Advance care planning is a conversation about personal values, future treatment choices, and designation of a surrogate decision-maker, that someone has in advance of a health crisis. Most existing studies on advance care planning have taken place outside of home health among populations with HIV/AIDS, cancer, dementia, and end stage renal disease. The U.S. home health population is living longer with chronic conditions such as pulmonary and cardiovascular illnesses, and hospitalization is a poor outcome. In 2016, Medicare implemented the Home Health Value-Based Purchasing Model, in which reimbursement rates for agencies in 9 regionally representative states were dependent on quantitative measures of quality performance. Part of the program was a process-level mandate requiring agencies to report on advance care planning. The aim of this study was to examine the relationship of home health advance care planning protocols with hospitalization rates. Descriptive and regression analyses were conducted on survey data of protocols and agency data of demographics and outcomes. Statistical significance was found in the positive correlation between advance care planning protocols and hospitalization. Recommendations are made for broadening the scope of evaluation of quality in home health to include goal-concordant care and transitions to appropriate services.

Background: Globally, cancers are the second leading cause of death. When the cancer can no longer be cured, the care can be re-focused to palliative care. It is then important for patients to be able to participate and influence their care, and the quality of life for patients improves. Advance care planning is a person-centered process, through for example conversations, that supports patients at different stages of health to understand and share their values, life goals and preferences about their future care. Aim: The purpose of this literature review is to describe views on advance care planning in patients with a cancer diagnosis.Method: Literature review based on 16 peer-reviewed qualitative articles that … via specific criteria, these have been quality reviewed, analyzed with thematic analysis, and compiled into a result. Searches were conducted in CINAHL, PubMed and PsycInfo. Results: Advance care planning (ACP) is associated with both positive and negative emotions linked to conducting the conversation, how the conversation is structured, and involving others in the conversation. Three main themes and 7 sub-themes emerged: (1) Views on participating in conversation - Positive to conversation; Negative to conversation. (2) Views on content and execution - The importance of information and how it is presented; The decision-making process. (3) Views on the role of others in the process - Family and other close relatives or friends; Healthcare staff; Spiritual support. Conclusion: Our conclusion is that patients believe that this is an important topic that needs to be addressed more, not only in palliative care but also before patients are in need of palliative care. It is important for the nurse to find out if the patient is ready for conversations, to contribute with the information the patient needs, to support the patient in the decisions they make, and to include relatives in the conversations if the patient so wishes.

Advance directives in Canada are instructions made by capable adults that pertain to future healthcare treatment choices at a time of incapacity. My experience as an ethicist working in an Ontario long-term care facility that provides medical treatment to patients with Alzheimer’s Dementia portrays a range of important ethical concerns that arise out of the use of advance directives, at least in terms of their current use. In this thesis I analyze composite case studies to identify the more prominent challenges that exist and I turn to the literature to seek ways to more clearly understand these problems and to determine if they can be overcome. What I conclude is that the use of advance directives with the Alzheimer’s Dementia population in long-term care, as it is currently used, is fraught with problems that are mainly irresolvable. I offer clinical and policy recommendations that are aligned with this view.

Advance directives in Canada are instructions made by capable adults that pertain to future healthcare treatment choices at a time of incapacity. My experience as an ethicist working in an Ontario long-term care facility that provides medical treatment to patients with Alzheimer’s Dementia portrays a range of important ethical concerns that arise out of the use of advance directives, at least in terms of their current use. In this thesis I analyze composite case studies to identify the more prominent challenges that exist and I turn to the literature to seek ways to more clearly understand these problems and to determine if they can be overcome. What I conclude is that the use of advance directives with the Alzheimer’s Dementia population in long-term care, as it is currently used, is fraught with problems that are mainly irresolvable. I offer clinical and policy recommendations that are aligned with this view.

The purpose of this article is to synthesize the evidence on advance care planning (ACP), determine what is applicable to the home health (HH) setting, and find where gaps in knowledge may exist. An integrative review methodology was chosen. Although there is ample literature on the topic of ACP, most research has been conducted in the acute care, outpatient, and general community settings. There is limited literature regarding ACP with patients living with chronic cardiovascular and pulmonary illnesses, who comprise the majority of the HH population. Some literature has been published regarding the interprofessional team's role in ACP in the HH setting. A gap in knowledge exists regarding ACP in HH, and recommendations for future research are provided.

The number of individuals aged more than 65 years in the United States and their life expectancy has been increasing in the past decades. In spite of the presence of federal and accreditation policies recommending completion of advance directive documents by patients admitted to health care settings, advance directive completion rates are low in most health care organizations. The purpose of this study was to determine the level of advance directive completion among home health patients. The health belief model provided the theoretical framework that guided this study. A retrospective chart review was carried out in a home health agency with about 51 patients. Demographic details, including age, gender, ethnicity, nature of illness and type of health insurance were collected. Descriptive statistics were used to determine the percentage of home health patients with existing advance directives and those who do not have an advance directive. The study revealed that only 25% of the patients in the home health care agency had a completed advance directive. The finding indicate a disconnect between the recommended and the actual practice with regards to end of life issues. There is a pressing need for more complete documentation of the patient's desires and wishes regarding end of life care at home health care facilities. Documenting the patient's end of life preferences and wishes may potentially ease the decision-making process, making the end of life days less stressful for the patients and their families at the same time promoting the provision of personalized health care at the end of life.

The purpose of this article is to synthesize the evidence on advance care planning (ACP), determine what is applicable to the home health (HH) setting, and find where gaps in knowledge may exist. An integrative review methodology was chosen. Although there is ample literature on the topic of ACP, most research has been conducted in the acute care, outpatient, and general community settings. There is limited literature regarding ACP with patients living with chronic cardiovascular and pulmonary illnesses, who comprise the majority of the HH population. Some literature has been published regarding the interprofessional team's role in ACP in the HH setting. A gap in knowledge exists regarding ACP in HH, and recommendations for future research are provided.

BACKGROUND: Studies have consistently demonstrated low rates of adoption of Advance Care Planning in the community. METHODS: We studied Medicare enrollees age 65 and over and non-Medicare patients using a cross-sectional survey undertaken in February and March 2019 using questionnaires completed by out-patients attending a teaching hospital clinic in East Tennessee USA. We evaluated patient knowledge, attitudes, satisfaction and aspirations towards Advance Care Planning. RESULTS: 141 properly completed questionnaires were used. All Medicare enrollees were aware of Advanced Care Planning compared to 43% in the non-Medicare group. 70% of the Medicare enrollees and 94% of non-Medicare group were not ready to complete a written Advanced Care Plan. Of the respondents, 46% had appointed spouses, 24% adult children, 11% siblings, 10% parents, 3.6% friends and 1.2% aunts as their surrogate medical decision makers. 41% agreed that they were satisfied with their current advance care planning arrangements. This research identified that individual's knowledge, attitudes and aspirations influenced the adoption of Advance Care. CONCLUSIONS: Patients have adopted the Advance Care Plan concept but have modified it to reduce their concerns by using family and loved ones to convey their wishes instead of filling the required legal documents. Clinicians could improve this informal system and increase the observability of the treatment choices including the use of video and web-based tools.

Aim. The aim of this study was to examine the relationship of advance care planning protocols with hospitalization, rehospitalization, and emergency department use rates in U. S. home health agencies (HHA). Background. Since 2003, CMS has required HHAs to report on quality outcomes such as hospitalization, rehospitalization, and emergency department use rates, made publicly available online. Advance care planning (ACP) is a conversation about beliefs, goals, values, future treatment choices, and designation of a surrogate decision-maker, that someone has in advance of a health crisis. Most existing studies on ACP have taken place outside of HHAs among populations with serious illnesses such as HIV/AIDS, cancer, dementia, and end stage renal disease. Meanwhile, the U.S. home health population is living longer with chronic conditions such as pulmonary and cardiovascular illnesses. Effective January 1, 2016, the Center for Medicare and Medicaid Innovation implemented the Home Health Value-Based Purchasing (HHVBP) Model among home health agencies (HHAs) in nine states representing each geographic region in the United States. Agencies in these states began competing on value in the HHVBP model, and reimbursement rates began to be tied to quality performance (innovation.cms.gov). As part of HHVBP, CMS implemented an additional process-level mandate requiring them to report on ACP, though this data is not publicly available. It is currently unknown how ACP protocols in HHAs may affect agencies’ overall rates of acute care services use. Methods. Electronic surveys about ACP protocols were distributed to HHAs. Existing data about demographics, diagnoses, hospitalization, rehospitalization, and ED use were accessed online via CMS websites. Descriptive and regression analyses were conducted using the electronic survey results and the existing data. Results. Associations between the variables were observed and compared to the hypotheses. Statistical significance was found in the relationship between ACP protocols and hospitalization, where one increased the other increased. Several trends were found: Agencies with increased total percentage of cardiac and pulmonary diagnoses tended to have increased hospitalization rates; agencies with increased average age of patients tended to have increased ACPP scores; and agencies with increased proportion of Black patients tended to have higher hospitalization rates.

En raison des multiples choix de traitements qui prolongent la vie, les décisions en matière de soins sont complexes pour les patients en oncologie. La planification préalable des soins (PPS), qui commence dès le diagnostic, permet de réfléchir et de communiquer ses valeurs et ses volontés en ce qui concerne les soins à venir, surtout en situation d’inaptitude. Particulièrement à la suite des changements législatifs au Québec avec la Loi concernant les soins de fin de vie (Éditeur officiel du Québec, 2014), il est important de pouvoir décrire l’expérience des professionnels de la santé avec cette clientèle. Cette étude a pour but d’explorer la perception des infirmières face à la PPS avec les personnes hospitalisées vivant avec un cancer. Comme cadre de référence, le présent mémoire s’appuie sur le Modèle humaniste des soins infirmiers UdeM (Cara et al., 2016). Dans le cadre de cette étude qualitative descriptive interprétative, des entretiens individuels semi-structurés ont eu lieu auprès d’infirmières (n=7) travaillant sur une unité de soins desservant une clientèle hospitalisée en oncologie et en soins palliatifs. Les résultats révèlent une confusion sur la PPS et une association de celle-ci avec les discussions de fin de vie. Pour les infirmières, la PPS est perçue comme un défi, qui est plus facilement surmonté quand l’état de santé se détériore. Des facteurs d’influence par rapport à la personne, l’environnent et le soin sont aussi décrits. La particularité de l’étude est le point de vue des infirmières sur une unité de soins dans le contexte québécois. / Oncology patients face increasingly complex care decisions because of the multiple treatment options that extend life. Advance care planning that begins early allows the patients to reflect and communicate their values and wishes regarding future care, especially when unable to do so. Particularly following the legislative changes in Quebec concerning end-of-life care, it is important to be able to describe nursing experience in ACP with oncology clientele. The purpose of this study is to explore the nurses’ perception of advance care planning (ACP) with hospitalized cancer patients. It is based on the framework of the Humanistic Model of Nursing Care – UdeM (Cara et al., 2016). For this qualitative study of interpretive description, individual semi-structured interviews were conducted with nurses (n = 7) working on a unit taking care of patients in oncology and in palliative care services. The results reveal nurses’ confusion about ACP and a direct association with the end-of-life discussion. For oncology nurses, ACP is a challenge, which is more easily overcome when their patient’s health condition deteriorates. Influencing factors in relation to the person, the environment and the care are also described in the results. The unique feature of this study is the nurses' point of view, in the context of inpatient oncology in Quebec.