BackgroundLimited data in our multi-ethnic South East Asian society on the feasibility of advance care planning (ACP) where different cultures have disparate beliefs with regards to death.AimA pilot study for the feasibility of basic ACP for patients with mild heart failure.MethodsPatients were recruited from a heart failure clinic over a 4 month period if they are in New York Heart Association class I/II with no readmission in preceding 6 months.ResultsOf 58 patients, 83% had formal ACP while 17% declined to participate. Mean age was 57 years with predominance of male (72%). Ethnic distribution followed the national demographic (84% Chinese, 9% Indian, 7% Malay). The participation rate among the different ethnic groups were 86% for Chinese, 100% for Indians and 25% for Malay. For the participants, 90% had more than one ACP session with a mean duration of 60 min per session, and 17% had completed the ACP forms upon enrolment of the last patient. Significant challenges faced were low awareness of ACP among patients and caregivers as well as need for coordination across multiple disciplines.DiscussionThere is a high acceptance of ACP among patients with mild heart failure. But there is a disparity in the attitudes of different ethnic groups towards ACP where Malay are less willing to discuss it compared to Chinese and Indian.ConclusionOur study highlights the feasibility of implementing ACP in South East Asian patients with heart failure, and the need for further research on the observed impact of ethnicity.
BackgroundNHCS Heart Failure team and Medical Social Workers (MSW) spearheaded the implementation of ACP in August 2012. The programme now incorporates a component of intra-institution education of HCWs, specifically with cardiac nurses and physicians.AimTo provide on-going education and address misconceptions of ACP amongst HCWs in a SEA acute hospital setting, in view that discussion of patients’ crucial end-of-life treatment preferences is an avoided topic amongst HCWs in their daily frontline patient interactions and care.MethodsNHCS ACP model was enhanced to include sub-clinical teams for education. Education on ACP was disseminated via interactive lecture-style presentations by the MSW team, with the support from key NHCS Senior Management.Results122 registered and enrolled nurses attended 3 one-hour lectures.About 40 Cardiologists and medical officers attended a 30-minute lecture.DiscussionFrontline HCWs tend to perceive ACP as a sensitive topic and are uncomfortable bringing it up in their patient care, despite perceiving ACP as an essential discussion framework to minimise conflict or dilemma during medical emergencies.ConclusionTo garner support from essential healthcare stakeholders and help them appreciate ACP as part of standard patient care, ongoing education for HCWs is necessary to overcome the cultural barriers and to shift perceptions on ACP. Further development of a skills-based education programme may be necessary to equip HCW with the soft skills of introducing ACP as standard patient care in NHCS.
BackgroundOur institution has initiated inpatient advance care planning (ACP) programme for heart failure patients in 2013. Enrollment rate has been low.AimExpansion of ACP programme to arrhythmia and myocardial infarction (MI) patients besides heart failure (HF) with support from nurse navigators to increase enrollment.MethodsPatients hospitalised for MI were approached by ACP trained nurse navigators from 1st October 2014 to 30th November 2014, while patients with arrhythmia were approached by ACP coordinators from 1st July 2014 to 30 November 2014. Heart failure patients were approached by ACP coordinators from 1st June 2013 to 30th November 2014.Results112 (5.8%) patients were enrolled from a total screening of 1943 patients. The mean age of patients was 63.9 years and majority was male (73.2%). Ethnic distribution: Chinese 83%, Malay 8%, Indians 7%. 7 out of 61 MI patients were enrolled by the nurse navigators. 8 out of 273 arrhythmia patients and 97 out of 1609 HF patients were enrolled by ACP coordinators. Enrollment rates for MI 11.5%, arrhythmia 2.9%, HF 6.0%.DiscussionThere is a significant increase in enrollment rate of ACP programme after the engagement of nurse navigators’ support. During the patient’s hospital stay, rapport and trust have built up among the patient, caregiver and nurse navigator. This resulted in patient being more open and able to accept ACP when approached by nurse navigator.ConclusionHealthcare providers who have built up a rapport with patients play an important role in advocating ACP programme.
BackgroundNHCS Heart Failure team and Medical Social Workers (MSWs) spearheaded ACP in August 2012. The Programme now incorporates sub-clinical teams, with support from 2 Clinical Coordinators, covering: Education, Research, and Clinical.AimThe team aims to increase awareness of ACP amongst Healthcare Workers (HCWs) in a South-East Asian (SEA) acute hospital, and to facilitate the understanding amongst MSWs of the impact of ACP on patients. ACP programme strives to ensure that patients of different disease stages and cardiac sub-specialities can benefit.MethodsThe ACP programme involves educational lectures delivered by MSWs for HCWs, pre/post-test surveys with patients and collaboration with DUKE-National University of Singapore and Singapore General Hospital MSWs. NHCS specialist physicians are involved in the formulation of workflows and protocols.ResultsThe educational lectures enjoyed good participation (162 registered/enrolled nurses and physicians). 20 HCWs trained in facilitating the delivery of ACP. Collaboration with the aforementioned institutions produced a manuscript, a research paper and two ongoing studies. Subspecialty-specific workflows were developed after consultation with NHCS cardiologists, targeting wide range of cardiac patients.DiscussionPatients and HCWs often find it difficult to discuss the crucial issue of ACP in view of Asian sensitivities. A holistic approach towards ACP in terms of educational lectures, training, and formulation of workflows greatly assisted NHCS in establishing a platform for future studies, research and improvement to the provision of care to our patients.ConclusionOngoing education and advocacy of ACP to patients and healthcare stakeholders is necessary in increasing the recognition of ACP as part of standard patient care.
BackgroundNo previous evaluation was carried out to determine the satisfaction and knowledge of ACP among heart failure patients in Singapore.AimStudy the impact of ACP on heart failure patients using a pre and post survey in National Heart Centre Singapore (NHCS).MethodsPre survey with patients who consented to ACP discussion during screening and follow up with post survey via telephone by the ACP clinical coordinators two weeks after the first ACP discussion.ResultsPre-survey (N = 94), 82.4% never heard of ACP, 95.6% had no written documentations on their end-of-life preferences, 60.4% were comfortable to discuss end-of-life preferences, 34.1% had thought about their preferences.Post-survey (N = 88), 82.1% rated satisfied or very satisfied with the ACP discussion. 67.9% felt that it helped them reflect their personal values and identify end-of-life preferences. 71.4% had good understanding towards ACP and 74% had improved health knowledge after the discussion. 93.4% agreed that planning for end-of-life care preferences is important.DiscussionThe awareness of ACP is low among NHCS patients. Majority of patients believe that it is important to plan for their healthcare wishes but very few have initiated this conversation or documented their wishes with their healthcare providers or their family members.ConclusionMore publicity is needed to promote the literacy of this ACP Programme among Singaporeans, especially those with unpredictable disease trajectories. Findings show that the Programme is beneficial to patients who are ready for such discussion. A more proactive approach by healthcare stakeholders is needed to expand this Programme.
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