Advance Care Planning in Obstetrics: Effectiveness of a Didactic Intervention on Provider Comfort and Knowledge

INTRODUCTION: Within obstetrics care, it can be difficult to discuss death and advances directives (AD). Recent maternal illnesses and deaths secondary to COVID-19 highlight the importance of these conversations. There is little available research regarding AD in obstetrics, especially within medical education. This study aimed to establish a baseline of obstetric provider comfort and knowledge with this material, provide education, and then reassess comfort and knowledge. METHODS: Institutional review board committee approval was waived for this study. A pre-intervention survey, including a unique identifier to allow for pairing of pre/post-surveys, was emailed to residents of a large university obstetrics and gynecology department with questions assessing comfort and knowledge of AD. The intervention was a 45-minute lecture covering definitions and local state laws relating to AD. A postsurvey, with identical questions to the presurvey, was sent 2 weeks after the intervention. Only paired responses were analyzed, using paired t test. RESULTS: Twenty-three residents (96% of program) participated in the presurvey;17 (71%) participated in the postsurvey. All were matched to presurvey responses and analyzed. In the presurvey, 41% of respondents were usually or always comfortable identifying surrogate decision makers, which increased to 82% in the postsurvey, a 41% difference (P =.01). With regards to the knowledge-based questions, the mean correct response was 56% in the presurvey and 87% in the postsurvey, a 31% difference (P <.001). CONCLUSION: A simple didactic intervention showed improvement in comfort and knowledge surrounding topics of AD for ob-gyn residents. Additional research relating to patient awareness of AD during pregnancy could be explored. [ FROM AUTHOR] Copyright of Obstetrics & Gynecology is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

ADVANCE CARE PLANNING VIRTUALLY DURING A PANDEMIC Debbie Ripley

The Marie Curie Virtual Advance Care Planning service was set up in response to the vulnerability of care home residents during the COVID-19 crisis. The high degree of variation in completed Coordinate My Care (CMC) records pan-London was identified. Many care home residents and their families had not had discussions about their end-of-life care preferences recorded. As well as providing holistic person-centred information, documenting evidence for the transfer to hospital for those for whom it would be appropriate is vital to enable the health and social care system to provide better person-centred care. Marie Curie had existing experience of working with care home staff and GPs to create CMC records. This experience was used to initiate and provide this virtual service across several areas in London involving care home residents and the service has expanded to receive referrals from hospital consultants for their out-patients who they believe would benefit from advance care planning and the creation of a CMC record. The project is staffed with registered nurses, initially with those who were shielding, and Marie Curie were able to recruit these staff from widespread locations because of its virtual nature. A training programme was established involving recognised CMC training, using webinars on advance care planning and issues surrounding mental capacity of patients, including Lasting Power of Attorneys Best Interest Decisions for patients who lack capacity. This was underpinned by the experience of Marie Curie Nurses with excellent communication skills as well as foundational mandatory training such as general data protection, safeguarding and mental capacity assessment. On receipt of the referral, the Marie Curie Nurse identified individual needs and began liaising with necessary parties in order to create an advance care plan that was of a high quality and would contain the most useful information about personal preferences to the multi-disciplinary teams.

Impact of an interdisciplinary goals of care program on hospital outcomes at a comprehensive cancer center during the COVID-19 pandemic: A propensity score analysis

Background: Many hospitals have established goals-of-care (GOC) programs in response to the COVID- 19 pandemic;however, few have reported their outcomes. MD Anderson Cancer Center launched a multicomponent interdisciplinary GOC (myGOC) program in March 2020 that involved risk stratification, team huddles to discuss care planning, oncologist-initiated GOC discussions, communication training, palliative care involvement, rapid-response GOC team deployment, and daily monitoring with immediate feedback. We examined the impact of this myGOC program among medical inpatients. Methods: This single-center study with a quasi-experimental design included consecutive adult patients with cancer admitted to medical units at MD Anderson Cancer Center, Texas during an 8-month pre-implementation (May 1, 2019 to December 31, 2019) and post-implementation period (May 1, 2020 to December 31, 2020). The primary outcome was intensive care unit (ICU) mortality. Secondary outcomes included ICU length of stay, hospital mortality, and proportion/timing of patients with inhospital do-not-resuscitate (DNR) orders, medical power of attorney (MPOA), living will (LW) and outof- hospital DNR (OOHDNR). Propensity score weighting was used to adjust for differences in potential covariates, including age, sex, cancer diagnosis, race/ethnicity, and Sequential Organ Failure Assessment (SOFA) Score. With a sample size of 600 ICU patients over each time period and a baseline ICU mortality of 28%, we had 80% power to detect a 5% reduction in mortality using a two-tailed test at 5% significance level. Results: This study involved 12,941 hospitalized patients with cancer (Pre n = 6,977;Post n = 5,964) including 1365 ICU admissions (Pre n = 727;Post n = 638). After myGOC initiation, we observed a significant reduction in ICU mortality (28.2% vs. 21.9%;change -6.3%, 95% CI -9.6, -3.1;P = 0.0001). We also observed significant decreases in length of ICU stay (mean change -1.4 days, 95% CI -2.0, -0.7 days;P < 0.0001) and in-hospital mortality (7% vs. 6.1%, mean change -0.9%, 95% CI -1.5%, -0.3%;P = 0.004). The proportion of hospitalized patients with an inhospital DNR order increased significantly from 14.7% to 19.6% after implementation (odds ratio [OR] 1.4, 95% CI 1.3, 1.5;P < 0.0001) and DNR was established earlier (mean difference -3.0 d, 95% CI -3.9 d, -2.1 d;P < 0.0001). OOHDNR (OR 1.3, 95% CI 1.1, 1.6, P < 0.0007) also increased post-implementation but not MPOA and LW. MPOA, LW and OOHDNR were documented significantly earlier relative to the index hospitalization in the post-implementation period (P < 0.005 for all). Conclusions: This study showed improvement in hospital outcomes and care plan documentation after implementation of a system-wide, multicomponent GOC intervention. Our findings may have implications for GOC programs during the pandemic and beyond.

Patterns of Deaths in People With Dementia and Alzheimer's During the COVID-19 Pandemic in England: Lessons for Palliative Care Before the Next Pandemic

Background/aims: Older people had the highest death rates in England during the COVID-19 pandemic, before the vaccination programme. Deaths in care homes were especially high in the 1st Wave (W1) - April 2020 of the pandemic, with a lower peak in the 2nd Wave (W2) - December 2020/January 2021. People with Dementia and Alzheimer's (D&A)) were among the most vulnerable to become victims to COVID-19. Aims: To describe mortality patterns in people with (D&A) during the COVID-19 pandemic to learn lessons for Palliative and End of Life Care (P&EOLC) for D&A in pandemics. Methods: Mortality data in England, January 2019 to May 2021 analysed by calendar month and place of death for D&A as underlying cause (UC) and contributory cause (CC) on death registrations. The key underlying causes for D&A CC deaths were identified. Comparisons were made for 2020 with 2019 and for W1 and W2 the same months in 2019/20 using descriptive statistics. Results: In 2019, 64,468 people died with D&A as UC vs. 67,872 in 2020 (+5.3%), but strikingly deaths with D&A as CC increased 69% (26,445 to 44,624). The W1 and W2 peaks for D&A deaths were highly significant but different in nature. In W1 79% (8,435) D&A UC deaths were in care homes vs. 64% (3,435) 2019. For D&A CC deaths in W1 (April 2020) there was ∼400% increase in deaths (2,146 to 10,682) and 325% and 569% increases in hospital and care home deaths. In W1 COVID-19 (7,496 deaths) was the main (70%) UC for people dying with D&A as CC, increases also for Circulatory Disease +44%, Cancer +31%, Parkinsons +117% and respiratory disease (COPD) + 69.3%. W2 saw a 19% reduction in D&A UC deaths but +139% as CC with COVID-19 main UC. Conclusions: People with D&A were extremely vulnerable to risk of death during the COVID-19 pandemic, especially if living in a care-home and due to pressures on healthcare. The speed of surge in deaths and impact on care homes highlights the critical need for Advance Care Plans/Power of Attorney for people with D&A and especially training of care home staff in P&EOLC.

Dying Wish: A Case of Controversial Covid Vaccination Near the End of Life

Background: This case describes the circumstances of an older woman and her daughter faced with the dilemma of whether or not to receive the COVID-19 vaccine at the end of life. Methods: Ms. V was a 90-year-old woman with past medical history of major neurocognitive disorder, asthma, and hypertension on home hospice after experiencing a rapid decline beginning in November 2020. By January 2021, she had significantly deteriorated with a prognosis of weeks. At this time, the COVID-19 vaccine had become available to high-risk individuals and their household members. Because Ms. V lacked capacity to make her medical decisions, her daughter and healthcare power of attorney, Ms. B, had to determine her wishes. Ms. V's goals were comfort care and to avoid hospitalization. Although she had worked as a nurse, she had declined her annual influenza vaccine in the past. However, Ms. B felt that her mother would have wanted to help her children and caretakers get the vaccine, which would only be possible if she got the vaccine first. Results: Extensive conversations with Ms. V's children, hospice team, and geriatrician were held utilizing the 4-box approach to ethical decision making.1 Ms. B decided that her mother would have wanted to receive the vaccine for the main purpose of also vaccinating her children, who both had advanced heart failure and were at high risk for complications from COVID-19. She received one dose of the Pfizer COVID-19 vaccine and died ten days later. Her children and live-in caregiver all received the Pfizer Covid-19. Conclusion: Although Ms. V had previously refused annual influenza vaccinations, her daughter felt that her mother would have gotten the vaccine to provide protection for her children and caregiver. While it was acknowledged that Ms. V would probably gather little immunity benefit from the vaccine due to her poor prognosis, her daughter felt that the benefits of the entire household receiving the vaccine outweighed any potential risks. Her family called this final act of protection her dying wish.

Addressing end-of-life care in the chronically ill: Conversations in the emergency department.

Patients present to the emergency department in various stages of chronic illness. Advance directives (ADs) aid emergency physicians in making treatment decisions, but only a minority of Americans have completed an AD, and the percentage of those who have discussed their end-of-life wishes may be even lower. This article addresses the use of common ADs and roadblocks to their use from the perspectives of families, patients, and physicians. Cases to examine new approaches to optimizing end-of-life conversations in patients who are chronically ill, such as the Improving Palliative Care in Emergency Medicine Project, a decision-making framework that opens discussion for patients to gain understanding and determine preferences, and the Brief Negotiated Interview, a 7-minute, scripted, motivational interview that determines willingness for behavior change and initiates care planning, are used.