BACKGROUND: Advance care planning is widely advocated to improve outcomes in end-of-life care for patients suffering from heart failure. But until now, there has been no systematic evaluation of the impact of advance care planning (ACP) on clinical outcomes. Our aim was to determine the effect of ACP in heart failure through a meta-analysis of randomized controlled trials (RCTs). METHODS: We searched CINAHL, Cochrane Central Register of Controlled Trials, Database of Systematic Reviews, Embase, ERIC, Ovid MEDLINE, Science Citation Index and PsycINFO (inception to July 2018). We selected RCTs including adult patients with heart failure treated in a hospital, hospice or community setting. Three reviewers independently screened studies, extracted data, assessed the risk of bias (Cochrane risk of bias tool) and evaluated the quality of evidence (GRADE tool) and analysed interventions according to the Template for Intervention Description and Replication (TIDieR). We calculated standardized mean differences (SMD) in random effects models for pooled effects using the generic inverse variance method. RESULTS: Fourteen RCTs including 2924 participants met all of the inclusion criteria. There was a moderate effect in favour of ACP for quality of life (SMD, 0.38; 95% CI [0.09 to 0.68]), patients' satisfaction with end-of-life care (SMD, 0.39; 95% CI [0.14 to 0.64]) and the quality of end-of-life communication (SMD, 0.29; 95% CI [0.17 to 0.42]) for patients suffering from heart failure. ACP seemed most effective if it was introduced at significant milestones in a patient's disease trajectory, included family members, involved follow-up appointments and considered ethnic preferences. Several sensitivity analyses confirmed the statistically significant direction of effect. Heterogeneity was mainly due to different study settings, length of follow-up periods and compositions of ACP. CONCLUSIONS: ACP improved quality of life, patient satisfaction with end-of-life care and the quality of end-of-life communication for patients suffering from heart failure and could be most effective when the right timing, followup and involvement of important others was considered.KEY WORDS: heart failure; palliative care; advance care planning; effect; outcomes; systematic review; meta-analysis. J Gen Intern Med
Background: Advance care planning (ACP) can improve the quality of life of patients suffering from heart failure (HF). However, primary care healthcare professionals (HCPs) find ACP difficult to engage with and patient care remains suboptimal.Aim: To explore the views of primary care HCPs on how to improve their engagement with ACP in heart failure.Design and Setting: A qualitative interview study with GPs and primary care nurses in England.Method: Semi-structured interviews were conducted with a purposive sample of 24 primary HCPs. Data were analysed using reflexive thematic analysis.Results: Three main themes were constructed from the data: ACP as integral to holistic care in HF; potentially limiting factors to the doctor-patient relationship; approaches to improve professional performance. Many HCPs saw the benefits of ACP as synonymous with providing holistic care and improving patients’ quality of life. However, some feared that initiating ACP could irrevocably damage their doctor-patient relationship. Their own fear of death and dying, a lack of disease specific communication skills and uncertainty about the right timing were significant barriers to ACP. To optimise their engagement with ACP in HF, HCPs recommended better clinician-patient dialogue through question prompts, enhanced shared decision-making approaches, synchronising ACP across medical specialities, and disease specific training. Conclusion: GPs and primary care nurses are vital to deliver ACP for patients suffering from HF. HCPs highlighted important areas to improve their practice and the urgent need for investigations into better clinician-patient engagement with ACP.
Background: E-mentoring had the potential to improve medical training, patient services, could be cost-effective, and support continued professional development. Research in terms of required core-competences for its effective utilisation in medical education seemed to be inconsistent, fragmented with significant variations in methodological rigor. Aim: The primary aim was to review and synthesise existing evidence in educational science that addressed the question: ''what are the required core-competences in e-mentoring for medical educators?'' Methods: A systematic literature search covered 25 literature databases and employed 42 single search terms and concepts and their Boolean combinations. Coverage was improved by Internet searches, further focus on ''Grey literature'' and the manual searching of library journals and inspecting the bibliographies of the references obtained by these methods. Results: A total of 4344 citations from the literature search were identified. Altogether 44 items were finally selected for inclusion in the study. The extant quality of published research was generally weak. The weight of the best available evidence suggested that seven specific e-mentoring core-competence domains were seen as significant. Conclusions: E-mentoring seemed educationally effective and complemented face-to-face mentoring for continuous professional development. Research in this field needs improvement in terms of rigor and quality.
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