Tele-ACP amidst COVID-19 pandemic and beyond

BackgroundWhen COVID-19 hit Singapore in 2020, the public was advised to avoid visiting the hospitals unless for essential services. Advance Care Planning (ACP) services in hospital and community had to be stopped to reduce exposure for the public. However, it was not feasible for ACP services to stop with no foresight of when it could resume. Ironically, ACP should all the more be advocated amidst the pandemic.Henceforth, the team planned and implemented a tele-ACP workflow in February 2020 to ensure accessibility in continuity of care and reduce waiting time for ACP appointments.MethodsTele-ACP is conducted only via Zoom, given its security and encryption features. Criteria of patients include ability to read basic English, having electronic device with internet access, and having no severe hearing or speech impairment.Pre-ACP appointment: Zoom details including a guide were sent to patients and/or NHS.On appointment day: Before session starts, ACP Facilitator will ensure that patient and/or NHS are at a space where there is privacy. Internet stability will also be checked.Post-ACP appointment: Signatures will be obtained electronically or via post, while ensuring personal data is well-protected.ResultsFrom February 2020 to November 2022, 105 tele-ACPs (14 General ACPs and 91 Preferred Plan of Care) were completed. 45 were completed in 2020 and 2021 each, while 15 were done in 2022 (as of November). The average duration for tele vs in-person ACPs is both about 90 minutes, indicating that the effort and time spent are not any less despite ACP discussions being done virtually.ConclusionsLooking at the number of tele-ACPs completed and how it is still actively carried out despite COVID-19 situation being stable and restrictions lifted, tele-ACP is clearly in healthy demand. This shows that tele-ACP is here to stay, being both sustainable and transferable to multiple settings.

Review of the advance care planning (ACP) 2.0 programme in TTSH on training, practice and implementation

Aim(s)To evaluate ACP 2.0 programme in TTSH by doing comparative evaluation of 3 aspects namely, training, practice and implementation from FY2017 to FY2022, and the effects of COVID-19 pandemic on the programme.MethodologyRetrospective analysis of ACP data in TTSH and historical developments of the TTSH ACP 2.0 programme was conducted. New developments that were implemented included:Trial of Tele-ACP in FY21–22Implementation of ACP FYI-flag in EPIC systemSelf-registration of access to AIC ACP IT portal by TTSH ACP facilitatorsVirtual ACP training in FY20–22Physical and virtual ACP talks and webinars in partnership with community partnersResultsThe following results were observed:1121 participants attended ACP facilitation training from FY17–21. There was a 39% decrease in training enrolment in FY20 due to COVID-19 pandemic but a 52% increase was recorded in FY21 after training was converted to virtual format.Reduction in number of completed ACP with 12% drop in FY20 and 14% decrease in FY21. Total number of 5312 ACP were completed from FY17–21.240 staff were trained as ACP advocates from FY17–2124 tele-ACP were conducted from April 2021 to March 2022 with monthly average of 2 tele-ACP sessions.ConclusionCOVID-19 pandemic has affected ACP training and facilitation significantly due to nation-wide strict no-visitation policy in hospital, safe distancing measures and general uneasiness of patients and families to visit hospital. In spite of these challenges, the ACP team persevered with continual engagement with different clinical disciplines. The implementation of virtual training, Zoom meetings, webinars and tele-ACP helped to improve the overall outcomes in awareness, educational talks, training and facilitation.

Effectiveness of a complex advance care planning intervention focusing on nursing home residents: first results of the cluster-randomized controlled BEVOR-trial

BackgroundFew trials on advance care planning (ACP) have investigated the clinical effect on care consistency with care preferences (3CP) in the nursing home (NH) setting.MethodsBEVOR is a multi-centre, cluster-randomized controlled trial aimed to improve 3CP in NH residents (09/2019–02/2023). A total of 44 NHs from 4 German regions were randomized either to the control group (n=24) or the intervention group (n=24). The complex ACP intervention comprised the offer to lead ACP conversations with qualified facilitators on the individual (resident) level and offers for organizational development and staff education on the institutional (NH) level. Educational ACP modules were offered to emergency medical services, hospitals and other regional players relevant for these residents' medical care.After a run-in phase of the intervention, which was extended due to the Covid19-pandemic from originally 9 to (up to) 18 months, the observation period was 12 months from September 2021 to August 2022. Primary outcome was defined as hospitalization rate, understood as a surrogate parameter for 3CP, collected as anonymous data from all residents of the participating NHs. Main secondary outcome is 3CP, taken from a subset of 892 residents (20.5%) who gave informed consent. To measure 3CP, treatment decisions in potentially life-threatening events (‘care delivered') were identified retrospectively every 3 months from the NH records. Correspondingly, ‘care preferences' were assessed retrospectively, integrating data from residents' files and interviews with residents, proxies and nurses, also taking into account the effected level of shared decision making. Analysis of the primary outcome follows the intention-to-treat principle.ResultsThe main outcomes will be available by the time of the acp-i conference.ConclusionResults of the BEVOR trial will give insights into possible clinical effects of a complex regional ACP intervention.

PP07.002 The impact of advance care planning on place of death during the COVID-19 pandemic

BackgroundAt the beginning on the COVID-19 pandemic, advance care planning (ACP) was widely encouraged and endorsed for adults with serious illness to ensure their treatment and care preferences would be honoured, including location of death, often considered a surrogate quality indicator for end-of-life care. Coordinate My Care (CMC) represents the UK's largest Electronic Palliative Care Coordination System that comprises an ACP component.We aimed to examine the impact of ACP on place of death for people who died during the COVID-19 pandemic with a CMC record.MethodsRetrospective cohort analysis of CMC records for people aged over 18 who died between 20/03/20 and 05/03/21 with recorded place of death. Socio-demographic, clinical and ACP-related factors associated with achieving preferred place of death (PPD) were examined using logistic regression.Results11,913 records were included. 76.9% patients died in their preferred place location of death (57.7% Home, 31.4% Care Home, 7.5% Hospice, 3.3% Hospital, 0.1% Other). An increased likelihood of dying in PPD was associated with a ‘Not for resuscitation' (DNACPR) status (OR=1.51, 95% CI 1.17 to 1.93), a Ceiling of Treatment for Symptomatic Treatment (when compared to Full active treatment, OR=3.52, 95% CI 2.77 to 4.50), documented family discussions regarding resuscitation recommendations (OR=1.51, 95% CI 1.33 to 1.72) and 2+ non-urgent care record views in the 30 days before death (OR=1.27, 95% CI 1.13 to 1.43). People from materially deprived areas had a decreased likelihood of dying in their PPD (OR= 0.65, 95% CI 0.54 to 0.79).ConclusionsModifiable elements of ACP significantly influence place of death, even when controlling for socio-economic and demographic determinants. In times of crisis, effective ACP is central to delivering high quality end-of-life care;ACP related factors must be considered in ongoing research on end-of-life outcomes.

BOS4c.002 Evaluation of a complex advance care planning intervention in the general practice setting (ACP-GP): cluster-randomized controlled trial

BackgroundAdvance care planning (ACP) is an iterative communication process about patients' values and preferences for future care. The general practice setting can provide opportunities for ACP, but deficits remain in its initiation due to barriers at the patient, general practitioner (GP), or health care system level. A complex intervention may be necessary to reduce barriers. We aimed to evaluate the effects of a complex ACP intervention for patients with chronic, life-limiting illness in general practice (ACP-GP).MethodCluster-randomized controlled trial with randomization at the GP level. The intervention consists of a patient workbook, GP training, ACP conversations, and a documentation template. Outcomes were the 15-item ACP Engagement Survey for patients and the ACP Self-Efficacy Scale for GPs. Linear mixed models evaluated differences at 3 months (T1, effectiveness evaluation) and 6 months (T2) post-baseline. Analysis was per intention-to-treat.Results35 GPs and 95 patients were randomized. Patient ACP engagement did not differ between the intervention and control group at T1 (baseline-adjusted mean difference, 0.34;95% CI, -0.02 to 0.69;p=0.062) or T2 (baseline-adjusted mean difference, 0.20;95% CI, -0.17 to 0.57;p = 0.28). for GP ACP self-efficacy, there were no significant differences between groups at T1 (baseline-adjusted mean difference, 0.16;95% CI, -0.04 to 0.35;p = 0.11) or at T2 (baseline-adjusted mean difference, 0.11;95% CI, -0.09 to 0.31;p = 0.27).ConclusionACP-GP did not improve patient engagement and GP self-efficacy more than usual care. Both groups showed patterns of increase from baseline. Trial procedures and the COVID-19 pandemic that coincided with the trial may have increased awareness about ACP, which may have also stimulated the control group to conduct more ACP than expected. It may be necessary to also look further at what patients and surrogate decision makers want and need from the ACP process.

EP01.010 Characteristics of home-dwelling persons with dementia and families who have initiated advance care planning during the COVID-19 pandemic in Japan

BackgroundAdvance care planning (ACP) is an increasing priority for people with dementia during the COVID-19 pandemic. This study aimed to investigate characteristics of home-dwelling persons with dementia and families that are related to ACP implementation.MethodsAn internet-based questionnaire survey was conducted with Japanese family caregivers of home-dwelling persons with dementia in June 2021. Registered members of a Japan-based survey company were recruited;inclusion criteria were being aged 40 years or older and having been a primary, non-professional caregiver of a family member with dementia. Respondents rated their level of agreement with six statements regarding advance-care-planning-related concerns. Respondents also evaluated the level of depressive symptoms in persons with dementia using the Neuropsychiatric Inventory (NPI).ResultsA total of 379 family caregivers participated in the survey. A total of 155 persons with dementia (40.9%) had initiated ACP, of which 88 (56.8%) had care professionals involved in ACP conversation. Persons with professional involvement showed significantly more severe depressive symptoms and lower family-caregiver concern compared to those who did not initiate ACP.ConclusionPresence of psychological distress such as depressive symptoms may have been a trigger to initiate ACP among people with dementia. Optimal and proactive ACP approaches need to be developed to address family concern regarding conducting ACP.

Use of do-not-resuscitate orders

Use of patient/health proxy authorised do-not-resuscitate (DNR) or do-not-attempt-resuscitation (DNAR) orders is widespread in palliative, hospice and hospital-based chronic illness care. Such orders often reflect self-determination, avoidance of futile care and quality of dying principles. Reports during COVID-19 of physicians writing DNR/DNAR orders for people with intellectual disabilities at rates higher than the general population amplify past concerns about the value placed on their lives. Yet, absence of a DNR/DNAR or processes to permit one when someone cannot consent may result in painful and unnecessary prolongation of life. This chapter considers rationales for DNR/DNAR orders, use among people with intellectual disabilities, advance care planning, protocols when an individual is unable to consent and strategies for oversight of DNR/DNAR orders. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Initiating advance care planning in New South Wales general practices using a structured conversation guide

There is variation in ACP terminology and legislation of ACDs between different jurisdictions within Australia.4 General practice is the ideal setting for ACP discussions, and evidence supports patient preference for initiation of ACP while they are still healthy in the community.5-7 The Royal Australian College of General Practitioners (RACGP) recommends that general practitioners (GPs) discuss ACP as part of routine care for older patients during the annual 75 years and over health assessment.8 The COVID-19 pandemic highlighted the need for GPs to have these conversations, and there have been calls for ACP to be an integral part of pandemic health planning responses.9 Evaluating the prevalence of ACP conversations is difficult, with most studies focusing on the more tangible assessment of ACD completion. Some barriers to GPs initiating ACP include difficulties in defining the right moment to discuss the topic, a perceived lack of knowledge in the ACP process and concern regarding the potential time-consuming nature of ACP discussions.11'12 Strategies to increase initiation of ACP in general practice have focused on workshops and communication skills training for GPs and general practice nurses (GPNs), which are time and resource intensive.13-15 Some studies have shown that discussion guides and question prompt lists can improve the frequency of ACP discussions with patients, but these have been limited to palliative care settings.16-18 Most doctors believe it is their responsibility to initiate these discussions but struggle with timing.19 More evidence is needed to understand how to help GPs facilitate these conversations in a way that is acceptable and meaningful for older patients and their families. [...]it's the family that's really going to make the decision. [Female GP, FG 1.1] Some GPs preferred to focus on clinical decisions such as cardiopulmonary resuscitation (CPR) as the main subject of the conversation, while others preferred to broaden the discussion to general healthcare goals.

Let's Talk: Advance Care Planning. How can we improve the quality of advance care planning both in hospital and community?

BackgroundEnd of life care (EoLC) and advance care planning (ACP) conversations can be challenging for staff and patients. Drawing on published guidance and building on previous local work1–4 this Trustwide project aims to improve the experience of patients, carers and staff in engaging with ACP discussions and to measure progress.Method(s)This project is led by an ACP Nurse Specialist, overseen by the EoLC clinical lead and Deputy Head of Nursing. NHS Quality improvement methodology underpins the work which is supported by a steering group and governance structure.Implementation of our previously developed ‘Let's Talk' resources (supporting information to aid understanding of ACP: videos, leaflet, website5), building stakeholder relationships, staff education, clinical visibility and role modelling were undertaken to increase engagement in ACP. A Gap Analysis Action Plan (GAAP) was developed by benchmarking against recommendations from the Care Quality Commission(2) and used at strategic and governance meetings to engage key stakeholders and agree measureable actions.Data were collated from audits, patient and staff surveys and website viewing clicks.ResultsOver 900 staff have received bespoke training. Changes from pre- to post-implementation include: increased awareness of and staff-reported use of materials (respectively 20%/ 90%;21%/ 75%), increased staff confidence in ACP (30%/ 75%), increased documented use of materials to support cardiopulmonary resuscitation discussions (6%/ 9%). 65% of staff who used materials stated patients/families found them helpful. Website5 clicks increased (520/572) and staff webpage (270/424). Data show increased access to resources and what we hope is a meaningful and sustainable improvement to ACP.Conclusion(s)Our data suggests that our approach to embedding use of our ‘Let's Talk' materials improves staff and patient engagement with ACP. More work is needed to fully develop our Trust framework including a focus on staff and patient education.ReferencesTalking about dying: How to have honest conversations about what lies ahead. Royal College of Physicians. October 2018. Available at: https://www.rcplondon.ac.uk/projects/outputs/talking-about-dying-how-begin-honest-conversations-about-what-lies-ahead [accessed 19/10/2022].Protect, respect, connect – decisions about living and dying well during COVID-19. March 2021. Available at: www.cqc.org.uk/publications/themed-work/protect-respect-connect-decisions-about-living-dying-well-during-covid-19 [accessed 19/10/2022]Universal Principles for Advance Care Planning. NHS England. March 2022. Available at: https://www.england.nhs.uk/publication/universal-principles-for-advance-care-planning/[accessed 19/10/2022].Dying to Talk – Let's Talk: Transforming End of Life Care Conversations. Guy's & St Thomas' NHS Foundation Trust. January 2019. Available at: www.guysandstthomas.nhs.uk/news/dying-talk [accessed 19/10/2022].Let's Talk: Advance Care Planning. Online resource and website – updated September 2022 www.guysandstthomas.nhs.uk/LetsTalk [accessed 19/10/2022].

COVID-19: End-of-life care decision-making and preferences in older people

Elderly patients, frail, and with underlying many chronic comorbidities or severe illness are most at risk from COVID-19 pandemic. Recent data from the Italian Istituto Superiore di Sanità (ISS) showed that COVID-19 is more lethal in older subjects. In Italy, on the date of March 17, 2020, the overall case-fatality rate was 7.2%, and 96.4% of died patients had more than 60 years. When age groups stratified data, individuals aged 70 years or older represent 35.5% of cases, while subjects aged ≥80 years were 52.3% [1]. With respect to the severe context of widespread world mortality, the main aims of the palliative care (quality of life, discernment of patient goals, advance care planning, pain and symptom management, and support for caregivers over protracted trajectories) may appear not essential [2]. The COVID-19 pandemic showed, conversely, the limits of the healthcare system on managing elderly patient's wishes even and expectations during the dreadful COVID-19 disease. During epidemic such as that of SARS CoV 2, the necessity of intensive care unit (ICU) beds could be not sufficient for the patients with severe respiratory distress (ARDS). Many recommendations suggest, in these contests, that the physicians should guarantee the healthcare resources to the patients with a higher life expectancy. The evaluation for the need for intensive care should include the severity of the disease, the comorbidity and the presence of multi-organ failure. Have still, in this period, the insight of patient goals such as wishes, advance care planning and even end of life preferences a central value? This chapter would analyse this prerogative in light of the severity of COVID pandemic. © Springer Nature Switzerland AG 2020.

Use of do-not-resuscitate orders

Use of patient/health proxy authorised do-not-resuscitate (DNR) or do-not-attempt-resuscitation (DNAR) orders is widespread in palliative, hospice and hospital-based chronic illness care. Such orders often reflect self-determination, avoidance of futile care and quality of dying principles. Reports during COVID-19 of physicians writing DNR/DNAR orders for people with intellectual disabilities at rates higher than the general population amplify past concerns about the value placed on their lives. Yet, absence of a DNR/DNAR or processes to permit one when someone cannot consent may result in painful and unnecessary prolongation of life. This chapter considers rationales for DNR/DNAR orders, use among people with intellectual disabilities, advance care planning, protocols when an individual is unable to consent and strategies for oversight of DNR/DNAR orders. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Volunteer advance care planning service pilot

BackgroundAdvance care planning (ACP), with particular reference to care home residents, has been brought to the fore by the COVID-19 pandemic, with concern over residents’ involvement in resuscitation decisions leading to a review by the Care Quality Commission (2021). Whilst recently published Universal Principles (NHS England. 2022) will be helpful, achieving high quality ACP consistently with impact and at scale has proved elusive. In response to this need we piloted an innovative ACP service for capacitous care home residents;delivered remotely by trained volunteers to include treatment escalation plans.AimsTo evaluate our ACP service with reference to: a) concordance between treatment escalation decisions made by residents when supported by a volunteer compared to a GP;b) time taken by volunteers and GPs;c) acceptability of remote ACP in this population;d) feedback on the service from GPs, residents and care home managers.MethodsApr – June 2020: service set up with PCN leads’ support, recruitment and training of volunteers (counsellors and medical students), partial funding from West Yorkshire & Harrogate Health Inequalities Fund. Residents completed an ACP with a volunteer which was then re-discussed with GP. July 2020: Pilot commencement with data collection on time taken, outcomes and feedback questionnaires to all involved. Service evaluation after 25 appropriate referrals.Results95% concordance in escalation plans created with volunteer compared to GP. Average time taken;volunteer 52 mins, GP 12 mins. 100% of residents found the service useful and would recommend to others, with 88% finding the remote platform acceptable. The GPs reported the service as being useful for 96% of referrals.ConclusionAn ACP service for capacitous care home residents delivered remotely by trained volunteers is feasible and acceptable. This has the potential to allow GPs, or clinicians within an ACP service, to reduce down the time taken by building on volunteer-led ACPs or concentrate on complex ACP decisions where clinical input is needed.

Working in co-production: Creative approaches to advance care planning with people excluded by identity, culture, ethnicity and race

BackgroundThe COVID-19 pandemic highlighted the health inequalities experienced by people from Black, Asian and minority ethnic people and communities in the UK (Chidiac, Feuer, Flatley, et al., 2020. Palliat Med. 34:1241). There is a lack of understanding of the needs of different BAME communities in the palliative care workforce (Hussain, Koffman & Bajwah, 2021. Palliat Med. 35:810). Consequently, people from BAME communities have less access to advance care planning (ACP).Aim(s)The research project had two main aims:To explore whether our equity-focused, arts-based approach to advance care planning (the No Barriers Here model) could be further developed to gain better understanding of the needs and experiences of people excluded by identity, ethnicity, culture and race in the locality.To take this understanding and develop an education programme for healthcare professionals to improve cultural competence in the workforce.MethodsA co-production group was formed including members of different communities often excluded by identity, culture, ethnicity or race. The co-production group supported the development of the model and recruitment of participants into three cohorts and each cohort took part in three arts-based ACP workshops. The data from the workshops were analysed using reflexive thematic analysis (Braun, Clarke, 2014. Int J Qual Stud Health Well-being. 9:1;Braun & Clarke, 2006. Qual Res Psychol. 3:77) and the findings used to inform the development of an education programme.ResultsKey themes are developed within the data analysis and will be presented in the session (data analysis is currently ongoing at the time of writing).ConclusionsThe conclusions will be presented at conference. Early indications highlight that adoption of co-production methods and an equity-focused, arts-based approach to advance care planning offer communities often excluded by identity, culture, ethnicity and race an opportunity to explore and share what matters most at the end of life, what barriers are experienced in accessing care and what services and support are available. The method appears to amplify voices of communities which organisations and healthcare professionals sometimes struggle to hear.A film about the No Barriers Here study with people excluded due to identity, culture, ethnicity and race is available at: https://youtu.be/G-ToRCT3UiU

Impacts of the COVID-19 Pandemic on a Community-Based, Palliative Care Lay Advisor Project for Latinos with Cancer

The COVID-19 pandemic posed challenges to a community-based participatory research (CBPR) project for rural-dwelling adults with cancer in eastern North Carolina. This project trained Latino community leaders as palliative care lay advisors (PCLAs) to deliver information on cancer symptom management and advance care planning (ACP). Pandemic impacts were assessed using data from team meetings and fieldnotes, journal memos, online booster sessions, participant encounter forms and digital correspondence. Three key results were: 1) the disproportionate effects of COVID -19 on PCLAs and their communities;2) the need for a major study redesign that extended the recruitment region and changed the mode of intervention delivery;and 3) the adoption of new channels of communication. Online discussions and in-person meetings with PCLAs sustained engagement, resulting in a two-year, 73 percent retention rate, and addressed community concerns about COVID-19. Applied outcomes included the selection by the regional cancer center of a 2022 goal to improve cultural care for Latinos and the empowerment of PCLAs as community advocates. The challenges created by COVID-19 were met by the study team's ongoing commitment to CBPR principles, flexible adaptations to a changing environment, and strong relationships forged with community members and advocacy groups.

Careful hand feeding in a geriatric step-down hospital: a retrospective study

Objective. To evaluate the safety and effectiveness of the careful hand feeding (CHF) programme in a geriatric step-down hospital. Methods. Medical records of patients aged >65 years who received CHF in FungYiu King Hospital between February 2017 and November 2021 were retrospectively reviewed. Results. 446 patients (178 men and 268 women) aged 66 to 109 (mean, 91) years were included for analysis. 88% of patients were severely frail or very severely frail. 70% of patients had advanced dementia. 81.3% of patients had dysphagia. 44% of patients were in imminent death status (who were highly likely to die within a week) before starting CHF. Food intake during CHF was poor or very poor in 51 % of patients and satisfactory or good in 49% of patients. 90% of patients required clinically assisted hydration. The mean length of hospital stay was 19.3?16 days, and the mean duration of CHF was 14?13.5 days. 39% of patients died during the index admission;most of the remaining 61% of patients were discharged to their original placement. 27 (6%) patients had pneumonia. Independent predictors for pneumonia were the length of hospital stay (odds ratio=1.024, p=0.014) and poor/very poor intake (odds ratio=1.82, p=0.017). Conclusion. CHF is safe in a geriatric step-down hospital and avoids use of a nasogastric feeding tube in patients in their last phase of life. It fosters comfort and dignity for dying patients. Most patients can return to their original placement for CHF after discharge.

Providing Palliative Care to Patients Throughout the State of Indiana from a Centralized Virtual Palliative Care Hub.

BACKGROUND: Access to palliative care clinicians is a limited resource. Expanding the reach of existing palliative care expertise by utilizing virtual care is one strategy to reach areas that lack access. We delivered virtual services through a centralized hub across multiple health settings and tracked outcomes. METHODS: Through a centralized virtual palliative care hub based in an urban academic health center, access to specialty palliative care was offered across homes, critical access hospitals (CAHs), and extended care facilities (ECFs) in the state of Indiana. Webpage-based platforms were used, and hardware included a cart on wheels for rural hospital sites. Data specific to palliative care were monitored for each encounter. RESULTS: Over one year, 372 patients were seen for virtual palliative care consultations, of whom 275 (73.9%) were seen in the outpatient setting (where the patient was at home or in an ECF) and 97 (26.1%) were inpatient visits performed in CAHs. Visits occurred with patients from almost all counties in Indiana. Advance directives were established for 286 (76.9%) patients seen, and 107 (28.8%) patients were referred to hospice. CONCLUSION: Specialty palliative care is a limited resource that has been further constrained by the COVID-19 pandemic. Our experience demonstrates that centralized virtual hub-based palliative care can be leveraged to provide effective, patient-centered, and compassionate care in regions without a specialist and has the potential to improve access to specialty palliative care.

The Impact of COVID-19 on Completion of Advance Directives in Healthcare Workers in the United States

The need for advanced care planning, including advanced directives (ADs), has become evident since the onset of the COVID-19 pandemic brought end-of-life care to a global audience. To study the influence of COVID-19 on AD completion among healthcare workers, a total of 3301 individuals, including healthcare and non-healthcare workers, were surveyed between August 1,2020 and November 1, 2020. Respondents were asked to report whether they had spoken with anyone since the onset of the pandemic regarding their wishes in case they became critically ill. Most participants reported that COVID-19 did not change their opinion on AD completion. The results of our survey also suggest the opinions of healthcare students on AD completion were not changed by COVID-19. Further research is needed to explore whether religious beliefs, culture, lack of knowledge, or fear of the topic can help to explain behaviors among healthcare workers.

Nursing Home Palliative Care During the Pandemic: Directions for the Future.

Background and Objectives: Palliative care addresses physical, emotional, psychological, and spiritual suffering that accompanies serious illness. Emphasis on symptom management and goals of care is especially valuable for seriously ill nursing home residents. We investigated barriers to nursing home palliative care provision highlighted by the coronavirus disease 2019 (COVID-19) pandemic and the solutions nursing home staff used to provide care in the face of those barriers. Research Design and Methods: For this descriptive qualitative study, seven Massachusetts nursing home directors of nursing were interviewed remotely about palliative care provision before and during the COVID-19 pandemic. Interview data were analyzed using thematic analysis. Results: Before the pandemic, palliative care was delivered primarily by nursing home staff depending on formal and informal consultations from palliative care specialists affiliated with hospice providers. When COVID-19 lockdowns precluded these consultations, nursing staff did their best to provide palliative care, but were often overwhelmed by shortfalls in resources, resident decline brought on by isolation and COVID-19 itself, and a sense that their expertise was lacking. Advance care planning conversations focused on hospitalization decisions and options for care given resource constraints. Nevertheless, nursing staff discovered previously untapped capacity to provide palliative care on-site as part of standard care, building trust of residents and families. Discussion and Implications: Nursing staff rose to the palliative care challenge during the COVID-19 pandemic, albeit with great effort. Consistent with prepandemic analysis, we conclude that nursing home payment and quality standards should support development of in-house staff capacity to deliver palliative care while expanding access to the formal consultations and family involvement that were restricted by the pandemic. Future research should be directed to evaluating initiatives that pursue these aims.

What’s the plan in 2021?

BackgroundTreatment escalation plans (TEP) are increasingly used to document individualised advance care planning decisions in acute settings. A form initially co-designed by a multi-disciplinary working group at a tertiary referral UK cancer centre during the COVID-19 pandemic was later adapted based on clinician feedback and its utilisation re-analysed.MethodA retrospective study was performed of TEP completion in adult non-elective admissions during April 2021. 100 notes were included in the final analysis (11 sets unavailable). Data gathered included patient demographics, capacity, diagnosis, disease information, prognosis and possible clinical interventions.ResultsOf the 100 patients, 45% had a TEP form (53.3% in 2020). 61% were for consideration of critical care and of those for ward-based care, appropriateness of interventions was fully completed for 76%. Clinicians were more likely to record information regarding anti-cancer treatment (89%), treatment intent (80%) and concurrent problems (87%) than prognosis (62%). Of those with a TEP, 53% were for resus. However, palliative care consultation was more common in those with a TEP form (58%) than those without (18%) and mortality was higher 13.3% (with TEP) vs 0% (without TEP).ConclusionTEP forms remain an important aspect of clinical documentation for all non-elective admissions to our tertiary referral cancer centre. However, there remains challenge in ensuring all patients have this completed during admission. Those patients with a TEP form are more likely to have palliative care consultation during their admission and therefore more likely to have advance care planning discussed.