Experiences of dialogue in advance care planning educational programs.

BACKGROUND: Advance care planning (ACP) is a process in which adults engage in an ongoing dialogue about future medical treatment and care. Though ACP is recommended to improve the quality of end-of-life care, the details of the dialogue experience in ACP are unknown. OBJECTIVE: To explore participants' experiences of dialogue in an ACP educational program that encouraged them to discuss the value of a way of life. RESEARCH DESIGN: This qualitative descriptive study used the focus group interview method. Data were analyzed using qualitative content analysis. PARTICIPANTS AND RESEARCH CONTEXT: A dialogue-based ACP educational program was conducted in four regions in Japan for local citizens to discuss the value of their way of life. A total of 66 individuals (mean age = 55.5 ± 17.2 years; 50 women and 16 men) participated in focus group interviews. ETHICAL CONSIDERATIONS: This study was approved by the Ethical Review Committee of Tokyo Women's Medical University (no. 4723) and Kyoto University (no. R2099). FINDINGS: Five main themes were extracted: discussing one's thoughts with others in a considerate manner, reflecting on one's way of life through others, feeling a sense of connection with others through storytelling, realizing the difficulties of talking about "what if" topics, and turning one's eyes toward the future through the dialogue. These themes were interrelated and illustrated the complexity of the experience of discussing values. CONCLUSIONS: The results suggest that dialogue in ACP is useful in clarifying values. They also indicated the need for dealing with the ethical challenges of discussing value and the importance of caring for the interlocutor to have a safe dialogue. In the ACP process, safety in dialogue may improve readiness in ACP, and health practitioners who support ACP need to address the ethical challenges entailing dialogue about values.

Developing an Instrument to Assess the Readiness for Advance Care Planning.

CONTEXT: In recent times, advance care planning for patients' end-of-life care preferences has attracted much attention worldwide. OBJECTIVES: To develop the Readiness for Advance Care Planning (RACP) Scale. METHODS: Participants included 624 Japanese citizens who were registered with a web-based survey company as of February 2019. Items regarding the process of advance care planning (ACP) were developed based on a literature review and expert panel discussions. The expert panel included nine experts and practitioners in the field of end-of-life care. Construct validity, concurrent validity, internal consistency, and test-retest reliability were evaluated. RESULTS: Initially, 37 items were collected. Examination of the floor effect, item-total, good-poor analysis, and exploratory factor analysis yielded a five-factor model with 28 items. The goodness of fit of the model was GFI = 0.80, CFI = 0.91, and RMSEA = 0.08. The concurrent validity was statistically significant (rs = 0.26-0.45, ps < 0.001). Cronbach's alpha for the overall scale was 0.95. The corresponding values for the subscales ranged from 0.90 to 0.97. The intraclass correlation coefficients indicating test-retest reliability was 0.66 (P < 0.001) for the total scale and ranged from 0.52-0.65 for the five subscales. CONCLUSIONS: The validity and reliability of the scale were generally acceptable. The RACP is an appropriate instrument to evaluate the level of readiness for ACP behaviors among people of various generations at every health stage. More studies are needed to examine the clinical utility of the RACP, both nationally and internationally.

Sensitivity and specificity of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) for detecting post-cardiac surgery delirium: A single-center study in Japan.

OBJECTIVE: To compare the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) for detecting post-cardiac surgery delirium. BACKGROUND: These tools have not been tested in a specialized cardio-surgical ICU. METHODS: Sensitivities and specificities of each tool were assessed in a cardio-surgical ICU in Japan by two trained nurses independently. Results were compared with delirium diagnosed by psychiatrists using the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. RESULTS: There were 110 daily, paired assessments in 31 patients. The CAM-ICU showed 38% sensitivity and 100% specificity for both nurses. All 20 false-negative cases resulted from high scores in the auditory attention screening in CAM-ICU. The ICDSC showed 97% and 94% sensitivity, and 97% and 91% specificity for the two nurses (cutoff ≥4). CONCLUSION: In a Japanese cardio-surgical ICU, the ICDSC had a higher sensitivity than the CAM-ICU.

A novel scale predicting postoperative delirium (POD) in patients undergoing cerebrovascular surgery.

PURPOSE: The purpose of this study was to develop and test a scale for predicting POD in patients undergoing cerebrovascular surgery. METHODS: The predictive scale for POD was composed of 32 items reflecting the strongest risk factors as determined by a literature review. The NEECHAM Confusion Scale determined POD onset and severity. RESULTS: Delirium developed in 38 (31.1%) of the 122 patients in our sample. Logistic regression revealed the following risk factors: dehydration, age, disturbance of consciousness, underlying illness, and anxiety or depression. The final scale was weighted by referring to odds ratios. The area under the curve was 0.844 (95% CI=0.766-0.921). The possible total score on this scale was 20 points. A cutoff score of 11 was set for risk of POD (patients scoring over 12 were considered at higher risk). The median score was 8 (range: 4-9) in the non-delirium group and 13 (range: 9-16) in the delirium group (U=499.0; df=120; p<0.001). Scale scores were moderately correlated with delirium duration (ρ=0.532; p<0.001). CONCLUSION: The present scale is a promising a tool for predicting POD but needs to be studied further.