days). The probability of being cost-effective was 85% (28 days)/100% (84 days) based on the cost-effectiveness thresholds recommended both by National Institute for Health and Clinical Excellence (£20,000/quality-adjusted life years) and World Health Organization (Hong Kong gross domestic product/capita in 2015, HK$328117).
Conclusion:
Results suggest that a transitional home-based palliative care program is more cost-effective than customary palliative care service. Limitations of the study include small sample size, study confined to one city, clinic consultation costs, and societal costs including patient costs and unpaid care-giving costs were not included.
To examine the effects of home-based transitional palliative care for patients with end-stage heart failure (ESHF) after hospital discharge.
This was a randomised controlled trial conducted in three ...hospitals in Hong Kong. The recruited subjects were patients with ESHF who had been discharged home from hospitals and referred for palliative service, and who met the specified inclusion criteria. The interventions consisted of weekly home visits/telephone calls in the first 4 weeks then monthly follow-up, provided by a nurse case manager supported by a multidisciplinary team. The primary outcome measures were any readmission and count of readmissions within 4 and 12 weeks after index discharge, compared using χ(2) tests and Poisson regression, respectively. Secondarily, change in symptoms over time between control and intervention groups were evaluated using generalised estimating equation analyses of data collected using the Edmonton Symptom Assessment Scale (ESAS).
The intervention group (n=43) had a significantly lower readmission rate than the control group (n=41) at 12 weeks (intervention 33.6% vs control 61.0% χ(2)=6.8, p=0.009). The mean number (SE) of readmissions for the intervention and control groups was, respectively, 0.42 (0.10) and 1.10 (0.16) and the difference was significant (p=0.001). The relative risk (CI) for 12-week readmissions for the intervention group was 0.55 (0.35 to 0.88). There was no significant difference in readmissions between groups at 4 weeks. However, when compared with the control group, the intervention group experienced significantly higher clinical improvement in depression (45.9% vs 16.1%, p<0.05), dyspnoea (62.2% vs 29.0%, p<0.05) and total ESAS score (73.0% vs 41.4%, p<0.05) at 4 weeks. There were significant differences between groups in changes over time in quality of life (QOL) measured by McGill QOL (p<0.05) and chronic HF (p<0.01) questionnaires.
This study provides evidence of the effectiveness of a postdischarge transitional care palliative programme in reducing readmissions and improving symptom control among patients with ESHF.
HKCTR-1562; Results.
Background Advance care planning (ACP) is the process of ongoing communication among patient, family, and health care professional regarding the planning for future care preferred in the event when ...the patient becomes unable to make own decisions. Such communication and decision-making about the goals of care are identified by seriously ill hospitalized patients and their families as important elements for improvement in the quality of end-of-life (EOL) care. As a significant proportion of deaths occur in acute care wards in Hong Kong, nurses working in acute care settings are expected to provide EOL care and play important roles to initiate ACP and act as decision coaches. However, nurses in acute care settings have a low involvement in ACP discussions due to limited training in ACP and EOL care conversation. The aim of this study was to examine the effectiveness of a multi-media experiential ACP (MEACP) training programme guided by Theory of Planned Behaviour and experiential learning model for nurses working in acute care settings. Nurses’ performing skills, attitude, knowledge, confidence, and actual practice in supporting patients’ decision-making on ACP were evaluated. Methodology A cluster randomised controlled trial was adopted. Eligible nurses were recruited and randomised at ward level in a 1:1 ratio into either control or intervention groups. Intervention group received the MEACP training programme including a mobile application, a training workshop with mini-lectures, role play with standardised patients and reflective journaling. Control group received a usual ACP training workshop. Both the nurses and the outcome assessors were blinded to the group assignment. The outcomes of the MEACP training program were evaluated by means of the improvement in nurses’ skill performance on decision support, attitude towards ACP, knowledge about ACP and advance directive (AD), level of confidence to conduct ACP, and actual experience in ACP discussion. The measurement tools used were the brief Decision Support Analysis Tool (DSAT-10) (Stacey et al., 2008), the 9-item five-point Likert scale developed by Putman-Casdorph et al. (2009) for assessing attitude towards ACP, a 10-item true/false questionnaire developed with reference to Siu et al. (2010) and Yee et al. (2011) for assessing knowledge on ACP and AD, a single item five-point Likert scale developed by Putman-Casdorph et al. (2009) for assessing confidence to conduct ACP, and a single question asking “how many times have you participated in ACP discussion with your patients in the past 12 weeks?”. The process of intervention was assessed by means of observing nurses’ utility of the online training component and their level of involvement and responses to the activities. Nurses’ satisfaction with the training programme was also collected using an 8-item five-point Likert scale developed with reference to So et al. (2019). Result Due to tight nursing taskforce and infection control concern in the clinical area during COVID-19 pandemic and emergency response level in Hospital Authority (HA) since January 2020, only four medical and geriatric wards (two from United Christian Hospital (UCH) and two from Haven of Hope Hospital (HHH)) with 42 nurses (22 in the control group and 20 in the intervention group) participated in the study. No significant differences in sociodemographic characteristics, except for gender, were detected between the two groups (the control group had significantly more female nurses than the intervention group, p<0.05). No significant difference in baseline outcome variables was detected between the two groups (all p>0.05). Both groups had improvement in all outcome measures. Nurses’ skill performance on decision support measured by DSAT-10 was significantly improved in both groups after training, and the improvement was significantly greater in the intervention group than in the control group (p<0.001). Within 1 week post training (T1), the attitude, knowledge and confidence scores were also significantly improved in both groups (p≤0.001). The control group had more positive change in knowledge than the intervention group at T1 (p<0.05). The improvement in the knowledge and confidence scores in both groups were still significant (p<0.05) at 12-week post training (T2) but no significant difference between groups. The overall number of ACP discussions with patients in the past 12 weeks at T2 increased in the control group (B=0.74) but decreased in the intervention group (B=-0.48). However, the change and difference between the groups was not significant (p>0.05). For process evaluation, majority of the participants (95.0% in intervention group and 90.9% in control group) showed high levels of attention and interest in the workshop and both groups gave positive response to the satisfaction survey. Conclusion The implementation of the MEACP training programme for nurses in acute care settings appears to be feasible, showing positive effect in improving nurses’ performing skills, attitude, knowledge, and confidence in supporting patients’ decision-making on ACP. However, the sample size was small that the preliminary results just indicate the high possibility of effective outcomes from the intervention, a future full-scale study with an adequate sample is warranted.
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