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Advance Care Planning(ACP)has long been a staple of caring for people with serious illness. Over its history, it has been defined in different ways. Clinicians, researchers, patients, and the public have developed a variety of perspectives about the many aspects of ACP, ranging from the definition to the timing, goals, outcomes, and value of ACP. To better understand the challenges and opportunities for ACP, acknowledge and highlight divergent viewpoints, and examine what is empirically known and not known about ACP and its outcomes, the National Academies of Sciences, Engineering, and Medicine's Roundtable on Quality Care for People with Serious Illness hosted a virtual public workshop, Advance Care Planning: Challenges and Opportunities, on October 26 and November 2, 2020. The workshop explored the paradox of ACP, its evidence base, ways to think differently about ACP, and various approaches to making it more effective.This Proceedings of a Workshop summarizes the presentations and discussions from that workshop.
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For patients and their loved ones, no care decisions are more profound than those made near the end of life. Unfortunately, the experience of dying in the United States is often characterized by fragmented care, inadequate treatment of distressing symptoms, frequent transitions among care settings, and enormous care responsibilities for families. According to this report, the current health care system of rendering more intensive services than are necessary and desired by patients, and the lack of coordination among programs increases risks to patients and creates avoidable burdens on them and their families. Dying in America is a study of the current state of health care for persons of all ages who are nearing the end of life. Death is not a strictly medical event. Ideally, health care for those nearing the end of life harmonizes with social, psychological, and spiritual support. All people with advanced illnesses who may be approaching the end of life are entitled to access to high-quality, compassionate, evidence-based care, consistent with their wishes. Dying in America evaluates strategies to integrate care into a person- and family-centered, team-based framework, and makes recommendations to create a system that coordinates care and supports and respects the choices of patients and their families. The findings and recommendations of this report will address the needs of patients and their families and assist policy makers, clinicians and their educational and credentialing bodies, leaders of health care delivery and financing organizations, researchers, public and private funders, religious and community leaders, advocates of better care, journalists, and the public to provide the best care possible for people nearing the end of life.
ACP is an essential part of end of life care with patients improving their chances of 'a good death' by creating plans with their families and carers. This new edition gives a comprehensive overview of ACP, explores a wide range of issues and practicalities in providing end of life care, and offers a worldwide perspective.
"This is a very substantive book that encompasses the various aspects of advance care planning, both prior to and after a diagnosis of a life-limiting disease. The realistic case studies help readers understand the complexities of decision-making by the individual and the family."--Doody's Medical Reviews While advance directives hold a great deal of promise for ensuring self-determination and quality of life near its end, the majority of Americans face life-threatening illness without having completed effective advance care planning.. This volume recounts the history of advance directives, chronicling the evolution of an approach that initially focused on completing forms, to one that now emphasizes more comprehensive strategies for facilitating conversations about end-of-life care and planning for dying and death. It provides helpful strategies for initiating and guiding discussions among providers, patients, and their loved ones, easing the burdens of uncertainty, and improving the efficacy of surrogate decision making near the end of life. Scholars and practitioners from a variety of disciplines provide a well-rounded view of the history and challenges of advance directives. Authors include palliative care physicians, nurses, social workers, grief counselors, educators, lawyers, psychologists, sociologists, and medical ethicists. The book shares successful strategies on how effective advance care planning can provide smoother transitions at the end of life and ensure better quality of living before death. It incorporates effective multidisciplinary, relationship-based models of advance care planning along with multidisciplinary perspectives to help caregiving professionals initiate conversations and disseminate relevant information to patients and their loved ones and advocates. Case studies illustrate the importance of, challenges with, and prospects for advance directives and advance care planning. The book addresses common barriers to advance care planning and offers ways to overcome them, as well as detailing public health, legal, and comprehensive community planning approaches to change how our current American society deals with dying, death, and end-of-life care. Key Features: Introduces a multidisciplinary, pragmatic approach to advance care planning Addresses strategies to reform advance care planning Presents case studies illustrating the importance, benefits, and challenges of advance directives Features successful initiatives in advance care planning and new directions that shift community practice related to dying, death, and end-of-life care. Includes the contributions of physicians, grief counselors, medical ethicists, social workers, psychologists, medical ethicists, lawyers, nurses, educators, and others
Congenital heart disease with its worldwide incidence of 1% is themost common inborn defect. Increasingly, patients are living intoadulthood, with ongoing congenital heart and other medical needs.Sadly, only a small minority have specialist follow-up. However,all patients see their family doctor and may also seek advice fromother health professionals. This practical guide with its straightforward a,b,c approach iswritten for those professionals. Special features of this book: • Introduces the principles of congenital heart diseaseand tells you whom and when to refer for specialist care • Discusses common congenital heart lesions in a practical,easy-to-follow way, with an emphasis on diagnosis and managementissues • Includes an extensive chapter on 'Pregnancy andContraception' (by Philip J. Steer), essential both for familyplanning and for managing safely the pregnant woman with congenitalheart disease • Includes chapters on non-cardiac surgery and lifestyleissues such as work, insurability, travel and driving • Provides invaluable information on dealing with commonemergencies; what to do and what not to do With a wealth of illustrations (including diagrams, EKGs, CXRs,Echos and cardiac MRIs) and with key point tables, this is anessential guide for all health care professionals managing patientswith adult congenital heart disease.
Meeting the Needs of Older Adults with Serious Illness: Challenges and Opportunities in the Age of Health Care Reform provides an introduction to the principles of palliative care; describes current models of delivering palliative care across care settings, and examines opportunities in the setting of healthcare policy reform for palliative care to improve outcomes for patients, families and healthcare institutions. The United States is currently facing a crisis in health care marked by unsustainable spending and quality that is poor relative to international benchmarks. Yet this is also a critical time of opportunity. Because of its focus on quality of care, the Affordable Care Act is poised to expand access to palliative care services for the sickest, most vulnerable, and therefore most costly, 5% of patients- a small group who nonetheless drive about 50% of all healthcare spending. Palliative care is specialized medical care for people with serious illnesses. It focuses on providing patients with relief from the symptoms, pain, and stress of a serious illness—whatever the diagnosis or stage of illness. The goal is to improve quality of life for both the patient and the family. Research has demonstrated palliative care’s positive impact on health care value. Patients (and family caregivers) receiving palliative care experience improved quality of life, better symptom management, lower rates of depression and anxiety, and improved survival. Because patient and family needs are met, crises are prevented, thereby directly reducing need for emergency department and hospital use and their associated costs. An epiphenomenon of better quality of care, the lower costs associated with palliative care have been observed in multiple studies. Meeting the Needs of Older Adults with Serious Illness: Challenges and Opportunities in the Age of Health Care Reform, a roadmap for effective policy and program design, brings together expert clinicians, researchers and policy leaders, who tackle key areas where real-world policy options to improve access to quality palliative care could have a substantial role in improving value.
This comprehensive guide thoroughly covers all aspects of neuropalliative care, from symptom-specific considerations, to improving communication between clinicians, patients and families. Neuropalliative Care: A Guide to Improving the Lives of Patients and Families Affected by Neurologic Disease addresses clinical considerations for diseases such as dementia, multiple sclerosis, and severe acute brain injury, as well discussing the other challenges facing palliative care patients that are not currently sufficiently met under current models of care. This includes methods of effective communication, supporting the caregiver, how to make difficult treatment decisions in the face of uncertainty, managing grief, guilt and anger, and treating the pain itself. Written by leaders in the field of neuropalliative care, this book is an exceptional, well-rounded resource of neuropalliative care, serving as a reference for all clinicians caring for patients with neurological disease and their families: neurologists and palliative care specialists, physicians, nurses, chaplains, social workers, as well as trainees in these areas.
Advance Care Planning (ACP) refers to the communication of decisions regarding end-of-life treatment decisions prior to incapacitation. ACP has been associated with better health outcomes at the end of life such as less aggressive care prior to death, improved bereavement outcomes, earlier acceptance of a terminal condition and earlier acceptance of palliative care and hospice. The completion and documentation of ACP in the Electronic Health Record (EHR) is important so that end-of-life treatment decisions can be honored when patients are unable to speak for themselves. This process is multi-faceted and burdened with inconsistencies. Through three related studies, this dissertation used Donabedian's Structure, Process, and Outcome model as a framework for understanding the problem. Study one focused on the structural component of the EHR as it relates to the functionality and documentation of ACP. Results from a survey of over 400 end-of-life physicians indicated a mutual understanding of the importance of ACP documentation in the EHR coupled with critical challenges. Specific challenges included a lack of time and training. Having a consistent tab or area within the EHR was cited as a specific opportunity for facilitating the completion of ACP in the EHR. Study two analyzed the association between several process-related predictors and the completion of ACP documentation in the EHR. Findings indicated that older adults (over age 70) were less likely to have several process-related components of ACP and more likely to operationalized elements of ACP such as a verified Do Not Resuscitate (DNR) order. These findings indicate that there may be a gap in comprehensive communication with older adults, and they are more likely to have a DNR without documentation of a prior conversation or a scanned document in the medical record. Study three examined the association between outcomes and the documentation of ACP in the EHR. Findings indicate that having a DNR documented in the EHR and having an ACP note in the problem list are associated with reduced odds of an admission in the last 30 days of life. Having ACP documentation in the EHR was not associated with reduced charges at the end of life. The results of this dissertation may be used to strengthen the case that improvement in the documentation and functionality of ACP in the EHR is required. There are several key practical considerations resulting from these studies that could be applied in the form of local quality improvement initiatives aimed at improving consistency in documentation. Other implications from these studies point toward continuing to support efforts to reimburse physicians for ACP conversations and improving standardized end-of-life communication training requirements for all clinicians.