BACKGROUND: Considering social cognitive theory and current literature about successful advance care planning in nursing homes, sufficient knowledge and self-efficacy are important preconditions for staff to be able to carry out advance care planning in practice.
AIM: Exploring to what extent nurses' knowledge about and self-efficacy is associated with their engagement in advance care planning in nursing homes.
DESIGN: Survey study as part of a baseline measurement of a randomised controlled cluster trial (NCT03521206).
SETTING/PARTICIPANTS: Nurses in a purposive sample of 14 nursing homes in Belgium.
METHODS: A survey was distributed among nurses, evaluating knowledge (11 true/false items), self-efficacy (12 roles and tasks on 10-point Likert-type scale) and six advance care planning practices (yes/no), ranging from performing advance care planning conversations to completing advance directives.
RESULTS: A total of 196 nurses participated (66% response rate). While knowledge was not significantly associated with advance care planning practices, self-efficacy was. One unit's increase in self-efficacy was statistically associated with an estimated 32% increase in the number of practices having carried out.
CONCLUSIONS: Nurses' engagement in advance care planning practices is mainly associated with their self-efficacy rather than their knowledge. Further research is necessary to improve the evidence regarding the causal relationship between constructs. However, these results suggest that educational programmes that focus solely on knowledge might not lead to increasing uptake of advance care planning in nurses.
BACKGROUND: Research has highlighted the need for improving the implementation of advance care planning (ACP) in nursing homes. We developed a theory-based multicomponent ACP intervention (the ACP+ programme) aimed at supporting nursing home staff with the implementation of ACP into routine nursing home care. We describe here the protocol of a cluster randomised controlled trial (RCT) that aims to evaluate the effects of ACP+ on nursing home staff and volunteer level outcomes and its underlying processes of change.
METHODS: We will conduct a cluster RCT in Flanders, Belgium. Fourteen eligible nursing homes will be pair-matched and one from each pair will be randomised to either continue care and education as usual or to receive the ACP+ programme (a multicomponent programme which is delivered stepwise over an eight-month period with the help of an external trainer). Primary outcomes are: nursing home care staff's knowledge of, and self-efficacy regarding ACP. Secondary outcomes are: 1) nursing home care staff's attitudes towards ACP and ACP practices; 2) support staff's and volunteer's ACP practices and 3) support staff's and volunteers' self-efficacy. Measurements will be performed at baseline and eight months post-measurement, using structured self-reported questionnaires. A process evaluation will accompany the outcome evaluation in the intervention group, with measurements throughout and post-intervention to assess implementation, mechanisms of impact and context and will be carried out using a mixed-methods design.
DISCUSSION: There is little high-quality evidence regarding the effectiveness and underlying processes of change of ACP in nursing homes. This combined outcome and process evaluation of the ACP+ programme aims to contribute to building the necessary evidence to improve ACP and its uptake for nursing home residents and their family.
TRIAL REGISTRATION: The study is registered at ClinicalTrials.gov (no. NCT03521206). Registration date: May 10, 2018. Inclusion of nursing homes started March, 2018. Hence, the trial was retrospectively registered but before end of data collection and analyses.
Purpose: Balancing medications that are needed and beneficial and avoiding medications that may be harmful is important to prevent drug-related problems, and improve quality of life. The aim of this study is to describe medication use, the prevalence of deprescribing of medications suitable for deprescribing, and the prevalence of new initiation of potentially inappropriate medications (PIMs) in nursing home (NH) residents with life-limiting disease in Flanders.
Methods: NH residents aged = 65, suffering from end stage organ failure, advanced cancer, and/or dementia (n = 296), were included in this cross-sectional study with retrospective analyses of medication use at the time of data collection (t2) and 3 to 6 months before (t1). The appraisal of appropriateness of medications was done using a list of medications documented as suitable for deprescribing, and STOPPFrail criteria.
Results: Residents’ (mean age 86 years, 74% female) mean number of chronic medications increased from 7.4 (t1) to 7.9 (t2). In 31% of those using medications suitable for deprescribing, at least one medication was actually deprescribed. In 30% at least one PIM from the group of selected PIMs was newly initiated. In the subgroup (n = 76) for whom deprescribing was observed, deprescribing was associated with less new initiations of PIMs (r = - 0.234, p = 0.042).
Conclusion: Medication use remained high at the end of life for NH residents with life-limiting disease, and deprescribing was limited. However, in the subgroup of 76 residents for whom deprescribing was observed, less new PIMs were initiated.
BACKGROUND: While various initiatives have been taken to improve advance care planning in nursing homes, it is difficult to find enough details about interventions to allow comparison, replication and translation into practice.
OBJECTIVES: We report on the development and description of the ACP+ program, a multi-component theory-based program that aims to implement advance care planning into routine nursing home care. We aimed to 1) specify how intervention components can be delivered; 2) evaluate the feasibility and acceptability of the program; 3) describe the final program in a standardized manner.
DESIGN: To develop and model the intervention, we applied multiple study methods including a literature review, expert discussions and individual and group interviews with nursing home staff and management. We recruited participants through convenience sampling.
SETTING AND PARTICIPANTS: Management and staff (n = 17) from five nursing homes in Flanders (Belgium), a multidisciplinary expert group and a palliative care nurse-trainer.
METHODS: The work was carried out by means of 1) operationalization of key intervention components-identified as part of a previously developed theory on how advance care planning is expected to lead to its desired outcomes in nursing homes-into specific activities and materials, through expert discussions and review of existing advance care planning programs; 2) evaluation of feasibility and acceptability of the program through interviews with nursing home management and staff and expert revisions; and 3) standardized description of the final program according to the TIDieR checklist. During step 2, we used thematic analysis.
RESULTS: The original program with nine key components was expanded to include ten intervention components, 22 activities and 17 materials to support delivery into routine nursing home care. The final ACP+ program includes ongoing training and coaching, management engagement, different roles and responsibilities in organizing advance care planning, conversations, documentation and information transfer, integration of advance care planning into multidisciplinary meetings, auditing, and tailoring to the specific setting. These components are to be implemented stepwise throughout an intervention period. The program involves the entire nursing home workforce. The support of an external trainer decreases as nursing home staff become more autonomous in organizing advance care planning.
CONCLUSIONS: The multicomponent ACP+ program involves residents, family, and the different groups of people working in the nursing home. It is deemed feasible and acceptable by nursing home staff and management. The findings presented in this paper, alongside results of the subsequent randomized controlled cluster trial, can facilitate comparison, replicability and translation of the intervention into practice.
BACKGROUND: Knowing the barriers/enablers to deprescribing in people with a life-limiting disease is crucial for the development of successful deprescribing interventions. These barriers/enablers have been studied, but the available evidence has not been summarized in a systematic review.
AIM: To identify the barriers/enablers to deprescribing of medications in people with a life-limiting disease.
DESIGN: Systematic review, registered in PROSPERO (CRD42017073693).
DATA SOURCES: A systematic search of MEDLINE, Embase, Web of Science and CENTRAL was conducted and extended with a hand search. Peer-reviewed, primary studies reporting on barriers/enablers to deprescribing in the context of explicit life-limiting disease were included in this review.
RESULTS: A total of 1026 references were checked. Five studies met the criteria and were included in this review. Three types of barriers/enablers were found: organizational, professional and patient (family)-related barriers/enablers. The most prominent enablers were organizational support (e.g. for standardized medication review), involvement of multidisciplinary teams in medication review and the perception of the importance of coming to a joint decision regarding deprescribing, which highlighted the need for interdisciplinary collaboration and involving the patient and his family in the decision-making process. The most important barriers were shortages in staff and the perceived difficulty or resistance of the nursing home resident's family - or the resident himself.
Conclusion and implications of key findings: The scarcity of findings in the literature highlights the importance of filling this gap. Further research should focus on deepening the knowledge on these barriers/enablers in order to develop sustainable multifaceted deprescribing interventions in palliative care.
CONTEXT: According to guideline recommendations, barbiturates and neuromuscular relaxants are the recommended drugs for euthanasia.
OBJECTIVES: To describe changes over time in drugs used to perform euthanasia and differences in case characteristics according to the drugs used.
METHODS: Repeated population-based mortality follow-back study among physicians attending a large representative sample of deaths in 1998, 2007 and 2013 in Flanders, Belgium.
RESULTS: In 1998 we identified 25 euthanasia cases (1.2% of all deaths), 142 cases in 2007 (2.0% of all deaths), and 349 cases in 2013 (4.6% of all deaths). Use of recommended drugs to perform euthanasia increased from 11.9% of euthanasia cases in 1998 to 55.3% in 2007 and 66.8% in 2013 (P<.001). In 2013, cases with recommended drugs compared to non-recommended drugs more often involved requests expressed both orally and in writing (86.8%/14.1%, P<.001), consultation with colleague physicians (93.8%/69.1%, P<.001), and administration in the presence of another physician (98.3%/54.3%, P<.001), and were more often self-labelled by physicians as euthanasia (95.5%/0.9%, P<.001) and reported to the euthanasia review committee (92.3%/3.8%, P<.001). Between 2007 and 2013, physicians consistently labelled cases in which non-recommended drugs were used as palliative sedation (72.8%/78.4%, P=.791) or alleviation of pain and symptoms (13.2%/15.0%, P>.999).
CONCLUSION: Physicians in Flanders are increasingly using the recommended drugs for euthanasia. This suggests that guidelines and training regarding the conduct and pharmacological aspects of euthanasia have had important effects on the practice of euthanasia. However, the declining but persisting use of non-recommended drugs requires further attention. Guidelines and training regarding the conduct and pharmacological aspects of euthanasia may have had important effects on the practice of euthanasia. The declining but persisting use of non-recommended drugs requires further attention.
BACKGROUND: Information on medication use in the last months of life is limited.
AIM: To describe which medications are prescribed and deprescribed in advanced cancer patients receiving palliative care in relation to time before death and to explore associations with demographic variables.
DESIGN: Prospective study, using case report forms for monthly data collection. Medication included cancer treatment and 19 therapeutic groups, grouped into four categories for: (1) cancer therapy, (2) specific cancer-related symptom relief, (3) other symptom relief and (4) long-term prevention. Data were analysed retrospectively using death as the index date. We compared medication use at 5, 4, 3, 2 and 1 month(s) before death by constructing five cross-sectional subsamples with medication use during that month. Paired analyses were done on a subsample of patients with at least two assessments before death.
SETTING/PARTICIPANTS: We studied the medication use of 720 patients (mean age 67, 56% male) in 30 cancer centres representing 12 countries.
RESULTS: From 5 to 1 month(s) before death, cancer therapy decreased (55%-24%), most medications for symptom relief increased, for example, opioids (62%-81%) and sedatives (35%-46%), but medication for long-term prevention decreased (38%-27%). The prevalence of chemotherapy was 15.5% in the last month of life, with 9% of new courses started in the last 2 months. With higher age, chemotherapy and opioid use decreased.
CONCLUSION: Medications for symptom relief increased in almost all medication groups. Deprescribing was found in heart medication/anti-hypertensives and cancer therapy, although use of the latter remained relatively high.
Background: A feasibility evaluation of a comprehensive quality indicator set for palliative care identified the need for a minimal selection of these indicators to monitor quality of palliative care services with short questionnaires for the patients, caregivers, and family carers.
Objectives: To develop a minimal indicator set for efficient quality assessment in palliative care.
Design: A 2 round modified Research ANd Development corporation in collaboration with the University of California at Los Angeles (RAND/UCLA) expert consultation.
Setting/Patients: Thirteen experts in palliative care (professionals and patient representatives).
Measurements: In a home assignment, experts were asked to score 80 developed indicators for "priority" to be included in the minimal set on a scale from 0 (lowest priority) to 9 (highest priority). The second round consisted of a plenary meeting in which the minimal set was finalized.
Results: Thirty-nine of the 80 indicators were discarded, while 19 were definitely selected after the home assignment, and 22 were proposed for discussion during the meeting; 12 of these survived the selection round. The final minimal indicator set for palliative care consists of 5 indicators about the physical aspects of care; 6 about the psychosocial aspects of care; 13 about information, communication, and care planning; 5 about type of care; and 2 about continuity of care.
Conclusion: A minimal set of 31 indicators reflecting all the important issues in palliative care was created for palliative care services to assess the quality of their care in a quick and efficient manner. Additional topic-specific optional modules are available for more thorough assessment of specific aspects of care.
D'après cette étude, les aidants familiaux n'ont souvent pas conscience que leur proche a une démence (dans 1/4 des cas de démence et dans 1/5 des cas de démence avancée), posant des défis considérables pour fournir des soins optimaux et prendre des décisions de fin de vie adaptées. Considérant que les aidants familiaux des résidents qui développent une démence tardivement après l'admission en maison de retraite médicalisée sont moins susceptibles d'en être conscients, il y a une marge dans l'amélioration des stratégies de communication.
Interprétation des résultats d'une étude réalisée auprès de médecins belges des Flandres, dont l'objectif était l'estimation de l'euthanasie (sur demande explicite des patients), du suicide médicalement assisté ainsi que d'autres pratiques dans les décisions de fin de vie.
Il en ressort que la fréquence des fins de vie médicalement assistées est similaire à celle opérée aux Pays-Bas mais moindre qu'en Australie. Cependant, le taux d'administration de doses létales sans accord explicite du patient reste égal à celui de l'Australie et bien plus important qu'aux Pays-Bas.
Les auteurs ont examiné dans quelle mesure les patients nouvellement diagnostiqués avec un cancer du poumon avancé voulaient être informés et
impliqués dans la prise de décision médicale. L'étude a aussi cherché à savoir si les patients sentaient que leurs préférences avaient été respectées. Pour cela, des patients de 13 hôpitaux en Flandre ont été interrogés.
L'étude conclue que les préférences de ces patients concernant les informations sur des sujets délicats et une prise de décision partagée avec le médecin n'étaient pas été bien remplies.
Cette étude transversale menée auprès de 67 hôpitaux de soins aigus en Flandre a pour but de rapporter l'existence et la nature des politiques de fin de vie menées dans ces établissements. Plusieurs critères servent de repères pour cette étude : la communication autour des décisions, la présence de formations en soins spécialisés pour la fin de vie et l'usage de critères de mesure de satisfaction à destination des patients.
Compte-rendu et résultats d'une étude portant sur les changements survenus, durant le processus de légalisation de l'euthanasie en Belgique de 1998 à 2001, dans les décisions médicales en fin de vie ayant pour effet possible ou certain d'abréger la vie, sur un échantillon aléatoire représentatif de décès enregistrés durant cette période à l'état civil en Flandres.
Compte-rendu et résultats d'une étude portant sur les changements survenus, durant le processus de légalisation de l'euthanasie en Belgique de 1998 à 2001, dans les décisions médicales en fin de vie ayant pour effet possible ou certain d'abréger la vie, sur un échantillon aléatoire représentatif de décès enregistrés durant cette période à l'état civil de Flandres.
Cette enquête a été réalisée sous forme de questionnaire anonyme envoyé à ces pharmaciens un mois avant le vote parlementaire belge de la loi sur l'euthanasie. A partir de 359 réponses, différents thèmes ont été analysés: opinions sur l'euthanasie et le suicide médicalement assisté, expériences en rapport avec la délivrance de médicaments prescrits par les médecins, intérêt envers les guides de recommandations professionnelles, réactions à trois cas exemplaires. Des tableaux statistiques illustrent ces résultats.