간호사의 사전돌봄계획에 대한 인식, 태도 및 참여여부

이상민 중앙대학교 대학원 2022 국내석사

Purpose: Advance care planning helps patients with life-threatening illnesses receive care that they wanted or would have wanted at the end of life. Nurses are expected to play important roles in advance care planning, but little is known about how prepared to assist patients or surrogates in advance care planning and whether they participate in advance care planning at work. Thus, this study aimed to identify nurses’ awareness of, attitudes toward, and participation in advance care planning, as well as related facilitators and barriers. Also, this study examined differences in such awareness, attitudes, participation, facilitators, and challenges by types of healthcare institutions. Methods: This study was a descriptive study using a survey of 498 nurses from primary, secondary, and tertiary healthcare institutions and long-term care institutions. A self-developed questionnaire included five domains: (a) nurses’ general characteristics; (b) awareness of advance care planning; (c) attitudes toward advance care planning; (d) participation in advance care planning; and (e) facilitators and barriers to having advance care planning with patients or surrogates. The collected data were analyzed using frequency, percentage, mean, standard deviation, chi-square test, binary logistic regression, and one-way ANOVA. Results: 1) Forty-nine percent of participants had heard of advance care planning. Among them, 33.2% responded that they were able to explain types and procedures of advance care planning. Approximately, 76% of participants answered that it was necessary to designate a health care agent, but only 31.5% of them perceived that that they were able to explain procedures of designating health care agents. About 71% and 65% of participants responded that they had heard of an advance directive (AD) and a physician order for life-sustaining treatment (POLST), respectively; however, 28.5~45.7% of them perceived that they could explain procedures to fill out each form or alter or withdraw completed documents. However, most participants showed positive attitudes toward advance care planning, such as a willingness to participate in advance care planning (61.2%), recommend advance care planning to patients and surrogates (51.4%), and receive education about advance care planning (76.9%). There were statistically significant differences in participants’ awareness of advance care planning by types of medical institutions. Compared to those from tertiary healthcare institutions, nurses from primary and secondary healthcare institutions and long-term care institutions were less likely to be aware of advance care planning, AD, and POLST. 2) Approximately, 25% of nurses had experiences of explaining advance care planning to patients or their surrogates. Participants who had experiences of checking the presence of surrogates and completed AD or POLST accounted for 36.7~47.4%. However, only 9.2~35.7% of participants had experiences of explaining procedures to designate health care agents or complete AD or POLST or assisting patients to designate health care agent or alter or withdraw the completed documents. Particularly, compared to those from tertiary healthcare institutions, participants from secondary healthcare institutions had lower odds of checking the presence of AD (OR 0.46, p<.01) and POLST (OR 0.37, p<.001), assisting patients to alter or withdraw the completed AD (OR 0.52, p<.05), and explaining procedures to completed POLST (OR 0.62, p<.05). 3) Among the factors promoting nurses' participation in advance care planning, the highest priority was given to nurses' high understanding of advance care planning (average priority rank 2.41±1.34). Nurses’ positive experiences regarding death and dying was marked in a higher priority among participants from primary healthcare institutions (3.24±1.55) and long-term care institutions (3.73±1.21) than those from tertiary (3.91±1.47) and secondary healthcare institutions (3.94±1.33), with statistical significance (F=4.96, p<.01). On the other hand, the highest priority in barriers to nurses’ participation in advance care planning was given to lack of time due to excessive workload (2.58±1.90) and lack of patients’ and families’ understanding of end-of-life care (3.22±1.58). The absence of appropriate institutional guidelines and policies related to advance care planning was marked in a lower priority among participants from tertiary healthcare institutions (4.19±1.66) than those from primary and secondary healthcare institutions and long-term care institutions, with statistical significance (F=6.37, p<.001). Conclusion: Nurses' awareness of advance care planning, including health care agents, AD, and POLST, was generally low, and they had little experience of participating in advance care planning. Considering nurses' willingness to participate in advance care planning and receive education about advance care planning and their high understanding of advance care planning as a facilitator, educational programs about advance care planning should be developed for nurses. In addition, as the excessive workload of nurses and lack of knowledge about end-of-life care among patients and surrogates are barriers, it is necessary to supplement nurses, including those in charge of advance care planning and provide patients and surrogates with educational programs regarding advance care planning. 연구 목적: 최근 생애 말 치료와 관련하여 환자의 자기 결정권을 존중하기 위한 사전돌봄계획의 중요성이 대두되고 있다. 특히 다양한 의료 현장에서 간호사가 사전돌봄계획에 참여했을 때 많은 긍정적인 환자결과들을 야기할 것이라 기대되고 있으나 간호사의 사전돌봄계획 참여 실태를 확인할 수 있는 국내 연구가 부족한 실정이다. 본 연구의 목적은 간호사의 사전돌봄계획에 대한 인식과 태도, 참여여부를 파악하고 간호사가 사전돌봄계획에 참여하는데 있어서 촉진요인과 방해요인이 무엇인지를 확인하며, 의료기관 유형에 따라 그 차이를 파악하기 위함이다. 연구 방법: 본 연구는 서술적 조사연구로서 연구 대상은 1차, 2차, 3차 의료기관 및 장기요양기관의 간호사 498명을 대상으로 시행하였다. 구조화된 설문지를 통해 사전돌봄계획에 대한 인식 및 태도, 참여여부와 사전돌봄계획에 참여하는데 있어서 촉진요인과 방해요인이 무엇인지를 조사하였다. 수집된 자료는 빈도, 백분율, 평균, 표준편차, Chi-square test, Binominal logistic Regression, One-way ANOVA로 분석하였다. 연구 결과: 1) 사전돌봄계획에 대한 들어본 적이 있는 간호사는 불과 49.0%로, 이 중 33.2%만이 사전돌봄계획의 종류와 절차에 대해 설명할 수 있다고 응답하였다. 간호사의 76.5%는 대리인 선정이 필요하다고 하였으나, 이 중 31.5%만이 대리인 선정의 절차에 대한 설명할 수 있다고 하였고, 사전연명의료의향서와 연명의료계획서에 대해 들어본 적이 있다고 응답한 간호사는 각각 71.1%, 65.5%였으나, 이 중 각 양식을 작성하는 절차나 이미 작성된 문서를 변경 또는 철회하는 절차에 대해 설명할 수 있다고 응답한 간호사는 28.5%~45.7%였다. 또한, 사전연명의료의향서와 연명의료계획서의 차이점에 대해 설명할 수 있다고 응답한 간호사는 전체 간호사의 35.6%이었다. 하지만, 사전돌봄계획에 참여할 의사(61.2%)나 환자나 보호자(대리인)에게 사전돌봄계획을 권장할 의사(51.4%), 사전돌봄계획에 대해 교육받을 의사(76.9%)와 같은 사전돌봄계획에 대한 간호사의 태도는 비교적 높게 나타났다. 간호사의 사전돌봄계획에 대한 인식에서 의료기관 유형에 따른 차이를 보였는데, 3차의료기관에 비해 1ㆍ2차 의료기관과 장기요양기관 간호사에게서 사전돌봄계획, 사전연명의료의향서, 연명의료계획서에 대한 인식이 낮게 나타났다. 2) 사전돌봄계획에 대한 간호사의 참여경험의 경우, 간호사의 24.5%만이 환자나보호자에게 사전돌봄계획에 대해 설명한 경험이 있었다. 환자에게 지정된 대리인이 있는지, 사전연명의료의향서나 연명의료계획서 작성여부에 대한 확인을 해본 적이 있다고 응답한 간호사는 36.7~47.4%였으나, 직접 대리인 지정 절차나 사전연명의료의향서나 연명의료계획서를 작성 절차에 대해 설명하거나 대리인 지정을 도와주고, 변경ㆍ철회의사를 확인하고 변경ㆍ철회를 도와준 경험은 9.2~35.7%로 적었다. 의료기관 유형별로 3차 의료기관 간호사에 비해 2차 의료기관 간호사에게서 환자의 사전연명의료의향서 작성 여부 확인 경험(OR 0.46, p<.01), 변경ㆍ철회를 도와준 경험(OR 0.52, p<.05), 연명의료의향서 작성 여부를 확인한 경험(OR 0.37, p<.001), 작성절차를 설명한 경험(OR 0.62, p<.05)이 적게 나타났다. 3) 간호사의 사전돌봄계획 참여를 촉진하는 요인들 중에 간호사의 사전돌봄계획에 대한 높은 이해도(평균 순위 2.41±1.34)가 가장 우선순위가 높은 것으로 나타났다. 생애말기 또는 죽음에 대한 간호사의 긍정적 경험의 경우 3차 의료기관(9.91±1.47), 2차 의료기관(3.94±1.33)에 비해 1차 의료기관(3.24±1.55), 장기요양기관(3.73±1.21)에서 우선순위가 높게 나타났으며 그룹 간 유의한 차이를 보였다(F=4.96, p<.01). 반면, 간호사의 사전돌봄계획 참여를 방해하는 요인들 중, 과도한 업무량으로 인한 시간부족(2.58±1.90)과 환자와 가족의 생애말 돌봄에 대한 지식과 이해부족(3.22±1.58)이 가장 높은 우선순위로 나타났다. 기관의 적절한 지침 및 정책 부재의 경우, 다른 의료기관에 비해 3차 의료기관(4.19±1.66)에서 우선순위가 더 낮게 나타났으며 그룹 간 유의한 차이를 보였다(F=6.37, p<.001). 결론: 대리인 지정, 사전연명의료의향서, 연명의료계획서를 포함하는 사전돌봄계획에 대한 간호사의 인식은 전반적으로 낮았고, 사전돌봄계획에 직접 참여한 경험도 적었다. 간호사의 사전돌봄계획에 대한 참여 의사와 교육받을 의사가 높은 점과 간호사의 사전돌봄계획에 대한 높은 이해도와 양질의 의사소통기술이 환자 및 보호자와의 사전돌봄계획을 촉진시키는 요소인 점을 고려하여, 간호사를 대상으로 한 사전돌봄계획에 대한 교육프로그램의 개발이 필요하다. 또한 간호사의 과도한 업무량과 환자와 보호자의 생애말 돌봄에 대한 지식부족이 방해요인인 점을 고려하여 사전돌봄계획 전담 인력를 포함하여 간호사 인력 보충과 환자 및 보호자를 대상으로 한 사전돌봄계획에 대한 교육프로그램 또한 필요하다.

“It's Not Something That’s Really Been Brought Up”: Advance Care Planning Among Individuals Living with Mechanical Circulatory Support

Dzou, Tiffany ProQuest Dissertations & Theses University of Cali 2021 해외박사(DDOD)

Despite the well-established evidence about catastrophic complications in individuals living with durable mechanical circulatory support, little is known about the decision-making processes in advance care planning for this population. While findings from current studies give insights into clinicians’ attitudes and protocol development to integrate palliative care specialists in advance care planning, these results do not describe the patients’ experiences in managing the uncertain outcomes of living with durable mechanical circulatory support. Therefore, this dissertation research explored the personal experiences of individuals living with mechanical circulatory support to analyze how their complex disease trajectories impact decision-making about advance care planning.Constructivist grounded theory guided all aspects for this dissertation. In-depth interviews, using a semi-structured guide to navigate the conversations, were conducted with 24 individuals who were implanted with durable mechanical circulatory support devices. Systematic analysis of the interview transcripts led to the identification of emergent categories and the development of the Theory of Pivoting Uncertainties, a situation-specific theory. The first paper, a systematic literature review, points to the dearth of ongoing ACP communication and the potential for nurses to provide primary palliative care for the MCS population. Consistent with the findings from the literature review, the paucity of ACP communication continued to be evident within the sample of participants. In the first data-based paper, participants’ perceptions of opportunities for ongoing advance care planning conversations were elucidated in four categories: 1) identifying the optimal context and timing for advance care planning; 2) sharing information with key stakeholders; 3) examining their understanding of advance care planning, and 4) assessing satisfaction with the information that had been received. These four categories were interrelated and occurred simultaneously to present ongoing opportunities for advance care planning across the mechanical circulatory support trajectory. In the second data-based paper on the Theory of Pivoting Uncertainties describes the process of decision-making about advance care planning in the context of living with mechanical circulatory support. Within the core category of complexities in decision-making about advance care planning, there were three dynamic subcategories: 1) impediments; 2) uncertainties; and 3) promoters. Collectively, the subcategories in the Theory of Pivoting Uncertainties gave insight into participants’ patterned responses towards these uncertainties and ultimately decision-making around ACP.These insights into the experiences of the complicated disease trajectories among individuals with mechanical circulatory support evidence their growing awareness of the uncertainties of living. The awareness of uncertain outcomes holds the potential for clinicians to engage individuals in sensitive advance care planning conversations. Additionally, the current sample highlight the need for clinicians, including MCS-trained clinical nurses and MCS coordinators, to initiate ongoing conversations with mechanical circulatory support individuals and their families. By exploring the firsthand experiences of individuals living with mechanic circulatory support, these findings are useful for informing clinical practice, future research, and policy-making around advance care planning.

Factors related to advance care planning among Korean older adults : an ecological approach

김보라 Graduate School, Yonsei University 2024 국내박사

Introduction: Advance Care Planning (ACP) holds various advantages, including reducing decision-making burdens for healthcare providers and families, minimizing futile life-sustaining treatments, enhancing the quality of end-of-life care for older adults, and preventing unnecessary healthcare expenditures. With increasing societal attention to dignified and comfortable end-of-life care in Korea, the Life-sustaining Treatment Decisions Act was enacted in 2018, fostering a culture of self-determination in end-of-life care planning. However, in Korea, ACP is still a relatively unfamiliar concept. Instead, emphasis is often placed solely on components like completing advance directives (ADs), thus neglecting the designation of surrogate decision-makers and discussions surrounding end-of-life care. Furthermore, despite the influence that various environmental factors have on ACP for older adults, previous studies have focused mainly on intrapersonal factors, highlighting the need for research that also considers interpersonal and community factors. Therefore, this study aimed to determine the overall level and subdomains of ACP among Korean older adults, based on the ecological model (McLeroy et al.,1988), and to elucidate the multilevel associations of ecological factors (intrapersonal, interpersonal, and community) with ACP. Methods: This study is a descriptive correlational research project. It was conducted after having translated and performed a content validity verification of the measurement tools for the dependent variable, and a pilot study. The study population consisted of 500 community-dwelling older adults aged 65 years, recruiting 490 participants for the main survey and 10 participants for the pilot study. The pilot study involved a convenient sample from one community center for older adults who were surveyed face-to-face. The main survey was conducted using an online panel company that employed region-based quota sampling to survey 490 older adults through an online questionnaire. The dependent variable, ACP, was measured using the 34-item version of the “Advance Care Planning Engagement Survey” tool developed by Sudore et al. (2017), which was translated through a committee approach. Three translation committee members independently translated the original text. The final translation was developed in meetings with the researcher, as all members considered readability and appropriateness. A doctoral student in Korean literature then reviewed the Korean expressions. Introductory questions were then added to align the questionnaire with Korea’s cultural context. Subsequently, seven experts evaluated the translated version to calculate the content validity index, and necessary revisions were made for translation accuracy and cultural differences, resulting in a Korean version of the ACP measurement tool. Ecological factors included intrapersonal factors (demographic and health-related characteristics, attitudes toward death, eHealth literacy), interpersonal factors (type of household, family cohesion, family communication, social networks), and community factors (residential area, available resources) as independent variables. Data analysis was conducted using STATA 18.0, employing a multilevel analysis to identify ecological factors influencing overall ACP level. Results: The mean score for overall ACP among the 490 participants was 2.63 ± 0.76 out of 5.00. Among the five subdomains, planning regarding specific health conditions and flexibility was particularly low. For intrapersonal factors, higher numbers of diagnosed diseases (β=0.24, p<.001), more positive attitudes toward death (β=-0.03, p=.002), and higher eHealth literacy (β=0.03, p<.001) were associated with a greater level of overall ACP. Regarding interpersonal factors, stronger family cohesion (β=0.02, p=.011), daily interaction with natural support network (β=0.16, p=.041), and higher function of professional support networks (β=0.01, p=.003) were associated with higher overall ACP. In terms of community factors, a greater number of social welfare facilities (β=0.00, p=.030) were associated with a higher level of overall ACP. Conclusion: Through this study’s findings, it became evident that Korea still lags behind the USA and Europe in terms of ACP levels. This is due to limitations in current laws focusing solely on legal documents and cultural discomfort with discussing death. Additionally, it was recognized that older adults’ ACP reflects various social contexts, including interpersonal and community-level factors. Therefore, to activate ACP among Korean older adults, efforts should focus on facilitating discussions with family members to plan for end-of-life care while simultaneously addressing negative attitudes toward death through institutional support. In particular, the guidelines for healthcare providers who continuously manage chronic diseases must include the roles of consulting, registering, and reviewing advance care planning. Additionally, specialized training programs on specific consultation guidelines are required. Moreover, promoting older adults’ active participation in ACP requires a comprehensive approach that considers sociodemographic characteristics, environmental factors, and the individual’s worldview and beliefs. 사전돌봄계획은 의료진과 가족의 의사결정 부담을 감소시키며, 무의미한 연명의료를 줄여 노인의 생애말기 돌봄의 질을 증진하고 불필요한 의료비 지출도 방지하는 등 다양한 측면의 장점을 지닌다. 한국은 존엄하고 편안한 생애말기에 대한 사회적 관심이 높아지면서, 2018년도부터 연명의료결정법이 시행되었고, 본인의 생애말기 돌봄에 대하여 스스로 결정하는 문화가 점차 조성되어 가고 있다. 그러나 한국에서는 사전연명의료의향서 작성과 같이 사전돌봄계획 구성요소의 일부만 강조될 뿐, 의료의사 결정을 위한 대리인의 지정과 생애말기 돌봄에 대한 논의 과정을 포함한 사전돌봄계획은 아직 생소하고 낯선 개념으로 남아있다. 또한 노인의 사전돌봄계획이 다양한 환경적 요인에 의하여 영향을 받음에도 불구하고 선행연구들은 주로 개인 내적 요인에 초점을 두고 있어, 대인관계 및 지역사회 요인까지 한번에 고려한 연구가 필요하였다. 이에, 본 연구는 McLeroy 등(1988)의 생태학적 모형에 기반하여 한국 노인의 사전돌봄계획의 전반적 수준과 하위영역 별 수준을 파악하고, 이에 대한 생태학적 요인(개인 내적 요인, 대인관계 요인, 지역사회 요인)의 다층적 관련성을 규명하고자 하였다. 본 연구는 서술적 상관관계 연구이며, 종속변수 측정을 위한 도구 번역 및 내용 타당도 검증과 예비 조사를 진행한 후에 본 조사를 진행하였다. 연구 대상자는 만 65세 이상이며 한국 지역사회에 거주하는 재가 노인으로, 예비 조사는 경로당 1개소를 이용하는 노인 10인을 편의 표집하여 대면 설문 조사를 시행하였고, 본 조사는 온라인 패널 업체를 통하여 지역 구분에 기반한 할당 표집을 활용하여 노인 490명을 대상으로 온라인 설문 조사를 시행하였다. 종속변수인 사전돌봄계획은 Sudore 등(2017)의 Advance Care Planning Engagement Survey 도구의 34개 문항 버전을 위원회 접근법을 통하여 번역하였다. 번역위원 3인이 원문을 독립적으로 번역한 후에 연구자와의 회의로써 가독성과 번역의 적절성을 고려한 최종 번역본을 마련하고, 이의 한국어 표현에 대하여 국문학과 박사과정생이 검수를 시행하였다. 이러한 과정을 거친 후 한국의 문화적 배경에 맞추어 도입 질문을 추가하였다. 그 후에 이 번역본에 대한 전문가 7인의 평가를 통하여 내용 타당도 지수를 산출하고, 번역의 정확성과 문화적 차이로 보완이 필요한 문항을 수정하여 사전돌봄계획 측정 도구의 한국어판을 완성하였다. 생태학적 요인은 개인 내적 요인(인구사회학적 특성, 건강 관련 특성, 죽음에 대한 태도, 인터넷 건강정보 이해능력), 대인관계 요인(거주 형태, 가족응집성, 가족의사소통, 사회적 관계망), 지역사회 요인(거주 지역, 가용자원)이 독립 변수로 포함되었다. 수집된 자료들은 STATA 18.0 프로그램으로 분석하였고, 사전돌봄계획 전반적 수준에 영향을 미치는 생태학적 요인을 파악하기 위하여 다수준 분석을 이용하였다. 본 조사의 대상자 490명의 사전돌봄계획 전반적 수준의 평균값은 5.00점 만점에 2.63 ± 0.76이었고, 5가지 하위 영역 중에서는 특히 특정 건강 상태에서 중요한 것에 대한 계획 수준과 융통성에 대한 계획 수준이 낮았다. 다수준 분석에 따르면, 개인 내적 요인 중에서 진단받은 질환의 수가 증가할수록(β=0.24, p<.001), 죽음에 대한 태도가 긍정적일수록(β=-0.03, p=.002), 인터넷 건강 정보 이해능력이 높아질수록(β=0.03, p<.001) 사전돌봄계획 전반적 수준이 높은 것으로 나타났다. 대인관계 요인으로는 가족 응집성이 높을수록(β=0.02, p=.011), 자연적 원조관계망과의 상호작용이 매일 존재하는 경우에(β=0.16, p=.041), 전문적 원조관계망의 기능적 특성이 높을수록(β=0.01, p=.003) 사전돌봄계획 전반적 수준이 높았다. 지역사회 요인에서는 노인여가복지시설의 수가 많을수록 (β=0.00, p=.030) 사전돌봄계획 전반적 수준이 높은 것으로 확인되었다. 본 연구의 결과를 통하여 한국은 법적 문서에만 초점을 둔 현행법의 제한점과 죽음을 불편하게 여기는 문화적 특성 때문에 미국이나 유럽에 비하여 사전돌봄계획의 수준이 아직 낮음을 알 수 있었다. 또한 노인의 사전돌봄계획에 노인의 개인 내적 요인뿐만 아니라 대인관계와 지역사회를 포함한 다양한 사회적 맥락이 반영된다는 점을 파악하였다. 따라서 한국 노인의 사전돌봄계획을 활성화하기 위해서는 노인이 가족과의 충분한 대화를 통하여 생애말기에 대한 계획을 세울 수 있도록 함과 동시에, 죽음에 대한 부정적 태도를 완화하는 제도적인 지원이 필요하다. 특히, 만성질환을 지속적으로 관리하는 의료진의 업무지침에 사전돌봄계획의 상담 및 등록, 재검토에 대한 역할을 부여하고 구체적인 상담 가이드라인에 대한 전문적인 교육 프로그램을 제공하는 것이 요구된다. 그리고 노인의 적극적인 사전돌봄계획 참여를 위해서는 인구사회학적 특성 외에도 대상자의 환경적 특성과 대상자의 인생관 및 신념까지 포괄적으로 고려하는 접근이 필요하다.

Advance Care Planning in the Homeless Population

Bakas, Connie Tran ProQuest Dissertations & Theses The University of 2022 해외박사(DDOD)

Purpose: The purpose of this quality improvement project was to increase knowledge of advance care planning and readiness for advance care planning in the Houston, TX homeless population.Background: The homeless population is at higher risk of mortality due to chronic disease burden, poor living conditions, and mental health issues. Although both the general population and the homeless population benefit from advance care planning, many patients do not participate in advance care planning due to provider mistrust, lack of knowledge, and discomfort with the topic.Methods: This quality improvement project used a quantitative pre-intervention and post-intervention survey single group design to assess knowledge of and readiness for advance care planning before and after participation in a 30-minute educational presentation about advance care planning. Participants were conveniently sampled from the Turning Point Center, a transitional housing center in Houston, TX and descriptive statistics and Wilcoxon signed-rank test were used to analyze data.Results: A one-tailed Wilcoxon signed-rank test with α = 0.05 showed a statistically significant improvement for both knowledge assessment questions and one readiness assessment question.Conclusions: There was an improvement in knowledge of advance care planning and its benefits, as well as readiness to talk to decision makers about medical care during sickness and end of life, but no change in readiness to sign official papers documenting end of life wishes or naming health care proxies.

Evaluation of an Advance Care Planning Workshop to Improve the Self-Efficacy of Health Care Providers

Patrick, Joy University of Nevada, Las Vegas ProQuest Dissertat 2022 해외박사(DDOD)

Advance care planning (ACP) involves discussions between the patient and their care providers and those close to them about future care. Every patient is entitled to ACP; however, research has shown that providers do not regularly implement them for various reasons. In addition, multiple barriers may be preventing providers from initiating ACP. Among them are lack of knowledge and confidence, apprehension, time, and fear. This Doctor of Nursing Practice (DNP) addresses the problematic barriers to regular ACP discussions between providers and the patients. Specifically, the purpose of this DNP project is to develop, implement and evaluate an online module to improve healthcare providers' knowledge and self-efficacy in facilitating ACP discussions with their patients. To accomplish the above purpose, an education training which consisted of a pre-test/post-test was conducted. In addition to the education training, an assessment utilizing the ACP-SE survey was administered to measure participants perceived self-efficacy before and after the education. The goal was to improve ACP awareness for health care providers, thereby increasing self-efficacy in facilitating these conversations. The overall results demonstrated positive gains in perceived self-efficacy, knowledge gain, and positive evaluations of the online education training. The implications of this DNP project confirmed there remains a need to educate and build health care workers' self-efficacy as it relates to advance care planning and goals of care discussions. Improving the providers' capacity to facilitate ACP may improve patient-centered communication of end-of-life care discussions.

Proactive Advance Care Planning in Rural Primary Care

Trimble, Chelsea Marie ProQuest Dissertations & Theses University of Kans 2019 해외박사(DDOD)

Relying on a family member to make medical decisions on behalf of a person who is unable to speak for themselves can cause unnecessary stress, cost, and dissatisfaction for both patients and their family. Making decisions without knowing a person’s preference for care often leads to a poorer quality of life and discordant care. Without an advance directive to guide care, family members are left to assume the patient’s wishes which can cause them to second guess a decision. Lack of knowledge and understanding are among the top reasons for not completing advance directives. As part of routine check-ups or well visits, primary care providers have the responsibility to introduce advance care planning to patients while patients are of sound mind and continue this discussion to include caregivers and/or family members. This quality improvement project helped facilitate a new process for beginning the advance care planning conversation in one rural Midwest primary care clinic. Current practices were identified to develop methods for change followed by an eight- week period where educational materials were offered to patients being seen for wellness visits which allowed the provider an opportunity to introduce advance care planning. Ancillary staff helped identify patients meeting inclusion criteria and facilitate a post-educational handout regarding patient satisfaction that was used to measure outcomes of implementing a standardized process.

Impact of life-sustaining treatment plan on healthcare utilization and expenditure at the end of life among patients with cancer

강수현 Graduate School, Yonsei University 2022 국내박사

서론: 환자가 생애말연명의료를 결정할 수 있는 권리가 논의되어 자신의 생애말 연명의료결정을 보정하는 법이 2018년 발효되었다. 말기 환자와 임종단계에 있는 환자는 연명의료계획서를 작성하여 생애말연명의료 유보 및 중단을 결정할 수 있습니다. 생애말기에 의료비 지출이 증가함에 따라, 이 연구는 연명의료계획 사망 전 30일 동안의 의료비 지출 및 의료이용에 미치는 영향을 분석하는 것을 목표로 한다. 연구방법: 이 연구는 2002년부터 2020년까지 수집된 국민건강보험공단 맞춤형 자료를 사용했다. 이 연구는 2018년에서 2020년 사이에 사망한 암 환자 268,410명을 대상으로. 연명의료계획서 작성은 2018~2020년의 'IA71-3' 건강보험청구부호를 이용하여 정의하였다. 마지막 30일 동안의 의료비 및 의료이용에는 전체 의료이용, 입원, 집중치료실, 연명의료, 마취 진통제, 입원일수를 고려하였다. 생애말 의료비 및 의료이용에 대한 연명의료계획의 효과는 감마 및 음이항 분포를 가진 일반화 선형 모델에 의해 분석하였다. 연구결과: 연구 인구의 9.2%는 연명의료계획을 완료한 작성군이다 (작성군: 24,753명, 비교군: 243,544명). 연명의료계획 작성군이 비교군에 비하여 사망 전 30일의 총 의료비(EXP(β) = 0.85, p-value = <.0001) 및 입원비(EXP(β) = 0.87, p-value = <.0001)가 감소하였다.연명의료계획의 의사결정자에 따라 분석한 결과, 가족의 의사에 따라 작성한 경우 총 의료비(EXP(β) = 0.71, p-value = <.0001)와 입원비 (EXP(β) = 0.73 p-value = <.0001)가 가장 두드러지게 감소하였다. 연명의료계획 작성 후 이행여부에 따라서는 유사하게 감소하는 결과를 보였다. 결론: 이 연구에서는 연명의료계획이 생애 마지막 30일 동안의 의료비와 의료이용을 감소시켰다. 연명의료계획은 연명의료와 관련된 비용과 의료이용을 감소시키고, 호스피스와 마약성 진통제의 비용과 지출의 증가를 확인하였다. 이번 연구결과는 연명의료계획이 환자의 결정에 따라 불필요한 의료서비스를 줄여 생애말 치료에 대한 환자의 권리를 보장하고 재정 부담을 덜어줄 수 있음을 시사한다. Background: The rights of patients to refuse life-sustaining treatment (LST) have been discussed, and the law allowing the choice to opt out of LST has been established. Terminally ill patients and those at the end stage of life have the option to write a Life-Sustaining Treatment Plan (LST plan) to determine their end-of-life (EOL) treatment. We use healthcare claim data and hypothesize that reductions in healthcare expenditures among patients who suspend LST at EOL might be the result indicator of a well-operated LST decision system observing their rights. Because healthcare expenditures increase at the EOL, this study aims to analyze the effects of the LST plan on healthcare utilization and expenditures for the last 30 days of life. Methods: This study uses data from the National Health Insurance Service-National Health Information Database (NHIS-NHID) from 2002 to 2020. The study sample includes 268,410 patients with cancer who died between 2018 and 2020. An LST plan is defined using “IA71-3” claim codes between 2018 and 2020. Healthcare expenditures and utilization for the last 30 days of life are divided into the following categories: total healthcare, hospitalization, ICU, LST, narcotic painkiller, and length of stay. An analysis of the effect of the LST plan on healthcare utilization and expenditures was performed using a generalized linear model with gamma and negative binomial distributions. Results: Of study participants, 9.2% represents the intervention group comprised of patients who completed an LST plan (intervention: 24,753; control: 243,544). The results show that having an LST plan is associated with significant lower total healthcare (EXP(β) = 0.85, p-value = <.0001) and hospitalization (EXP(β) = 0.87, p-value = <.0001) expenditures. A family-determined LST plan shows a salient reduction in total (EXP(β) = 0.71, p-value = <.0001) and hospitalization (EXP(β) = 0.73, p-value = <.0001) expenditures. Similar decreases in total and hospitalization expenditures occur when implementing of an LST plan. Conclusions: This study found that an LST plan is associated with a reduction in healthcare expenditures and utilization in the last 30 days of life. An LST plan also leads to decreases in expenditures and utilization related to LST and increases in hospice and narcotic painkiller. The findings suggest that LST plans, when chosen by patients, may reduce opted-out medical services helping to relieve financial burdens at EOL to the same degree that they did if they decide to opt out to observe their self-determination right. Additionally, further research is needed to examine the reduction in healthcare utilization related to the withdrawal of the LST plan at EOL, which might help redistribute the resources to better observed self-determination rights.

Advance Directives in Primary Care: Increasing Patient Engagement through Community Outreach

Ottusch, Stephanie Marie ProQuest Dissertations & Theses The University of 2022 해외박사(DDOD)

Purpose: The purpose of this project was to demonstrate the efficacy of an hour-long educational, interactive seminar to increase participant readiness and engagement in advance care planning activities in the Benson, Arizona community.Background: Advance care planning is the process of identifying values, preferences and goals of healthcare decisions, in the event an individual is unable to make the choice for themselves. Advance directives provide a means to document these decisions in a legally meaningful way but only about one-third of adult Americans report having completed an advance directive. Research has shown that outcomes may be negatively impacted in the absence of advance care planning, especially in cases of critical illness or end-of-life. The providers affiliated with Benson Hospital have recently undergone training to promote advanced care planning in their practice, but the research has demonstrated that multi-modal interventions have been more successful in promoting advanced care planning engagement than any single intervention alone.Methods: This project utilized pre- and post-intervention survey data to demonstrate the change in advance care planning engagement utilizing the Advance Care Planning Engagement Survey, a validated survey tool that utilizes four Likert-type questions. Results were then statistically analyzed using frequencies and Wilcoxon signed-rank test to determine statistical significance.Results: Fifteen adults participated in the seminar and completed the pre-post survey which demonstrated an overall increase in participant engagement in advance care planning activities. One-third of the participants reported already completing advance care planning documentation prior to the seminar, consistent with the national average. Survey results demonstrated a marked increase in median engagement in advance care planning activities, although the p-values were greater than 0.05 and thus not statistically significant.Conclusion: The survey results for this project did not demonstrate statistically significant changes, however participant responses were generally positive showing increased engagement in advance care planning activities. Future projects should focus on recruiting larger sample sizes, measuring advance directive completion rates and the effect of advance directive documentation on care outcomes.

The Impact of Advance Care Planning on Avoidable Hospital Admissions and Visits

Contreras, Nicola Elizabeth Grand Canyon University ProQuest Dissertations & T 2019 해외박사(DDOD)

Residents of post-acute long-term care (PALTC) settings have an increased risk of unwanted acute care transfers. Proactive conversations about treatment preferences could prevent these events. The purpose of this quantitative project was to examine the cause and effect relationship of advance care planning (ACP) completion and documentation on decreasing avoidable hospital admissions, hospital readmissions within 30-days of discharge, and Emergency Department (ED) visits for those admitted to, and thosestratified as high risk for acute care visits, residing in a 71-bed PALTC setting in rural New Hampshire. The person-centered nursing (PCN) framework emphasizes shared decision-making and supports ACP to elicit and capture treatment preferences. A quantitative pretest/posttest design examined ACP’s ability to decrease avoidable acute care visits. These events were assessed pre- and 30-days post-ACP completion. Acute care visits for cognitively intact newly admitted and at risk residents in this setting (n=17) were tracked post- ACP. None of the post-intervention group experienced an acute care transfer in the post intervention period. It was not possible to determine, with statistical significance, if ACP was directly responsible for the absence of acute care visits for these individuals. The systematic approach to initiating ACP did result in the documentation of care preferences (n=17) in this PALTC setting. Tracking PALTC transfers over a longer period and over the progression of illness may capture the impact of ACP on these events.Key words: Advance care planning, quality, resource utilization, person-centered.

Clinical Practice Guideline Implementation to Increase Advance Care Plans among Hospice Patients

Cupid, Sheena Ann Grand Canyon University ProQuest Dissertations & T 2022 해외박사(DDOD)

Advance care plans (ACPs) for hospice patients may support goal concordant care and quality of life. The project site did not utilize a guideline to support the development and implementation of ACPs, so an evidence-based solution was sought. The purpose of this quantitative quasi-experimental quality improvement project was to determine if or to what degree the implementation of the National Consensus Project’s Clinical Practice Guidelines for Quality Palliative Care (NCP Guidelines), Domain 7–Care of the Patient Nearing the End of Life would impact the number of advance care plans when compared to current practice among adult patients admitted to hospice in southeastern North Carolina over four weeks. Katherine Kolcaba’s comfort theory and Kurt Lewin’s change theory provided the theoretical underpinnings for the project. Data were collected from the electronic medical record on a total sample of 79 patients, with n = 35 in the comparative group and n = 44 in the intervention group. A chi-square test was conducted, and results showed χ2 (1, N = 79) = 33.72, p = .001, which was statistically significant.The 61.2% improvement in ACPs demonstrated the clinical significance of the projectfollowing the intervention. Based on the results, the implementation of the National Consensus Project’s Clinical Practice Guidelines for Quality Palliative Care Domain 7 -Care of the Patient Nearing the End of Life, may impact this population. Recommendations include continuing the project and disseminating the results.