Barriers to advance care planning in chronic obstructive pulmonary disease

Gott, Merryn; Gardiner, Clare; Small, Neil; Payne, Sheila; Seamark, David; Barnes, Sarah; Halpin, David; Ruse, Charlotte

doi:10.1177/0269216309106790

Cited by 185 publications

(200 citation statements)

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“…It is unsurprising that participants reported difficulties in recognising that a patient has entered the last 12 months of life given previous research regarding clinician barriers to prognostication, particularly in 'non-cancer' conditions [100][101][102][103][104] in which dying trajectories are typically unpredictable. 105 These are issues that are not unique to the hospital setting.…”

Section: Discussionmentioning

confidence: 99%

“…Indeed, no documented evidence of advance care planning was found for this sample of 183 patients with palliative care needs according to GSF criteria. Various barriers to advance care planning have been identified in the literature 103,133 and advanced communications skills training programmes such as Connected have been initiated across some clinical settings (mandatory in oncology settings), including acute hospitals, to address these. Our findings lend weight to the need to address the gap between policy promotion of advance care planning and current practice.…”

Section: Extent Of Transitions To Palliative Carementioning

confidence: 99%

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Transitions to palliative care for older people in acute hospitals: a mixed-methods study

Gott

Ingleton

Gardiner

et al. 2013

Health Services and Delivery Research

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BackgroundImproving the provision of palliative and end-of-life care is a priority for the NHS. Ensuring an appropriately managed ‘transition’ to a palliative approach for care when patients are likely to be entering the last year of life is central to current policy. Acute hospitals represent a significant site of palliative care delivery and specific guidance has been published regarding the management of palliative care transitions within this setting.Aims(1) to explore how transitions to a palliative care approach are managed and experienced in acute hospitals and to identify best practice from the perspective of clinicians and service users; (2) to examine the extent of potentially avoidable hospital admissions amongst hospital inpatients with palliative care needs.DesignA mixed-methods design was adopted in two hospitals in England, serving diverse patient populations. Methods included (1) two systematic reviews; (2) focus groups and interviews with 58 health-care professionals to explore barriers to, and facilitators of, palliative care transitions in hospital; (3) a hospital inpatient survey examining palliative care needs and aspects of management including a self-/proxy-completed questionnaire, a survey of medical and nursing staff and a case note review; (4) in-depth interviews with 15 patients with palliative care needs; (5) a retrospective case note review of all inpatients present in the hospital at the time of the survey who had died within the subsequent 12 months; and (6) focus groups with 83 key decision-makers to explore the implications of the findings for service delivery and policy.ResultsOf the 514 patients in the inpatient survey sample, just over one-third (n = 185, 36.0%) met one or more of the Gold Standards Framework (GSF) prognostic indicator criteria for palliative care needs. The most common GSF prognostic indicator was frailty, with almost one-third of patients (27%) meeting this criteria. Agreement between medical and nursing staff and the GSF with respect to identifying patients with palliative care needs was poor. In focus groups, health professionals reported difficulties in recognising that a patient had entered the last 12 months of life. In-depth interviews with patients found that many of those interviewed were unaware of their prognosis and showed little insight into what they could expect from the trajectory of their disease. The retrospective case note review found that 35 (7.2%) admissions were potentially avoidable. The potential annual cost saving across both hospitals of preventing these admissions was approximately £5.3M. However, a 2- or 3-day reduction in length of stay for these admissions would result in an annual cost saving of £21.6M or £32.4M respectively.ConclusionsPatients with palliative care needs represent a significant proportion of the hospital inpatient population. There is a significant gap between NHS policy regarding palliative and end-of-life care management in acute hospitals in England and current practice.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Section: Discussionmentioning

confidence: 99%

Section: Extent Of Transitions To Palliative Carementioning

confidence: 99%

Transitions to palliative care for older people in acute hospitals: a mixed-methods study

Gott

Ingleton

Gardiner

et al. 2013

Health Services and Delivery Research

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“…3 Also, in the United Kingdom, a study concluded that discussions related to ACP are very rarely initiated among a group of chronically ill patients. 42 It seems safe to suggest that advance directives are still more prevalent in the United States than in Europe. A reason for this may be that advance directives have a much longer tradition in the United States and the fact that advance directives, which usually limit treatment, are considered more necessary in the United States because American physicians are more inclined to more aggressive treatment options than their European colleagues.…”

Section: Discussionmentioning

confidence: 99%

Advance Care Planning in Belgium and The Netherlands: A Nationwide Retrospective Study Via Sentinel Networks of General Practitioners

Meeussen

Block

Echteld

et al. 2011

Journal of Pain and Symptom Management

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Context. Advance care planning (ACP) is an important part of patient-centered palliative care. There have been few nationwide studies of ACP, especially in Europe.Objectives. To investigate the prevalence and characteristics of ACP in two European countries and identify the associated factors.Methods. A mortality follow-back study was undertaken in 2007 via representative nationwide Sentinel Networks of general practitioners (GPs) in Belgium and The Netherlands using similar standardized procedures. All GPs reported on each non-suddenly deceased patient in their practice. Our main outcome measure was whether or not ACP, that is, an agreement for medical treatment and/or medical decisions in the last phase of life in the case of the patient losing competence, was present.Results. Among 1072 non-sudden deaths, ACP was done with 34% of patients and most often related to the forgoing of potential life-prolonging treatments in general (24%). In 8% of cases, ACP was made in consultation with the patient and in writing. In 23% of cases, care was planned with the patient's family only. Multivariate analysis revealed that ACP was more often made with patients if they were capable of decision making during the last three days of life (odds ratio [OR] 3.86; 95% confidence interval [CI] 2.4e6.1), received treatment aimed at palliation in the last week (OR 2.57; 95% CI 1.6e4.2), had contact with a GP in the last week (OR 2.71; 95% CI 1.7e4.1), died of cancer (OR 1.46; 95% CI 1.1e2.0), or died at home (OR 2.16; 95% CI 1.5e3.0).

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“…Advance care planning for people with end-stage cardiorespiratory disease is considered challenging, as the disease progression is often variable and gradual, hospitalisations are episodic, prognosis may be unclear and people may not recognise the seriousness of their condition [95]. Earlier work has shown that people with COPD were eager for discussions while in a stable state of health [98,99] and that nonmedical facilitators are an acceptable source of information. As pulmonary rehabilitation involves people with COPD working closely with healthcare professionals over several weeks, it is likely that these programmes are an appropriate forum to commence discussions pertaining to advance care planning [100].…”

Section: Advance Care Planningmentioning

confidence: 99%

The importance of components of pulmonary rehabilitation, other than exercise training, in COPD

Hill¹,

Vogiatzis²,

Burtin³

2013

Eur Respir Rev

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Comprehensive pulmonary rehabilitation is an important component in the clinical management of people with chronic obstructive pulmonary disease (COPD). Although supervised exercise training is considered the cornerstone of effective pulmonary rehabilitation, there are many other components that should be considered to manage the impairments and symptom burden, as well as the psychosocial and lifestyle changes imposed by COPD. These include approaches designed to: 1) facilitate smoking cessation; 2) optimise pharmacotherapy; 3) assist with early identification and treatment of acute exacerbations; 4) manage acute dyspnoea; 5) increase physical activity; 6) improve body composition; 7) promote mental health; 8) facilitate advance care planning; and 9) establish social support networks. This article will describe these approaches, which may be incorporated within pulmonary rehabilitation, to optimise effective chronic disease self-management. @ERSpublications This paper describes several components of comprehensive pulmonary rehabilitation, other than simply exercise training http://ow.ly/mMNRp Pulmonary rehabilitation for chronic obstructive pulmonary diseaseChronic obstructive pulmonary disease (COPD) is characterised by persistent airflow limitation due to chronic inflammation within the airways and lung in response to noxious particles or gases [1]. People with this condition are limited by dyspnoea and have impaired exercise capacity and health-related quality of life [1]. The prevalence of COPD amongst adults aged o40 years is ,10% [2], and increases to 21% in those with a significant smoking history who are visiting their family physician for any reason [3]. The natural course of COPD is punctuated with episodes of acute worsening, known as exacerbations, which contribute

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Barriers to advance care planning in chronic obstructive pulmonary disease

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Cited by 185 publications

References 13 publications

Transitions to palliative care for older people in acute hospitals: a mixed-methods study

Transitions to palliative care for older people in acute hospitals: a mixed-methods study

Advance Care Planning in Belgium and The Netherlands: A Nationwide Retrospective Study Via Sentinel Networks of General Practitioners

The importance of components of pulmonary rehabilitation, other than exercise training, in COPD

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