Promoting advance care planning (ACP) in community health clinics in Israel: Perceptions of older adults with pro-ACP attitudes and their family physicians.

OBJECTIVE: We examined barriers and facilitators to patient-family physician discussions in Israel about advance care planning, including preparation of an advance directive by adults over age 65, as part of a program in two community health clinics which afforded family physicians the opportunity to dedicate time to such discussions with patients. To the best of our knowledge, the program is the first of its kind in Israel. METHOD: We used thematic analyses of qualitative data collected through 22 interviews with patients with pro-advanced care planning attitudes and three focus groups with eleven family physicians. RESULTS: Overall, three themes in the interviews with patients and two themes in the focus groups with physicians emerged. The program gave people with pro-advanced care planning attitudes the opportunity to follow through with their ideas. We found that patients viewed their family physicians as facilitators and that the use of an information leaflet was an effective way to promote advance directives. Family physicians expressed positive attitudes toward assisting patients in the preparation of advance directives and welcomed an allotment of time for this endeavor as part of their schedule but expressed hesitation about assisting patients concerning legal and moral issues. SIGNIFICANCE OF RESULTS: A pro-advanced care planning attitude is not enough for patients to complete the process of creating an advance directive; patients need active encouragement and intervention in order to turn their ideas into action. More patient and physician education are necessary to enable patients to protect their right to self-determination in end-of-life medical decision-making and to support physicians as facilitators of the process.

Quality of end-of-life care for cancer patients: does home hospice care matter?

OBJECTIVES: Since metastasized cancer patients receive many treatments and services, it is important to ascertain whether home hospice (HH) care makes a meaningful contribution to end-of-life quality for terminal patients. This study examines whether people who had died from metastasized cancer-both recipients of HH care and nonrecipients-were cared for according to palliative indicators and whether HH care made a difference. STUDY DESIGN: Three to 6 months after the deaths of 193 metastatic cancer patients, members of their families were interviewed face-to-face. Information on their loved ones' utilization of healthcare services in the last 2 months of life was retrieved from computerized administrative files. RESULTS: The patients' average age was 69.5 years (SD=13.9), 56% were men, and 21% received HH care. More patients with HH care than without received opiate medication (92% vs 68%, respectively; P<.01), appropriate treatment for anxiety (57% vs 30%, respectively; P<.01), had advance directives, and received explanations about their rights. Only 5% of HH patients were treated with curative care in the last 2 month of life, compared with 40% of those without HH (P<.01). Of those who received curative care, more of them died at home (56% vs 26%, respectively; P<.01), and more died at the place of their choice (60% vs 30%, respectively; P<.01). No differences were found regarding healthcare service utilization. CONCLUSIONS: The findings demonstrate the valuable contributions of HH and palliative care. Clinicians should consider referring cancer patients to palliative care services and establishing working relationships with HH and palliative care providers.

Coping strategies for existencial and spiritual suffering in Israeli patients with advanced cancer.

UNLABELLED: Coping with existential and spiritual concerns is inescapable in end-of-life care although not enough is known about the strategies and mechanisms involved. This pilot study focused on identifying the strategies for coping with existential and spiritual suffering at the end of life of secular Jews with advanced-stage cancer. Using the phenomenological approach to data collection, in-depth interviews were conducted with 22 patients receiving symptom relief care at a daycare oncology clinic. The interviews were recorded and transcribed verbatim, and the content was analyzed. Advanced-stage cancer patients employ several approaches to cope with existential and spiritual concerns. The themes emerging from the interviews present five dimensions of coping strategies: openness and choosing to face reality, connectedness and the significance of family, pursuit of meaning, the connection of body, mind and spirit and, lastly, humor and a positive outlook. CONCLUSIONS: Since these concerns cause suffering and distress, intervention models targeting existential and spiritual suffering should be disseminated among professionals involved in caring for people with life-threatening illnesses.

Utilization and cost of services in the last 6 months of life of patients with cancer - with and without home hospice care.

This study examined the utilization and cost of all health services consumed during the last six months of life by cancer patients, and compared those with and without home-hospice care. Detailed information was extracted from the health care electronic administrative data files on 193 deceased cancer patients that their family approved the study (out of 429, 45%). About 88% had been hospitalized for 19 days on average and 53% visited the ER. One quarter received home-hospice care. Their average cost was $13,648 compared to $18,503 for patients without home-hospice care. Hospitalization contributed 32% to the total cost of patients with home-hospice care and 64% for those with it. The findings support the justification for significant expansion of home-hospice care.

Challenges and achievements in the development of spiritual-care training and implementation in Israel.

In recent years, pioneering spiritual-care training programs and services have been developed in Israel. This paper examines the implementation of the training programs and the challenge of integrating program graduates in the healthcare services. The information was collected through in-depth interviews with 12 students and graduates and the directors of the three training programs. All the interviews were transcribed in full and analyzed using qualitative study methods. The interviewees emphasized the importance of practical experience, although many of them encountered some degree of antagonism during their training or placement. Continuation of personal counseling and supervision after the conclusion of the program is also essential. Some were worried that they would not find work or were concerned about negotiations with potential employers. Evidently, the implementation of spiritual-care education must continue apace and careful consideration be given to optimizing its acceptance by the establishment.

Can family caregivers of terminally ill patients be a reliable source of information about the severity of patient symptoms?

This study examines the reliability of family caregivers' assessments of a terminally ill patient's symptoms and identifies patient and caregiver characteristics that affect the reliability of caregiver reports. It compares the reports of 143 patients in home hospice units with those of their family caregiver about patient symptoms during the 3 days preceding the interview (Edmonton scale). Correlation coefficients between the patients' and proxies' reports were 0.5 to 0.8, indicating moderate-to-high agreement. Characteristics that had an independent effect on identical reporting were the patient being fully disabled, the care-giver being a woman in good health, the caregiver living with the patient, and the caregiver providing assistance with activities of daily living and medical care. These results suggest that primary caregivers can be a good source of information about a patient's symptoms, although their reports should be used with caution.

Validation of the McGill Quality of Life Questionnaire in home hospice settings in Israel.

Given that the meaning and significance of 'quality of life' can differ among language and cultural groups, it is incumbent upon researchers to assess whether the tool they have chosen is appropriate to the population under study. This study aimed to test the reliability and validity of the McGill Quality of Life Questionnaire (MQOL) translated into Hebrew for use with palliative care patients in Israel. In this, as in previous studies, the 16 questions of the tool clustered into four domains (physical, psychological, existential well-being and support), although the distribution of items among them differed somewhat. The existential well-being and psychological domains had an independent effect on the overall quality of life of patients in Israel, as in other countries. It seems that this tool produces similar responses in metastatic cancer patients around the world, and hence can be used to compare palliative care services in different countries.

Care of acute stroke patients in general hospitals in Israel.

BACKGROUND: An important question on the health agenda concerns the most appropriate place to hospitalize stroke patients and its effect on acute stroke care. OBJECTIVES: To examine how the existing hospital system treats these patients, specifically: a) the departments to which stroke patients are admitted; b) differences in the admission, diagnosis and rehabilitative care of stroke patients, by department,' c) patient characteristics, by department; and d) mortality rates during hospitalization. METHODS: We surveyed 616 people with acute stroke (ICD-CM9 430-433, 436) admitted consecutively to one of seven large general hospitals in Israel between October 1998 and January 1999. Data were collected from medical records at admission and at discharge. RESULTS: Forty-two percent of the patients were admitted to an internal medicine department, 56% to a neurology department, and only 2% to a geriatric department. The majority (95%) underwent a computed tomography scan of the brain, but other imaging tests were performed on fewer patients, with significant differences among hospitals and between internal medicine and neurology departments. Patients admitted to neurology departments were younger and had milder stroke symptoms than did patients admitted to internal medicine departments. Fifty-three percent of patients received at least one type of rehabilitative care during their hospital stay--usually physiotherapy, and least often occupational therapy. Seventeen percent of stroke patients died during hospitalization. Mortality was not found to be related to the admitting department. CONCLUSIONS: Uniform realistic policies and work procedures should be formulated for all hospitals in Israel regarding the admitting department and processes as well as the performance of diagnostic imaging. Standards of medical and rehabilitative care and discharge destination should be developed to promote quality of care while containing utilization and costs.