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Sample records for advance care plan

  1. Advance Care Planning

    MedlinePlus

    ... Division of Geriatrics and Clinical Gerontology Division of Neuroscience FAQs Funding Opportunities Intramural Research Program Office of ... Is Advance Care Planning? Advance care planning involves learning about the types of decisions that might need ...

  2. Advance Care Planning.

    PubMed

    Stallworthy, Elizabeth J

    2013-04-16

    Advance care planning should be available to all patients with chronic kidney disease, including end-stage kidney disease on renal replacement therapy. Advance care planning is a process of patient-centred discussion, ideally involving family/significant others, to assist the patient to understand how their illness might affect them, identify their goals and establish how medical treatment might help them to achieve these. An Advance Care Plan is only one useful outcome from the Advance Care Planning process, the education of patient and family around prognosis and treatment options is likely to be beneficial whether or not a plan is written or the individual loses decision making capacity at the end of life. Facilitating Advance Care Planning discussions requires an understanding of their purpose and communication skills which need to be taught. Advance Care Planning needs to be supported by effective systems to enable the discussions and any resulting Plans to be used to aid subsequent decision making. PMID:23586906

  3. Advance Care Planning

    Cancer.gov

    The thirteenth module of the EPEC-O (Education in Palliative and End-of-Life Care for Oncology) Self-Study: Cultural Considerations When Caring for African Americans explores the attitudes and practices of African Americans related to completion of advance directives, and recommends effective strategies to improve decision-making in the setting of serious, life-threatening illness, in ways that augment patient autonomy and support patient-centered goal-setting and decision-making among African American patients and their families.

  4. [Advance Care Planning in Cancer Care].

    PubMed

    Kizawa, Yoshiyuki; Yamaguchi, Takashi; Yotani, Nobuyuki

    2016-03-01

    Advance care planning (ACP) is one of the most important issues to consider in providing quality end of life care for cancer patients. ACP has been described as a process whereby a patient, in consultation with health care providers, family members, and important others, makes decisions about his or her future health care, in the event he or she becomes incapable of participating in medical treatment decisions. ACP improves rates of following end of life wishes, increases patient and family satisfaction, and reduces family stress, anxiety, and depression. This article clarifies the differences among ACP, advance directives, and living wills. Additionally, we describe, based on clinical experience, how to introduce ACP most effectively for all stages of cancer care. PMID:27067841

  5. Improving patient-centered care through advance care planning.

    PubMed

    Motley, Molly

    2013-06-01

    Advance care planning is crucial for patients confronting incurable, debilitating, or terminal disease. Discussing end-of-life issues can reduce overtreatment and undertreatment as defined by the patient, and improve satisfaction with care. PMID:23805592

  6. Advance care planning in the elderly.

    PubMed

    Lum, Hillary D; Sudore, Rebecca L; Bekelman, David B

    2015-03-01

    Key components of advance care planning (ACP) for the elderly include choosing a surrogate decision maker, identifying personal values, communicating with surrogates and clinicians, documenting wishes in advance directives, and translating values and preferences for future medical care into medical orders. ACP often involves multiple brief discussions over time. This article outlines common benefits and barriers to ACP in primary care, and provides practical approaches to integrating key ACP components into primary care for older adults. Opportunities for multidisciplinary teams to incorporate ACP into brief clinic visits are highlighted. PMID:25700590

  7. Advance care planning for people with dementia.

    PubMed

    2016-05-27

    Advance care planning (ACP) provides a framework for discussing and documenting care preferences in preparation for situations in which a person loses the cognitive capacity to make decisions. It can be particularly valuable in assisting people in the early stages of living with a dementia, supported by their families, to document their preferences for care at the later stages of their illness. While the potential benefits of ACP are widely acknowledged, there remain gaps in the research evidence on ACP and challenges in implementing ACP in practice. The three recently-published studies described below address these issues. PMID:27231079

  8. Not that way: Advance Care Planning

    PubMed Central

    How, Choon How; Koh, Lip Hoe

    2015-01-01

    Advance Care Planning (ACP) is a process of discussion of healthcare decisions with regard to a patient’s future health and personal care, should they become unable to make or communicate their own decisions in the future. ACP can be as simple as a chat about the patient’s end-of-life wishes with their trusted loved ones, and may involve their doctors, organisations and trained facilitators. The process can be documented with available online resources, such as structured tools. Family physicians, with whom patients share unique therapeutic relationships, are in the best position to introduce and start the ACP conversation with their patients. PMID:25640095

  9. Advance Care Planning for Serious Illness

    MedlinePlus

    ... conversations Caring Connections National Hospice and Palliative Care Organization Links to every state’s advance care directive forms http: / / www. caringinfo. org/ i4a/ pages/ index. cfm? ...

  10. Development of an interactive computer program for advance care planning

    PubMed Central

    Green, Michael J.; Levi, Benjamin H.

    2013-01-01

    Objective To describe the development of an innovative, multimedia decision aid for advance care planning. Background Advance care planning is an important way for people to articulate their wishes for medical care when they are not able to speak for themselves. Living wills and other types of advance directives are the most commonly used tools for advance care planning, but have been criticized for being vague, difficult to interpret, and inconsistent with individuals’ core beliefs and values. Results We developed a multimedia, computer-based decision aid for advance care planning (‘Making Your Wishes Known: Planning Your Medical Future’) to overcome many of the limitations of standard advance directive forms. This computer program guides individuals through the process of advance care planning, and unlike standard advance directives, provides tailored education, values clarification exercises, and a decision-making tool that translates an individual’s values and preferences into a specific medical plan that can be implemented by a health-care team. Pilot testing with 50 adult volunteers recruited from an outpatient primary care clinic showed high levels of satisfaction with the program. Further pilot testing with 34 cancer patients indicated that the program was perceived to be highly accurate at representing patients’ wishes. Conclusions This paper describes the development of an innovative decision aid for advance care planning that was designed to overcome common problems with standard advance directives. Preliminary testing suggests that it is acceptable to users and is accurate. PMID:18823445

  11. Advance care planning in South Korea: Social work perspective.

    PubMed

    Kwon, Sung Ae; Kolomer, Stacey

    2016-08-01

    As ethical issues arise concerning the continuation of futile medical treatment for dying patients in Korean society, advance directive planning initiatives have been put into place to guide practice. This article describes the awareness and attitudes of social workers in Korea regarding advance care planning and related factors. A total of 246 gerontological/geriatric social workers completed a mailed or in-person survey regarding awareness and attitudes toward advance care planning. Seventy-three percent (n = 180) of the participants reported no knowledge of advance directives. Social workers who emphasized self-determination as a professional value, professed a preference for hospice care, and who were comfortable discussing death were more likely to have a positive attitudes toward advance care planning. This study reinforces the need for the infusion of advance care planning and end-of-life training in social work education in Korea. PMID:27428654

  12. Advanced Directives and Advanced Care Planning for Healthcare Professionals.

    PubMed

    Booth, Adam T; Lehna, Carlee

    2016-01-01

    The purposes of this study were to assess healthcare professionals' need for information on advanced directives and to implement and evaluate an educational plan for change in knowledge and behaviors related to advanced directives. End-of-life (EOL) care is an important topic for patients to discuss with their families and healthcare professionals (HP). Needs assessment data were collected from healthcare providers at an urban trauma intensive care unit (ICU) in Louisville, Kentucky on concepts related to end-of-life. Next, healthcare professionals participated in an educational intervention focused on: knowledge about advanced directives; communication techniques for healthcare professionals to use with patients and their families; awareness of the patient's level of illness in advanced care planning; and specifics about living wills in Kentucky and how to complete one. Pre- and post-test data were collected to evaluate change in knowledge, capability an average of 8.7 years (SD = 9.1; range = 1.9-35 years) in healthcare and worked an average of 8.4 years (SD = 9.3; range = 4 months to 35 years) in their respective ICUs. Eighty-seven percent did not have an AD in place even though their perceived knowledge about AD remained moderate throughout pre- and post-test scores (3.3 to 3.8 on a 5 point scale, respectively). Total post-test scores revealed a 2% improvement in correct responses. These findings point to the need for education of healthcare providers in the ICU to increase early AD and ACP discussions with patients and their families. PMID:27183766

  13. Promoting perioperative advance care planning: a systematic review of advance care planning decision aids.

    PubMed

    Aslakson, Rebecca A; Schuster, Anne L R; Reardon, Jessica; Lynch, Thomas; Suarez-Cuervo, Catalina; Miller, Judith A; Moldovan, Rita; Johnston, Fabian; Anton, Blair; Weiss, Matthew; Bridges, John F P

    2015-11-01

    This systematic review identifies possible decision aids that promote perioperative advance care planning (ACP) and synthesizes the available evidence regarding their use. Using PubMed, EMBASE, Cochrane, SCOPUS, Web of Science, CINAHL, PsycINFO and Sociological Abstracts, researchers identified and screened articles for eligibility. Data were abstracted and risk of bias assessed for included articles. Thirty-nine of 5327 articles satisfied the eligibility criteria. Primarily completed in outpatient ambulatory populations, studies evaluated a variety of ACP decision aids. None were evaluated in a perioperative population. Fifty unique outcomes were reported with no head-to-head comparisons conducted. Findings are likely generalizable to a perioperative population and can inform development of a perioperative ACP decision aid. Future studies should compare the effectiveness of ACP decision aids. PMID:26346494

  14. Legal Briefing: Medicare Coverage of Advance Care Planning.

    PubMed

    Pope, Thaddeus Mason

    2015-01-01

    This issue's "Legal Briefing" column covers the recent decision by the Centers for Medicare and Medicaid Services (CMS) to expand Medicare coverage of advance care planning, beginning 1 January 2016. Since 2009, most "Legal Briefings" in this journal have covered a wide gamut of judicial, legislative, and regulatory developments concerning a particular topic in clinical ethics. In contrast, this "Legal Briefing" is more narrowly focused on one single legal development. This concentration on Medicare coverage of advance care planning seems warranted. Advance care planning is a frequent subject of articles in JCE. After all, it has long been seen as an important, albeit only partial, solution to a significant range of big problems in clinical ethics. These problems range from medical futility disputes to decision making for incapacitated patients who have no available legally authorized surrogate. Consequently, expanded Medicare coverage of advance care planning is a potentially seismic development. It may materially reduce both the frequency and severity of key problems in clinical ethics. Since the sociological, medical, and ethical literature on advance care planning is voluminous, I will not even summarize it here. Instead, I focus on Medicare coverage. I proceed, chronologically, in six stages: 1. Prior Medicare Coverage of Advance Care Planning 2. Proposed Expanded Medicare Coverage in 2015 3. Proposed Expanded Medicare Coverage in 2016 4. The Final Rule Expanding Medicare Coverage in 2016 5. Remaining Issues for CMS to Address in 2017 6. Pending Federal Legislation. PMID:26752396

  15. The Evolution of Health Care Advance Planning Law and Policy

    PubMed Central

    Sabatino, Charles P

    2010-01-01

    Context: The legal tools of health care advance planning have substantially changed since their emergence in the mid-1970s. Thirty years of policy development, primarily at the state legislative level addressing surrogate decision making and advance directives, have resulted in a disjointed policy landscape, yet with important points of convergence evolving over time. An understanding of the evolution of advance care planning policy has important implications for policy at both the state and federal levels. Methods: This article is a longitudinal statutory and literature review of health care advance planning from its origins to the present. Findings: While considerable variability across the states still remains, changes in law and policy over time suggest a gradual paradigm shift from what is described as a “legal transactional approach” to a “communications approach,” the most recent extension of which is the emergence of Physician Orders for Life-Sustaining Treatment, or POLST. The communications approach helps translate patients’ goals into visible and portable medical orders. Conclusions: States are likely to continue gradually moving away from a legal transactional mode of advance planning toward a communications model, albeit with challenges to authentic and reliable communication that accurately translates patients’ wishes into the care they receive. In the meantime, the states and their health care institutions will continue to serve as the primary laboratory for advance care planning policy and practice. PMID:20579283

  16. [Depression screening and possible applications of advance care planning].

    PubMed

    Wada, Taizo

    2013-01-01

    Depression screening was conducted to determine the health status of community-dwelling elderly individuals, and the concept of advance care planning was introduced. While depression screening among the elderly often uses the Geriatric Depression Scale, a single question regarding depressive mood also provides a valid measure of depression in elderly persons. Depression is associated with lower activities of daily living, competence, and subjective quality of life among the elderly living in Vietnam and Indonesia, as well as in Japan. Advance care planning is a process of discussion between individuals and their care providers to make decisions about future care preferences and priorities, while they are still capable. If they wish, they may prepare an advance directive to inform others about their decisions and best interests, such as a written advance decision to refuse treatment and/or appointment of a person with lasting powers of attorney. The purpose of advance care planning is to enable elderly persons to receive better end-of-life care. To promote introduction of advance care planning in Japan, voluntary discussion among family members should be encouraged. PMID:23979330

  17. Advance Care Planning in Nursing Homes: Correlates of Capacity and Possession of Advance Directives

    ERIC Educational Resources Information Center

    Allen, Rebecca S.; DeLaine, Shermetra R.; Chaplin, William F.; Marson, Daniel C.; Bourgeois, Michelle S.; Dijkstra, Katinka; Burgio, Louis D.

    2003-01-01

    Purpose: The identification of nursing home residents who can continue to participate in advance care planning about end-of-life care is a critical clinical and bioethical issue. This study uses high quality observational research to identify correlates of advance care planning in nursing homes, including objective measurement of capacity. Design…

  18. Advance Care Planning and the Quality of End-of-Life Care among Older Adults

    PubMed Central

    Bischoff, Kara E.; Sudore, Rebecca; Miao, Yinghui; Boscardin, W. John; Smith, Alexander K.

    2013-01-01

    Background Advance care planning is increasingly common, but whether it influences end-of-life quality of care remains controversial. Design Medicare data and survey data from the Health and Retirement Study were combined to determine whether advance care planning was associated with quality metrics. Setting The nationally representative Health and Retirement Study. Participants 4394 decedent subjects (mean age 82.6 years at death, 55% women). Measurements Advance care planning was defined as having an advance directive, durable power of attorney or having discussed preferences for end-of-life care with a next-of-kin. Outcomes included previously reported quality metrics observed during the last month of life (rates of hospital admission, in-hospital death, >14 days in the hospital, intensive care unit admission, >1 emergency department visit, hospice admission, and length of hospice ≤3 days). Results Seventy-six percent of subjects engaged in advance care planning. Ninety-two percent of advance directives stated a preference to prioritize comfort. After adjustment, subjects who engaged in advance care planning were less likely to die in a hospital (adjusted RR 0.87, 95% CI 0.80-0.94), more likely to be enrolled in hospice (aRR 1.68, 1.43-1.97), and less likely to receive hospice for ≤3 days before death (aRR 0.88, 0.85-0.91). Having an advance directive, a durable-power-of-attorney or an advance care planning discussion were each independently associated with a significant increase in hospice use (p<0.01 for all). Conclusion Advance care planning was associated with improved quality of care at the end of life, including less in-hospital death and increased use of hospice. Having an advance directive, assigning a durable power of attorney and conducting advance care planning discussions are all important elements of advance care planning. PMID:23350921

  19. Pediatric advance care planning from the perspective of health care professionals: A qualitative interview study

    PubMed Central

    Jox, Ralf J; Borasio, Gian Domenico; Führer, Monika

    2015-01-01

    Background: Pediatric advance care planning differs from the adult setting in several aspects, including patients’ diagnoses, minor age, and questionable capacity to consent. So far, research has largely neglected the professionals’ perspective. Aim: We aimed to investigate the attitudes and needs of health care professionals with regard to pediatric advance care planning. Design: This is a qualitative interview study with experts in pediatric end-of-life care. A qualitative content analysis was performed. Setting/participants: We conducted 17 semi-structured interviews with health care professionals caring for severely ill children/adolescents, from different professions, care settings, and institutions. Results: Perceived problems with pediatric advance care planning relate to professionals’ discomfort and uncertainty regarding end-of-life decisions and advance directives. Conflicts may arise between physicians and non-medical care providers because both avoid taking responsibility for treatment limitations according to a minor’s advance directive. Nevertheless, pediatric advance care planning is perceived as helpful by providing an action plan for everyone and ensuring that patient/parent wishes are respected. Important requirements for pediatric advance care planning were identified as follows: repeated discussions and shared decision-making with the family, a qualified facilitator who ensures continuity throughout the whole process, multi-professional conferences, as well as professional education on advance care planning. Conclusion: Despite a perceived need for pediatric advance care planning, several barriers to its implementation were identified. The results remain to be verified in a larger cohort of health care professionals. Future research should focus on developing and testing strategies for overcoming the existing barriers. PMID:25389347

  20. [Advance care planning for people with intellectual disability].

    PubMed

    Wagemans, Annemieke M A; van Wijmen, Frans C B

    2014-01-01

    Difficult medical decisions regularly need to be made for people with intellectual disability. They are often unable to play a meaningful role in this and the decisions fall to the family or guardians. A useful aid to proactive medical management is advance care planning. This is a long-term care plan which is centred on the well-being of patients and their quality of life. Ideally it should be a matter for patients and those closest to them, the responsible medical practitioner and those tasked with the day-to-day care of patients. It is important to draw up this plan carefully and to regularly review it in the light of current circumstances. PMID:25424633

  1. WHAT INFLUENCES INDIVIDUALS TO ENGAGE IN ADVANCE CARE PLANNING?

    PubMed Central

    Dellasega, Cheryl; Whitehead, Megan; Green, Michael J.

    2013-01-01

    Background Advance care planning (ACP) is an under-utilized process that involves thinking about what kind of life-prolonging medical care one would want should the need arise, identifying a spokesperson, and then communicating these wishes. Objective To better understand what influences individuals to engage in ACP. Design Three focus groups using semi-structured interactive interviews were conducted with 23 older individuals from three diverse populations in central Pennsylvania. Results Four categories of influences for engaging in ACP were identified: 1) Concern for Self; 2) Concern for Others; 3) Expectations About the Impact of Advance Care Planning; and 4) Anecdotes, Stories, & Experiences. Conclusions The motivations for undertaking ACP that we have identified offer healthcare providers insight into effective strategies for facilitating the process of ACP with their patients. PMID:20103783

  2. An unequivocal good? Acknowledging the complexities of advance care planning.

    PubMed

    Robins-Browne, K; Palmer, V; Komesaroff, P

    2014-10-01

    Over the past few decades advance care planning (ACP) has become the subject of debate, research and legislation in many countries. Encouraging people to express their preference for treatment in advance, ideally in written form, seems a natural way to identify what someone might have wanted when they can no longer participate in decision-making. The notion of ACP as an unequivocal good permeates much of the research and policy work in this area. For example, ACP is now actively encouraged in Australian federal and state government policies and the Victorian Government has recently published a practical ACP strategy for Victorian health services (2014-2018). However, advance care plan is ethically complex and the introduction of the Victorian health services strategy provides an opportunity to reflect on this complexity, particularly on the benefits and risks of ACP. PMID:25302719

  3. Documentation of Advance Care Planning for Community-Dwelling Elders

    PubMed Central

    Yung, Victoria Y.; Walling, Anne M.; Min, Lillian; Wenger, Neil S.

    2010-01-01

    Abstract Background Advance planning for end-of-life care has gained acceptance, but actual end-of-life care is often incongruent with patients' previously stated goals. We assessed the flow of advance care planning information from patients to medical records in a community sample of older adults to better understand why advance care planning is not more successful. Methods Our study used structured interview and medical record data from community-dwelling older patients in two previous studies: Assessing Care of Vulnerable Elders (ACOVE)-1 (245 patients age ≥65 years and screened for high risk of death/functional decline in 1998–1999) and ACOVE-2 (566 patients age ≥75 who screened positive for falls/mobility disorders, incontinence, and/or dementia in 2002–2003). We compared interview data on patients' preferences, advance directives, and surrogate decision-makers with findings from the medical record. Results In ACOVE-1, 38% of surveyed patients had thought about limiting the aggressiveness of medical care; 24% of surveyed patients stated that they had spoken to their doctor about this. The vast majority of patients (88%–93%) preferred to die rather than remain permanently in a coma, on a ventilator, or tube fed. Regardless of patients' specific preferences, 15%–22% of patients had preference information in their medical record. Among patients who reported that they had completed an advance directive and had given it to their health-care provider, 15% (ACOVE-1) and 47% (ACOVE-2) had advance directive information in the medical record. Among patients who had not completed an advance directive but had given surrogate decision-maker information to their provider, 0% (ACOVE-1) and 16% (ACOVE-2) had documentation of a surrogate decision-maker in the medical record. Conclusions Community-dwelling elders' preferences for end-of-life care are not consistent with documentation in their medical records. Electronic health records and standardized data

  4. Development and evaluation of an aged care specific Advance Care Plan

    PubMed Central

    Silvester, William; Parslow, Ruth A; Lewis, Virginia J; Fullam, Rachael S; Sjanta, Rebekah; Jackson, Lynne; White, Vanessa; Hudson, Rosalie

    2013-01-01

    Objectives To report on the quality of advance care planning (ACP) documents in use in residential aged care facilities (RACF) in areas of Victoria Australia prior to a systematic intervention; to report on the development and performance of an aged care specific Advance Care Plan template used during the intervention. Design An audit of the quality of pre-existing documentation used to record resident treatment preferences and end-of-life wishes at participating RACFs; development and pilot of an aged care specific Advance Care Plan template; an audit of the completeness and quality of Advance Care Plans completed on the new template during a systematic ACP intervention. Participants and setting 19 selected RACFs (managed by 12 aged care organisations) in metropolitan and regional areas of Victoria. Results Documentation in use at facilities prior to the ACP intervention most commonly recorded preferences regarding hospital transfer, life prolonging treatment and personal/cultural/religious wishes. However, 7 of 12 document sets failed to adequately and clearly specify the resident's preferences as regards life prolonging medical treatment. The newly developed aged care specific Advance Care Plan template was met with approval by participating RACFs. Of 203 Advance Care Plans completed on the template throughout the project period, 49% included the appointment of a Medical Enduring Power of Attorney. Requests concerning medical treatment were specified in almost all completed documents (97%), with 73% nominating the option of refusal of life-prolonging treatment. Over 90% of plans included information concerning residents’ values and beliefs, and future health situations that the resident would find to be unacceptable were specified in 78% of completed plans. Conclusions Standardised procedures and documentation are needed to improve the quality of processes, documents and outcomes of ACP in the residential aged care sector. PMID:23626906

  5. Building successful coalitions to promote advance care planning.

    PubMed

    Marchand, Lucille; Fowler, Kathryn J; Kokanovic, Obrad

    2005-01-01

    This qualitative study explored the challenges and successes of an advance care planning (ACP) coalition formed at the University of Wisconsin called Life Planning 2000. Data were obtained from key informant interviews (n = 24) and grounded theory. Major themes included commitment (the need for leadership, recruitment of key persons, and funding); cohesiveness (disparate groups collaborating toward a common purpose); and outcomes (including educational tool development). Coalitions need to define short-, intermediate-, and long-term goals that result in measurable outcomes and an evaluation process. Resources must be commensurate with goals. Results indicate that strong leadership, paid staff adequate funding, and the collaboration of diverse groups working toward a common goal are essential if a coalition promoting end-of-life (EOL) care planning is to be successful. PMID:16323714

  6. Future care planning: a first step to palliative care for all patients with advanced heart disease.

    PubMed

    Denvir, M A; Murray, S A; Boyd, K J

    2015-07-01

    Palliative care is recommended for patients with end-stage heart failure with several recent, randomised trials showing improvements in symptoms and quality of life and more studies underway. Future care planning provides a framework for discussing a range of palliative care problems with patients and their families. This approach can be introduced at any time during the patient's journey of care and ideally well in advance of end-of-life care. Future care planning is applicable to a wide range of patients with advanced heart disease and could be delivered systematically by cardiology teams at the time of an unplanned hospital admission, akin to cardiac rehabilitation for myocardial infarction. Integrating cardiology care and palliative care can benefit many patients with advanced heart disease at increased risk of death or hospitalisation. Larger, randomised trials are needed to assess the impact on patient outcomes and experiences. PMID:25900977

  7. It's just too hard! Australian health care practitioner perspectives on barriers to advance care planning.

    PubMed

    Boddy, Jennifer; Chenoweth, Lesley; McLennan, Vanette; Daly, Michelle

    2013-01-01

    This article presents findings from six focus groups with health care practitioners in an Australian hospital during 2010, which sought to elicit their perspectives on the barriers for people to plan their future health care should they become unwell. Such knowledge is invaluable in overcoming the barriers associated with advance care planning and enhancing the uptake of advance directives and the appointment of an enduring power of attorney for people of all ages. A person's rights to self-determination in health care, including decision making about their wishes for future care in the event they lose cognitive capacity, should not be overlooked against the backdrop of increasing pressure on health care systems. Findings suggest that multiple barriers exist, from practitioners' perspectives, which can be divided into three major categories, namely: patient-centred, practitioner-centred and system-centred barriers. Specifically, patient-centred barriers include lack of knowledge, accessibility concerns, the small 'window of opportunity' to discuss advance care planning, emotional reactions and avoidance when considering one's mortality, and demographic influences. At the practitioner level, barriers relate to a lack of knowledge and uncertainty around advance care planning processes. Systemically, legislative barriers (including a lack of a central registry and conflicting state legislation), procedural issues (particularly in relation to assessing cognitive capacity and making decisions ad hoc) and questions about delegation, roles and responsibilities further compound the barriers to advance care planning. PMID:22951247

  8. Advance care planning and palliative medicine in advanced dementia: a literature review.

    PubMed

    Jethwa, Ketan Dipak; Onalaja, Oluwademilade

    2015-04-01

    Aims and method To assess the factors that affect the clinical use of advanced care planning and palliative care interventions in patients with dementia. A literature search of Medline, Embase and PsycINFO was performed to identify themes in advanced care planning and palliative care in dementia. Results In total, 64 articles were found, including 12 reviews, and three key areas emerged: barriers to advanced care planning, raising awareness and fostering communication between professionals and patients, and disease-specific interventions. Clinical implications Most of the studies analysed were carried out in the USA or Continental Europe. This narrative review aims to help guide future primary research, systematic reviews and service development in the UK. PMID:26191437

  9. Advance care planning and palliative medicine in advanced dementia: a literature review

    PubMed Central

    Jethwa, Ketan Dipak; Onalaja, Oluwademilade

    2015-01-01

    Aims and method To assess the factors that affect the clinical use of advanced care planning and palliative care interventions in patients with dementia. A literature search of Medline, Embase and PsycINFO was performed to identify themes in advanced care planning and palliative care in dementia. Results In total, 64 articles were found, including 12 reviews, and three key areas emerged: barriers to advanced care planning, raising awareness and fostering communication between professionals and patients, and disease-specific interventions. Clinical implications Most of the studies analysed were carried out in the USA or Continental Europe. This narrative review aims to help guide future primary research, systematic reviews and service development in the UK. PMID:26191437

  10. Advance Care Planning among People Living with Dialysis

    PubMed Central

    Elliott, Barbara A.; Gessert, Charles E.

    2016-01-01

    Purpose: Recent nephrology literature focuses on the need for discussions regarding advance care planning (ACP) for people living with dialysis (PWD). PWD and their family members’ attitudes toward ACP and other aspects of late-life decision making were assessed in this qualitative study. Methodology: Thirty-one interviews were completed with 20 PWD over the age of 70 (mean dialysis 34 months) and 11 family members, related to life experiences, making medical decisions, and planning for the future. Interviews were recorded, transcribed and analyzed. Findings: Four themes regarding ACP emerged from this secondary analysis of the interviews: how completing ACP, advance directives (AD), and identifying an agent fit into PWD experiences; PWD understanding of their prognosis; what gives PWD lives meaning and worth; and PWD care preferences when their defined meaning and worth are not part of their experience. These PWD and family members revealed that ACP is ongoing and common among them. They did not seem to think their medical providers needed to be part of these discussions, since family members were well informed. Practical implications: These results suggest that if health care providers and institutions need AD forms completed, it will important to work with both PWD and their family members to assure personal wishes are documented and honored. PMID:27417605

  11. [Study of 4 patients implemented to Advance Care Planning].

    PubMed

    Kawabata, Megumi; Fujiwara, Yoko; Kawabata, Hidenobu

    2015-11-01

    This is a study of 4 patients implemented to Advance Care Planning (ACP) reflecting on the health care professionals' role and the outcomes. ACP has been defined as a process of formal decision making that aims to help patients establish their decision about future care that take effect when they lose capacity. For about two years, we tried to engage all patients who were referred to our palliative care team and their families to ACP since their first consultation. We informed their conditions at that time, how their health might change and how treatment might impact on their life goals. We also attempted to help patients' decision making and then fulfill their wishes in cooperation with patients' families and healthcare professionals. We learned three important elements: understanding patients' values and wishes, explaining prediction of the clinical course of the patients and establishing a collaborative healthcare team in order to fulfill the patients' hopes. ACP improved quality of life (QOL) not only for the patients involved, but also for the family members. ACP can play a crucial role in ensuring that patients receive the care they want throughout various stages of their lives. PMID:26742180

  12. Palliative Care, Hospice, and Advance Care Planning: Views of People Living with HIV and Other Chronic Conditions.

    PubMed

    Slomka, Jacquelyn; Prince-Paul, Maryjo; Webel, Allison; Daly, Barbara J

    2016-01-01

    People living with HIV (PLWH) who survive to older adulthood risk developing multiple chronic medical conditions. Health policymakers recognize the role of early palliative care and advance care planning in improving health quality for at-risk populations, but misperceptions about palliative care, hospice, and advance care planning are common. Before testing a program of early palliative care for PLWH and other chronic conditions, we conducted focus groups to elicit perceptions of palliative care, hospice, and advance care planning in our target population. Overall, participants were unfamiliar with the term palliative care, confused concepts of palliative care and hospice, and/or associated hospice care with dying. Participants misunderstood advance care planning, but valued communication about health care preferences. Accepting palliative care was contingent on distinguishing it from hospice and historical memories of HIV and dying. Provision of high-quality, comprehensive care will require changing public perceptions and individuals' views in this high-risk population. PMID:27053406

  13. Advance care planning for cancer patients in primary care: a feasibility study

    PubMed Central

    Boyd, Kirsty; Mason, Bruce; Kendall, Marilyn; Barclay, Stephen; Chinn, David; Thomas, Keri; Sheikh, Aziz; Murray, Scott A

    2010-01-01

    Background Advance care planning is being promoted as a central component of end-of-life policies in many developed countries, but there is concern that professionals find its implementation challenging. Aim To assess the feasibility of implementing advance care planning in UK primary care. Design of study Mixed methods evaluation of a pilot educational intervention. Setting Four general practices in south-east Scotland. Method Interviews with 20 GPs and eight community nurses before and after a practice-based workshop; this was followed by telephone interviews with nine other GPs with a special interest in palliative care from across the UK. Results End-of-life care planning for patients typically starts as an urgent response to clear evidence of a short prognosis, and aims to achieve a ‘good death’. Findings suggest that there were multiple barriers to earlier planning: prognostic uncertainty; limited collaboration with secondary care; a desire to maintain hope; and resistance to any kind of ‘tick-box’ approach. Following the workshop, participants' knowledge and skills were enhanced but there was little evidence of more proactive planning. GPs from other parts of the UK described confusion over terminology and were concerned about the difficulties of implementing inflexible, policy-driven care. Conclusion A clear divide was found between UK policy directives and delivery of end-of-life care in the community that educational interventions targeting primary care professionals are unlikely to address. Advance care planning has the potential to promote autonomy and shared decision making about end-of-life care, but this will require a significant shift in attitudes. PMID:21144189

  14. Advance care planning: identifying system-specific barriers and facilitators

    PubMed Central

    Hagen, N.A.; Howlett, J.; Sharma, N.C.; Biondo, P.; Holroyd-Leduc, J.; Fassbender, K.; Simon, J.

    2015-01-01

    Background Advance care planning (acp) is an important process in health care today. How to prospectively identify potential local barriers and facilitators to uptake of acp across a complex, multi-sector, publicly funded health care system and how to develop specific mitigating strategies have not been well characterized. Methods We surveyed a convenience sample of clinical and administrative health care opinion leaders across the province of Alberta to characterize system-specific barriers and facilitators to uptake of acp. The survey was based on published literature about the barriers to and facilitators of acp and on the Michie Theoretical Domains Framework. Results Of 88 surveys, 51 (58%) were returned. The survey identified system-specific barriers that could challenge uptake of acp. The factors were categorized into four main domains. Three examples of individual system-specific barriers were “insufficient public engagement and misunderstanding,” “conflict among different provincial health service initiatives,” and “lack of infrastructure.” Local system-specific barriers and facilitators were subsequently explored through a semi-structured informal discussion group involving key informants. The group identified approaches to mitigate specific barriers. Conclusions Uptake of acp is a priority for many health care systems, but bringing about change in multi-sector health care systems is complex. Identifying system-specific barriers and facilitators to the uptake of innovation are important elements of successful knowledge translation. We developed and successfully used a simple and inexpensive process to identify local system-specific barriers and enablers to uptake of acp, and to identify specific mitigating strategies. PMID:26300673

  15. Strategic targeting of advance care planning interventions: the Goldilocks phenomenon.

    PubMed

    Billings, J Andrew; Bernacki, Rachelle

    2014-04-01

    Strategically selecting patients for discussions and documentation about limiting life-sustaining treatments-choosing the right time along the end-of-life trajectory for such an intervention and identifying patients at high risk of facing end-of-life decisions-can have a profound impact on the value of advance care planning (ACP) efforts. Timing is important because the completion of an advance directive (AD) too far from or too close to the time of death can lead to end-of-life decisions that do not optimally reflect the patient's values, goals, and preferences: a poorly chosen target patient population that is unlikely to need an AD in the near future may lead to patients making unrealistic, hypothetical choices, while assessing preferences in the emergency department or hospital in the face of a calamity is notoriously inadequate. Because much of the currently studied ACP efforts have led to a disappointingly small proportion of patients eventually benefitting from an AD, careful targeting of the intervention should also improve the efficacy of such projects. A key to optimal timing and strategic selection of target patients for an ACP program is prognostication, and we briefly highlight prognostication tools and studies that may point us toward high-value AD interventions. PMID:24493203

  16. Advance Care Planning: practicalities, legalities, complexities and controversies.

    PubMed

    Horridge, Karen A

    2015-04-01

    Increasing numbers, complexities and technology dependencies of children and young people with life-limiting conditions require paediatricians to be well prepared to meet their changing needs. Paediatric Advance Care Planning provides a framework for paediatricians, families and their multidisciplinary teams to consider, reflect and record the outcome of their conversations about what might happen in the future in order to optimise quality of clinical care and inform decision-making. For some children and young people this will include discussions about the possibility of death in childhood. This may be unexpected and sudden, in the context of an otherwise active management plan or may be expected and necessitate discussions about the process of dying and attention to symptoms. Decision-making about appropriate levels of intervention must take place within a legal and ethical framework, recognising that the UK Equality Act (2010) protects the rights of disabled children and young people and infants and children of all ages to the same high quality healthcare as anyone else. PMID:25275088

  17. Reliability of an interactive computer program for advance care planning.

    PubMed

    Schubart, Jane R; Levi, Benjamin H; Camacho, Fabian; Whitehead, Megan; Farace, Elana; Green, Michael J

    2012-06-01

    Despite widespread efforts to promote advance directives (ADs), completion rates remain low. Making Your Wishes Known: Planning Your Medical Future (MYWK) is an interactive computer program that guides individuals through the process of advance care planning, explaining health conditions and interventions that commonly involve life or death decisions, helps them articulate their values/goals, and translates users' preferences into a detailed AD document. The purpose of this study was to demonstrate that (in the absence of major life changes) the AD generated by MYWK reliably reflects an individual's values/preferences. English speakers ≥30 years old completed MYWK twice, 4 to 6 weeks apart. Reliability indices were assessed for three AD components: General Wishes; Specific Wishes for treatment; and Quality-of-Life values (QoL). Twenty-four participants completed the study. Both the Specific Wishes and QoL scales had high internal consistency in both time periods (Knuder Richardson formula 20 [KR-20]=0.83-0.95, and 0.86-0.89). Test-retest reliability was perfect for General Wishes (κ=1), high for QoL (Pearson's correlation coefficient=0.83), but lower for Specific Wishes (Pearson's correlation coefficient=0.57). MYWK generates an AD where General Wishes and QoL (but not Specific Wishes) statements remain consistent over time. PMID:22512830

  18. Reliability of an Interactive Computer Program for Advance Care Planning

    PubMed Central

    Levi, Benjamin H.; Camacho, Fabian; Whitehead, Megan; Farace, Elana; Green, Michael J

    2012-01-01

    Abstract Despite widespread efforts to promote advance directives (ADs), completion rates remain low. Making Your Wishes Known: Planning Your Medical Future (MYWK) is an interactive computer program that guides individuals through the process of advance care planning, explaining health conditions and interventions that commonly involve life or death decisions, helps them articulate their values/goals, and translates users' preferences into a detailed AD document. The purpose of this study was to demonstrate that (in the absence of major life changes) the AD generated by MYWK reliably reflects an individual's values/preferences. English speakers ≥30 years old completed MYWK twice, 4 to 6 weeks apart. Reliability indices were assessed for three AD components: General Wishes; Specific Wishes for treatment; and Quality-of-Life values (QoL). Twenty-four participants completed the study. Both the Specific Wishes and QoL scales had high internal consistency in both time periods (Knuder Richardson formula 20 [KR-20]=0.83–0.95, and 0.86–0.89). Test-retest reliability was perfect for General Wishes (κ=1), high for QoL (Pearson's correlation coefficient=0.83), but lower for Specific Wishes (Pearson's correlation coefficient=0.57). MYWK generates an AD where General Wishes and QoL (but not Specific Wishes) statements remain consistent over time. PMID:22512830

  19. Exploring Advance Care Planning from the Nephrology Nurse Perspective: A Literature Review.

    PubMed

    Haras, Mary S; Astroth, Kim S; Woith, Wendy L; Kossman, Susan P

    2015-01-01

    Advance care planning is a process that engages healthcare providers and patients to articulate wishes of patients as their illness progresses. Persons with chronic kidney disease require earlier and more frequent advance care planning conversations because they are faced with increased co-morbidities and a shortened lifespan. This literature review explores the phenomenon of advance care planning and the potential factors affecting nephrology nurse engagement in these discussions. PMID:26290915

  20. An overview of advance care planning for patients with advanced chronic kidney disease: The basics.

    PubMed

    Wasylynuk, Betty Ann; Davison, Sara N

    2016-01-01

    As the number of Canadians living with end-stage kidney disease (ESKD) continues to grow, even higher numbers are living with advanced chronic kidney disease (CKD). Many of these people will eventually require renal replacement therapy (RRT), either dialysis or transplantation. More than 50% of patients starting RRT today are aged 65 or older, with the fastest growing group being patients 75 years and older. Despite advances to dialysis technology and dialysis care, the mortality rates remain high and dialysis patients' end-of-life care may not align with their preferences or values. Advance care planning (ACP) is an essential component of quality comprehensive kidney care. Kidney care teams develop strong relationships with their patients and are well positioned to integrate ACP into routine kidney care. This article defines ACP, outlines the essential components of ACP, and discusses the benefits, challenges, and special considerations of ACP. By enhancing the kidney care team's understanding of ACP, this article aims to assist in integrating ACP into routine kidney care for patients with advanced CKD. PMID:27215058

  1. Care of Patients at the End of Life: Advance Care Planning.

    PubMed

    Ackermann, Richard J

    2016-08-01

    Advance directives are legal documents that give instructions about how to provide care when patients develop life-threatening illnesses and can no longer communicate their wishes. Two types of documents are widely used-a living will and a durable power of attorney for health care. Most states also authorize physician orders for life-sustaining treatment. Physicians should encourage patients, particularly those with severe chronic or terminal conditions, to prepare advance directives. Medicare now reimburses billing codes for advance care consultations. Directions regarding cardiopulmonary resuscitation and artificial ventilation often are included in advance care plans, and use of artificial nutrition and hydration (ANH) also should be addressed, particularly for patients with advanced dementia. Evidence shows that in such patients, ANH does not prolong survival, increase comfort, or improve quality of life. Given the lack of benefit, physicians should recommend against use of ANH for patients with dementia. Finally, physicians should encourage use of hospice services by patients whose life expectancy is 6 months or less. Although Medicare and most other health care insurers cover hospice care, and despite evidence that patient and family satisfaction increase when hospice services are used, many patients do not use these services. PMID:27490070

  2. Intervention thresholds: a conceptual frame for advance care planning choices

    PubMed Central

    2014-01-01

    Background Advance care planning (ACP) provides for decisions in the event of decisional incapacity. Determining ahead of time what a person may want is challenging and limits the utility of ACP. We present empirical evidence for a new approach to ACP: the individual’s “intervention threshold.” The intervention threshold is intuitively understood by clinicians and lay people, but has not been thoroughly described, measured, or analyzed. Methods Using a mixed-methods approach to address the concept of the intervention thresholds, we recruited 52 subjects from a population of chronically ill outpatients for structured telephone interviews assessing knowledge, attitudes, and prior ACP activities. Respondents were presented with 11 interventions for each of four medical scenarios. For each scenario, they were asked whether they would accept each intervention. Data was evaluated by descriptive statistics and chi-squared statistics. Results Complete data were obtained from 52 patients, mean age of 64.5, 34.6% of whom were male. Only 17.3% reported prior ACP discussion with a physician. Rates of accepting and refusing interventions varied by scenario (p < 0.0001) and intervention intensity (p < 0.0001). Conclusions These data provide evidence that people display transitions between wanting or not wanting interventions based on scenarios. Further research is needed to determine effective ways to identify, measure, and represent the components of an individual’s intervention threshold in order to facilitate informed decision making during future incapacity. PMID:24721698

  3. Education and Advance Care Planning in Nursing Homes: The Impact of Ownership Type.

    ERIC Educational Resources Information Center

    Walker, Leslie C.; Bradley, Elizabeth H.

    1998-01-01

    A study of 25 nonprofit and 87 for-profit nursing homes showed both types likely to offer education on advance care planning. However, nonprofits were more likely to have ongoing discussions that covered more than life support decisions and to have ethics committees to support advance care planning. (SK)

  4. The Era of “E”: The Use of New Technologies in Advance Care Planning

    PubMed Central

    Green, Michael J.; Levi, Benjamin H.

    2012-01-01

    In this paper, we review developments in technology that can help patients, their loved ones, and healthcare providers engage in more effective advance care planning (ACP). We begin with a brief description of ACP and its purpose; then proceed to discuss various electronically available resources for ACP in the U.S.; and finally provide a critical assessment of the achievements, challenges, and future prospects for electronic advance care planning, or “e-planning.” PMID:23141197

  5. Creating an advance-care-planning decision aid for high-risk surgery: a qualitative study

    PubMed Central

    2014-01-01

    Background High-risk surgery patients may lose decision-making capacity as a result of surgical complications. Advance care planning prior to surgery may be beneficial, but remains controversial and is hindered by a lack of appropriate decision aids. This study sought to examine stakeholders’ views on the appropriateness of using decision aids, in general, to support advance care planning among high-risk surgery populations and the design of such a decision aid. Methods Key informants were recruited through purposive and snowball sampling. Semi-structured interviews were conducted by phone until data collected reached theoretical saturation. Key informants were asked to discuss their thoughts about advance care planning and interventions to support advance care planning, particularly for this population. Researchers took de-identified notes that were analyzed for emerging concordant, discordant, and recurrent themes using interpretative phenomenological analysis. Results Key informants described the importance of initiating advance care planning preoperatively, despite potential challenges present in surgical settings. In general, decision aids were viewed as an appropriate approach to support advance care planning for this population. A recipe emerged from the data that outlines tools, ingredients, and tips for success that are needed to design an advance care planning decision aid for high-risk surgical settings. Conclusions Stakeholders supported incorporating advance care planning in high-risk surgical settings and endorsed the appropriateness of using decision aids to do so. Findings will inform the next stages of developing the first advance care planning decision aid for high-risk surgery patients. PMID:25067908

  6. Does facilitated Advance Care Planning reduce the costs of care near the end of life? Systematic review and ethical considerations

    PubMed Central

    Klingler, Corinna; in der Schmitten, Jürgen; Marckmann, Georg

    2015-01-01

    Background: While there is increasing evidence that Advance Care Planning has the potential to strengthen patient autonomy and improve quality of care near the end of life, it remains unclear whether it could also reduce net costs of care. Aim: This study aims to describe the cost implications of Advance Care Planning programmes and discusses ethical conflicts arising in this context. Design: We conducted a systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Data sources: We systematically searched the databases PubMed, NHS EED, EURONHEED, Cochrane Library and EconLit. We included empirical studies (no limitation to study type) that investigated the cost implications of Advance Care Planning programmes involving professionally facilitated end-of-life discussions. Results and discussion: Seven studies met our inclusion criteria. Four of them used a randomised controlled design, one used a before-after design and two were observational studies. Six studies found reductions in costs of care ranging from USD1041 to USD64,827 per patient, depending on the study period and the cost measurement. One study detected no differences in costs. Studies varied considerably regarding the Advance Care Planning intervention, patient selection and costs measured which may explain some of the variations in findings. Normative appraisal: Looking at the impact of Advance Care Planning on costs raises delicate ethical issues. Given the increasing pressure to reduce expenditures, there may be concerns that cost considerations could unduly influence the sensitive communication process, thus jeopardising patient autonomy. Safeguards are proposed to reduce these risks. Conclusion: The limited data indicate net cost savings may be realised with Advance Care Planning. Methodologically robust trials with clearly defined Advance Care Planning interventions are needed to make the costs and returns of Advance Care Planning transparent. PMID

  7. The views of older Malaysians on advanced directive and advanced care planning: a qualitative study.

    PubMed

    Htut, Y; Shahrul, K; Poi, P J H

    2007-01-01

    The provision of optimum care for the ageing population is dependent on the understanding of their views and values on end of life issues. A qualitative descriptive study was conducted to describe views of elderly Malaysians on Advanced Care Planning (henceforth ACP) and Advanced Directives (henceforth AD), and explore factors influencing these views. Fifteen elderly subjects with ages ranging from 65 to 83 years, representing different ethnic and religious groups in Malaysia were selected for in-depth interviews guided by a questionnaire. Five core themes were extracted from the interviews: 1) Considering the future 2) Contingency plans for future illnesses 3) Attitudes towards life prolonging treatment procedures 4) Doctor-patient relationships and 5) Influence of religion on decisions related to future illness. Despite the lack of knowledge on ACP and AD, older respondents were very receptive to their concept. Although the majority agreed on the importance of planning for future medical management and having open discussion on end of life issues with their doctor, they felt it unnecessary to make a formal written AD. Most felt that the future was best left to fate or God, and none had made any contingency plan for severe future illnesses citing religion as reason for this view. Cardiopulmonary resuscitation, mechanical ventilation and dialysis were considered by most to be invasive life prolonging treatments. We suggest that doctors initiate discussions on end of life care with every older patient and their family so as to promote awareness and introduce the concept of ACP/AD to a Malaysian setting. PMID:18330404

  8. Quality of advance care planning policy and practice in residential aged care facilities in Australia

    PubMed Central

    Silvester, William; Fullam, Rachael S; Parslow, Ruth A; Lewis, Virginia J; Sjanta, Rebekah; Jackson, Lynne; White, Vanessa; Gilchrist, Jane

    2013-01-01

    Objectives To assess existing advance care planning (ACP) practices in residential aged care facilities (RACFs) in Victoria, Australia before a systematic intervention; to assess RACF staff experience, understanding of and attitudes towards ACP. Design Surveys of participating organisations concerning ACP-related policies and procedures, review of existing ACP-related documentation, and pre-intervention survey of RACF staff covering their role, experiences and attitudes towards ACP-related procedures. Setting 19 selected RACFs in Victoria. Participants 12 aged care organisations (representing 19 RACFs) who provided existing ACP-related documentation for review, 12 RACFs who completed an organisational survey and 45 staff (from 19 RACFs) who completed a pre-intervention survey of knowledge, attitudes and behaviour. Results Findings suggested that some ACP-related practices were already occurring in RACFs; however, these activities were inconsistent and variable in quality. Six of the 12 responding RACFs had written policies and procedures for ACP; however, none of the ACP-related documents submitted covered all information required to meet ACP best practice. Surveyed staff had limited experience of ACP, and discrepancies between self reported comfort, and levels of knowledge and confidence to undertake ACP-related activities, indicated a need for training and ongoing organisational support. Conclusions Surveyed organisations â policies and procedures related to ACP were limited and the quality of existing documentation was poor. RACF staff had relatively limited experience in developing advance care plans with facility residents, although attitudes were positive. A systematic approach to the implementation of ACP in residential aged care settings is required to ensure best practice is implemented and sustained. PMID:24644755

  9. 38 CFR 17.32 - Informed consent and advance care planning.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... in 38 CFR Part 16, Protection of Human Subjects. (h) Advance health care planning. Subject to the... damage or sterilization, except as provided in this paragraph (g). Before treatment is initiated,...

  10. 38 CFR 17.32 - Informed consent and advance care planning.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... in 38 CFR Part 16, Protection of Human Subjects. (h) Advance health care planning. Subject to the... unusual or extremely hazardous treatment or procedure, e.g., that which might result in irreversible...

  11. 38 CFR 17.32 - Informed consent and advance care planning.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... in 38 CFR Part 16, Protection of Human Subjects. (h) Advance health care planning. Subject to the... unusual or extremely hazardous treatment or procedure, e.g., that which might result in irreversible...

  12. 38 CFR 17.32 - Informed consent and advance care planning.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... in 38 CFR Part 16, Protection of Human Subjects. (h) Advance health care planning. Subject to the... unusual or extremely hazardous treatment or procedure, e.g., that which might result in irreversible...

  13. 38 CFR 17.32 - Informed consent and advance care planning.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... in 38 CFR Part 16, Protection of Human Subjects. (h) Advance health care planning. Subject to the... unusual or extremely hazardous treatment or procedure, e.g., that which might result in irreversible...

  14. Impact of a Disease-Specific Advance Care Planning Intervention on End-of-life Care

    PubMed Central

    Kirchhoff, Karin T.; Hammes, Bernard J.; Kehl, Karen A.; Briggs, Linda A.; Brown, Roger L.

    2012-01-01

    Background/Objectives Advance Care Planning (ACP) allows patients to state preferences for their end of life care but these preferences are frequently ignored. Following a Patient-Centered ACP interview (PC-ACP), patients’ preferences were compared to care received at end of life. Design A randomized controlled trial was conducted with patients with Congestive Heart Failure or End-stage Renal Disease and their surrogates who were randomized to receive either PC-ACP or usual care. Setting Two centers in Wisconsin with associated clinics/dialysis units provided patients. Participants Of the 313 patients and their surrogates who completed entry data, 110 died. Intervention During PC-ACP the trained facilitator assessed the patient and surrogate understanding of and experiences with the illness, provided information about disease-specific treatment options and their benefits and burden, assisted in documentation of patient treatment preferences, and assisted the surrogates in understanding the patient’s preferences and their role. Measurements Preferences were documented and then compared to the care received at end of life determined by surrogate interviews or medical charts. Results Patients (74%) frequently continued to make their own decisions about care to the end. The experimental group had fewer (1/62) but not significantly so cases where the patients could not get their wishes met about CPR than control (6/48). Significantly more experimental patients withdrew from dialysis than control. Conclusions Patients and their surrogates were generally willing to discuss preferences with a trained facilitator. Most patients received the care they desired at end of life or altered their preferences to be in accord with the care they could receive. A larger sample with surrogate decision makers is needed to detect significance. PMID:22458336

  15. Decision aids for advance care planning: an overview of the state of the science.

    PubMed

    Butler, Mary; Ratner, Edward; McCreedy, Ellen; Shippee, Nathan; Kane, Robert L

    2014-09-16

    Advance care planning honors patients' goals and preferences for future care by creating a plan for when illness or injury impedes the ability to think or communicate about health decisions. Fewer than 50% of severely or terminally ill patients have an advance directive in their medical record, and physicians are accurate only about 65% of the time when predicting patient preferences for intensive care. Decision aids can support the advance care planning process by providing a structured approach to informing patients about care options and prompting them to document and communicate their preferences. This review, commissioned as a technical brief by the Agency for Healthcare Research and Quality Effective Health Care Program, provides a broad overview of current use of and research related to decision aids for adult advance care planning. Using interviews of key informants and a search of the gray and published literature from January 1990 to May 2014, the authors found that many decision aids are widely available but are not assessed in the empirical literature. The 16 published studies testing decision aids as interventions for adult advance care planning found that most are proprietary or not publicly available. Some are constructed for the general population, whereas others address disease-specific conditions that have more predictable end-of-life scenarios and, therefore, more discrete choices. New decision aids should be designed that are responsive to diverse philosophical perspectives and flexible enough to change as patients gain experience with their personal illness courses. Future efforts should include further research, training of advance care planning facilitators, dissemination and access, and tapping potential opportunities in social media or other technologies. PMID:25069709

  16. Teaching Advance Care Planning to Medical Students with a Computer-Based Decision Aid

    PubMed Central

    Levi, Benjamin H.

    2013-01-01

    Discussing end-of-life decisions with cancer patients is a crucial skill for physicians. This article reports findings from a pilot study evaluating the effectiveness of a computer-based decision aid for teaching medical students about advance care planning. Second-year medical students at a single medical school were randomized to use a standard advance directive or a computer-based decision aid to help patients with advance care planning. Students' knowledge, skills, and satisfaction were measured by self-report; their performance was rated by patients. 121/133 (91%) of students participated. The Decision-Aid Group (n=60) outperformed the Standard Group (n=61) in terms of students´ knowledge (p<0.01), confidence in helping patients with advance care planning (p<0.01), knowledge of what matters to patients (p=0.05), and satisfaction with their learning experience (p<0.01). Likewise, patients in the Decision Aid Group were more satisfied with the advance care planning method (p<0.01) and with several aspects of student performance. Use of a computer-based decision aid may be an effective way to teach medical students how to discuss advance care planning with cancer patients. PMID:20632222

  17. Learning to Facilitate Advance Care Planning: The Novice Social Worker's Experience

    ERIC Educational Resources Information Center

    Washington, Karla; Bowland, Sharon; Mueggenburg, Kay; Pederson, Margaret; Otten, Sheila; Renn, Tanya

    2014-01-01

    Professional leaders have identified clear roles for social workers involved in advance care planning (ACP), a facilitated process whereby individuals identify their preferences for future medical care; yet information about effective teaching practices in this area is scant. This study reports on the experiences of 14 social workers who…

  18. An Assessment of Social Diffusion in the Respecting Choices Advance Care Planning Program

    ERIC Educational Resources Information Center

    Moorman, Sara M.; Carr, Deborah; Kirchhoff, Karin T.; Hammes, Bernard J.

    2012-01-01

    This study examines the potential social diffusion effects of the Respecting Choices advance care planning program administered in La Crosse, Wisconsin, since 1991. The program produces educational materials for patients, trains facilitators to help patients prepare for end of life, and ensures that advance directives are connected to patients'…

  19. Family Relationships and Advance Care Planning: Do Supportive and Critical Relations Encourage or Hinder Planning?

    PubMed Central

    2013-01-01

    Objectives. The effectiveness of advance care planning (ACP) may depend on family members’ understanding of patient preferences. However, we know of no studies that explore the association between family relationship dynamics and ACP. ACP includes a living will, durable power of attorney for health care (DPAHC) appointment, and discussions. We evaluated the effects of three aspects of family relations—general family functioning, support and criticism from spouse, and support and criticism from children—on both overall ACP and specific DPAHC designations. Method. Using multinomial logistic regression models and data from a sample of 293 older adults, we estimated the effects of family relationship quality on the likelihood of completing ACP and appointing a spouse or adult child as DPAHC. Analyses controlled for demographic and health characteristics. Results. Better overall family functioning increased the odds of ACP. Higher levels of spousal support increased the odds of holding informal discussions, whereas spousal criticism reduced the odds of naming one’s spouse as DPAHC. Both criticism and emotional support from children increased the odds that a child was named as DPAHC. Discussion. Family dynamics affect ACP in complex ways and should be considered when patients and their families discuss end-of-life care and make DPAHC designations. PMID:23286929

  20. Estimating the Effect of Palliative Care Interventions and Advance Care Planning on ICU Utilization: A Systematic Review

    PubMed Central

    Khandelwal, Nita; Kross, Erin K.; Engelberg, Ruth A.; Coe, Norma B.; Long, Ann C.; Curtis, J. Randall

    2015-01-01

    Objective We conducted a systematic review to answer three questions: 1) Do advance care planning and palliative care interventions lead to a reduction in ICU admissions for adult patients with life-limiting illnesses? 2) Do these interventions reduce ICU length of stay? and 3) Is it possible to provide estimates of the magnitude of these effects? Data Sources We searched MEDLINE, EMBASE, Cochrane Controlled Clinical Trials, and Cumulative Index to Nursing and Allied Health Literature databases from 1995 through March 2014. Study Selection We included studies that reported controlled trials (randomized and nonrandomized) assessing the impact of advance care planning and both primary and specialty palliative care interventions on ICU admissions and ICU length of stay for critically ill adult patients. Data Extraction Nine randomized controlled trials and 13 nonrandomized controlled trials were selected from 216 references. Data Synthesis Nineteen of these studies were used to provide estimates of the magnitude of effect of palliative care interventions and advance care planning on ICU admission and length of stay. Three studies reporting on ICU admissions suggest that advance care planning interventions reduce the relative risk of ICU admission for patients at high risk of death by 37% (sd, 23%). For trials evaluating palliative care interventions in the ICU setting, we found a 26% (sd, 23%) relative risk reduction in length of stay with these interventions. Conclusions Despite wide variation in study type and quality, patients who received advance care planning or palliative care interventions consistently showed a pattern toward decreased ICU admissions and reduced ICU length of stay. Although sds are wide and study quality varied, the magnitude of the effect is possible to estimate and provides a basis for modeling impact on healthcare costs. PMID:25574794

  1. Advance Care Planning and Goals of Care Communication in Older Adults with Cardiovascular Disease and Multi-Morbidity.

    PubMed

    Lum, Hillary D; Sudore, Rebecca L

    2016-05-01

    This article provides an approach to advance care planning (ACP) and goals of care communication in older adults with cardiovascular disease and multi-morbidity. The goal of ACP is to ensure that the medical care patients receive is aligned with their values and preferences. In this article, the authors outline common benefits and challenges to ACP for older adults with cardiovascular disease and multimorbidity. Recognizing that these patients experience diverse disease trajectories and receive care in multiple health care settings, the authors provide practical steps for multidisciplinary teams to integrate ACP into brief clinic encounters. PMID:27113144

  2. Development and Validation of a Questionnaire to Detect Behavior Change in Multiple Advance Care Planning Behaviors

    PubMed Central

    Sudore, Rebecca L.; Stewart, Anita L.; Knight, Sara J.; McMahan, Ryan D.; Feuz, Mariko; Miao, Yinghui; Barnes, Deborah E.

    2013-01-01

    Introduction Advance directives have traditionally been considered the gold standard for advance care planning. However, recent evidence suggests that advance care planning involves a series of multiple discrete behaviors for which people are in varying stages of behavior change. The goal of our study was to develop and validate a survey to measure the full advance care planning process. Methods The Advance Care Planning Engagement Survey assesses “Process Measures” of factors known from Behavior Change Theory to affect behavior (knowledge, contemplation, self-efficacy, and readiness, using 5-point Likert scales) and “Action Measures” (yes/no) of multiple behaviors related to surrogate decision makers, values and quality of life, flexibility for surrogate decision making, and informed decision making. We administered surveys at baseline and 1 week later to 50 diverse, older adults from San Francisco hospitals. Internal consistency reliability of Process Measures was assessed using Cronbach's alpha (only continuous variables) and test-retest reliability of Process and Action Measures was examined using intraclass correlations. For discriminant validity, we compared Process and Action Measure scores between this cohort and 20 healthy college students (mean age 23.2 years, SD 2.7). Results Mean age was 69.3 (SD 10.5) and 42% were non-White. The survey took a mean of 21.4 minutes (±6.2) to administer. The survey had good internal consistency (Process Measures Cronbach's alpha, 0.94) and test-retest reliability (Process Measures intraclass correlation, 0.70; Action Measures, 0.87). Both Process and Action Measure scores were higher in the older than younger group, p<.001. Conclusion A new Advance Care Planning Engagement Survey that measures behavior change (knowledge, contemplation, self-efficacy, and readiness) and multiple advance care planning actions demonstrates good reliability and validity. Further research is needed to assess whether survey scores

  3. Advance Care Planning Beyond Advance Directives: Perspectives from Patients and Surrogates

    PubMed Central

    McMahan, Ryan; Knight, Sara J.; Fried, Terri R.; Sudore, Rebecca L.

    2014-01-01

    Context Advance care planning (ACP) has focused on documenting life-sustaining treatment preferences in advance directives (ADs). ADs alone may be insufficient to prepare diverse patients and surrogates for complex medical decisions. Objectives To understand what steps best prepare patients and surrogates for decision making. Methods We conducted 13 English/Spanish focus groups with participants from a Veterans Affairs and county hospital and the community. Seven groups included patients (n=38) aged ≥65 years, who reported making serious medical decisions. Six separate groups included surrogates (n=31), aged ≥18 years, who made decisions for others. Semi-structured focus groups asked what activities best prepared participants for decision making. Two investigators independently coded data and performed thematic content analysis. Disputes were resolved by consensus. Results Mean±SD patient age was 78±8 years and 61% were non-white. Mean±SD surrogate age was 57±10 years and 91% were non-white. Qualitative analysis identified four overarching themes about how to best prepare for decision making: 1) identify values based on past experiences and quality of life, 2) choose surrogates wisely and verify they understand their role, 3) decide whether to grant leeway in surrogate decision making, and 4) inform other family and friends of one's wishes to prevent conflict. Conclusion Beyond ADs, patients and surrogates recommend several additional steps to prepare for medical decision making including using past experiences to identify values, verifying the surrogate understands their role, deciding whether to grant surrogates leeway, and informing other family and friends of one's wishes. Future ACP interventions should consider incorporating these additional ACP activities. PMID:23200188

  4. Attitudes on end-of-life care and advance care planning in the lesbian and gay community.

    PubMed

    Stein, G L; Bonuck, K A

    2001-01-01

    Gay men and lesbians have special interests in documenting their preferences regarding advance care planning and end-of-life care. A 64-item survey instrument was developed to ascertain the preferences of this community regarding approaches to end-of-life care, viewpoints on physician-assisted suicide (PAS) and euthanasia, and practices regarding advance care planning. The survey was completed by 575 participants recruited through community-based health care and social service organizations serving the lesbian and gay community, primarily in the New York metropolitan area. Respondents represent a diverse group of women (36%) and men (63%) from various age, racial/ethnic, and religious/spiritual backgrounds; 10% were human immunodeficiency virus (HIV)-positive. Respondents' perspectives on end-of-life care are generally consistent with findings from other attitudinal studies of U.S. adults: a majority supported legalization of PAS and preferred a palliative approach to end-of-life care. However, the gay community sample revealed even stronger support for assisted suicide and palliative care. Although respondents completed advance directives at a higher rate than adults generally, the legal importance for gay men and lesbians to execute directives should encourage health care providers and community organizations to assume a larger educational role on advance care planning. Results confirm other reports on the need to address provider communication skills. It is speculated that the HIV epidemic was a major influence behind these results because of the overwhelming personal impact of the epidemic on most gay men and lesbians during the past two decades. PMID:11441626

  5. HIV, Aging, and Advance Care Planning: Are We Successfully Planning for the Future?

    PubMed Central

    Allshouse, Amanda A.; Duong, Syki; MaWhinney, Samantha; Kohrt, Wendy M.; Campbell, Thomas B.

    2012-01-01

    Abstract Introduction Studies of advance care planning (ACP) completion rates in HIV-infected persons pre-date the “graying” of the HIV epidemic. We sought to examine current ACP completion rates and factors influencing completion among HIV-infected persons. Methods HIV-1-seropositive persons aged 45–65 years on effective antiretroviral therapy for a minimum of 6 months were enrolled in a cross-sectional survey. Likelihood of ACP was assessed by demographic and clinical characteristics, tested with odds ratios (OR) and 95% Wald confidence intervals (CI), and adjusted for gender. Results Of 238 participants, 112 (47%) completed ACP. Persons ≥55 years of age (OR 2.8; CI 1.6,5.0; p<0.001), males (OR 4.1; CI 1.8,9.3; p=0.004), and persons with higher education (OR 2.2; CI 1.3,4.0; p=0.007) were more likely to have completed ACP. Persons with a cardiac event were more likely to have completed ACP (OR 5.5; CI 1.6,25; p=0.03), although this effect was diminished after adjusting for gender (OR 4.5; CI 0.95,21.4; p=0.06). HIV infection diagnosed for greater than 5 years was not associated with ACP completion (OR 1.3; CI 0.7,2.7; p=0.4). Current CD4+ cell counts were similar between those completing and not completing documentation (588 cells/μL and 604 cells/μL, respectively; p=0.7). The likelihood of ACP did not significantly differ with other comorbidities. Discussion Less than 50% of middle-aged patients in HIV care had documented ACP. In particular, women and those with lower education were at greatest risk of non-completion and may need interventions to improve ACP. PMID:22694717

  6. Engaging Chinese American Adults in Advance Care Planning: A Community-Based, Culturally Sensitive Seminar.

    PubMed

    Lee, Mei Ching; Hinderer, Katherine A; Friedmann, Erika

    2015-08-01

    Ethnic minority groups are less engaged than Caucasian American adults in advance care planning (ACP). Knowledge deficits, language, and culture are barriers to ACP. Limited research exists on ACP and advance directives in the Chinese American adult population. Using a pre-posttest, repeated measures design, the current study explored the effectiveness of a nurseled, culturally sensitive ACP seminar for Chinese American adults on (a) knowledge, completion, and discussion of advance directives; and (b) the relationship between demographic variables, advance directive completion, and ACP discussions. A convenience sample of 72 urban, community-dwelling Chinese American adults (mean age=61 years) was included. Knowledge, advance directive completion, and ACP discussions increased significantly after attending the nurse-led seminar (p<0.01). Increased age correlated with advance directive completion and ACP discussions; female gender correlated with ACP discussions. Nursing education in a community setting increased advance directive knowledge and ACP engagement in Chinese American adults. PMID:25912237

  7. An Assessment of Social Diffusion in the Respecting Choices Advance Care Planning Program

    PubMed Central

    Moorman, Sara M.; Carr, Deborah; Kirchhoff, Karin T.; Hammes, Bernard J.

    2012-01-01

    This study examines the potential social diffusion effects of the Respecting Choices® advance care planning program, administered in La Crosse, Wisconsin since 1991. The program produces educational materials for patients, trains facilitators to help patients prepare for end-of-life, and ensures that advance directives are connected to patients' medical records. Using data from a survey of more than 5,000 white Wisconsin high school graduates in their mid-60s, we found that participants who were living in the La Crosse area were significantly less likely than their peers living elsewhere to have executed a living will or appointed a health care power of attorney. This pattern may reflect psychological reactance, where individuals reject a message or lesson when they perceive compliance as a threat to their autonomy. There was no evidence of social diffusion effects; participants who lived in the La Crosse region themselves or who had social network members residing in the area were no more likely than those with no known ties to the region to have engaged in advance care planning. Future studies should explore the processes through which individuals learn and share with others their knowledge of advance care planning. PMID:24567988

  8. Exploring the district nurse role in facilitating individualised advance care planning.

    PubMed

    Boot, Michelle

    2016-03-01

    Health-care policy recognises the importance of engaging people in making decisions related to the management of their health. Advance care planning (ACP) offers a framework for decision making on end-of-life care. There are positive indicators that ACP enables health professionals to meet people's preferences. However, there are reports of insensitive attempts to engage people in end-of-life care decision making. District nurses are in the ideal position to facilitate ACP, as they have the opportunity to build relationships with the people they are caring for--an antecedent to sensitive ACP--and in recognising and fulfilling this role, they could ameliorate the risk of insensitive ACP. Distric nurse leaders also have a role to play in ensuring that organisational and environmental factors support appropriate ACP facilitation including: training, fostering a team culture that empowers district nurses to recognise and meet their ACP role, and advocating for appropriate ACP evaluation outcome measures. PMID:26940617

  9. End-of-life communication in Korean older adults: With focus on advance care planning and advance directives.

    PubMed

    Shin, Dong Wook; Lee, Ji Eun; Cho, BeLong; Yoo, Sang Ho; Kim, SangYun; Yoo, Jun-Hyun

    2016-04-01

    The present article aimed to provide a comprehensive review of current status of end-of-life (EOL) care and sociocultural considerations in Korea, with focus on the EOL communication and use of advance directives (AD) in elderly Koreans. Through literature review, we discuss the current status of EOL care and sociocultural considerations in Korea, and provide a look-ahead. In Korea, patients often receive life-sustaining treatment until the very end of life. Advance care planning is rare, and most do-not-resuscitate decisions are made between the family and physician at the very end of patient's life. Koreans, influenced mainly by Confucian tradition, prefer a natural death and discontinuation of life-sustaining treatment. Although Koreans generally believe that death is natural and unavoidable, they tend not to think about or discuss death, and regard preparation for death as unnecessary. As a result, AD are completed by just 4.7% of the general adult population. This situation can be explained by several sociocultural characteristics including opting for natural death, wish not to burden others, preference for family involvement and trust in doctor, avoidance of talking about death, and filial piety. Patients often receive life-sustaining treatment until the very EOL, advance care planning and the use of AD is not common in Korea. This was related to unique sociocultural characteristics of Korea. A more active role of physicians, development of a more deliberate EOL discussion process, development of culturally appropriate AD and promotion of advance care planning might be required to provide good EOL care in Korea. PMID:26459613

  10. Advance care planning for older people in Australia presenting to the emergency department from the community or residential aged care facilities.

    PubMed

    Street, Maryann; Ottmann, Goetz; Johnstone, Megan-Jane; Considine, Julie; Livingston, Patricia M

    2015-09-01

    The purpose of this retrospective, cross-sectional study was to determine the prevalence of advance care planning (ACP) among older people presenting to an Emergency Department (ED) from the community or a residential aged care facility. The study sample comprised 300 older people (aged 65+ years) presenting to three Victorian EDs in 2011. A total of 150 patients transferred from residential aged care to ED were randomly selected and then matched to 150 people who lived in the community and attended the ED by age, gender, reason for ED attendance and triage category on arrival. Overall prevalence of ACP was 13.3% (n = 40/300); over one-quarter (26.6%, n = 40/150) of those presenting to the ED from residential aged care had a documented Advance Care Plan, compared to none (0%, n = 0/150) of the people from the community. There were no significant differences in the median ED length of stay, number of investigations and interventions undertaken in ED, time seen by a doctor or rate of hospital admission for those with an Advance Care Plan compared to those without. Those with a comorbidity of cerebrovascular disease or dementia and those assessed with impaired brain function were more likely to have a documented Advance Care Plan on arrival at ED. Length of hospital stay was shorter for those with an Advance Care Plan [median (IQR) = 3 days (2-6) vs. 6 days (2-10), P = 0.027] and readmission lower (0% vs. 13.7%). In conclusion, older people from the community transferred to ED were unlikely to have a documented Advance Care Plan. Those from residential aged care who were cognitively impaired more frequently had an Advance Care Plan. In the ED, decisions of care did not appear to be influenced by the presence or absence of Advance Care Plans, but length of hospital admission was shorter for those with an Advance Care Plan. PMID:25443161

  11. A review of advance care planning programs in long-term care homes: are they dementia friendly?

    PubMed

    Wickson-Griffiths, Abigail; Kaasalainen, Sharon; Ploeg, Jenny; McAiney, Carrie

    2014-01-01

    Background. Persons living with dementia in the long-term care home (LTCH) setting have a number of unique needs, including those related to planning for their futures. It is therefore important to understand the advance care planning (ACP) programs that have been developed and their impact in order for LTCH settings to select a program that best suits residents' needs. Methods. Four electronic databases were searched from 1990 to 2013, for studies that evaluated the impact of advance care planning programs implemented in the LTCH setting. Studies were critically reviewed according to rigour, impact, and the consideration of the values of residents with dementia and their family members according to the Dementia Policy Lens Toolkit. Results and Conclusion. Six ACP programs were included in the review, five of which could be considered more "dementia friendly." The programs indicated a variety of positive impacts in the planning and provision of end-of-life care for residents and their family members, most notably, increased ACP discussion and documentation. In moving forward, it will be important to evaluate the incorporation of residents with dementia's values when designing or implementing ACP interventions in the LTCH settings. PMID:24757563

  12. A Review of Advance Care Planning Programs in Long-Term Care Homes: Are They Dementia Friendly?

    PubMed Central

    Wickson-Griffiths, Abigail; Kaasalainen, Sharon; McAiney, Carrie

    2014-01-01

    Background. Persons living with dementia in the long-term care home (LTCH) setting have a number of unique needs, including those related to planning for their futures. It is therefore important to understand the advance care planning (ACP) programs that have been developed and their impact in order for LTCH settings to select a program that best suits residents' needs. Methods. Four electronic databases were searched from 1990 to 2013, for studies that evaluated the impact of advance care planning programs implemented in the LTCH setting. Studies were critically reviewed according to rigour, impact, and the consideration of the values of residents with dementia and their family members according to the Dementia Policy Lens Toolkit. Results and Conclusion. Six ACP programs were included in the review, five of which could be considered more “dementia friendly.” The programs indicated a variety of positive impacts in the planning and provision of end-of-life care for residents and their family members, most notably, increased ACP discussion and documentation. In moving forward, it will be important to evaluate the incorporation of residents with dementia's values when designing or implementing ACP interventions in the LTCH settings. PMID:24757563

  13. Advance care planning: A systematic review of randomised controlled trials conducted with older adults.

    PubMed

    Weathers, Elizabeth; O'Caoimh, Rónán; Cornally, Nicola; Fitzgerald, Carol; Kearns, Tara; Coffey, Alice; Daly, Edel; O'Sullivan, Ronan; McGlade, Ciara; Molloy, D William

    2016-09-01

    Advance care planning (ACP), involving discussions between patients, families and healthcare professionals on future healthcare decisions, in advance of anticipated impairment in decision-making capacity, improves satisfaction and end-of-life care while respecting patient autonomy. It usually results in the creation of a written advanced care directive (ACD). This systematic review examines the impact of ACP on several outcomes (including symptom management, quality of care and healthcare utilisation) in older adults (>65years) across all healthcare settings. Nine randomised controlled trials (RCTs) were identified by searches of the CINAHL, PubMed and Cochrane databases. A total of 3646 older adults were included (range 72-88 years). Seven studies were conducted with community dwellers and the other two RCTs were conducted in nursing homes. Most studies did not implement a standardised ACD, or measure the impact on quality of end-of-life care or on the death and dying experience. All studies had some risk of bias, with most scoring poorly on the Oxford Quality Scale. While ACP interventions are well received by older adults and generally have positive effects on outcomes, this review highlights the need for well-designed RCTs that examine the economic impact of ACP and its effect on quality of care in nursing homes and other sectors. PMID:27451328

  14. Assessing Advance Care Planning: Examining Autonomous Selections in an Advance Directive.

    PubMed

    Klugman, Craig M; Tolwin, Nicole M

    2015-01-01

    We examined the management of completed advance directives including why participants completed a document, what procedures and values they chose, with whom they held end-of-life conversations, and where they stored their document. Participants elected to complete a SurveyMonkey survey that was made available to individuals who wrote an advance directive through TexasLivingWill.org; 491 individuals elected to fill out the survey, aged 19 to 94 years. The survey asked multiple questions about why participants completed an advance directive, where they would store it, and with whom they had conversations about their end-of-life wishes. A list of procedures and values allowed participants to indicate what they refused or requested in their advance directive. Advance directives are most often completed to allow patients to prepare and control the healthcare they wish to receive when dying. One-half to two-thirds of individuals refuse common end-of-life medical procedures, and the rest request the procedures. We found a correlation between the choice to refuse or request a procedure and the age of the participant. Participants reported that their end-of-life conversations most often occurred with their spouse. Respondents often reported that their advance directive was stored with their physician and power of attorney for healthcare, conversations with those individuals rarely happened. Advance directives document patients' requests for and refusals of end-of-life care. Physicians and surrogates need to be better educated so that the documents are part of a meaningful conversation with the patient. Because patients' choices change over their lifespan, these documents need to be revisited regularly and not completed as a onetime event. PMID:26399671

  15. Trends in Engagement in Advance Care Planning Behaviors and the Role of Socioeconomic Status.

    PubMed

    Khosla, Nidhi; Curl, Angela L; Washington, Karla T

    2016-08-01

    We investigated the trends in advance care planning (ACP) between 2002 and 2010 and whether socioeconomic status explained such trends. We conducted a pooled regression analysis of Health and Retirement Study data from 6052 proxies of deceased individuals. We studied 3 ACP behaviors, discussing end-of-life (EOL) care preferences, providing written EOL care instructions, and appointing a durable power of attorney for health care (DPAHC). ACP increased by 12% to 23% every 2 years from 2002 to 2010. Higher household income increased the odds of having a DPAHC. Education was not associated with ACP. Socioeconomic status alone appears to play a very limited role in predicting ACP. Engagement in ACP likely depends on a constellation of many social and contextual factors. PMID:25900854

  16. Lessons learned from New York's community approach to advance care planning and MOLAT.

    PubMed

    Bomba, Patricia A; Orem, Katie

    2015-01-01

    This article reviews the lessons learned from the development and implementation of New York's community approach to advance care planning (ACP) as a wellness initiative and the key components of the complementary programs: Community Conversations on Compassionate Care (CCCC) and Medical Orders for Life-Sustaining Treatment (MOLST). Shared, informed medical decision-making is a patient-centered process that is critical to ensuring patient preferences for care are honored at the end of life. Providers must be trained, qualified, and comfortable with the discussions needed for effective shared, informed medical decision-making. Development, implementation, outcomes, lessons learned and sustainability of the CCCC and MOLST programs highlight the success of a healthcare and community collaborative initiative focused on improving care at the end of life. Community data support the value of implementing the CCCC and New York's MOLST throughout the country. PMID:25813415

  17. [Timing of Advance Care Planning in frail elderly patients: when to start?].

    PubMed

    Ott, Brenda; van Thiel, Ghislaine J M W; de Ruiter, Corinne M; van Delden, Hans J J M

    2015-01-01

    Advance Care Planning (ACP) is the process of discussing and recording patient preferences concerning goals for end-of-life care and to facilitate decision-making. ACP is an essential element of care for frail elderly patients because frailty increases the risks of negative health outcomes and loss of function. In this article, we present three patient cases to illustrate how general practitioners (GPs) can perform ACP and to demonstrate the importance of early and iterative end-of-life discussions with frail elderly patients. Good timing is decisive for the success of the intervention. GPs are in a key position to identify and discuss ACP matters at an early stage, supported by the geriatrician if necessary. Posing the 'surprise question' has proved helpful to determine timing. Complex ACP interventions contribute to care which is better adapted to the needs of frail elderly patients. PMID:25650032

  18. "I Don't Want to Die like that...": The Impact of Significant Others' Death Quality on Advance Care Planning

    ERIC Educational Resources Information Center

    Carr, Deborah

    2012-01-01

    Purpose of the Study: I examine whether 5 aspects of a significant other's death quality (pain, decision-making capacity, location, problems with end-of life care, and preparation) affect whether one does advance care planning (ACP). I also identify specific aspects of others' deaths that respondents say triggered their own planning. Design and…

  19. Impact of a Care Directives Activity Tab in the Electronic Health Record on Documentation of Advance Care Planning

    PubMed Central

    Turley, Marianne; Wang, Susan; Meng, Di; Kanter, Michael; Garrido, Terhilda

    2016-01-01

    Context: To ensure patient-centered end-of-life care, advance care planning (ACP) must be documented in the medical record and readily retrieved across care settings. Objective: To describe use of the Care Directives Activity tab (CDA), a single-location feature in the electronic health record for collecting and viewing ACP documentation in inpatient and ambulatory care settings, and to assess its association with ACP documentation rates. Design: Retrospective pre- and postimplementation analysis in 2012 and 2013 at Kaiser Permanente Southern California among 113,309 patients aged 65 years and older with ACP opportunities during outpatient or inpatient encounters. Main Outcome Measures: Providers’ CDA use rates and documentation rates of advance directives and physician orders for life-sustaining treatments stratified by CDA use. Results: Documentation rates of advance directives and physician orders for life-sustaining treatments among patients with outpatient and inpatient encounters were 3.5 to 9.6 percentage points higher for patients with CDA use vs those without it. The greatest differences were for orders for life-sustaining treatments among patients with inpatient encounters and for advance directives among patients with outpatient encounters; both were 9.6 percentage points higher among those with CDA use than those without it. All differences were significant after controlling for yearly variation (p < 0.001). Conclusion: Statistically significant differences in documentation rates between patients with and without CDA use suggest the potential of a standardized location in the electronic health record to improve ACP documentation. Further research is required to understand effects of CDA use on retrieval of preferences and end-of-life care. PMID:27057820

  20. Incidence and Predictors of Advance Care Planning Among Persons with Cognitive Impairment

    PubMed Central

    Garand, Linda; Dew, Mary Amanda; Lingler, Jennifer H.; DeKosky, Steven T.

    2010-01-01

    Objective Persons with mild cognitive impairment (MCI) and Alzheimer’s disease (AD) are at heightened risk for future decisional incapacity. We sought to characterize advance care planning (ACP) rates over time in individuals who had no advance directives (living will or durable power of attorney) in place when they initially presented for a cognitive evaluation. Design Retrospective analysis of data that had been prospectively collected. Setting Alzheimer’s Disease Research Center memory disorders clinic. Participants Persons (N=127) with a diagnosis of MCI or early AD (n = 72) or moderate to severe AD (n = 55) and no advance directives upon initial presentation for a cognitive evaluation. Measurements Extraction of responses to items pertaining to advance care planning assessed during annual semi-structured interviews. Results By 5 years of follow-up, 39% of the sample had initiated ACP, with little difference by baseline diagnosis. Younger subjects (under 65 years old) were significantly more likely to initiate advance directives (43%) than were older subjects (37%). This age effect was more pronounced in men than women as well as in married subjects, those with a family history of dementia, no depressive disorder, and subjects with moderate to severe AD (versus those with MCI or early AD) at baseline. Conclusion Only a minority of subjects initiated ACPs. The findings suggest the need for interventions aimed at enhancing ACP completion rates, particularly among older adults with cognitive impairment since these individuals may have a timed-limited opportunity to plan for future medical, financial, and other major life decisions. PMID:21785291

  1. Implementing advance care planning: a qualitative study of community nurses' views and experiences

    PubMed Central

    2010-01-01

    Background Advance care planning (ACP) is a process of discussion about goals of care and a means of setting on record preferences for care of patients who may lose capacity or communication ability in the future. Implementation of ACP is widely promoted by policy makers. This study examined how community palliative care nurses in England understand ACP and their roles within ACP. It sought to identify factors surrounding community nurses' implementation of ACP and nurses' educational needs. Methods An action research strategy was employed. 23 community nurses from two cancer networks in England were recruited to 6 focus group discussions and three follow up workshops. Data were analysed using a constant comparison approach. Findings Nurses understood ACP to be an important part of practice and to have the potential to be a celebration of good nursing care. Nurses saw their roles in ACP as engaging with patients to elicit care preferences, facilitate family communication and enable a shift of care focus towards palliative care. They perceived challenges to ACP including: timing, how to effect team working in ACP, the policy focus on instructional directives which related poorly to patients' concerns; managing differences in patients' and families' views. Perceived barriers included: lack of resources; lack of public awareness about ACP; difficulties in talking about death. Nurses recommended the following to be included in education programmes: design of realistic scenarios; design of a flow chart; practical advice about communication and documentation; insights into the need for clinical supervision for ACP practice. Conclusions Nurses working in the community are centrally involved with patients with palliative care needs who may wish to set on record their views about future care and treatment. This study reveals some important areas for practice and educational development to enhance nurses' use and understanding of ACP. PMID:20377876

  2. Advance care planning in stroke: influence of time on engagement in the process

    PubMed Central

    Green, Theresa; Gandhi, Shreyas; Kleissen, Tessa; Simon, Jessica; Raffin-Bouchal, Shelley; Ryckborst, Karla

    2014-01-01

    Purpose Individuals who experience stroke have a higher likelihood of subsequent stroke events, making it imperative to plan for future medical care. In the event of a further serious health event, engaging in the process of advanced care planning (ACP) can help family members and health care professionals (HCPs) make medical decisions for individuals who have lost the capacity to do so. Few studies have explored the views and experiences of patients with stroke about discussing their wishes and preferences for future medical events, and the extent to which stroke HCPs engage in conversations around planning for such events. In this study, we sought to understand how the process of ACP unfolded between HCPs and patients post-stroke. Patients and methods Using grounded theory (GT) methodology, we engaged in direct observation of HCP and patient interactions on an acute stroke unit and two stroke rehabilitation units. Using semi-structured interviews, 14 patients and four HCPs were interviewed directly about the ACP process. Results We found that open and continual ACP conversations were not taking place, patients experienced an apparent lack of urgency to engage in ACP, and HCPs were uncomfortable initiating ACP conversations due to the sensitive nature of the topic. Conclusion In this study, we identified lack of engagement in ACP post-stroke, attributable to patient and HCP factors. This encourages us to look further into the process of ACP in order to develop open communication between the patient with stroke, their families, and stroke HCPs. PMID:24493922

  3. How Do General Practitioners Conceptualise Advance Care Planning in Their Practice? A Qualitative Study

    PubMed Central

    De Vleminck, Aline; Pardon, Koen; Beernaert, Kim; Houttekier, Dirk; Vander Stichele, Robert; Deliens, Luc

    2016-01-01

    Objectives To explore how GPs conceptualise advance care planning (ACP), based on their experiences with ACP in their practice. Methods Five focus groups were held with 36 GPs. Discussions were analysed using a constant comparative method. Results Four overarching themes in the conceptualisations of ACP were discerned: (1) the organisation of professional care required to meet patients’ needs, (2) the process of preparing for death and discussing palliative care options, (3) the discussion of care goals and treatment decisions, (4) the completion of advance directives. Within these themes, ACP was both conceptualised in terms of content of ACP and/or in terms of tasks for the GP. A specific task that was mentioned throughout the discussion of the four different themes was (5) the task of actively initiating ACP by the GP versus passively waiting for patients’ initiation. Conclusions This study illustrates that GPs have varying conceptualisations of ACP, of which some are more limited to specific aspects of ACP. A shared conceptualisation and agreement on the purpose and goals of ACP is needed to ensure successful implementation, as well as a systematic integration of ACP in routine practice that could lead to a better uptake of all the important elements of ACP. PMID:27096846

  4. Honoring Choices Minnesota: Preliminary Data from a Community-Wide Advance Care Planning Model

    PubMed Central

    Wilson, Kent S; Kottke, Thomas E; Schettle, Sue

    2014-01-01

    Advance care planning (ACP) increases the likelihood that individuals who are dying receive the care that they prefer. It also reduces depression and anxiety in family members and increases family satisfaction with the process of care. Honoring Choices Minnesota is an ACP program based on the Respecting Choices model of La Crosse, Wisconsin. The objective of this report is to describe the process, which began in 2008, of implementing Honoring Choices Minnesota in a large, diverse metropolitan area. All eight large healthcare systems in the metropolitan area agreed to participate in the project, and as of April 30, 2013, the proportion of hospitalized individuals 65 and older with advance care directives in the electronic medical record was 12.1% to 65.6%. The proportion of outpatients aged 65 and older was 11.6% to 31.7%. Organizations that had sponsored recruitment initiatives had the highest proportions of records containing healthcare directives. It was concluded that it is possible to reduce redundancy by recruiting all healthcare systems in a metropolitan area to endorse the same ACP model, although significantly increasing the proportion of individuals with a healthcare directive in their medical record requires a campaign with recruitment of organizations and individuals. PMID:25516036

  5. Measuring engagement in advance care planning: a cross-sectional multicentre feasibility study

    PubMed Central

    Howard, Michelle; Bonham, Aaron J; Heyland, Daren K; Sudore, Rebecca; Fassbender, Konrad; Robinson, Carole A; McKenzie, Michael; Elston, Dawn; You, John J

    2016-01-01

    Objectives To assess the feasibility, acceptability and clinical sensibility of a novel survey, the advance care planning (ACP) Engagement Survey, in various healthcare settings. Setting A target sample of 50 patients from each of primary care, hospital, cancer care and dialysis care settings. Participants A convenience sample of patients without cognitive impairment who could speak and read English was recruited. Patients 50 and older were eligible in primary care; patients 80 and older or 55 and older with clinical markers of advanced chronic disease were recruited in hospital; patients aged 19 and older were recruited in cancer and renal dialysis centres. Outcomes We assessed feasibility, acceptability and clinical sensibility of the ACP Engagement Survey using a 6-point scale. The ACP Engagement Survey measures ACP processes (knowledge, contemplation, self-efficacy and readiness) on 5-point Likert scales and actions (yes/no). Results 196 patients (38–96 years old, 50.5% women) participated. Mean (±SD) time to administer was 48.8±19.6 min. Mean acceptability scores ranged from 3.2±1.3 in hospital to 4.7±0.9 in primary care, and mean relevance ranged from 3.5±1.0 in hospital to 4.9±0.9 in dialysis centres (p<0.001 for both). The mean process score was 3.1±0.6 and the mean action score was 11.2±5.6 (of a possible 25). Conclusions The ACP Engagement Survey demonstrated feasibility and acceptability in outpatient settings but was less feasible and acceptable among hospitalised patients due to length. A shorter version may improve feasibility. Engagement in ACP was low to moderate. PMID:27338877

  6. Advance Care Planning in Norwegian nursing homes-Who is it for?

    PubMed

    Thoresen, Lisbeth; Ahlzén, Rolf; Solbrække, Kari Nyheim

    2016-08-01

    Advance care planning (ACP) is an international concept for improving patient autonomy and communication in the context of anticipated deterioration and end-of-life care. In a preparatory conversation, health care professionals facilitate one or more conversations where nursing home residents are invited to reflect on, and articulate wishes and preferences concerning future medical treatment and end-of-life care. Our aim with this study was to increase knowledge of existing ACP practices in Norwegian nursing homes. We wanted to know how nursing home residents, relatives and nursing home staff take part in the conversations, and to what extent these conversations can be regarded as promoting autonomy, legal rights and individual needs for the residents. We conducted participant observation of seven preparatory conversations, followed by interviews with health care staff (together) and resident and relative (together). In the result section, we present an informative case example of an ACP conversation where common and important characteristics running through our data are present. These are further elaborated under the following headings: Life critical questions, Residents' quiet participation in the conversations, the Dying phase - a clinical issue, Nurses and physicians; different domains and Timing. We find that nursing home staff in our study wants to contribute to open awareness, autonomy and a good death, but there are little reflections about the purpose and content of the conversations, how they should be carried out and when, and what frail nursing home residents are able to understand and express in ACP conversations. PMID:27531449

  7. Coping Styles, Health Status and Advance Care Planning in Patients with Hematologic Malignancies

    PubMed Central

    Loberiza, Fausto R; Swore-Flecther, Barbara A.; Block, Susan D.; Back, Anthony L.; Goldman, Roberta E.; Tulsky, James A.; Lee, Stephanie J.

    2014-01-01

    This study evaluated if measures of psychological well-being, including coping style are associated with advance care planning (ACP). Data were from the HEMA-COMM study, a prospective observational study of physician-patient communication in patients with hematologic malignancies. ACP was defined as having a living will, having a health care proxy, discussing life support with family or friends, and discussing life support with a doctor or nurse. 293 patients participated: only 45 (15%) had all the elements of ACP, 215 (73%) had at least 1 element of ACP, while 33 (11%) did not engage in ACP. In multivariate analysis, specific coping styles but not other measures of psychosocial well being were associated with having written ACP. Verbal ACP was associated with patient-reported health and physician estimate of life expectancy. Our study suggests that tailoring ACP discussions to a patient’s coping style may increase engagement in ACP. PMID:21851220

  8. Advance Care Planning and HIV Infection in the Era of Antiretroviral Therapy: A Review.

    PubMed

    Sangarlangkarn, Aroonsiri; Merlin, Jessica S; Tucker, Rodney O; Kelley, Amy S

    In the era of antiretroviral therapy, HIV infection has become a chronic illness with associated multimorbidity, and practitioners are faced with an emerging population of HIV-infected patients with evolving needs for advance care planning (ACP), defined as communication between individuals and their proxies to plan for future health care decisions. This article provides a review of original research studies on ACP in HIV-infected adults in the era of antiretroviral therapy (1996-present) from PubMed, EMBASE, and PsycINFO. Eleven studies conducted between 1996 and 2015 met the selection criteria, with study sizes ranging from 9 to 2864 participants. Most studies consisted of white men in outpatient settings and had poorly defined definitions of ACP. Prevalence of ACP was variable (36%-54% had end-of-life communication, 8%-47% had advance directives). Lack of ACP was most commonly associated with low income, followed by lower severity of illness, low education level, black or Hispanic race, female sex, younger age, injection drug use, and social isolation. Practitioners reported limited time or energy and inadequate preparation or training as barriers to ACP. Existing literature on ACP in the era of antiretroviral therapy is limited, but shows that ACP prevalence in HIV-infected individuals is variable depending on socioeconomic factors, severity of illness, and practitioner resources and training. More research is needed to increase ACP among HIV-infected individuals. PMID:27398771

  9. Accuracy of a Decision Aid for Advance Care Planning: Simulated End-of-Life Decision Making

    PubMed Central

    Levi, Benjamin H.; Heverley, Steven R.; Green, Michael J.

    2013-01-01

    Purpose Advance directives have been criticized for failing to help physicians make decisions consistent with patients’ wishes. This pilot study sought to determine if an interactive, computer-based decision aid that generates an advance directive can help physicians accurately translate patients’ wishes into treatment decisions. Methods We recruited 19 patient-participants who had each previously created an advance directive using a computer-based decision aid, and 14 physicians who had no prior knowledge of the patient-participants. For each advance directive, three physicians were randomly assigned to review the advance directive and make five to six treatment decisions for each of six (potentially) end-of-life clinical scenarios. From the three individual physicians’ responses, a “consensus physician response” was generated for each treatment decision (total decisions = 32). This consensus response was shared with the patient whose advance directive had been reviewed, and she/he was then asked to indicate how well the physician translated his/her wishes into clinical decisions. Results Patient-participants agreed with the consensus physician responses 84 percent (508/608) of the time, including 82 percent agreement on whether to provide mechanical ventilation, and 75 percent on decisions about cardiopulmonary resuscitation (CPR). Across the six vignettes, patient-participants’ rating of how well physicians translated their advance directive into medical decisions was 8.4 (range = 6.5–10, where 1 = extremely poorly, and 10 = extremely well). Physicians’ overall rating of their confidence at accurately translating patients’ wishes into clinical decisions was 7.8 (range = 6.1–9.3, 1 = not at all confident, 10 = extremely confident). Conclusion For simulated cases, a computer-based decision aid for advance care planning can help physicians more confidently make end-of-life decisions that patients will endorse. PMID:22167985

  10. Understanding the views of those who care for patients with cancer on advance care planning and end-of-life care.

    PubMed

    Mattes, Malcolm D; Tung, Kaity; Baum, Rachel; Parikh, Kapila; Ashamalla, Hani

    2015-12-01

    An electronic survey was used to assess the views of a diverse nationwide cohort of health care professionals regarding advance care planning and end-of-life care. A total of 645 responses were received. If diagnosed with a serious incurable illness with limited life expectancy, 97% would want to discuss their prognosis, 74% would refuse cardiopulmonary resuscitation, and 72% favored supportive/comfort care to more aggressive life-prolonging treatments. However, prognosis was thought to be discussed with only 52% of such patients, and just 5% thought doctors were either very or extremely successful at explaining advanced life-sustaining treatments to patients. Greater than 90% believed these discussions should best occur when a patient is thought to have one or more years to live and 80% thought they are best initiated in the outpatient setting. PMID:24939206

  11. Association of Experience with Illness and End-of-life Care with Advance Care Planning in Older Adults

    PubMed Central

    Amjad, Halima; Towle, Virginia; Fried, Terri

    2014-01-01

    Objectives To examine whether experiences with illness and end-of-life care are associated with increased readiness to participate in advance care planning (ACP). Design Observational cohort study. Setting Community. Participants Persons age ≥ 60 recruited from physician offices and a senior center. Measurements Participants were asked about personal experience with major illness or surgery and experience with others’ end-of-life care, including whether they had made a medical decision for someone dying, knew someone who had a bad death due to too much/too little medical care, or experienced the death of a loved one who made end-of-life wishes known. Stages of change were assessed for specific ACP behaviors: completion of living will and healthcare proxy, communication with loved ones regarding life-sustaining treatments and quantity versus quality of life, and communication with physicians about these same topics. Stages of change included precontemplation, contemplation, preparation and action/maintenance corresponding to whether the participant was not ready to complete the behavior, was considering participation in the next six months, was planning participation within thirty days, or had already participated. Results Of 304 participants, 84% had one or more personal experiences or experience with others. Personal experiences were not associated with increased readiness for most ACP behaviors. In contrast, having one or more experiences with others was associated with increased readiness to complete a living will and healthcare proxy, discuss life-sustaining treatment with loved ones and discuss quantity versus quality of life with loved ones and with physicians. Conclusion Older individuals who have experience with end-of-life care for others demonstrate increased readiness to participate in ACP. Discussions with older patients regarding these experiences may be a useful tool in promoting ACP. PMID:24934237

  12. Barriers and facilitators for general practitioners to engage in advance care planning: A systematic review

    PubMed Central

    2013-01-01

    Abstract Objective The aim of this systematic review is to identify the perceived factors hindering or facilitating GPs in engaging in advance care planning (ACP) with their patients about care at the end of life. Design Studies from 1990 to 2011 were found in four electronic databases (PubMed, CINAHL, EMBASE, PsycINFO); by contacting first authors of included studies and key experts; and searching through relevant journals and reference lists. Studies were screened, graded for quality, and analysed independently by two authors; those reporting the perception by GPs of barriers and facilitators to engagement in ACP were included. Results Eight qualitative studies and seven cross-sectional studies were included for data extraction. All barriers and facilitators identified were categorized as GP characteristics, perceived patient factors, or health care system characteristics. Stronger evidence was found for the following barriers: lack of skills to deal with patients’ vague requests, difficulties with defining the right moment, the attitude that it is the patient who should initiate ACP, and fear of depriving patients of hope. Stronger evidence was found for the following facilitators: accumulated skills, the ability to foresee health problems in the future, skills to respond to a patient's initiation of ACP, personal convictions about who to involve in ACP, and a longstanding patient–GP relationship and the home setting. Conclusion Initiation of ACP in general practice may be improved by targeting the GPs’ skills, attitudes, and beliefs but changes in health care organization and financing could also contribute. PMID:24299046

  13. Building on Individual, State, and Federal Initiatives for Advance Care Planning, an Integral Component of Palliative and End-of-Life Cancer Care

    PubMed Central

    Epstein, Andrew S.; Volandes, Angelo E.; O'Reilly, Eileen M.

    2011-01-01

    Federal and state provisions for advance care planning—the process by which patients, families, and medical professionals plan for future and, in particular, end-of-life care—continue to receive attention. Such planning remains an integral component of palliative care, complementing the recognition and treatment of pain and other symptoms that patients with advanced malignancies and their families encounter. Historically, advance care planning interventions (particularly those involving advance directives) have been unable to consistently demonstrate positive outcomes for patients with life-threatening illnesses. However, more recent literature, including that on patients with cancer, illustrates that both patients and caregivers report improved quality of life and less distress after discussions with their health care teams about end-of-life care. Herein, we discuss recent federal and state public policy that focuses on advance care planning, suggesting the promise for care delivery improvements and the means by which existing barriers might be surmounted. These care delivery issues apply to several disease states but are particularly pertinent to the adult oncology setting. PMID:22379415

  14. Agreement between Older Persons and their Surrogate Decision Makers Regarding Participation in Advance Care Planning

    PubMed Central

    Fried, Terri R.; Redding, Colleen A.; Robbins, Mark L.; O'Leary, John R.; Iannone, Lynne

    2014-01-01

    Objectives To examine agreement between older persons and their surrogates regarding participation in advance care planning (ACP). Design Observational cohort study. Setting Community Participants Persons age ≥ 65 and the individual they identified as most likely to make treatment decisions on their behalf. Measurements Older persons were asked about participation in four activities: 1. Completion of living will; 2. Completion of health care proxy; 3. Communication regarding views about life-sustaining treatment; 4. Communication regarding views about quality versus quantity of life. Surrogates were asked whether they believed the older person had completed these activities. Results Of 216 pairs, 81% agreed about whether a living will had been completed [k = .61, 95% confidence interval (CI) .51, .72]. Only 68% of pairs agreed about whether a health care proxy had been completed (k = .39, 95% CI .29, .50), 64% agreed about whether they had communicated regarding life-sustaining treatment (k = .22, 95% CI .09, .35), and 62% agreed about whether they had communicated regarding quality versus quantity of life (k = .23, 95% CI .11, .35). Conclusions While agreement between older persons and their surrogates regarding living will completion was good, agreement about participation in other aspects of ACP was fair to poor. Additional study is necessary to determine who is providing the most accurate report of objective ACP components and whether agreement regarding participation in ACP is associated with greater shared understanding of patients’ preferences. PMID:21649619

  15. Redefining the “Planning” in Advance Care Planning: Preparing for End-of-Life Decision Making

    PubMed Central

    Sudore, Rebecca L.; Fried, Terri R.

    2010-01-01

    The traditional objective of advance care planning has been to have patients make treatment decisions in advance in an attempt to provide care consistent with their goals. We argue that the objective for advance care planning ought to be the preparation of patients and surrogates to participate with clinicians in making the best possible in-the-moment medical decisions. We provide practical steps for clinicians to help patients and surrogate decision makers achieve this objective in the outpatient setting. Preparation for in-the-moment decision making shifts the focus from having patients make premature decisions based on incomplete information to preparing patients and their surrogates for the types of decisions and conflicts they may encounter when they do have to engage in in-the-moment decision making. This approach does not preclude the completion of advance directives, but acknowledges that they are but one piece of information to be used at the time of decision making. PMID:20713793

  16. Early experience with digital advance care planning and directives, a novel consumer-driven program

    PubMed Central

    Yang, Zhiyong; Spivey, Christy; Boardman, Bonnie; Courtney, Maureen

    2016-01-01

    Barriers to traditional advance care planning (ACP) and advance directive (AD) creation have limited the promise of ACP/AD for individuals and families, the healthcare team, and society. Our objectives were to determine the results of a digital ACP/AD through which consumers create, store, locate, and retrieve their ACP/AD at no charge and with minimal physician involvement, and the ACP/AD can be integrated into the electronic health record. The authors chose 900 users of MyDirectives, a digital ACP/AD tool, to achieve proportional representation of all 50 states by population size and then reviewed their responses. The 900 participants had an average age of 50.8 years (SD = 16.6); 84% of the men and 91% of the women were in self-reported good health when signing their ADs. Among the respondents, 94% wanted their physicians to consult a supportive and palliative care team if they were seriously ill; nearly 85% preferred cessation of life-sustaining treatments during their final days; 76% preferred to spend their final days at home or in a hospice; and 70% would accept attempted cardiopulmonary resuscitation in limited circumstances. Most respondents wanted an autopsy under certain conditions, and 62% wished to donate their organs. In conclusion, analysis of early experience with this ACP/AD platform demonstrates that individuals of different ages and conditions can engage in an interrogatory process about values, develop ADs that are more nuanced than traditional paper-based ADs in reflecting those values, and easily make changes to their ADs. Online ADs have the potential to remove barriers to ACP/AD and thus further improve patient-centered end-of-life care. PMID:27365867

  17. Early experience with digital advance care planning and directives, a novel consumer-driven program.

    PubMed

    Fine, Robert L; Yang, Zhiyong; Spivey, Christy; Boardman, Bonnie; Courtney, Maureen

    2016-07-01

    Barriers to traditional advance care planning (ACP) and advance directive (AD) creation have limited the promise of ACP/AD for individuals and families, the healthcare team, and society. Our objectives were to determine the results of a digital ACP/AD through which consumers create, store, locate, and retrieve their ACP/AD at no charge and with minimal physician involvement, and the ACP/AD can be integrated into the electronic health record. The authors chose 900 users of MyDirectives, a digital ACP/AD tool, to achieve proportional representation of all 50 states by population size and then reviewed their responses. The 900 participants had an average age of 50.8 years (SD = 16.6); 84% of the men and 91% of the women were in self-reported good health when signing their ADs. Among the respondents, 94% wanted their physicians to consult a supportive and palliative care team if they were seriously ill; nearly 85% preferred cessation of life-sustaining treatments during their final days; 76% preferred to spend their final days at home or in a hospice; and 70% would accept attempted cardiopulmonary resuscitation in limited circumstances. Most respondents wanted an autopsy under certain conditions, and 62% wished to donate their organs. In conclusion, analysis of early experience with this ACP/AD platform demonstrates that individuals of different ages and conditions can engage in an interrogatory process about values, develop ADs that are more nuanced than traditional paper-based ADs in reflecting those values, and easily make changes to their ADs. Online ADs have the potential to remove barriers to ACP/AD and thus further improve patient-centered end-of-life care. PMID:27365867

  18. Health Care Outcomes and Advance Care Planning in Older Adults Who Receive Home-Based Palliative Care: A Pilot Cohort Study

    PubMed Central

    Thorsteinsdottir, Bjorg; Cha, Stephen S.; Hanson, Gregory J.; Peterson, Stephanie M.; Rahman, Parvez A.; Naessens, James M.; Takahashi, Paul Y.

    2015-01-01

    Abstract Background: Approximately 20% of seniors live with five or more chronic medical illnesses. Terminal stages of their lives are often characterized by repeated burdensome hospitalizations and advance care directives are insufficiently addressed. This study reports on the preliminary results of a Palliative Care Homebound Program (PCHP) at the Mayo Clinic in Rochester, Minnesota to service these vulnerable populations. Objective: The study objective was to evaluate inpatient hospital utilization and the adequacy of advance care planning in patients who receive home-based palliative care. Methods: This is a retrospective pilot cohort study of patients enrolled in the PCHP between September 2012 and March 2013. Two control patients were matched to each intervention patient by propensity scoring methods that factor in risk and prognosis. Primary outcomes were six-month hospital utilization including ER visits. Secondary outcomes evaluated advance care directive completion and overall mortality. Results: Patients enrolled in the PCHP group (n=54) were matched to 108 controls with an average age of 87 years. Ninety-two percent of controls and 33% of PCHP patients were admitted to the hospital at least once. The average number of hospital admissions was 1.36 per patient for controls versus 0.35 in the PCHP (p<0.001). Total hospital days were reduced by 5.13 days. There was no difference between rates of ER visits. Advanced care directive were completed more often in the intervention group (98%) as compared to controls (31%), with p<0.001. Goals of care discussions were held at least once for all patients in the PCHP group, compared to 41% in the controls. PMID:25375663

  19. Advance planning in end-of-life care: legal and ethical considerations for neurologists.

    PubMed

    Kerrigan, Simon; Ormerod, Ian

    2010-06-01

    Neurological illnesses can leave patients unable to make legally valid decisions about their medical treatment. However, this loss of decision making capacity can often be predicted in advance. The law in the UK now enables patients to make legally binding arrangements to either refuse specific treatments in advance or to appoint others to make decisions on their behalf. This article discusses the mechanics of advance planning under UK law and the role of the neurologist in helping patients to plan ahead. PMID:20498185

  20. The impact of advance care planning of place of death, a hospice retrospective cohort study

    PubMed Central

    Abel, Julian; Pring, Andy; Rich, Alison; Malik, Tariq; Verne, Julia

    2013-01-01

    Objectives There is limited evidence of the impact of advance care planning (ACP) on outcomes. We conducted a retrospective cohort study on deaths of all patients known to a hospice in a 2.5-year period to see if use of ACP affected actual place of death, hospital use and cost of hospital care in the last year. Results 969 patients were included. 550 (57%) people completed ACP. 414 (75%) achieved their choice of place of death. For those who chose home, 34 (11.3%) died in hospital; a care home 2 (1.7%) died in hospital; a hospice 14 (11.2%) died in hospital and 6 (86%) who chose to die in hospital did so. 112 (26.5%) of people without ACP died in hospital. Mean number of days in hospital in the last year of life was 18.1 in the ACP group and 26.5 in the non-ACP group(p<0.001). Mean cost of hospital treatment during the last year of life for those who died in hospital was £11,299, those dying outside of hospital £7,730 (p<0.001). Mean number of emergency admissions for those who died in hospital was 2.2 and who died elsewhere was 1.7 (p<0.001). Conclusions ACP can be used routinely in a hospice setting. Those who used ACP spent less time in hospital in their last year. ACP is associated with a reduction in the number of days in hospital in the last year of life with less hospital costs, supporting the assumptions made in the End of Life Care Strategy 2008. PMID:23626905

  1. End-of-Life Treatment Preferences: A Key to Reducing Ethnic/Racial Disparities in Advance Care Planning?

    PubMed Central

    Garrido, Melissa M.; Harrington, Shannon T.; Prigerson, Holly G.

    2014-01-01

    Background This study sought to identify targets for interventions to reduce end-of-life care disparities among patients with advanced cancer. To do this, we evaluated the degree to which end-of-life care values and preferences are associated with advance care planning within racial/ethnic minority groups. Methods The Coping with Cancer study recruited patients with advanced cancer from outpatient clinics in five states from 2002-2008. We examined rates of one type of advance care planning, do not resuscitate [DNR] orders, reported at baseline interviews by 606 patients. Bivariate tests determined associations among DNR order completion, religious values, and treatment preferences within racial/ethnic groups. Results Non-Latino White patients were significantly more likely to have a DNR order (45%) than Black (25%) and Latino (20%) patients (p <.001). Preferences against specific life-prolonging treatments (e.g. chemotherapy, ventilation) were the only factor significantly associated with higher DNR order likelihood in each group, with non-Latino White patients more likely than Latino or Black patients to express preferences against life-prolonging care (e.g. 26% of non-Latino White, 46% of Black, and 41% of Latino patients wanted a feeding tube if it would extend life for one more day, p<.001). Conclusions Preferences against life-prolonging care differ dramatically by race/ethnicity, but they are uniformly significantly associated with DNR order completion rates across racial/ethnic groups of patients with advanced cancer. Advance care planning interventions that target preferences associated with DNR orders across racial/ethnic groups may reach a broad patient population and reduce end-of-life care disparities. PMID:25145489

  2. The Power of Advance Care Planning in Promoting Hospice and Out-of-Hospital Death in a Dialysis Unit

    PubMed Central

    Weaner, Barbara B.; Long, Dustin

    2015-01-01

    Abstract Background: Despite mortality rates that exceed those of most cancers, hospice remains underutilized in patients with end-stage renal disease (ESRD) on dialysis and nearly half of all dialysis patients die in the hospital. Objective: To review the impact of advance care planning on withdrawal from dialysis, use of hospice, and location of death. Design: Retrospective review. Setting: A rural outpatient dialysis unit. Participants: Former dialysis patients who died over a 5-year period. Exposure: Advance care planning, the use of physician orders for life-sustaining therapy program (POLST). Main Outcome and Measure: Use of hospice among patients withdrawing from dialysis, location of death. Results: Advance care planning was associated with a low incidence of in-hospital death and among those who withdrew, a high use of hospice. Conclusions and Relevance: Comprehensive and systematic advance care planning among patients with ESRD on dialysis promotes greater hospice utilization and may facilitate the chance that death will occur out of hospital. PMID:25006866

  3. Video decision aids to assist with advance care planning: a systematic review and meta-analysis

    PubMed Central

    Jain, Ashu; Corriveau, Sophie; Quinn, Kathleen; Gardhouse, Amanda; Vegas, Daniel Brandt; You, John J

    2015-01-01

    Objective Advance care planning (ACP) can result in end-of-life care that is more congruent with patients’ values and preferences. There is increasing interest in video decision aids to assist with ACP. The objective of this study was to evaluate the impact of video decision aids on patients’ preferences regarding life-sustaining treatments (primary outcome). Design Systematic review and meta-analysis of randomised controlled trials. Data sources MEDLINE, EMBASE, PsycInfo, CINAHL, AMED and CENTRAL, between 1980 and February 2014, and correspondence with authors. Eligibility criteria for selecting studies Randomised controlled trials of adult patients that compared a video decision aid to a non-video-based intervention to assist with choices about use of life-sustaining treatments and reported at least one ACP-related outcome. Data extraction Reviewers worked independently and in pairs to screen potentially eligible articles, and to extract data regarding risk of bias, population, intervention, comparator and outcomes. Reviewers assessed quality of evidence (confidence in effect estimates) for each outcome using the Grading of Recommendations Assessment, Development and Evaluation framework. Results 10 trials enrolling 2220 patients were included. Low-quality evidence suggests that patients who use a video decision aid are less likely to indicate a preference for cardiopulmonary resuscitation (pooled risk ratio, 0.50 (95% CI 0.27 to 0.95); I2=65%). Moderate-quality evidence suggests that video decision aids result in greater knowledge related to ACP (standardised mean difference, 0.58 (95% CI 0.38 to 0.77); I2=0%). No study reported on the congruence of end-of-life treatments with patients’ wishes. No study evaluated the effect of video decision aids when integrated into clinical care. Conclusions Video decision aids may improve some ACP-related outcomes. Before recommending their use in clinical practice, more evidence is needed to confirm these findings and

  4. Advance Care Planning: A Qualitative Study of Dialysis Patients and Families

    PubMed Central

    Eneanya, Nwamaka D.; Feinberg, Rebecca; Germain, Michael J.; Marr, Lisa; Berzoff, Joan; Cohen, Lewis M.; Unruh, Mark

    2015-01-01

    Background and objectives More than 90,000 patients with ESRD die annually in the United States, yet advance care planning (ACP) is underutilized. Understanding patients’ and families’ diverse needs can strengthen systematic efforts to improve ACP. Design, setting, participants, & measurements In-depth interviews were conducted with a purposive sample of patients and family/friends from dialysis units at two study sites. Applying grounded theory, interviews were audiotaped, professionally transcribed, and analyzed in an iterative process. Emergent themes were identified, discussed, and organized into major themes and subthemes. Results Thirteen patients and nine family/friends participated in interviews. The mean patient age was 63 years (SD 14) and five patients were women. Participants identified as black (n=1), Hispanic (n=4), Native American (n=4), Pacific Islander (n=1), white (n=11), and mixed (n=1). Three major themes with associated subthemes were identified. The first theme, “Prior experiences with ACP,” revealed that these discussions rarely occur, yet most patients desire them. A potential role for the primary care physician was broached. The second theme, “Factors that may affect perspectives on ACP,” included a desire for more of a connection with the nephrologist, positive and negative experiences with the dialysis team, disenfranchisement, life experiences, personality traits, patient-family/friend relationships, and power differentials. The third theme, “Recommendations for discussing ACP,” included thoughts on who should lead discussions, where and when discussions should take place, what should be discussed and how. Conclusions Many participants desired better communication with their nephrologist and/or their dialysis team. A number expressed feelings of disenfranchisement that could negatively impact ACP discussions through diminished trust. Life experiences, personality traits, and relationships with family and friends may

  5. Stages of Change for the Component Behaviors of Advance Care Planning

    PubMed Central

    Fried, Terri R.; Redding, Colleen; Robbins, Mark; Paiva, Andrea; O’Leary, John R.; Iannone, Lynne

    2010-01-01

    Objectives 1) To develop stages of change measures for advance care planning (ACP), conceptualized as a group of interrelated but separate behaviors. 2) To use these measures to characterize older persons’ engagement in and factors associated with readiness to participate in ACP. Design Observational cohort study. Setting Community. Participants Persons age ≥ 65 recruited from physician offices and a senior center. Measurements Stages of change for six ACP behaviors: completion of a living will and health care proxy, communication with loved ones regarding use of life-sustaining treatments and quantity versus quality of life (QOL), and communication with physicians about these same issues. Results Readiness to participate in ACP varied widely across behaviors. Whereas between approximately 50–60% of participants were in the action or maintenance stage for communicating with loved ones and completing a living will, 40% were in the precontemplation stage for communicating with loved ones about quantity versus QOL, and 70–75% were in the precontemplation stage for communicating with physicians. Participants were frequently in different stages for the different behaviors. Relatively few sociodemographic, health, or psychosocial factors were associated with stages of change for completing a living will, but a broader range of factors was associated with stages of change for communication with loved ones about quantity versus QOL. Conclusion Older persons show a range of readiness to engage in different aspects of ACP. Individualized assessment and interventions targeted to stage of behavior change for each component of ACP may be an effective strategy to increase participation in ACP. PMID:21143441

  6. Peer education for advance care planning: volunteers’ perspectives on training and community engagement activities

    PubMed Central

    Seymour, Jane E; Almack, Kathryn; Kennedy, Sheila; Froggatt, Katherine

    2013-01-01

    Background Peer education by volunteers may aid attitudinal change, but there is little understanding of factors assisting the preparation of peer educators. This study contributes to conceptual understandings of how volunteers may be prepared to work as peer educators by drawing on an evaluation of a training programme for peer education for advance care planning (ACP). Objectives To report on volunteers’ perspectives on the peer education training programme, their feelings about assuming the role of volunteer peer educators and the community engagement activities with which they engaged during the year after training. To examine broader implications for peer education. Design Participatory action research employing mixed methods of data collection. Participants Twenty-four older volunteers and eight health and social care staff. Data collection methods Evaluative data were gathered from information provided during and at the end of training, a follow-up survey 4 months post-training; interviews and focus groups 6 and 12 months post-training. Findings Volunteers’ personal aims ranged from working within their communities to using what they had learnt within their own families. The personal impact of peer education was considerable. Two-thirds of volunteers reported community peer education activities 1 year after the training. Those who identified strongly with a community group had the most success. Conclusion We reflect on the extent to which the programme aided the development of ‘critical consciousness’ among the volunteers: a key factor in successful peer education programmes. More research is needed about the impact on uptake of ACP in communities. PMID:21615641

  7. Advance Care Planning Among Hematopoietic Cell Transplant Patients and Bereaved Caregivers

    PubMed Central

    Loggers, Elizabeth Trice; Lee, Stephanie; Chilson, Kate; Back, Anthony L.; Block, Susan; Loberiza, Fausto R.

    2014-01-01

    Younger, healthier patients contemplating high-risk (but potentially curative) hematopoietic cell transplants (HCT) may not consider advance care planning (ACP). We investigated the effect of pre-transplant ACP in surviving HCT patients and bereaved caregivers using retrospective, audiotaped telephone surveys. Subjects were identified between 2001–2003 via databases at two high-volume HCT centers. Transcripts were coded by 2 investigators, with differences resolved by consensus. HCT survivors (n=18) were interviewed a median of 13 months after HCT for acute leukemia (7), lymphoma (5), or other (6); 50% had living wills, 72% had a formal proxy. Twelve (67%) had discussed mortality risk pre-HCT with the medical team. Of those, 92% felt their hope and perception of the medical team's truthfulness was increased or unchanged (I/U) by the conversation, while all felt clinician commitment to transplant was I/U. Bereaved caregivers (n=11) were interviewed a median of 10 months post-death (median 31 days post-HCT, range 13–152). Nine (82%) had discussed mortality risk pre-HCT with the medical team; 7 (78%) felt hope was I/U, all felt clinician commitment to transplant and truthfulness was I/U, and most felt ACP reduced burden (67%). ACP discussions with patients and caregivers pre-HCT did not affect hope and supported confidence in medical teams. PMID:25068417

  8. Consensus views on advance care planning for dementia: a Delphi study.

    PubMed

    Sinclair, James B; Oyebode, Jan R; Owens, R Glynn

    2016-03-01

    The uptake of advance care planning (ACP) is particularly low among people with dementia. This may reflect barriers to communication between professionals, patients and families in the face of lack of consensus about the process. This study aimed to methodically investigate consensus views of how ACP should be explained and carried out with people with dementia. A three-round Delphi study explored views of how and when ACP should be addressed, what should be covered, who should be involved and why rates of ACP are low. Seventeen participants took part comprising family members, old age psychiatrists and policy makers. Thirty-two items reached consensus. The panel agreed on 11 different areas for discussion. They concurred that ACP was best addressed after the person has come to terms with the diagnosis when the individual feels ready to do so. There was a consensus view that the process should be couched in terms of 'certain possibilities'. Consensus items emphasised personal choice and autonomy, while also prioritising the need to discuss financial aspects and to include spouses. There was no consensus that professionals should be involved, although the panel viewed them as carrying some responsibility for low uptake. It is suggested that ACP should include general discussion of values as well as coverage of specific points. Professionals need to offer discussion and information on ACP, but also make clear that the patient has the right to choose whether to pursue ACP or not. PMID:25684278

  9. Role of Advance Care Planning in Proxy Decision Making Among Individuals With Dementia and Their Family Caregivers.

    PubMed

    Kwak, Jung; De Larwelle, Jessica A; Valuch, Katharine O'Connell; Kesler, Toni

    2016-03-01

    Health care proxies make important end-of-life decisions for individuals with dementia. A cross-sectional survey was conducted to examine the role of advance care planning in proxy decision making for 141 individuals with cognitive impairment, Alzheimer's disease, or other types of dementia. Proxies who did not know the preferences of individuals with dementia for life support treatments reported greater understanding of their values. Proxies of individuals with dementia who did not want life support treatments anticipated receiving less support and were more uncertain in decision making. The greater knowledge proxies had about dementia trajectory, family support, and trust of physicians, the more informed, clearer, and less uncertain they were in decision making. In addition to advance care planning, multiple factors influence proxy decision making, which should be considered in developing interventions and future research to support informed decision making for individuals with dementia and their families. [Res Gerontol Nurs. 2016; 9(2):72-80.]. PMID:26020579

  10. The Process of Advance Care Planning in HCT Candidates and Proxies: Self-Efficacy, Locus of Control, and Anxiety Levels

    PubMed Central

    Duckworth, Katharine E.; Forti, Allison M.; Russell, Gregory B.; Naik, Seema; Hurd, David; McQuellon, Richard P.

    2013-01-01

    The purpose of this study was to examine the relationship between hematopoietic cell transplant candidate and proxy advance care planning (ACP) behavior and attitudes. A total of 49 candidates and 44 proxies completed the Advance Directive Attitudes Survey, Multidimensional Health Locus of Control Scale, Family Decision Making Self-Efficacy Scale, and the State-Trait Anxiety Inventory. In all, 45% of candidates reported completing an advance directive (AD), while only 26% had ADs on file; 80% of candidates discussed ACP wishes with their loved ones and 15% discussed ACP wishes with their medical team. The AD completers were significantly (1) older, (2) more positive about ADs, and (3) were less likely to believe that health events happen by chance. Discrepancies between reported ACP behavior and communication with health care practitioners have implications for end-of-life care. PMID:23946253

  11. The process of advance care planning in HCT candidates and proxies: self-efficacy, locus of control, and anxiety levels.

    PubMed

    Duckworth, Katharine E; Forti, Allison M; Russell, Gregory B; Naik, Seema; Hurd, David; McQuellon, Richard P

    2014-11-01

    The purpose of this study was to examine the relationship between hematopoietic cell transplant candidate and proxy advance care planning (ACP) behavior and attitudes. A total of 49 candidates and 44 proxies completed the Advance Directive Attitudes Survey, Multidimensional Health Locus of Control Scale, Family Decision Making Self-Efficacy Scale, and the State-Trait Anxiety Inventory. In all, 45% of candidates reported completing an advance directive (AD), while only 26% had ADs on file; 80% of candidates discussed ACP wishes with their loved ones and 15% discussed ACP wishes with their medical team. The AD completers were significantly (1) older, (2) more positive about ADs, and (3) were less likely to believe that health events happen by chance. Discrepancies between reported ACP behavior and communication with health care practitioners have implications for end-of-life care. PMID:23946253

  12. Religious Coping and Behavioral Disengagement: Opposing Influences on Advance Care Planning and Receipt of Intensive Care Near Death

    PubMed Central

    Maciejewski, Paul K.; Phelps, Andrea C.; Kacel, Elizabeth L.; Balboni, Tracy A.; Balboni, Michael; Wright, Alexi A.; Pirl, William; Prigerson, Holly G.

    2011-01-01

    Objective This study examines the relationships between methods of coping with advanced cancer, completion of advance care directives, and receipt of intensive, life-prolonging care near death. Methods The analysis is based on a sample of 345 patients interviewed between January 1, 2003, and August 31, 2007, and followed until death as part of the Coping with Cancer Study, an NCI/NIMH-funded, multi-site, prospective, longitudinal, cohort study of patients with advanced cancer. The Brief COPE was used to assess active coping, use of emotional-support, and behavioral disengagement. The Brief RCOPE was used to assess positive and negative religious coping. The main outcome was intensive, life-prolonging care near death, defined as receipt of ventilation or resuscitation in the last week of life. Results Positive religious coping was associated with lower rates of having a living will (AOR=0.39, p=0.003) and predicted higher rates of intensive, life-prolonging care near death (AOR, 5.43; p<0.001), adjusting for other coping methods and potential socio-demographic and health status confounds. Behavioral disengagement was associated with higher rates of DNR order completion (AOR, 2.78; p=0.003) and predicted lower rates of intensive life-prolonging care near death (AOR, 0.20; p=0.036). Not having a living will partially mediated the influence of positive religious coping on receipt of intensive, life-prolonging care near death. Conclusion Positive religious coping and behavioral disengagement are important determinants of completion of advance care directives and receipt of intensive, life-prolonging care near death. PMID:21449037

  13. Promoting advance planning for health care and research among older adults: A randomized controlled trial

    PubMed Central

    2012-01-01

    Background Family members are often required to act as substitute decision-makers when health care or research participation decisions must be made for an incapacitated relative. Yet most families are unable to accurately predict older adult preferences regarding future health care and willingness to engage in research studies. Discussion and documentation of preferences could improve proxies' abilities to decide for their loved ones. This trial assesses the efficacy of an advance planning intervention in improving the accuracy of substitute decision-making and increasing the frequency of documented preferences for health care and research. It also investigates the financial impact on the healthcare system of improving substitute decision-making. Methods/Design Dyads (n = 240) comprising an older adult and his/her self-selected proxy are randomly allocated to the experimental or control group, after stratification for type of designated proxy and self-report of prior documentation of healthcare preferences. At baseline, clinical and research vignettes are used to elicit older adult preferences and assess the ability of their proxy to predict those preferences. Responses are elicited under four health states, ranging from the subject's current health state to severe dementia. For each state, we estimated the public costs of the healthcare services that would typically be provided to a patient under these scenarios. Experimental dyads are visited at home, twice, by a specially trained facilitator who communicates the dyad-specific results of the concordance assessment, helps older adults convey their wishes to their proxies, and offers assistance in completing a guide entitled My Preferences that we designed specifically for that purpose. In between these meetings, experimental dyads attend a group information session about My Preferences. Control dyads attend three monthly workshops aimed at promoting healthy behaviors. Concordance assessments are repeated at the

  14. Advance Care Planning Discussions: Why They Should Happen, Why They Don't, and How We Can Facilitate the Process.

    PubMed

    Norals, Taira Everett; Smith, Thomas J

    2015-08-01

    Recent data suggest that we are not successfully getting the message across about the importance of advance care planning for patients who have a life-ending illness. Half to three-quarters of patients with incurable cancer think that they might be cured by chemotherapy, radiation, or surgery. The source of this denial may lie with them, it may be traceable to their physicians, or it may be a combination of the two. This avoidance has consequences, since those patients with "prognostic awareness" have end-of-life care pathways that involve little use of the hospital, ICU, end-of-life chemo, or "codes" with almost no chance of success, and much more dying at home with hospice care. If we can successfully initiate advance care planning discussions with our patients and families, their end-of-life processes will improve, resulting in better care, less use of the hospital, and more honoring of newly discerned choices. We show how this can be done in regular oncology practice by introducing the Johns Hopkins "Palliative Care Temporary Tattoo" and by providing some ways to discuss cardiopulmonary resuscitation in settings where it will not be helpful. PMID:26281841

  15. The Role of Social Workers in Spiritual Care to Facilitate Coping With Chronic Illness and Self-Determination in Advance Care Planning.

    PubMed

    Francoeur, Richard B; Burke, Nancy; Wilson, Alicia M

    2016-01-01

    Spiritual values and beliefs of patients and families influence resilience during chronic illness and shape patient choices during advance care planning. The spiritual needs of Baby Boomers will be more diverse than previous generations, in connection with the questioning, experimental mind-set of this group and the fact that it includes a higher proportion of immigrant populations outside the Judeo-Christian tradition. Social workers are trained explicitly to intervene with diverse populations and are well positioned to offer spiritual support in ways that do not necessarily conform to traditional religions. To the extent of their individual expertise and competence, social workers should assess and provide spiritual care to clients, including those who either are underserved or prefer not to seek assistance from clergy or chaplains because they feel alienated from religious institutions and representatives. They should also be aware of ethical dilemmas in consulting with spiritual care professionals in developing spiritual interventions. Social work education should address clients' humanistic and existential concerns, beliefs and behaviors of the major religions, and forms of nontraditional religious and spiritual experiences; it should also provide experiential opportunities for engaging with grief and earlier advance care planning. There should be attention to different theodical perspectives of the major religions regarding the problem of good and evil, which may preoccupy even clients who no longer participate in organized religion, because these unresolved existential issues may weaken client coping with chronic conditions and may diminish clarity and self-awareness for engaging authentically and effectively in advance care planning. PMID:27187806

  16. Development and pilot of an advance care planning website for women with ovarian cancer: A randomized controlled trial

    PubMed Central

    Vogel, Rachel Isaksson; Petzel, Sue V.; Cragg, Julie; McClellan, Molly; Chan, Daniel; Dickson, Elizabeth; Jacko, Julie A.; Sainfort, François; Geller, Melissa A.

    2015-01-01

    Objective Few available tools facilitate cancer patients and physicians' discussions of quality of life and end-of-life. Our objective was to develop a web-based tool to promote advance care planning for women with ovarian cancer. Methods Women with ovarian cancer, their families, clinicians and researchers met to identify ways to improve cancer care. A prototype website was created to address advance care planning, focusing on advance healthcare directives (AHD) and palliative care consultation. Patients were recruited from a gynecologic oncology clinic for a pilot randomized controlled trial. Primary outcomes included completion of an AHD and palliative care consultation. Results At study completion, 53 women with ovarian cancer were enrolled and 35 completed the study. The mean age at enrollment was 57.9 ± 9.5 years; most were newly diagnosed or at first recurrence. There were no statistical differences in completion of AHD (p = 0.220) or palliative care consultation (p = 0.440) between intervention and control groups. However, women in the intervention group showed evidence of moving toward decision making regarding AHD and palliative care and lower decisional conflict. Women assigned to the intervention, compared to control website, were highly satisfied with the amount (p = 0.054) and quality (p = 0.119) of information and when they accessed the website, used it longer (p = 0.049). Overall website use was lower than expected, resulting from several patient-related and design barriers. Conclusions A website providing information and decisional support for women with ovarian cancer is feasible. Increasing frequency of website use requires future research. PMID:23988413

  17. Thinking ahead – the need for early Advance Care Planning for people on haemodialysis: A qualitative interview study

    PubMed Central

    Horsley, Helen L; Shepherd, Kate; Brown, Heather; Carey, Irene; Matthews, Beverley; O’Donoghue, Donal; Vinen, Katie; Murtagh, Felicity EM

    2015-01-01

    Background: There is a need to improve end-of-life care for people with end-stage kidney disease, particularly due to the increasingly elderly, frail and co-morbid end-stage kidney disease population. Timely, sensitive and individualised Advance Care Planning discussions are acceptable and beneficial for people with end-stage kidney disease and can help foster realistic hopes and goals. Aim: To explore the experiences of people with end-stage kidney disease regarding starting haemodialysis, its impact on quality of life and their preferences for future care and to explore the Advance Care Planning needs of this population and the timing of this support. Study design: Semi-structured qualitative interview study of people receiving haemodialysis. Interviews were analysed using thematic analysis. Recruitment ceased once data saturation was achieved. Setting/participants: A total of 20 patients at two UK National Health Service hospitals, purposively sampled by age, time on haemodialysis and symptom burden. Results: Themes emerged around: Looking Back, emotions of commencing haemodialysis; Current Experiences, illness and treatment burdens; and Looking Ahead, facing the realities. Challenges throughout the trajectory included getting information, communicating with staff and the ‘conveyor belt’ culture of haemodialysis units. Participants reported a lack of opportunity to discuss their future, particularly if their health deteriorated, and variable involvement in treatment decisions. However, discussion of these sensitive issues was more acceptable to some than others. Conclusion: Renal patients have considerable unmet Advance Care Planning needs. There is a need to normalise discussions about preferences and priorities in renal and haemodialysis units earlier in the disease trajectory. However, an individualised approach is essential – one size does not fit all. PMID:25527527

  18. Developing nursing care plans.

    PubMed

    Ballantyne, Helen

    2016-02-24

    This article aims to enhance nurses' understanding of nursing care plans, reflecting on the past, present and future use of care planning. This involves consideration of the central theories of nursing and discussion of nursing models and the nursing process. An explanation is provided of how theories of nursing may be applied to care planning, in combination with clinical assessment tools, to ensure that care plans are context specific and patient centred. PMID:26907149

  19. Facilitating advance care planning with ethnically diverse groups of frail, low-income elders in the USA: perspectives of care managers on challenges and recommendations.

    PubMed

    Kwak, Jung; Ko, Eunjeong; Kramer, Betty J

    2014-03-01

    This study examined care managers' perspectives on facilitating advance care planning (ACP) with ethnically diverse elders enrolled in a managed long-term care programme that coordinates medical and long-term care for frail, poor elders in the USA. Seven in-depth interviews and two focus groups were conducted with 24 lead supervisors and care managers of care management teams between July and August 2008; data were analysed with qualitative thematic analysis method. Participants identified four main sources of challenges: death and dying are taboo discussion topics; the dying process is beyond human control; family and others hold decision-making responsibility; and planning for death and dying is a foreign concept. Participants' recommendations to address these challenges were to develop trust with elders over time; cultivate cultural knowledge and sensitivity to respect value orientations; promote designating a healthcare proxy; recognise and educate families and community leaders as critical partners in ACP and provide practical support as needed throughout the illness experience. These findings suggest important practice implications for care managers working with increasingly diverse cultural groups of elders at the end of life. PMID:24495270

  20. Exploring uncertainty in advance care planning in African Americans: does low health literacy influence decision making preference at end of life.

    PubMed

    Melhado, Lolita; Bushy, Angeline

    2011-11-01

    African Americans over 65 represent 3.5 of the 35.6 million Americans. Morbidity and mortality rates are highest among this group; associated with lack of resources and awareness of health problems. But health needs are the same at end of life, yet care is less than optimal. African Americans are less likely to have advance directives nonetheless desire communication, information, respect, and a trusting doctor-patient relationship. Low health literacy may contribute to this disparity. This scholarly review examines the health literacy in advance care planning and refines concepts of uncertainty in illness theory deriving a model for advance care planning in African Americans. PMID:21398263

  1. Advance Care Planning Norms May Contribute to Hospital Variation in End-of-life ICU Use: A Simulation Study

    PubMed Central

    Barnato, Amber E.; Mohan, Deepika; Lane, Rondall K.; Huang, Yue Ming; Angus, Derek C.; Farris, Coreen; Arnold, Robert M.

    2014-01-01

    Background There is wide variation in end-of-life (EOL) intensive care unit (ICU) use among academic medical centers (AMCs). Objective To develop hypotheses regarding medical decision-making factors underlying this variation. Design High-fidelity simulation experiment involving a critically and terminally ill elder, followed by a survey and debriefing cognitive interview and evaluated using triangulated quantitative-qualitative comparative analysis. Setting 2 AMCs in the same state and health care system with disparate EOL ICU use. Subjects Hospital-based physicians responsible for ICU admission decisions. Measurements Treatment plan, prognosis, diagnosis, qualitative case perceptions and clinical reasoning. Main Results Sixty-seven of 111 (60%) eligible physicians agreed to participate; 48 (72%) could be scheduled. There were no significant between-AMC differences in 3-month prognosis or treatment plan, but there were systematic differences in perceptions of the case. Case perceptions at the low-intensity AMC seemed to be influenced by the absence of a DNR order in the context of norms of universal code status discussion and documentation upon admission, whereas case perceptions at the high-intensity AMC seemed to be influenced by the patient’s known metastatic gastric cancer in the context of norms of oncologists’ avoiding code status discussions. Conclusions In this simulation study of 2 AMCs, hospital-based physicians had different perceptions of an identical case. We hypothesize that different advance care planning norms may have influenced their decision-making heuristics. PMID:24615275

  2. Developing nursing care plans.

    PubMed

    Hooks, Robin

    2016-07-01

    What was the nature of the CPD activity and/or practice-related feedback and/or event or experience in your practice? The CPD article discussed the theories involved in developing nursing care plans. Care planning is a fundamental part of nursing, and aims to facilitate standardised, evidence-based and holistic care. PMID:27380704

  3. Palliative care in advanced dementia.

    PubMed

    Merel, Susan E; Merel, Susan; DeMers, Shaune; Vig, Elizabeth

    2014-08-01

    Because neurodegenerative dementias are progressive and ultimately fatal, a palliative approach focusing on comfort, quality of life, and family support can have benefits for patients, families, and the health system. Elements of a palliative approach include discussion of prognosis and goals of care, completion of advance directives, and a thoughtful approach to common complications of advanced dementia. Physicians caring for patients with dementia should formulate a plan for end-of-life care in partnership with patients, families, and caregivers, and be prepared to manage common symptoms at the end of life in dementia, including pain and delirium. PMID:25037291

  4. Advance care planning knowledge and documentation in a hospitalized cancer population

    PubMed Central

    Barakat, Ayman; Barnes, Sunni A.; Casanova, Mark A.; Stone, Marvin J.; Shuey, Kathleen M.

    2013-01-01

    To have a better understanding of our patients’ knowledge of advance directive planning and execution, as well as communication with their oncologists regarding their wishes, we conducted a survey on our inpatient hematology-oncology services. A total of 68 unique hospitalized patients with a diagnosis of cancer completed surveys. Surveys were given to all oncology patients regardless of their reason for admission. Overall, 29% of the patients reported having had a discussion with their oncologist regarding their wishes if they became seriously ill or near death. Of those who did have this conversation, the majority said that they, rather than their physician, initiated it. Although the vast majority of patients (97%) knew what a living will was, only 54% had one in place. Twenty patients had a discussion with their oncologist, and 14 of them (70%) had a living will. This percentage was higher than in the group that did not have a conversation with their physician (48%; 23 of 48 patients), but the difference was not statistically significant. Most cancer patients admitted to an inpatient oncology unit either did not have or did not recall having a discussion with their oncologist regarding end-of-life issues. This study gives us a baseline of information in evaluating future interventions directed to improve the quality of patient-physician communication regarding end-of-life planning. PMID:24082411

  5. An Exploratory Study of Spirituality in HIV Infected Adolescents and their Families: FAmily CEntered Advance Care Planning and Medication Adherence

    PubMed Central

    Lyon, Maureen E.; Garvie, Patricia A.; Kao, Ellin; Briggs, Linda; He, Jianping; Malow, Robert; D’Angelo, Lawrence J.; McCarter, Robert

    2010-01-01

    Purpose To explore the impact of spirituality and religious beliefs on FAmily CEntered (FACE) Advance Care Planning and medication adherence in HIV+ adolescents and their surrogate decision-makers. Methods A sample of HIV+ adolescents (n=40) and their surrogates, age 21 or older, (n=40) was randomized to an active Healthy Living Control group or the FACE Advance Care Planning intervention, guided by transactional stress and coping theory. Adolescents’ spirituality was assessed at baseline and 3 months post-intervention, using the FACIT-SP-4-EX, as was the belief that HIV is a punishment from God. Results Control adolescents increased faith and meaning/purpose more so than FACE adolescents (p=0.02). At baseline more behaviorally (16%) vs. perinatally (8%) infected adolescents believed HIV was a punishment from God, but not at 3-months post-intervention. Adolescents endorsing HIV was a punishment scored lower on spirituality (p=.05) and adherence to HAART (p= .04). Surrogates were more spiritual than adolescents (p=<.0001). Conclusion Providing family support in a friendly, facilitated, environment enhanced adolescents’ spirituality. Facilitated family conversations had an especially positive effect on behaviorally infected adolescents’ medication adherence and spiritual beliefs. PMID:21575826

  6. [Advance Care Planning and Decisions to limit treatment at the end of life - the view from medical ethics and psychooncology].

    PubMed

    Winkler, Eva C; Heußner, Pia

    2016-03-01

    Decisions to limit treatment are important in order to avoid overtreatment at the end of life. They proceed more than half of expected deaths in Europe and the US, but are not always communicated with the patient in advance. One reason for non-involvement is that conversations that prepare patients for end-of-life decisions and work out their preferences do not take place on a regular basis. At the same time there is growing evidence that such communication improves patients' quality of life, reduces anxiety and depression and allows patients to develop a realistic understanding of their situation - which in turn is a prerequisite for shared decision making about limiting treatment. In this paper we define "treatment limitation" and explain the medical ethics perspective. The main focus, however, is on the causes that hinder advanced care planning and conversations about limiting treatment in the care of patients with advanced disease. Finally the evidence for approaches to improve the situation is presented with concrete suggestions for solutions. PMID:26983109

  7. A systematic review of the effectiveness of advance care planning interventions for people with cognitive impairment and dementia

    PubMed Central

    Robinson, Louise; Dickinson, Claire; Rousseau, Nicolette; Beyer, Fiona; Clark, Alexa; Hughes, Julian; Howel, Denise; Exley, Catherine

    2012-01-01

    Background: advance care planning (ACP) allows a patient to state their preferences for care, so that if in future they cannot make decisions their wishes are known. Our aim was to review systematically the effectiveness of ACP interventions in people with cognitive impairment and dementia. Methods: systematic searches of key electronic databases, supplemented by hand searches of reference lists and consultation with experts. Two independent reviewers undertook screening, data extraction and quality assessment. Results: four studies were included; three allocated providers randomly to intervention or control arm. All took place in nursing homes. Three studies reported formal processes of capacity assessment, only up to 36% of participants were judged to have capacity. Three studies reported positive findings in terms of documentation of patient preferences for care. Two studies reported significant reductions in hospitalisation rates; a third found increased use of hospice services in the intervention group. A meta-analysis could not be carried out due to heterogeneity of outcome measures. Conclusions: there is limited evidence for the effectiveness of ACP in people with cognitive impairment/dementia in terms of ACP documentation and health-care use. In terms of capacity to discuss ACP, nursing home settings may be too late for people with dementia. PMID:22156555

  8. Barriers to Advance Care Planning at the End of Life: An Explanatory Systematic Review of Implementation Studies

    PubMed Central

    Lund, Susi; Richardson, Alison; May, Carl

    2015-01-01

    Context Advance Care Plans (ACPs) enable patients to discuss and negotiate their preferences for the future including treatment options at the end of life. Their implementation poses significant challenges. Objective To investigate barriers and facilitators to the implementation of ACPs, focusing on their workability and integration in clinical practice. Design An explanatory systematic review of qualitative implementation studies. Data sources Empirical studies that reported interventions designed to support ACP in healthcare. Web of Knowledge, Ovid MEDLINE, CINAHL, PsycINFO, British Nursing Index and PubMed databases were searched. Methods Direct content analysis, using Normalization Process Theory, to identify and characterise relevant components of implementation processes. Results 13 papers identified from 166 abstracts were included in the review. Key factors facilitating implementation were: specially prepared staff utilizing a structured approach to interactions around ACPs. Barriers to implementation were competing demands of other work, the emotional and interactional nature of patient-professional interactions around ACPs, problems in sharing decisions and preferences within and between healthcare organizations. Conclusions This review demonstrates that doing more of the things that facilitate delivery of ACPs will not reduce the effects of those things that undermine them. Structured tools are only likely to be partially effective and the creation of a specialist cadre of ACP facilitators is unlikely to be a sustainable solution. The findings underscore both the challenge and need to find ways to routinely incorporate ACPs in clinical settings where multiple and competing demands impact on practice. Interventions most likely to meet with success are those that make elements of Advance Care Planning workable within complex and time pressured clinical workflows. PMID:25679395

  9. They know!—Do they? A qualitative study of residents and relatives views on advance care planning, end-of-life care, and decision-making in nursing homes

    PubMed Central

    Bollig, Georg; Gjengedal, Eva; Rosland, Jan Henrik

    2015-01-01

    Background: Residents living in long-term care facilities are a vulnerable population. For many residents, a nursing home is their place of death. Palliative care and end-of-life decisions are important components of their care provision. Aim: To study the views of cognitively able residents and relatives on advance care planning, end-of-life care, and decision-making in nursing homes. Design: A qualitative study with in-depth interviews with nursing home residents and focus group interviews with relatives of nursing home residents. Analysis is based on interpretive description. Setting/participants: In total, 43 informants from nine nursing homes participated in the study (25 nursing home residents and 18 relatives). All included residents had capacity to provide informed consent and lived in long-term care. Results: The main findings of this study were the differing views about decision-making and advance care planning of residents and relatives. Residents do trust relatives and staff to make important decisions for them. The relatives are in contrast insecure about the residents’ wishes and experience decision-making as a burden. The majority of the residents had not participated in advance care planning. None of the residents stated challenges connected to end-of-life care or mentioned the wish for euthanasia. Conclusion: Although most residents seem to be satisfied with decision-making and end-of life care, there is a need for systematic advance care planning. Advance care planning could help to explore future wishes for care and ease decision-making for the relatives, physicians, and staff and should be offered to all cognitively able nursing homes residents. PMID:26396227

  10. Your cancer survivorship care plan

    MedlinePlus

    ... ency/patientinstructions/000822.htm Your cancer survivorship care plan To use the sharing features on this page, ... get one. What Is a Cancer Survivorship Care Plan? A cancer survivorship care plan is a document ...

  11. Pathways From Religion to Advance Care Planning: Beliefs About Control Over Length of Life and End-of-Life Values

    PubMed Central

    Garrido, Melissa M.

    2013-01-01

    Purpose of the Study: To evaluate the extent to which religious affiliation and self-identified religious importance affect advance care planning (ACP) via beliefs about control over life length and end-of-life values. Design and Methods: Three hundred and five adults aged 55 and older from diverse racial and socioeconomic groups seeking outpatient care in New Jersey were surveyed. Measures included discussion of end-of-life preferences; living will (LW) completion; durable power of attorney for healthcare (DPAHC) appointment; religious affiliation; importance of religion; and beliefs about who/what controls life length, end-of-life values, health status, and sociodemographics. Results: Of the sample, 68.9% had an informal discussion and 46.2% both discussed their preferences and did formal ACP (LW and/or DPAHC). Conservative Protestants and those placing great importance on religion/spirituality had a lower likelihood of ACP. These associations were largely accounted for by beliefs about God’s controlling life length and values for using all available treatments. Implications: Beliefs and values about control account for relationships between religiosity and ACP. Beliefs and some values differ by religious affiliation. As such, congregations may be one nonclinical setting in which ACP discussions could be held, as individuals with similar attitudes toward the end of life could discuss their treatment preferences with those who share their views. PMID:23161430

  12. Role of the community matron in advance care planning and 'do not attempt CPR' decision-making: a qualitative study.

    PubMed

    Kazmierski, Mandy; King, Nigel

    2015-01-01

    The community matron (CM) is often the key worker caring for patients with chronic, life-limiting, long-term conditions, but these patients are not always recognised as palliative cases. This study explored the experiences of CMs with regard to advance care planning (ACP) and 'do not attempt cardiopulmonary resuscitation' (DNACPR) decision-making to understand whether or not they felt adequately prepared for this aspect of their role, and why. Qualitative data were generated from six CMs using a broad interpretive phenomenological approach. Face-to-face recorded interviews were analysed using template analysis. The study found that although participants faced complex ethical situations around ACP and DNACPR almost on a daily basis, none had received any formal training despite the emphasis on training in national and local guidelines. Participants often struggled to get their patients accepted on to the Gold Standards Framework. The research found variability and complexity of cases to be the main barriers to clear identification of the palliative phase. PMID:25559025

  13. Uptake of a newly implemented advance care planning program in a dementia diagnostic service.

    PubMed

    2016-05-27

    Through a three-stage project in a specialist memory clinic in Australia, researchers introduced ACP to clients with mild cognitive impairment or recently diagnosed dementia and their families. Clients and carers were initially posted a survey assessing completed documentation for future care, understanding of the principles of ACP and willingness to receive further information. Those wanting more information were invited to a seminar introducing the ACP programme and service. Participants wanting to complete ACP documentation could make an appointment with the ACP clinicians. PMID:27231080

  14. Health care professionals' perspectives of advance care planning for people with dementia living in long-term care settings: a narrative review of the literature.

    PubMed

    2016-05-27

    This comprehensive synthesis of published literature from a team in Northern Ireland focused on the perspectives of healthcare professionals in relation to ACP for people with dementia living in long-term care settings. From the 14 papers discussed, the authors identified that people with dementia are often not recognised as having a terminal illness. Four key themes were identified: ■ Early integration and planning for palliative care in dementia is important. ■ Healthcare professionals' perspectives on ACP are influenced by ethical and moral concerns including presumptions regarding capacity of the person with dementia towards ACP and the impact of the increased role of the family in the decision-making processes. ■ Challenges in communicating with people who have dementia and their families. ■ A need for improvement in healthcare professionals' knowledge of the disease trajectory of dementia with emphasis on end of life care, and a greater understanding of the process of ACP itself. This would assist them in engaging in ACP discussions. PMID:27231081

  15. Augmenting Advance Care Planning in Poor Prognosis Cancer with a Video Decision Aid: A Pre-Post Study

    PubMed Central

    Volandes, Angelo E.; Levin, Tomer T.; Slovin, Susan; Carvajal, Richard D.; O’Reilly, Eileen M.; Keohan, Mary Louise; Theodoulou, Maria; Dickler, Maura; Gerecitano, John F.; Morris, Michael; Epstein, Andrew S.; Naka-Blackstone, Anastazia; Walker-Corkery, Elizabeth S.; Chang, Yuchiao; Noy, Ariela

    2012-01-01

    Background We tested whether an educational video on the goals of care in advanced cancer (life-prolonging, basic or comfort care) can help patients understand these goals and impact preferences for resuscitation. Methods Survey of 80 advanced cancer patients before and after viewing the video. Outcomes included changes in goals-of-care preference and knowledge, and consistency of preferences with code status. Results Before viewing the video, 10 patients (13%) preferred life-prolonging care; 24 (30%) basic care; and 29 (36%) comfort care; 17 (21%) were unsure. Preferences did not change after the video: 9 (11%) chose life-prolonging care; 28 (35%) basic care; 29 (36%) comfort care; and, 14 (18%) were unsure (p=0.28). Compared to baseline, after the video presentation more patients did not want CPR (71 vs 61%, p=0.03) or ventilation (79 vs 67%, p=0.008). Knowledge about goals of care and likelihood of resuscitation increased post-video (p<.001). Of the patients who did not want CPR or ventilation after the video augmentation, only 4 (5%) had a documented DNR order in the medical record (kappa statistic −0.01; 95% CI −0.06 – 0.04). Acceptability of the video was high. Conclusion Patients with advanced cancer did not change care preferences after viewing the video, but fewer wanted CPR or ventilation. Documented code status was inconsistent with patient preferences. Patients were more knowledgeable after the video, found the video acceptable, and would recommend it to others. Video may enable visualization of “goals of care,” enriching patient understanding of worsening health states and better informing decision-making. PMID:22252775

  16. A Novel Website to Prepare Diverse Older Adults for Decision Making and Advance Care Planning: A Pilot Study

    PubMed Central

    Sudore, Rebecca L.; Knight, Sara J.; McMahan, Ryan D.; Feuz, Mariko; Farrell, David; Miao, Yinghui; Barnes, Deborah E.

    2014-01-01

    Context We have reconceptualized advance care planning (ACP) as a multi-step process focused on preparing patients with skills needed for communication and in-the-moment decision making. Objectives To operationalize this paradigm, we created an easy-to-use ACP website (prepareforyourcare.org) based on a theoretical framework of behavior change and pilot-tested its efficacy to engage older adults in ACP. Methods At baseline and one week after viewing the PREPARE website, we assessed behavior change in ACP using a validated survey that includes Process Measures (knowledge, contemplation, self-efficacy, and readiness, 5-point Likert scales) and Action Measures (yes/no whether an ACP behavior was completed). We also assigned participants into behavior change stages (i.e., precontemplation, contemplation, preparation, action, maintenance) and determined the percentage of participants who moved from precontemplation at baseline to higher stages at one week. We also assessed PREPARE ease-of-use (10-point scale, 10 being the easiest). Changes were assessed with paired t-tests and McNemar’s tests. Results Participants’ mean age was 68.4 years (SD 6.6) and 65% were non-white. Process Measures average Likert scores increased from 3.1 (0.9) to 3.7 (0.7), P <0.001. Action Measures did not change significantly. However, precontemplation significantly decreased for most actions, (e.g., talking to doctor about desired medical care, 61% to 35%, P<0.003), with a mean decrease of 21% (range, 16%-33%). PREPARE was rated a 9 out of 10 (±1.9) for ease-of-use. Conclusion A new, patient-centered ACP website that focuses on preparing patients for communication and decision making significantly improves engagement in the process of ACP and behavior change. A clinical trial of PREPARE is currently underway. PMID:23972574

  17. Discussing dying in the diaspora: attitudes towards advance care planning among first generation Dutch and Italian migrants in rural Australia.

    PubMed

    Sinclair, Craig; Smith, Jessica; Toussaint, Yann; Auret, Kirsten

    2014-01-01

    Western cultural practices and values have largely shaped advance care planning (ACP) policies across the world. Low uptake of ACP among ethnic minority groups in Western countries has been interpreted with reference to cultural differences. This paper adopts a life-history approach to explore attitudes towards ACP among older, first-generation Dutch-Australian and Italian-Australian migrants. Thirty people participated in extended ethnographic interviews (N = 17) and group discussions (N = 13) during 2012. Transcripts were thematically analyzed and interpreted using a Foucauldian perspective on knowledge and power. Migration experiences, ongoing contact with the native country and participation in migrant community support networks influenced attitudes towards ACP. Dutch participants framed ACP discussions with reference to euthanasia, and adopted a more individualist approach to medical decision-making. Italian participants often spoke of familial roles and emphasized a family-based decision making style. The importance of migrant identity has been neglected in previous discussions of cultural factors influencing ACP uptake among ethnic minority groups. The unique migration experience should be considered alongside culturally appropriate approaches to decision-making, in order to ensure equitable access to ACP among migrant groups. PMID:24560228

  18. Advance Care Planning in Dementia: Do Family Carers Know the Treatment Preferences of People with Early Dementia?

    PubMed Central

    King, Michael; Jones, Louise; Vickestaff, Victoria; Sampson, Elizabeth L.

    2016-01-01

    Background and Aims When a person with dementia (PWD) has lost the ability to make treatment decisions, clinicians often rely on family carers to know and articulate these preferences with assumed accuracy. This study used the Life Support Preferences Questionnaire (LSPQ) to explore whether family carers’ choices show agreement with the end of life care preferences of the person with dementia for whom they care and what factors influence this. Methods A cross-sectional study interviewing 60 dyads (a person with early dementia and preserved capacity and their family carer) each completing a modified LSPQ. We assessed how closely carers’ choices resembled the PWD’s preferences for treatment in three proposed health states: the here and now; severe stroke with coma; terminal cancer. Agreement between the PWD and their family carer responses was assessed using Kappa and Prevalence-Adjusted Bias-Adjusted Kappa (PABAK) statistics. We examined whether carer burden and distress, and relationship quality, influenced agreement. Results In interviews PWD were able to indicate their treatment preferences across all three scenarios. In the here-and-now most wanted antibiotics (98%), fewer cardio-pulmonary resuscitation (CPR) (50%) and tube feeding (47%). In severe stroke and coma antibiotics remained the more preferred treatment (88%), followed by CPR (57%) and tube feeding (30%). In advanced cancer PWD expressed lower preferences for all treatments (antibiotics 68%; CPR 50%; tube feeding 37%). Carers’ choices were similar to the PWDs’ preferences in the here-and-now (71% (k = 0.03; PABAK = 0.4) with less agreement for future hypothetical health states. In severe stroke and coma carers tended wrongly to suggest that the PWD preferred more intervention (antibiotic, 67%; k = -0.022; PABAK = -0.60; CPR, 73%; k = 0.20; PABAK = -0.20, tube feeding, 66%; k = 0.25; PABAK = -0.12). In advanced cancer the agreement between PWD and carers was low (antibiotics; k = -0.03; PABAK

  19. “I Don’t Want to Die Like That …”: The Impact of Significant Others’ Death Quality on Advance Care Planning

    PubMed Central

    Carr, Deborah

    2012-01-01

    Purpose of the Study: I examine whether 5 aspects of a significant other’s death quality (pain, decision-making capacity, location, problems with end-of life care, and preparation) affect whether one does advance care planning (ACP). I also identify specific aspects of others’ deaths that respondents say triggered their own planning. Design and Methods: Data are from the New Jersey End of Life study, a survey of 305 adults age 55+ seeking care at 2 major New Jersey medical centers. I estimate multivariate logistic regression models for a subsample of 253 participants who recently lost a loved one and provide descriptive findings from an open-ended question regarding the motivation for one’s ACP. Results: Multivariate analyses revealed “positive” role model effects; persons who witnessed significant others’ deaths that occurred at home, were free of problems associated with end-of-life care, and where advance directives were used are more likely to make end-of-life preparations. Open-ended data showed that 19% cited others’ deaths as the main trigger for their own planning, with most citing negative factors (pain, connection to machines, coma) that they hoped to avoid. Implications: Practitioners should encourage patients to use conversations about others’ deaths as springboards for discussions about one’s own end-of-life care, and to engage in ACP together with family. Implications for health care reform are highlighted. PMID:22547085

  20. Do the elderly have a voice? Advance care planning discussions with frail and older individuals: a systematic literature review and narrative synthesis

    PubMed Central

    Sharp, Tim; Moran, Emily; Kuhn, Isla; Barclay, Stephen

    2013-01-01

    Background Recent years have seen marked improvements in end-of-life care, however concerns have been expressed that services are focused on the needs of patients with cancer. This review focuses on conversations about end-of-life care with frail and older people who have no main overriding diagnosis who are estimated to account for around 40% of deaths. Aim To investigate the attitudes of the public and healthcare professionals to advance care planning discussions with frail and older people. Design and setting Systematic literature review and narrative synthesis. Method Articles that related to frail or older individuals and either advance care plans or discussions on end-of-life care were included. Studies of specific conditions or that focused on prognosis, capacity, or resuscitation decisions were excluded. Results While a significant minority of frail older individuals would find them unwelcome, the majority would appreciate the chance to discuss end-of-life care, yet most do not have this opportunity. Attitudes to the timing of these discussions were variable, but most perceived the risk of leaving them too late. Most doctors believed it was their professional responsibility to initiate discussions, but felt limited by time pressures and the absence of a precipitating event. A wide range of barriers were identified including the reluctance of family members to discuss end-of-life care, the passive expectation that someone else would decide on an individual’s behalf, and significant uncertainty concerning future illness and decline. Conclusion The marked disparity between the majority of older individuals who would like the opportunity to discuss their end-of-life care and the minority that currently have this opportunity raises important questions if the wishes of this large group in society are to be respected. The challenge is to find effective ways of encouraging dialogue and choice within the constraints of the current healthcare systems and personal

  1. Feasibility and acceptability of advance care planning in elderly Italian and Greek speaking patients as compared to English-speaking patients: an Australian cross-sectional study

    PubMed Central

    Detering, Karen; Sutton, Elizabeth; Fraser, Scott; Wallis, Kasey; Silvester, William; Mawren, Daveena; Whiteside, Kathryn

    2015-01-01

    Objectives To assess the feasibility and acceptability of facilitated advance care planning (ACP) discussions in elderly Italian and Greek-speaking inpatients compared to English-speaking inpatients. Design, setting and participants This cross-sectional study with convenience sampling was conducted in Melbourne, Australia, and recruited hospital inpatients with medical decision-making capacity, aged 65 years or above, who spoke Greek (25 patients), Italian (24 patients) or English (63 patients). Intervention Facilitated ACP was offered, aiming to assists patients to consider and discuss their goals, values, beliefs and future treatment wishes with their family and doctor; to help them consider how they would like healthcare decisions made in the future if they become unable to do this for themselves; and to complete advance care directives. Main outcome measures The completion of ACP discussions, their duration, advance care directive completion and utilisation of interpreters. Results Of 112 patients, 109 (97%) had at least one discussion, 63 (54%) completed advance care directives, either nominating a substitute decision-maker, documenting their wishes or both, and 76 (68%) included family in discussions. The median duration of discussions for all patients was slightly more than 1 h, over two visits. There were no differences between the Greek-speaking and the Italian-speaking patients, or between the Non-English speaking and the English-speaking patients in any of these measures. Only 14 non-English speaking patients, (30%) utilised interpreters, but when utilised, patients were much more likely (p<0.005) to complete advance care directives. Conclusions Facilitated ACP in elderly Italian and Greek-speaking patients is feasible, acceptable and is similar to that for English-speaking patients. PMID:26319775

  2. Phase 2 Randomised Controlled Trial and Feasibility Study of Future Care Planning in Patients with Advanced Heart Disease.

    PubMed

    Denvir, Martin A; Cudmore, Sarah; Highet, Gill; Robertson, Shirley; Donald, Lisa; Stephen, Jacqueline; Haga, Kristin; Hogg, Karen; Weir, Christopher J; Murray, Scott A; Boyd, Kirsty

    2016-01-01

    Future Care Planning (FCP) rarely occurs in patients with heart disease until close to death by which time the potential benefits are lost. We assessed the feasibility, acceptability and tested a design of a randomised trial evaluating the impact of FCP in patients and carers. 50 patients hospitalised with acute heart failure or acute coronary syndrome and with predicted 12 month mortality risk of >20% were randomly allocated to FCP or usual care for 12 weeks upon discharge and then crossed-over for the next 12 weeks. Quality of life, symptoms and anxiety/distress were assessed by questionnaire. Hospitalisation and mortality events were documented for 6 months post-discharge. FCP increased implementation and documentation of key decisions linked to end-of-life care. FCP did not increase anxiety/distress (Kessler score -E 16.7 (7.0) vs D 16.8 (7.3), p = 0.94). Quality of life was unchanged (EQ5D: E 0.54(0.29) vs D 0.56(0.24), p = 0.86) while unadjusted hospitalised nights was lower (E 8.6 (15.3) vs D 11.8 (17.1), p = 0.01). Qualitative interviews indicated that FCP was highly valued by patients, carers and family physicians. FCP is feasible in a randomised clinical trial in patients with acute high risk cardiac conditions. A Phase 3 trial is needed urgently. PMID:27090299

  3. Phase 2 Randomised Controlled Trial and Feasibility Study of Future Care Planning in Patients with Advanced Heart Disease

    PubMed Central

    Denvir, Martin A.; Cudmore, Sarah; Highet, Gill; Robertson, Shirley; Donald, Lisa; Stephen, Jacqueline; Haga, Kristin; Hogg, Karen; Weir, Christopher J.; Murray, Scott A.; Boyd, Kirsty

    2016-01-01

    Future Care Planning (FCP) rarely occurs in patients with heart disease until close to death by which time the potential benefits are lost. We assessed the feasibility, acceptability and tested a design of a randomised trial evaluating the impact of FCP in patients and carers. 50 patients hospitalised with acute heart failure or acute coronary syndrome and with predicted 12 month mortality risk of >20% were randomly allocated to FCP or usual care for 12 weeks upon discharge and then crossed-over for the next 12 weeks. Quality of life, symptoms and anxiety/distress were assessed by questionnaire. Hospitalisation and mortality events were documented for 6 months post-discharge. FCP increased implementation and documentation of key decisions linked to end-of-life care. FCP did not increase anxiety/distress (Kessler score -E 16.7 (7.0) vs D 16.8 (7.3), p = 0.94). Quality of life was unchanged (EQ5D: E 0.54(0.29) vs D 0.56(0.24), p = 0.86) while unadjusted hospitalised nights was lower (E 8.6 (15.3) vs D 11.8 (17.1), p = 0.01). Qualitative interviews indicated that FCP was highly valued by patients, carers and family physicians. FCP is feasible in a randomised clinical trial in patients with acute high risk cardiac conditions. A Phase 3 trial is needed urgently. PMID:27090299

  4. Advancement Planning: An Objectives View.

    ERIC Educational Resources Information Center

    Druck, Kalman B.

    1986-01-01

    Planning must revolve around objectives related to students, faculty, money, and political support. When it is understood that all of the institution's advancement activity should help produce these four things, planning is easy. (MLW)

  5. InformedTogether: Usability Evaluation of a Web-Based Decision Aid to Facilitate Shared Advance Care Planning for Severe Chronic Obstructive Pulmonary Disease

    PubMed Central

    Uhler, Lauren M; Pérez Figueroa, Rafael E; Dickson, Mark; McCullagh, Lauren; Kushniruk, Andre; Monkman, Helen; Witteman, Holly O

    2015-01-01

    Background Advance care planning may help patients receive treatments that better align with their goals for care. We developed a Web-based decision aid called InformedTogether to facilitate shared advance care planning between chronic obstructive pulmonary disease (COPD) patients and their doctors. Objective Our objective was to assess the usability of the InformedTogether decision aid, including whether users could interact with the decision aid to engage in tasks required for shared decision making, whether users found the decision aid acceptable, and implications for redesign. Methods We conducted an observational study with 15 patients and 8 doctors at two ethnically and socioeconomically diverse outpatient clinics. Data included quantitative and qualitative observations of patients and doctors using the decision aid on tablet or laptop computers and data from semistructured interviews. Patients were shown the decision aid by a researcher acting as the doctor. Pulmonary doctors were observed using the decision aid independently and asked to think aloud (ie, verbalize their thoughts). A thematic analysis was implemented to explore key issues related to decision aid usability. Results Although patients and doctors found InformedTogether acceptable and would recommend that doctors use the decision aid with COPD patients, many patients had difficulty understanding the icon arrays that were used to communicate estimated prognoses and could not articulate the definitions of the two treatment choices—Full Code and Do Not Resuscitate (DNR). Minor usability problems regarding content, links, layout, and consistency were also identified and corresponding recommendations were outlined. In particular, participants suggested including more information about potential changes in quality of life resulting from the alternative advance directives. Some doctor participants thought the decision aid was too long and some thought it may cause nervousness among patients due to

  6. Advanced Production Planning Models

    SciTech Connect

    JONES,DEAN A.; LAWTON,CRAIG R.; KJELDGAARD,EDWIN A.; WRIGHT,STEPHEN TROY; TURNQUIST,MARK A.; NOZICK,LINDA K.; LIST,GEORGE F.

    2000-12-01

    >This report describes the innovative modeling approach developed as a result of a 3-year Laboratory Directed Research and Development project. The overall goal of this project was to provide an effective suite of solvers for advanced production planning at facilities in the nuclear weapons complex (NWC). We focused our development activities on problems related to operations at the DOE's Pantex Plant. These types of scheduling problems appear in many contexts other than Pantex--both within the NWC (e.g., Neutron Generators) and in other commercial manufacturing settings. We successfully developed an innovative and effective solution strategy for these types of problems. We have tested this approach on actual data from Pantex, and from Org. 14000 (Neutron Generator production). This report focuses on the mathematical representation of the modeling approach and presents three representative studies using Pantex data. Results associated with the Neutron Generator facility will be published in a subsequent SAND report. The approach to task-based scheduling described here represents a significant addition to the literature for large-scale, realistic scheduling problems in a variety of production settings.

  7. Attitudes towards Advance Care Planning and Healthcare Autonomy among Community-Dwelling Older Adults in Beijing, China

    PubMed Central

    Zhang, Ning; Ning, Xiao-hong; Zhu, Ming-lei; Liu, Xiao-hong; Li, Jing-bing; Liu, Qian

    2015-01-01

    Objectives. To investigate the preferences of ACP and healthcare autonomy in community-dwelling older Chinese adults. Methods. A community-based cross-sectional study was conducted with older adults living in the residential estate of Chaoyang District, Beijing. Results. 900 residents were enrolled. 80.9% of them wanted to hear the truth regarding their own condition from the physician; 52.4% preferred to make their own healthcare decisions. Only 8.9% of them preferred to endure life-prolonging interventions when faced with irreversible conditions. 78.3% of the respondents had not heard of an ACP; only 39.4% preferred to document in an ACP. Respondents with higher education had significantly higher proportion of having heard of an ACP, as well as preferring to document in an ACP, compared to those with lower education. Those aged <70 years had higher proportion of having heard of an ACP, as well as refusing life-prolonging interventions when faced with irreversible conditions, compared to those aged ≥70 years. Conclusions. Although the majority of community-dwelling older Chinese adults appeared to have healthcare autonomy and refuse life-prolonging interventions in terms of end-of-life care, a low level of “Planning ahead” awareness and preference was apparent. Age and education level may be the influential factors. PMID:26858955

  8. Improving advance care planning for English-speaking and Spanish-speaking older adults: study protocol for the PREPARE randomised controlled trial

    PubMed Central

    Sudore, Rebecca L; Barnes, Deborah E; Le, Gem M; Ramos, Roberto; Osua, Stacy J; Richardson, Sarah A; Boscardin, John; Schillinger, Dean

    2016-01-01

    Introduction Advance care planning (ACP) is a process that allows patients to identify their goals for medical care. Traditionally, ACP has focused on completing advance directives; however, we have expanded the ACP paradigm to also prepare patients to communicate their wishes and make informed decisions. To this end, we created an ACP website called PREPARE (http://www.prepareforyourcare.org) to prepare diverse English-speaking and Spanish-speaking older adults for medical decision-making. Here, we describe the study protocol for a randomised controlled efficacy trial of PREPARE in a safety-net setting. The goal is to determine the efficacy of PREPARE to engage diverse English-speaking and Spanish-speaking older adults in a full spectrum of ACP behaviours. Methods and analysis We include English-speaking and Spanish-speaking adults from an urban public hospital who are ≥55 years old, have ≥2 chronic medical conditions and have seen a primary care physician ≥2 times in the last year. Participants are randomised to the PREPARE intervention (review PREPARE and an easy-to-read advance directive) or the control arm (only the easy-to-read advance directive). The primary outcome is documentation of an advance directive and/or ACP discussion. Secondary outcomes include ACP behaviour change processes measured with validated surveys (eg, self-efficacy, readiness) and a broad range of ACP actions (eg, choosing a surrogate, identifying goals for care, discussing ACP with clinicians and/or surrogates). Using blinded outcome ascertainment, outcomes will be measured at 1 week and at 3, 6 and 12 months, and compared between study arms using mixed-effects logistic regression and mixed-effects linear, Poisson or negative binomial regression. Ethics and dissemination This study has been approved by the appropriate Institutional Review Boards and is guided by input from patient and clinical advisory boards and a data safety monitoring board. The results of this study will

  9. Types of Managed Care Plans

    MedlinePlus

    ... AAP Find a Pediatrician Family Life Medical Home Health Insurance Pediatric Specialists Family Dynamics Media Work & Play Getting ... Your Community Healthy Children > Family Life > Medical Home > Health Insurance > Types of Managed Care Plans Family Life Listen ...

  10. [Physician-assisted suicide and advance care planning--ethical considerations on the autonomy of dementia patients at their end of life].

    PubMed

    Gather, Jakov; Vollmann, Jochen

    2014-10-01

    Physician-assisted suicide (PAS), which is currently the subject of intense and controversial discussion in medical ethics, is barely discussed in psychiatry, albeit there are already dementia patients in Germany and other European countries who end their own lives with the assistance of physicians. Based on the finding that patients who ask for medical assistance in suicide often have in mind the loss of their mental capacity, we submit PAS to an ethical analysis and put it into a broader context of patient autonomy at the end of life. In doing so, we point to advance care planning, through which the patient autonomy of the person concerned can be supported as well as respected in later stages of the disease. If patients adhere to their autonomous wish for PAS, physicians find themselves in an ethical dilemma. A further tabooing of the topic, however, does not provide a solution; rather, an open societal and professional ethical discussion and regulation are essential. PMID:25068685

  11. End-of-Life Discussions and Advance Care Planning for Children on Long-Term Assisted Ventilation with Life-Limiting Conditions

    PubMed Central

    Kun, Sheila S.; Graham, Robert J.; Keens, Thomas G.

    2013-01-01

    Families of children with life-limiting conditions who are on long-term assisted ventilation need to undertake end-of-life advance care planning (ACP) in order to align their goals and values with the inevitability of their child's condition and the risks it entails. To discuss how best to conduct ACP in this population, we performed a retrospective analysis of end-of-life discussions involving our deceased ventilator-assisted patients between 1987 and 2009. A total of 34 (72 percent) of 47 study patients were the subject of these discussions; many discussions occurred after acute deterioration. They resulted in directives to forgo or limit interventions for 21 children (45 percent). We surmise that many families were hesitant to discuss end-of-life issues during periods of relative stability. By offering anticipatory guidance and encouraging contemplation of patients’ goals both in times of stability and during worsening illness, health care providers can better engage patients’ families in ACP. As the child's condition progresses, the emphasis can be recalibrated. How families respond to such encouragement can also serve as a gauge of their willingness to pursue ACP. PMID:22582468

  12. A complex regional intervention to implement advance care planning in one town's nursing homes: Protocol of a controlled inter-regional study

    PubMed Central

    2011-01-01

    Background Advance Care Planning (ACP) is an emerging strategy to ensure that well-reflected, meaningful and clearly documented treatment preferences are available and respected when critical decisions about life-sustaining treatment need to be made for patients unable to consent. In Germany, recent legislation confirms that advance directives (AD) have to be followed if they apply to the medical situation, but implementation of ACP has not yet been described. Methods/Design In a longitudinal controlled study, we compare 1 intervention region (4 nursing homes [n/hs], altogether 421 residents) with 2 control regions (10 n/hs, altogether 985 residents). Inclusion went from 01.02.09 to 30.06.09, observation lasted until 30.06.10. Primary endpoint is the prevalence of ADs at follow-up, 17 (12) months after the first (last) possible inclusion. Secondary endpoints compare relevance and validity of ADs, process quality, the rate of life-sustaining interventions and, in deceased residents, location of death and intensity of treatment before death. The regional multifaceted intervention on the basis of the US program Respecting Choices® comprises training of n/h staff as facilitators, training of General Practitioners, education of hospital and ambulance staff, and development of eligible tools, including Physician Orders for Life-Sustaining Treatment in case of Emergency (POLST-E). Participation data: Of 1406 residents reported to live in the 14 n/hs plus an estimated turnover of 176 residents until the last possible inclusion date, 645 (41%) were willing to participate. Response rates were 38% in the intervention region and 42% in the control region. Non-responder analysis shows an equal distribution of sex and age but a bias towards dependency on nursing care in the responder group. Outcome analysis of this study will become available in the course of 2011. Discussion Implementing an ACP program for the n/hs and related health care providers of a region requires a

  13. A randomised controlled trial on the efficacy of advance care planning on the quality of end-of-life care and communication in patients with COPD: the research protocol

    PubMed Central

    Houben, Carmen H M; Spruit, Martijn A; Wouters, Emiel F M; Janssen, Daisy J A

    2014-01-01

    Introduction Recent research shows that advance care planning (ACP) for patients with chronic obstructive pulmonary disease (COPD) is uncommon and poorly carried out. The aim of the present study was to explore whether and to what extent structured ACP by a trained nurse, in collaboration with the chest physician, can improve outcomes in Dutch patients with COPD and their family. Methods and analysis A multicentre cluster randomised controlled trial in patients with COPD who are recently discharged after an exacerbation has been designed. Patients will be recruited from three Dutch hospitals and will be assigned to an intervention or control group, depending on the randomisation of their chest physician. Patients will be assessed at baseline and after 6 and 12 months. The intervention group will receive a structured ACP session by a trained nurse. The primary outcomes are quality of communication about end-of-life care, symptoms of anxiety and depression, quality of end-of-life care and quality of dying. Secondary outcomes include concordance between patient's preferences for end-of-life care and received end-of-life care, and psychological distress in bereaved family members of deceased patients. Intervention and control groups will be compared using univariate analyses and clustered regression analysis. Ethics and dissemination Ethical approval was received from the Medical Ethical Committee of the Catharina Hospital Eindhoven, the Netherlands (NL42437.060.12). The current project provides recommendations for guidelines on palliative care in COPD and supports implementation of ACP in the regular clinical care. Clinical trial registration number NTR3940. PMID:24384905

  14. FAmily CEntered (FACE) advance care planning: Study design and methods for a patient-centered communication and decision-making intervention for patients with HIV/AIDS and their surrogate decision-makers

    PubMed Central

    Kimmel, Allison L.; Wang, Jichuan; Scott, Rachel; Briggs, Linda; Lyon, Maureen E.

    2016-01-01

    Although the Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) has become a chronic illness, disease-specific advance care planning has not yet been evaluated for the palliative care needs of adults with HIV/AIDS. This prospective, longitudinal, randomized, two-arm controlled clinical trial aims to test the efficacy of FAmily CEntered Advance Care Planning among adults living with AIDS and/or HIV with co-morbidities on congruence in treatment preferences, healthcare utilization, and quality of life. The FAmily CEntered intervention arm is two face-to-face sessions with a trained, certified facilitator: Session 1) Disease-Specific Advance Care Planning Respecting Choices Interview; Session 2) Completion of advance directive. The Healthy Living control arm is: Session 1) Developmental/Relationship History; Session 2) Nutrition. Follow-up data will be collected at 3, 6, 12, and 18-month post-intervention. A total of 288 patient/surrogate dyads will be enrolled from five hospital-based, out-patient clinics in Washington, District of Columbia. Participants will be HIV positive and ≥21 years of age; surrogates will be ≥18 years of age. Exclusion criteria are homicidality, suicidality, psychosis, and impaired cognitive functioning. We hypothesize that this intervention will enhance patient-centered communication with a surrogate decision-maker about end of life treatment preferences over time, enhance patient quality of life and decrease health care utilization. We further hypothesize that this intervention will decrease health disparities for Blacks in completion of advance directives. If proposed aims are achieved, the benefits of palliative care, particularly increased treatment preferences about end-of-life care and enhanced quality of life, will be extended to people living with AIDS. PMID:26044463

  15. Planning Ahead: Advanced Heart Failure

    MedlinePlus

    ... Pressure Tools & Resources Stroke More Planning Ahead: Advanced Heart Failure Updated:Aug 24,2016 An important part of ... content was last reviewed on 04/16/2015. Heart Failure • Home • About Heart Failure • Causes and Risks for ...

  16. Barriers to Advance Care Planning in Cancer, Heart Failure and Dementia Patients: A Focus Group Study on General Practitioners' Views and Experiences

    PubMed Central

    De Vleminck, Aline; Pardon, Koen; Beernaert, Kim; Deschepper, Reginald; Houttekier, Dirk; Van Audenhove, Chantal; Deliens, Luc; Vander Stichele, Robert

    2014-01-01

    Background The long-term and often lifelong relationship of general practitioners (GPs) with their patients is considered to make them the ideal initiators of advance care planning (ACP). However, in general the incidence of ACP discussions is low and ACP seems to occur more often for cancer patients than for those with dementia or heart failure. Objective To identify the barriers, from GPs' perspective, to initiating ACP and to gain insight into any differences in barriers between the trajectories of patients with cancer, heart failure and dementia. Method Five focus groups were held with GPs (n = 36) in Flanders, Belgium. The focus group discussions were transcribed verbatim and analyzed using the method of constant comparative analysis. Results Three types of barriers were distinguished: barriers relating to the GP, to the patient and family and to the health care system. In cancer patients, a GP's lack of knowledge about treatment options and the lack of structural collaboration between the GP and specialist were expressed as barriers. Barriers that occured more often with heart failure and dementia were the lack of GP familiarity with the terminal phase, the lack of key moments to initiate ACP, the patient's lack of awareness of their diagnosis and prognosis and the fact that patients did not often initiate such discussions themselves. The future lack of decision-making capacity of dementia patients was reported by the GPs as a specific barrier for the initiation of ACP. Conclusion The results of our study contribute to a better understanding of the factors hindering GPs in initiating ACP. Multiple barriers need to be overcome, of which many can be addressed through the development of practical guidelines and educational interventions. PMID:24465450

  17. Promoting Advance Care Planning as Health Behavior Change: Development of Scales to Assess Decisional Balance, Medical and Religious Beliefs, and Processes of Change

    PubMed Central

    Fried, Terri R.; Redding, Colleen A.; Robbins, Mark L.; Paiva, Andrea; O'Leary, John R.; Iannone, Lynne

    2011-01-01

    Objectives To develop measures representing key constructs of the Transtheoretical Model (TTM) of behavior change as applied to advance care planning (ACP) and to examine whether associations between these measures replicate the relationships posited by the TTM. Methods Sequential scale development techniques were used to develop measures for Decisional Balance (Pros and Cons of behavior change), ACP Values/Beliefs (religious beliefs and medical misconceptions serving as barriers to participation), Processes of Change (behavioral and cognitive processes used to foster participation) based on responses of 304 persons age ≥ 65 years. Results Items for each scale/subscale demonstrated high factor loading (> .5) and good to excellent internal consistency (Cronbach α .76–.93). Results of MANOVA examining scores on the Pros, Cons, ACP Values/Beliefs, and POC subscales by stage of change for each of the six behaviors were significant, Wilks' λ= .555–.809, η2=.068–.178, p ≤ .001 for all models. Conclusion Core constructs of the TTM as applied to ACP can be measured with high reliability and validity. Practice Implications Cross-sectional relationships between these constructs and stage of behavior change support the use of TTM-tailored interventions to change perceptions of the pros and cons of participation in ACP and promote the use of certain processes of change in order to promote older persons' engagement in ACP. PMID:21741194

  18. Palliative Care in Advanced Lung Disease: The Challenge of Integrating Palliation Into Everyday Care.

    PubMed

    Rocker, Graeme M; Simpson, A Catherine; Horton, Robert

    2015-09-01

    The tendency toward "either/or" thinking (either cure or comfort) in traditional biomedical care paradigms does little to optimize care in advancing chronic illness. Calls for improved palliation in chronic lung disease mandate a review of related care gaps and current clinical practices. Although specialist palliative services have their advocates, adding yet another element to an already fragmented, often complex, care paradigm can be a challenge. Instead, we propose a more holistic, patient-centered approach based on elements fundamental to palliative and best care practices generally and integrated as needed across the entire illness trajectory. To support this approach, we review the concept of primary palliative care competencies, identify vulnerability specific to those living with advanced COPD (an exemplar of chronic lung disease), and describe the need for care plans shaped by patient-centered communication, timely palliative responsiveness, and effective advance care planning. A costly systemic issue in the management of chronic lung disease is patients' increasing dependency on episodic ED care to deal with preventable episodic crises and refractory dyspnea. We address this issue as part of a proposed model of care that provides proactive, collaborative case management and the appropriate and carefully monitored use of opioids. We encourage and support a renewed primary care resolve to integrate palliative approaches to care in advanced lung disease that, in concert with judicious referral to appropriate specialist palliative care services, is fundamental to what should be a more sustainable systematic improvement in palliative care delivery. PMID:25742140

  19. Medicare and Advance Planning: The Importance of Context.

    PubMed

    Dresser, Rebecca

    2016-05-01

    In January 2016, a long-delayed Medicare change took effect. The Medicare program will now reimburse doctors for time they spend talking with patients about end-of-life care. This is the move that Sarah Palin and other Affordable Care Act critics said would authorize government "death panels" to decide whether older Americans should live or die. Today virtually no one buys into Palin's death panel rhetoric. But many people do think the Medicare change is a big deal. Representative Earl Blumenauer, a Democrat from Oregon who sponsored the original ACA reimbursement proposal, lauded the Medicare provision as "a turning point in end-of-life care." Others are not so sure about that. After all, laws promoting advance care planning have existed for decades. The federal Patient Self-Determination Act of 1990 and the many court decisions and state laws supporting advance care planning have had relatively little impact. Similarly, legal recognition of physician orders for life-sustaining treatment as advance planning instruments have not produced the improvements that were predicted. And from a broad perspective, advance care planning is a small piece of the puzzle. The effort to improve end-of-life care must take into account the limitations of advance decision-making, as well as the overriding importance of the general standard of care for terminally ill patients. PMID:27150411

  20. Interdisciplinary Care Planning and the Written Care Plan in Nursing Homes: A Critical Review

    ERIC Educational Resources Information Center

    Dellefield, Mary Ellen

    2006-01-01

    Purpose: This article is a critical review of the history, research evidence, and state-of-the-art technology in interdisciplinary care planning and the written plan of care in American nursing homes. Design and Methods: We reviewed educational and empirical literature. Results: Interdisciplinary care planning and the written care plan are…

  1. Preconception care: promoting reproductive planning

    PubMed Central

    2014-01-01

    Introduction Preconception care recognizes that many adolescent girls and young women will be thrust into motherhood without the knowledge, skills or support they need. Sixty million adolescents give birth each year worldwide, even though pregnancy in adolescence has mortality rates at least twice as high as pregnancy in women aged 20-29 years. Reproductive planning and contraceptive use can prevent unintended pregnancies, unsafe abortions and sexually-transmitted infections in adolescent girls and women. Smaller families also mean better nutrition and development opportunities, yet 222 million couples continue to lack access to modern contraception. Method A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for adolescents, women and couples of reproductive age on MNCH outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture. Results Comprehensive interventions can prevent first pregnancy in adolescence by 15% and repeat adolescent pregnancy by 37%. Such interventions should address underlying social and community factors, include sexual and reproductive health services, contraceptive provision; personal development programs and emphasizes completion of education. Appropriate birth spacing (18-24 months from birth to next pregnancy compared to short intervals <6 months) can significantly lower maternal mortality, preterm births, stillbirths, low birth weight and early neonatal deaths. Conclusion Improving adolescent health and preventing adolescent pregnancy; and promotion of birth spacing through increasing correct and consistent use of effective contraception are fundamental to preconception care. Promoting reproductive planning on a wider scale is closely interlinked with the

  2. Training Advanced Practice Palliative Care Nurses.

    ERIC Educational Resources Information Center

    Sherman, Deborah Witt

    1999-01-01

    Describes the role and responsibilities of advanced-practice nurses in palliative care and nursing's initiative in promoting high-quality care through the educational preparation of these nurses. (JOW)

  3. State Plan for Child Day Care [Virginia].

    ERIC Educational Resources Information Center

    Gravett, Marty; And Others

    Virginia's first state plan for child day care begins with 14 sections covering several aspects of child care. Section I reviews child care history and trends. Sections II, III, IV, and V argue, respectively, that child day care is important to government, business, families, and children. Elements of a comprehensive child day care delivery system…

  4. A typology of advance statements in mental health care.

    PubMed

    Henderson, Claire; Swanson, Jeffrey W; Szmukler, George; Thornicroft, Graham; Zinkler, Martin

    2008-01-01

    Advance statements documenting mental health service consumers' preferences for treatment during a future mental health crisis or period of incapacity have gained currency in recent years in the United States and some European countries. Several kinds of advance statements have emerged -- some as legal instruments, others as treatment planning methods -- but no formal comparison has been made among them. This article reviews the literature in English and German to develop a comparative typology of advance statements: joint crisis plans, crisis cards, treatment plans, wellness recovery action plans, and psychiatric advance directives (with and without formal facilitation). The features that distinguish them are the extent to which they are legally binding, whether health care providers are involved in their production, and whether an independent facilitator assists in their production. The differing nature of advance statements is related to the diverse models of care upon which they are based and the legislative and service contexts in which they have been developed. However, there is recent convergence between the United Kingdom and the United States with respect to research interventions that facilitate the production of advance statements, as evidence emerges for the effectiveness of facilitated psychiatric advance directives and joint crisis plans. Different types of advance statements can coexist and in some cases may interact in complementary ways. However, the relationship of advance statements to involuntary treatment is more problematic, as is their effective implementation in many mental health service settings. PMID:18182541

  5. Advanced technologies in trauma critical care management.

    PubMed

    Cannon, Jeremy W; Chung, Kevin K; King, David R

    2012-08-01

    Care of critically injured patients has evolved over the 50 years since Shoemaker established one of the first trauma units at Cook County Hospital in 1962. Modern trauma intensive care units offer a high nurse-to-patient ratio, physicians and midlevel providers who manage the patients, and technologically advanced monitors and therapeutic devices designed to optimize the care of patients. This article describes advances that have transformed trauma critical care, including bedside ultrasonography, novel patient monitoring techniques, extracorporeal support, and negative pressure dressings. It also discusses how to evaluate the safety and efficacy of future advances in trauma critical care. PMID:22850154

  6. Is it safe? Talking to teens with HIV/AIDS about death and dying: a 3-month evaluation of Family Centered Advance Care (FACE) planning – anxiety, depression, quality of life

    PubMed Central

    Lyon, Maureen E; Garvie, Patricia A; Briggs, Linda; He, Jianping; Malow, Robert; D’Angelo, Lawrence J; McCarter, Robert

    2010-01-01

    Purpose To determine the safety of engaging HIV-positive (HIV+) adolescents in a Family Centered Advance Care (FACE) planning intervention. Patients and methods We conducted a 2-armed, randomized controlled clinical trial in 2 hospital-based outpatient clinics from 2006–2008 with HIV+ adolescents and their surrogates (n = 76). Three 60–90 minutes sessions were conducted weekly. FACE intervention groups received: Lyon FCACP Survey©, the Respecting Choices® interview, and completion of The Five Wishes©. The Healthy Living Control (HLC) received: Developmental History, Healthy Tips, Future Planning (vocational, school or vocational rehabilitation). Three-month post-intervention outcomes were: completion of advance directive (Five Wishes©); psychological adjustment (Beck Depression, Anxiety Inventories); quality of life (PedsQL™); and HIV symptoms (General Health Self-Assessment). Results Adolescents had a mean age, 16 years; 40% male; 92% African-American; 68% with perinatally acquired HIV, 29% had AIDS diagnosis. FACE participants completed advance directives more than controls, using time matched comparison (P < 0.001). Neither anxiety, nor depression, increased at clinically or statistically significant levels post-intervention. FACE adolescents maintained quality of life. FACE families perceived their adolescents as worsening in their school (P = 0.018) and emotional (P = 0.029) quality of life at 3 months, compared with controls. Conclusions Participating in advance care planning did not unduly distress HIV+ adolescents. PMID:22096382

  7. Nursing Titles and Health Care Plans.

    ERIC Educational Resources Information Center

    Erceg, Linda

    1996-01-01

    Recommends choosing appropriate health care providers for camp, and referring to them by the title their credentials warrant. Explains distinctions among nursing titles and that they vary by state. Discusses developing a health care plan suited to camp's population, program, and location. Presents guidelines required of a health care plan by…

  8. Health Instruction Packages: Nursing Care Plans.

    ERIC Educational Resources Information Center

    Kowalski, Dorcas S.; And Others

    Text, illustrations, and exercises are provided in this set of learning modules to teach nurses and nursing students various patient care skills. The first module, "How to Write a Nursing Care Plan" by Dorcas S. Kowalski, discusses three tasks in developing patient care plans: identifying and prioritizing a patient's needs, gathering information…

  9. Managed Care Plans: Getting Good Care for Your Child

    MedlinePlus

    ... AAP Find a Pediatrician Family Life Medical Home Health Insurance Pediatric Specialists Family Dynamics Media Work & Play Getting ... Your Community Healthy Children > Family Life > Medical Home > Health Insurance > Managed Care Plans: Getting Good Care for Your ...

  10. Advanced Fuels Campaign Execution Plan

    SciTech Connect

    Kemal Pasamehmetoglu

    2010-10-01

    The purpose of the Advanced Fuels Campaign (AFC) Execution Plan is to communicate the structure and management of research, development, and demonstration (RD&D) activities within the Fuel Cycle Research and Development (FCRD) program. Included in this document is an overview of the FCRD program, a description of the difference between revolutionary and evolutionary approaches to nuclear fuel development, the meaning of science-based development of nuclear fuels, and the “Grand Challenge” for the AFC that would, if achieved, provide a transformational technology to the nuclear industry in the form of a high performance, high reliability nuclear fuel system. The activities that will be conducted by the AFC to achieve success towards this grand challenge are described and the goals and milestones over the next 20 to 40 year period of research and development are established.

  11. Advanced Fuels Campaign Execution Plan

    SciTech Connect

    Kemal Pasamehmetoglu

    2011-09-01

    The purpose of the Advanced Fuels Campaign (AFC) Execution Plan is to communicate the structure and management of research, development, and demonstration (RD&D) activities within the Fuel Cycle Research and Development (FCRD) program. Included in this document is an overview of the FCRD program, a description of the difference between revolutionary and evolutionary approaches to nuclear fuel development, the meaning of science-based development of nuclear fuels, and the 'Grand Challenge' for the AFC that would, if achieved, provide a transformational technology to the nuclear industry in the form of a high performance, high reliability nuclear fuel system. The activities that will be conducted by the AFC to achieve success towards this grand challenge are described and the goals and milestones over the next 20 to 40 year period of research and development are established.

  12. Oncology Advanced Practitioners Bring Advanced Community Oncology Care.

    PubMed

    Vogel, Wendy H

    2016-01-01

    Oncology care is becoming increasingly complex. The interprofessional team concept of care is necessary to meet projected oncology professional shortages, as well as to provide superior oncology care. The oncology advanced practitioner (AP) is a licensed health care professional who has completed advanced training in nursing or pharmacy or has completed training as a physician assistant. Oncology APs increase practice productivity and efficiency. Proven to be cost effective, APs may perform varied roles in an oncology practice. Integrating an AP into an oncology practice requires forethought given to the type of collaborative model desired, role expectations, scheduling, training, and mentoring. PMID:27249776

  13. Advanced planetary analyses. [for planetary mission planning

    NASA Technical Reports Server (NTRS)

    1974-01-01

    The results are summarized of research accomplished during this period concerning planetary mission planning are summarized. The tasks reported include the cost estimations research, planetary missions handbook, and advanced planning activities.

  14. Advances in prehospital trauma care

    PubMed Central

    Williamson, Kelvin; Ramesh, Ramaiah; Grabinsky, Andreas

    2011-01-01

    Prehospital trauma care developed over the last decades parallel in many countries. Most of the prehospital emergency medical systems relied on input or experiences from military medicine and were often modeled after the existing military procedures. Some systems were initially developed with the trauma patient in mind, while other systems were tailored for medical, especially cardiovascular, emergencies. The key components to successful prehospital trauma care are the well-known ABCs of trauma care: Airway, Breathing, Circulation. Establishing and securing the airway, ventilation, fluid resuscitation, and in addition, the quick transport to the best-suited trauma center represent the pillars of trauma care in the field. While ABC in trauma care has neither been challenged nor changed, new techniques, tools and procedures have been developed to make it easier for the prehospital provider to achieve these goals in the prehospital setting and thus improve the outcome of trauma patients. PMID:22096773

  15. Advanced Life Support Project Plan

    NASA Technical Reports Server (NTRS)

    2002-01-01

    Life support systems are an enabling technology and have become integral to the success of living and working in space. As NASA embarks on human exploration and development of space to open the space frontier by exploring, using and enabling the development of space and to expand the human experience into the far reaches of space, it becomes imperative, for considerations of safety, cost, and crew health, to minimize consumables and increase the autonomy of the life support system. Utilizing advanced life support technologies increases this autonomy by reducing mass, power, and volume necessary for human support, thus permitting larger payload allocations for science and exploration. Two basic classes of life support systems must be developed, those directed toward applications on transportation/habitation vehicles (e.g., Space Shuttle, International Space Station (ISS), next generation launch vehicles, crew-tended stations/observatories, planetary transit spacecraft, etc.) and those directed toward applications on the planetary surfaces (e.g., lunar or Martian landing spacecraft, planetary habitats and facilities, etc.). In general, it can be viewed as those systems compatible with microgravity and those compatible with hypogravity environments. Part B of the Appendix defines the technology development 'Roadmap' to be followed in providing the necessary systems for these missions. The purpose of this Project Plan is to define the Project objectives, Project-level requirements, the management organizations responsible for the Project throughout its life cycle, and Project-level resources, schedules and controls.

  16. Advanced Respite Care: Medically Challenged. Teacher Edition. Respite Care Series.

    ERIC Educational Resources Information Center

    Oklahoma State Dept. of Vocational and Technical Education, Stillwater. Curriculum and Instructional Materials Center.

    This curriculum guide is designed to help teachers to provide advanced-level training for care providers who want to work with individuals who are chronically or terminally ill and require specialized care. The curriculum contains seven units. Each of the instructional units includes some or all of these basic components: performance objectives,…

  17. Advance Planning by Same-Sex Couples

    ERIC Educational Resources Information Center

    Riggle, Ellen D. B.; Rostosky, Sharon S.; Prather, Robert A.

    2006-01-01

    The lack of legal recognition of same-sex couples can leave partners vulnerable in a crisis or emergency. Advance planning is one strategy couples can use to establish legal rights. Analyses of data collected from both partners in 131 same-sex couples suggested that executing advance-planning documents (wills, powers of attorney for finance and…

  18. Advance end-of-life treatment planning. A research review.

    PubMed

    Miles, S H; Koepp, R; Weber, E P

    1996-05-27

    The year 1996 marks the fifth anniversary of the federal Patient Self-Determination Act. The Patient Self-Determination Act required hospitals, nursing homes, and health plans to ask whether patients have advance directives and to incorporate them into the medical record. A "living will" is an advance directive by which a person tells caregivers the circumstances in which life-sustaining treatment is to be provided or forgone if the patient is unable to communicate. A "durable power of attorney for health care" enables one to designate a person to speak on his or her behalf if the author loses decision-making capacity. "Advance planning" is the process of reflection, discussion, and communication of treatment preferences for end-of-life care that precedes and may lead to an advance directive. PMID:8638992

  19. 45 CFR 1355.54 - Submittal of advance planning documents.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... accordance with procedures specified by 45 CFR part 95, subpart F. ... 45 Public Welfare 4 2011-10-01 2011-10-01 false Submittal of advance planning documents. 1355.54... FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND FAMILY SERVICES...

  20. 45 CFR 1355.54 - Submittal of advance planning documents.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... procedures specified by 45 CFR part 95, subpart F. ... 45 Public Welfare 4 2014-10-01 2014-10-01 false Submittal of advance planning documents. 1355.54... FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND FAMILY SERVICES...

  1. 45 CFR 1355.54 - Submittal of advance planning documents.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... procedures specified by 45 CFR part 95, subpart F. ... 45 Public Welfare 4 2013-10-01 2013-10-01 false Submittal of advance planning documents. 1355.54... FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND FAMILY SERVICES...

  2. 45 CFR 1355.54 - Submittal of advance planning documents.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... accordance with procedures specified by 45 CFR part 95, subpart F. ... 45 Public Welfare 4 2010-10-01 2010-10-01 false Submittal of advance planning documents. 1355.54... FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND FAMILY SERVICES...

  3. 45 CFR 1355.54 - Submittal of advance planning documents.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... procedures specified by 45 CFR part 95, subpart F. ... 45 Public Welfare 4 2012-10-01 2012-10-01 false Submittal of advance planning documents. 1355.54... FAMILIES, FOSTER CARE MAINTENANCE PAYMENTS, ADOPTION ASSISTANCE, AND CHILD AND FAMILY SERVICES...

  4. 42 CFR 460.106 - Plan of care.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 4 2010-10-01 2010-10-01 false Plan of care. 460.106 Section 460.106 Public Health... Services § 460.106 Plan of care. (a) Basic requirement. The interdisciplinary team must promptly develop a comprehensive plan of care for each participant. (b) Content of plan of care. The plan of care must meet...

  5. Medicare and Caregivers: Planning for Medical Care

    MedlinePlus

    ... turn Javascript on. Medicare and Caregivers Planning for Medical Care If you find that an older relative ... friend needs your help to deal with a medical condition, there are a number of steps you ...

  6. Planning health care delivery systems.

    PubMed Central

    Baum, M A; Bergwall, D F; Reeves, P N

    1975-01-01

    The increasing concern and interest in the health delivery system in the United States has placed the health system planners in a difficult position. They are inadequately prepared, in many cases, to deal with the management techniques that have been designed for use with system problems. This situation has been compounded by the failure, until recently, of educational programs to train new health professionals in these techniques. Computer simulation is a technique that allows the planners dynamic feedback on his proposed plans. This same technique provides the planning student with a better understanding of the systems planning process. PMID:1115292

  7. Plans for Advanced LIGO Instruments

    NASA Astrophysics Data System (ADS)

    Wilkinson, Carol

    2005-04-01

    The proposed Advanced LIGO detector will have an increase in sensitivity over initial LIGO by a factor of ten, with an increased bandwidth in the region of highest sensitivity and the ability to tune for specific astrophysical sources. Advanced LIGO will achieve the equivalent of the one-year integrated observation time of initial LIGO in just several hours, allowing observation of astrophysical gravitational waves on a regular basis. The Advanced LIGO detector will replace the existing detector at the LIGO Observatories while retaining the existing building and vacuum system infrastructure. The new instruments build on the initial LIGO Fabry-Perot Michelson Interferometer layout and take advantage of significant advances in technology since the design of initial LIGO in the 1990's. Signal strength/sensitivity will be improved by increasing the laser power, lowering optical absorption, and adding signal recycling to the Fabry-Perot arm cavities. Stray forces on the test masses will be controlled by reducing thermal noise sources in the suspensions and optics and using a multi-staged seismic isolation system with inertial sensing and feedback control. The LIGO laboratory, the LIGO Science Collaboration, and international partners have undertaken a structured program of research and development, including testing of full-scale prototypes in context. Significant progress has been made on several of the detector subsystems. The Advanced LIGO project has been through National Science Foundation peer review and the National Science Board has recommended it for funding. Based on a proposed funding start in 2007, detector installation will begin in 2010, with observations at an advanced level of commissioning in 2013.

  8. Real health plans manage care.

    PubMed

    Hurley, Robert

    2006-01-01

    The public sector might seem to be an appealing growth opportunity to commercial insurers confronted by stalled private-sector coverage expansion, but whether these insurers have the means and motivation to deliver value to Medicare and Medicaid is unproven. State Medicaid purchasers in particular have found alternative sources for care management and have sound reasons to question whether industry-leading commercial insurers will be responsive to their needs. PMID:17102171

  9. Advanced access: reducing waiting and delays in primary care.

    PubMed

    Murray, Mark; Berwick, Donald M

    2003-02-26

    Delay of care is a persistent and undesirable feature of current health care systems. Although delay seems to be inevitable and linked to resource limitations, it often is neither. Rather, it is usually the result of unplanned, irrational scheduling and resource allocation. Application of queuing theory and principles of industrial engineering, adapted appropriately to clinical settings, can reduce delay substantially, even in small practices, without requiring additional resources. One model, sometimes referred to as advanced access, has increasingly been shown to reduce waiting times in primary care. The core principle of advanced access is that patients calling to schedule a physician visit are offered an appointment the same day. Advanced access is not sustainable if patient demand for appointments is permanently greater than physician capacity to offer appointments. Six elements of advanced access are important in its application balancing supply and demand, reducing backlog, reducing the variety of appointment types, developing contingency plans for unusual circumstances, working to adjust demand profiles, and increasing the availability of bottleneck resources. Although these principles are powerful, they are counter to deeply held beliefs and established practices in health care organizations. Adopting these principles requires strong leadership investment and support. PMID:12597760

  10. Health Care Plan's Nurse Advice System.

    PubMed Central

    Wagner, D. E.; Reinhardt, M. T.; Lyons, J. P.; Sullivan, K. M.

    1992-01-01

    Staff model HMO's expend great effort in handling member phone calls. Health Care Plan, Inc. has developed a computer program to aid phone room nurses in their documentation and decision making processes. The Nurse Advice system has been successfully implemented in six of eight medical centers. By providing real-time access to patient clinical data, the quality of care and service is improved. PMID:1482969

  11. Factors affecting choice of health care plans.

    PubMed

    Grazier, K L; Richardson, W C; Martin, D P; Diehr, P

    1986-02-01

    The research reported here examined the factors which affected the decision to remain with either Blue Cross of Washington and Alaska or Group Health Cooperative of Puget Sound, or to change to an independent practice association (IPA) in which the primary care physicians control all care. The natural setting allowed examination of the characteristics of families with experience in structurally different plans; a decision not influenced by premium differentials; the importance of the role of usual provider; and a family-based decision using multivariate techniques. An expected utility model implied that factors affecting preferences included future need for medical care; access to care; financial resources to meet the need for care; and previous level of experience with plan and provider. Analysis of interview and medical record abstract data from 1,497 families revealed the importance of maintaining a satisfactory relationship with the usual sources of care in the decision to change plans. Adverse selection into the new IPA as measured by health status and previous utilization of medical services was not noted. PMID:3949539

  12. Factors affecting choice of health care plans.

    PubMed Central

    Grazier, K L; Richardson, W C; Martin, D P; Diehr, P

    1986-01-01

    The research reported here examined the factors which affected the decision to remain with either Blue Cross of Washington and Alaska or Group Health Cooperative of Puget Sound, or to change to an independent practice association (IPA) in which the primary care physicians control all care. The natural setting allowed examination of the characteristics of families with experience in structurally different plans; a decision not influenced by premium differentials; the importance of the role of usual provider; and a family-based decision using multivariate techniques. An expected utility model implied that factors affecting preferences included future need for medical care; access to care; financial resources to meet the need for care; and previous level of experience with plan and provider. Analysis of interview and medical record abstract data from 1,497 families revealed the importance of maintaining a satisfactory relationship with the usual sources of care in the decision to change plans. Adverse selection into the new IPA as measured by health status and previous utilization of medical services was not noted. PMID:3949539

  13. [Advance directives, a tool to humanize care].

    PubMed

    Olmari-Ebbing, M; Zumbach, C N; Forest, M I; Rapin, C H

    2000-07-01

    The relationship between the patient and a medical care giver is complex specially as it implies to the human, juridical and practical points of view. It depends on legal and deontological considerations, but also on professional habits. Today, we are confronted to a fundamental modification of this relationship. Professional guidelines exist, but are rarely applied and rarely taught in universities. However, patients are eager to move from a paternalistic relationship to a true partnership, more harmonious and more respectful of individual values ("value based medicine"). Advance directives give us an opportunity to improve our practices and to provide care consistent with the needs and wishes of each patient. PMID:10967645

  14. Social Marketing: Planning Before Conceiving Preconception Care

    PubMed Central

    Daniel, Katherine Lyon

    2006-01-01

    Social marketing approaches can help to shape the formation of and to create demand for preconception care services. This article describes four components of social marketing, often referred to as the 4 P’s, that should be carefully researched and set in place before a national effort to launch and sustain preconception care services is pursued. First, the product or package of services must be defined and adapted using the latest in scientific and health care standards and must be based on consumer needs and desires. Second, the pricing of the services in financial or opportunity costs must be acceptable to the consumer, insurers, and health care service providers. Third, the promotion of benefits must be carefully crafted to reach and appeal to both consumers and providers. Fourth, the placement and availability of services in the marketplace must be researched and planned. With the application of market research practices that incorporate health behavior theories in their exploration of each component, consumer demand for preconception care can be generated, and providers can take preconception care to the market with confidence. PMID:16755400

  15. Social marketing: planning before conceiving preconception care.

    PubMed

    Prue, Christine E; Daniel, Katherine Lyon

    2006-09-01

    Social marketing approaches can help to shape the formation of and to create demand for preconception care services. This article describes four components of social marketing, often referred to as the 4 P's, that should be carefully researched and set in place before a national effort to launch and sustain preconception care services is pursued. First, the product or package of services must be defined and adapted using the latest in scientific and health care standards and must be based on consumer needs and desires. Second, the pricing of the services in financial or opportunity costs must be acceptable to the consumer, insurers, and health care service providers. Third, the promotion of benefits must be carefully crafted to reach and appeal to both consumers and providers. Fourth, the placement and availability of services in the marketplace must be researched and planned. With the application of market research practices that incorporate health behavior theories in their exploration of each component, consumer demand for preconception care can be generated, and providers can take preconception care to the market with confidence. PMID:16755400

  16. Advancing the Community College Strategic Plan.

    ERIC Educational Resources Information Center

    Herbkersman, Neil; Hibbert-Jones, Karla

    2002-01-01

    Discusses the importance of developing a comprehensive grants development process to advance community college strategic plans, especially in the current economic climate. Details the process as developed and implemented by Sinclair Community College (Ohio). States that colleges that employ methodical processes and effective operating systems to…

  17. Planning quality patient care in today's marketplace.

    PubMed

    Malloch, K

    2000-06-01

    New skills and perspectives are essential for nursing to meet the demands of shrinking resources without co-opting professional standards. Planning patient care in a definitive, value-based framework that ensures a balance among cost, work time, and quality outcomes for the consumer is the new work of nursing. Translating current practice into a value-based model requires an orientation to the content of our care, the context in which it is provided, and the effectiveness of our collaborative skills. PMID:11249282

  18. End-of-Life Decisions and Palliative Care in Advanced Heart Failure.

    PubMed

    Meyers, Deborah E; Goodlin, Sarah J

    2016-09-01

    Advanced heart failure (HF) therapies are focused on extending life and improving function. In contrast, palliative care is a holistic approach that focuses on symptom alleviation and patients' physical, psychosocial, and spiritual needs. HF clinicians can integrate palliative care strategies by incorporating several important components of planning and decision-making for HF patients. Future care planning (FCP) for HF patients should incorporate the basic tenets of shared decision-making (SDM). These include understanding the patient's perspective and care preferences, articulating what is medically feasible, and integrating these considerations into the overall care plan. Use of defined triggers for FCP can stimulate important patient-caregiver conversations. Guidelines advocate an annual review of HF status and future care preferences. Advance directives are important for any individual with a chronic, life-limiting illness and should be integrated into FCP. Nevertheless, use of advance directives by HF patients is extremely low. Consideration of illness trajectories and risk-scoring tools might facilitate prognostication and delivery of appropriate HF care. Decisions about heart transplantation or left ventricular assist device implantation should include planning for potential complications associated with these therapies. Such decisions also should include a discussion of palliative management, as an alternative to intervention and also as an option for managing symptoms or adverse events after intervention. Palliative care, including FCP and SDM, should be integrated into the course of all patients with advanced HF. Clinicians who provide HF care should acquire the skills necessary for conducting FCP and SDM discussions. PMID:27568873

  19. Pain: advances and issues in critical care.

    PubMed

    Harrison, M; Cotanch, P H

    1987-09-01

    The milieu of the critical care unit is stressful for both the patient and health care professionals. As such, it has the potential to increase pain perception in patients, and decrease the nurse's awareness of pain relief needs of the patient. Several physical and pharmacologic methods of pain relief were discussed in this article. Nontechnologic analgesia such as hypnosis and relaxation were introduced as adjuncts or alternatives to more familiar methods of pain relief. Although critically ill patients are not always able to express their discomfort, it is the responsibility of the nurse to recognize the potential for pain, and plan treatment accordingly. This article suggests several strategies for dealing with pain in critically ill patients. PMID:3302958

  20. Palliative care for patients with advance chronic kidney disease.

    PubMed

    Douglas, C A

    2014-01-01

    Over the past three decades there has been a dramatic rise in the number of patients with advanced chronic kidney disease. The fastest expanding group receiving dialysis has been the elderly. However, for those patients who are very elderly with co-morbidity, dialysis may not offer a survival advantage. Therefore, active conservative management is a growing service offered by many renal units in the UK and focuses on non-dialytic correction of fluid and electrolyes, management of renal anaemia, and assessment and management of symptoms. The five-year survival of a patient over 75 years of age starting dialysis is 20% and if a patient is over 75 years, has co-morbidity, or a poor performance status, dialysis may not offer any survival advantage. Whether a patient is managed by dialysis or by conservative management the symptom burden suffered is high. These symptoms are under-recognised and often managed poorly because of increased drug toxicity in renal failure. This complex group of patients require close working between renal, palliative care, medicine for the elderly, and community teams, to allow best quality of life and end of life care. This review describes some of the challenges in providing Advanced Care Planning for dialysis and conservatively managed patients, highlights the symptom burden of patients with advanced chronic kidney disease, and offers guidance in how to manage the symptoms effectively. PMID:25318401

  1. 42 CFR 441.103 - Alternate plans of care.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... Medicaid for Individuals Age 65 or Over in Institutions for Mental Diseases § 441.103 Alternate plans of... otherwise need care in an institution for mental diseases. (b) These alternate plans of care must— (1)...

  2. 42 CFR 456.180 - Individual written plan of care.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: Mental Hospitals Plan of Care § 456.180 Individual written plan of care. (a) Before admission to a mental hospital...

  3. 42 CFR 456.180 - Individual written plan of care.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: Mental Hospitals Plan of Care § 456.180 Individual written plan of care. (a) Before admission to a mental hospital...

  4. 42 CFR 441.103 - Alternate plans of care.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... Medicaid for Individuals Age 65 or Over in Institutions for Mental Diseases § 441.103 Alternate plans of... would otherwise need care in an institution for mental diseases. (b) These alternate plans of care...

  5. 42 CFR 441.103 - Alternate plans of care.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... Medicaid for Individuals Age 65 or Over in Institutions for Mental Diseases § 441.103 Alternate plans of... otherwise need care in an institution for mental diseases. (b) These alternate plans of care must— (1)...

  6. 42 CFR 441.103 - Alternate plans of care.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... Medicaid for Individuals Age 65 or Over in Institutions for Mental Diseases § 441.103 Alternate plans of... would otherwise need care in an institution for mental diseases. (b) These alternate plans of care...

  7. 42 CFR 456.180 - Individual written plan of care.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: Mental Hospitals Plan of Care § 456.180 Individual written plan of care. (a) Before admission to a mental hospital...

  8. 42 CFR 456.180 - Individual written plan of care.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 4 2012-10-01 2012-10-01 false Individual written plan of care. 456.180 Section 456.180 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN... Plan of Care § 456.180 Individual written plan of care. (a) Before admission to a mental hospital...

  9. DOE planning workshop advanced biomedical technology initiative

    SciTech Connect

    Not Available

    1994-06-01

    The Department of Energy has mad major contributions in the biomedical sciences with programs in medical applications and instrumentation development, molecular biology, human genome, and computational sciences. In an effort to help determine DOE`s role in applying these capabilities to the nation`s health care needs, a planning workshop was held on January 11--12, 1994. The workshop was co-sponsored by the Department`s Office of Energy Research and Defense Programs organizations. Participants represented industry, medical research institutions, national laboratories, and several government agencies. They attempted to define the needs of the health care industry. identify DOE laboratory capabilities that address these needs, and determine how DOE, in cooperation with other team members, could begin an initiative with the goals of reducing health care costs while improving the quality of health care delivery through the proper application of technology and computational systems. This document is a report of that workshop. Seven major technology development thrust areas were considered. Each involves development of various aspects of imaging, optical, sensor and data processing and storage technologies. The thrust areas as prioritized for DOE are: (1) Minimally Invasive Procedures; (2) Technologies for Individual Self Care; (3) Outcomes Research; (4) Telemedicine; (5) Decision Support Systems; (6) Assistive Technology; (7) Prevention and Education.

  10. [Clinical case: Complicated grief in primary care. Care plan].

    PubMed

    Ruymán Brito-Brito, Pedro; Rodríguez-Ramos, Mercedes; Pérez-García-Talavera, Carlos

    2009-01-01

    This is the case of a 61-year-old patient woman that visits her nurse in Primary Health Care to get the control of blood pressure and glycemia. In the last two years has suffered the loss of her husband and of two brothers beside having lived through other vital stressful events that have taken her to a situation of complicated grief. The care plan is realized using the M. Gordon assessment system and standardized languages NANDA, NOC and NIC. The principal aims were the improvement of the depression level and the improvement in the affliction resolution. As suggested interventions were proposed to facilitate the grief and the derivation to a mental health unit. A follow-up of the patient was realized in nursing consultation at Primary health care to weekly intervals, in the beginning, and monthly, later. The evaluation of the care plan reflects an improvement in the criteria of Prigerson's complicated grief; an increase of the recreative activities; the retreat of the mourning that still she was guarding; as well as an improvement in the control of the blood pressure numbers. The attention of nurses before a case of complicated grief turns out to be complex. Nevertheless the suitable accomplishment of certain interventions orientated to facilitating the grief, with a follow-up in consultation, shows the efficiency. The difficulty in the boarding of the psychosocial problems meets increased at the moment of are necessary the nursing diagnostics adapted for every individual case. The work in group between nurses could improves the consensus. PMID:19854088

  11. 14 CFR 151.113 - Advance planning proposals: Sponsor eligibility.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... Engineering Proposals § 151.113 Advance planning proposals: Sponsor eligibility. The sponsor of an advance planning and engineering proposal must be a public agency, as defined in § 151.37(a), and must be...

  12. [Palliative care needs in advanced chronic illness].

    PubMed

    Tripodoro, Vilma A; Rynkiewicz, María C; Llanos, Victoria; Padova, Susana; De Lellis, Silvina; De Simone, Gustavo

    2016-01-01

    About 75% of population will die from one or more chronic progressive diseases. From this projection WHO urged countries to devise strategies for strengthening palliative treatment as part of comprehensive care. In Catalonia, Spain, direct measurement of the prevalence of these patients with NECPAL CCOMS-ICO© tool was 1.5% of the population. This tool is an indicative, not dichotomous, quali-quantitative multifactorial evaluation to be completed by the treating physician. In Argentina there is no information on these patients. Our goal was to explore and characterize the proportion of chronically ill patients in palliative care needs, by NECPAL CCOMS-ICO© tool, in an accessible population of the City of Buenos Aires. General hospitals of the Health Region 2 (Piñero, álvarez and Santojanni) and its program areas were surveyed. In Health Region 1, we surveyed the Udaondo gastroenterology hospital. A total of 53 physicians (704 patients) were interviewed. It was identified that 29.5% of these patients were affected by advanced chronic diseases; 72.1% of them were NECPAL positive, younger (median 64) than in others studies, and more than 98% presented high levels of comorbidity. Palliative care demand (31.4%) and needs (52.7%) were recorded. Specific indicators of fragility, progression, severity and kind of chronic disease were described. The main finding was to identify, with an instrument not based on mortality that, in Buenos Aires City, 1 in 3 patients with chronic diseases could die in the next year and had palliative care needs. PMID:27295702

  13. 75 FR 66319 - State Systems Advance Planning Document (APD) Process

    Federal Register 2010, 2011, 2012, 2013, 2014

    2010-10-28

    ... HUMAN SERVICES 45 CFR Part 95 RIN 0970-AC33 State Systems Advance Planning Document (APD) Process AGENCY... Health and Human Services (HHS). ACTION: Final rule. SUMMARY: The Advance Planning Document (APD) process... support programs for children and families. The Advance Planning Document (APD) process governs...

  14. Advanced Materials Laboratory User Test Planning Guide

    NASA Technical Reports Server (NTRS)

    Orndoff, Evelyne

    2012-01-01

    Test process, milestones and inputs are unknowns to first-time users of the Advanced Materials Laboratory. The User Test Planning Guide aids in establishing expectations for both NASA and non-NASA facility customers. The potential audience for this guide includes both internal and commercial spaceflight hardware/software developers. It is intended to assist their test engineering personnel in test planning and execution. Material covered includes a roadmap of the test process, roles and responsibilities of facility and user, major milestones, facility capabilities, and inputs required by the facility. Samples of deliverables, test article interfaces, and inputs necessary to define test scope, cost, and schedule are included as an appendix to the guide.

  15. Advanced Stirling Radioisotope Generator Life Certification Plan

    NASA Technical Reports Server (NTRS)

    Rusick, Jeffrey J.; Zampino, Edward J.

    2013-01-01

    An Advanced Stirling Radioisotope Generator (ASRG) power supply is being developed by the Department of Energy (DOE) in partnership with NASA for potential future deep space science missions. Unlike previous radioisotope power supplies for space exploration, such as the passive MMRTG used recently on the Mars Curiosity rover, the ASRG is an active dynamic power supply with moving Stirling engine mechanical components. Due to the long life requirement of 17 years and the dynamic nature of the Stirling engine, the ASRG project faced some unique challenges trying to establish full confidence that the power supply will function reliably over the mission life. These unique challenges resulted in the development of an overall life certification plan that emphasizes long-term Stirling engine test and inspection when analysis is not practical. The ASRG life certification plan developed is described.

  16. Advance Care Planning: Medical Issues to Consider

    MedlinePlus

    ... can be forced into the stomach, causing distress. Dialysis What does it entail? If a person develops ... kidneys and build up in the body. A dialysis machine filters the toxins out of the blood. ...

  17. Ready or not: planning for health declines in couples with advanced multiple sclerosis.

    PubMed

    Chen, Hannah; Habermann, Barbara

    2013-02-01

    This study explored how couples living with advanced multiple sclerosis approach planning for health changes together. A qualitative descriptive approach was used, with multiple in-depth interviews. Ten couples were interviewed, consisting of 10 participants with advanced multiple sclerosis and their 10 respective spouses. Interviews were transcribed verbatim and analyzed for themes related to dyad decision making. Particular focus was paid to how or if couples planned for worsening health, including advance care planning. Characteristics of couples who had made plans for worsening health included a desire to make decisions ahead of time, work in a healthcare field, and a life-threatening health event for the care-giving partner. Characteristics of couples who had not discussed plans for worsening health included diminished quality of communication between partners and hoping for a cure. Findings suggest that providers may need to assess quality of communication between partners, because strained communication may negatively affect the process of informed healthcare decision making. PMID:23291870

  18. Palliative care for advanced dementia in Japan: knowledge and attitudes.

    PubMed

    Nakanishi, Miharu; Miyamoto, Yuki

    This study examined factors contributing to the knowledge and attitudes of nursing home staff regarding palliative care for advanced dementia in Japan. A cross-sectional survey of 275 nurses and other care workers from 74 long-term care facilities was conducted across three prefectures in August 2014. The Japanese versions of the Questionnaire on Palliative Care for Advanced Dementia (qPAD) and Frommelt Attitudes Toward Care of the Dying scale, Form B (FATCOD-B-J) were used. Greater knowledge was exhibited among nursing home staff in facilities that established a manual for end-of-life care. Higher levels of positive attitudes were observed among nursing home staff in facilities that had established a manual and those in facilities with a physician's written opinions on end-of-life care. An organisational effort should be explored to establish end-of-life care policies among nursing home staff for advanced dementia. PMID:26878406

  19. Advanced cerebral monitoring in neurocritical care.

    PubMed

    Barazangi, Nobl; Hemphill, J Claude

    2008-01-01

    New cerebral monitoring techniques allow direct measurement of brain oxygenation and metabolism. Investigation using these new tools has provided additional insight into the understanding of the pathophysiology of acute brain injury and suggested new ways to guide management of secondary brain injury. Studies of focal brain tissue oxygen monitoring have suggested ischemic thresholds in focal regions of brain injury and demonstrated the interrelationship between brain tissue oxygen tension (P bt O 2 ) and other cerebral physiologic and metabolic parameters. Jugular venous oxygen saturation (SjVO 2 ) monitoring may evaluate global brain oxygen delivery and consumption, providing thresholds for detecting brain hypoperfusion and hyperperfusion. Furthermore, critically low values of P bt O 2 and SjVO 2 have also been predictive of mortality and worsened functional outcome, especially after head trauma. Cerebral microdialysis measures the concentrations of extracellular metabolites which may be relevant to cerebral metabolism or ischemia in focal areas of injury. Cerebral blood flow may be measured in the neurointensive care unit using continuous methods such as thermal diffusion and laser Doppler flowmetry. Initial studies have also attempted to correlate findings from advanced neuromonitoring with neuroimaging using dynamic perfusion computed tomography, positron emission tomography, and Xenon computed tomography. Additionally, new methods of data acquisition, storage, and analysis are being developed to address the increasing burden of patient data from neuromonitoring. Advanced informatics techniques such as hierarchical data clustering, generalized linear models, and heat map dendrograms are now being applied to multivariable patient data in order to better develop physiologic patient profiles to improve diagnosis and treatment. PMID:19127034

  20. Prevalence of Advance Directives Among Older Adults Admitted to Intensive Care Units and Requiring Mechanical Ventilation.

    PubMed

    Gamertsfelder, Elise M; Seaman, Jennifer Burgher; Tate, Judith; Buddadhumaruk, Praewpannarai; Happ, Mary Beth

    2016-04-01

    Because older adults are at high risk for hospitalization and potential decisional incapacity, advance directives are important components of pre-hospital advanced care planning, as they document individual preferences for future medical care. The prevalence of pre-hospital advance directive completion in 450 critically ill older adults requiring mechanical ventilation from two Mid-Atlantic hospitals is described, and demographic and clinical predictors of pre-hospital advance directive completion are explored. The overall advance directive completion rate was 42.4%, with those in older age groups (75 to 84 years and 85 and older) having approximately two times the odds of completion. No significant differences in the likelihood of advance directive completion were noted by sex, race, or admitting diagnosis. The relatively low prevalence of advance directive completion among older adults with critical illness and high mortality rate (24%) suggest a need for greater awareness and education. [Journal of Gerontological Nursing, 42(4), 34-41.]. PMID:26651862

  1. Advanced Education and Technology Business Plan, 2008-11

    ERIC Educational Resources Information Center

    Alberta Advanced Education and Technology, 2008

    2008-01-01

    The Ministry of Advanced Education and Technology's 2008-11 business plan identifies how it plans to work over the next three years to enhance advanced learning opportunities and innovation for all Albertans. Alberta's advanced learning system is composed of public board-governed institutions, the apprenticeship and industry training system,…

  2. Communicating Nursing Care Using the Health Level Seven Consolidated Clinical Document Architecture Release 2 Care Plan.

    PubMed

    Matney, Susan A; Dolin, Gay; Buhl, Lindy; Sheide, Amy

    2016-03-01

    A care plan provides a patient, family, or community picture and outlines the care to be provided. The Health Level Seven Consolidated Clinical Document Architecture (C-CDA) Release 2 Care Plan Document is used to structure care plan data when sharing the care plan between systems and/or settings. The American Nurses Association has recommended the use of two terminologies, Logical Observation Identifiers Names and Codes (LOINC) for assessments and outcomes and Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) for problems, procedures (interventions), outcomes, and observation findings within the C-CDA. This article describes C-CDA, introduces LOINC and SNOMED CT, discusses how the C-CDA Care Plan aligns with the nursing process, and illustrates how nursing care data can be structured and encoded within a C-CDA Care Plan. PMID:26765657

  3. 14 CFR 151.111 - Advance planning proposals: General.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... Engineering Proposals § 151.111 Advance planning proposals: General. (a) Each advance planning and engineering... application, under §§ 151.21(c) and 151.27, or both. (c) Each proposal must relate to planning and engineering... “Airport Activity Statistics of Certificated Route Air Carriers” (published jointly by FAA and the...

  4. 14 CFR 151.111 - Advance planning proposals: General.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... Engineering Proposals § 151.111 Advance planning proposals: General. (a) Each advance planning and engineering... application, under §§ 151.21(c) and 151.27, or both. (c) Each proposal must relate to planning and engineering... “Airport Activity Statistics of Certificated Route Air Carriers” (published jointly by FAA and the...

  5. 14 CFR 151.111 - Advance planning proposals: General.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... Engineering Proposals § 151.111 Advance planning proposals: General. (a) Each advance planning and engineering... application, under §§ 151.21(c) and 151.27, or both. (c) Each proposal must relate to planning and engineering... “Airport Activity Statistics of Certificated Route Air Carriers” (published jointly by FAA and the...

  6. 14 CFR 151.111 - Advance planning proposals: General.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... Engineering Proposals § 151.111 Advance planning proposals: General. (a) Each advance planning and engineering... application, under §§ 151.21(c) and 151.27, or both. (c) Each proposal must relate to planning and engineering... “Airport Activity Statistics of Certificated Route Air Carriers” (published jointly by FAA and the...

  7. 14 CFR 151.111 - Advance planning proposals: General.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... Engineering Proposals § 151.111 Advance planning proposals: General. (a) Each advance planning and engineering... application, under §§ 151.21(c) and 151.27, or both. (c) Each proposal must relate to planning and engineering... “Airport Activity Statistics of Certificated Route Air Carriers” (published jointly by FAA and the...

  8. Patient Satisfaction With Breast and Colorectal Cancer Survivorship Care Plans

    PubMed Central

    Sprague, Brian L.; Dittus, Kim L.; Pace, Claire M.; Dulko, Dorothy; Pollack, Lori A.; Hawkins, Nikki A.; Geller, Berta M.

    2015-01-01

    Cancer survivors face several challenges following the completion of active treatment, including uncertainty about late effects of treatment and confusion about coordination of follow-up care. The authors evaluated patient satisfaction with personalized survivorship care plans designed to clarify those issues. The authors enrolled 48 patients with breast cancer and 10 patients with colorectal cancer who had completed treatment in the previous two months from an urban academic medical center and a rural community hospital. Patient satisfaction with the care plan was assessed by telephone interview. Overall, about 80% of patients were very or completely satisfied with the care plan, and 90% or more agreed that it was useful, it was easy to understand, and the length was appropriate. Most patients reported that the care plan was very or critically important to understanding an array of survivorship issues. However, only about half felt that it helped them better understand the roles of primary care providers and oncologists in survivorship care. The results provide evidence that patients with cancer find high value in personalized survivorship care plans, but the plans do not eliminate confusion regarding the coordination of follow-up care. Future efforts to improve care plans should focus on better descriptions of how survivorship care will be coordinated. PMID:23722604

  9. [Nurses' knowledge about the health care proxy and advance directives].

    PubMed

    Georget, Jean-Philippe; Cecire-Denoyer, Catherine

    2015-06-01

    The Basse-Normandie palliative care nurses' group carried out a survey regarding nurses' knowledge of the health care proxy and advance directives. The study revealed a lack of connection between these two arrangements, poor knowledge about advance directives but an understanding of the role of the health care proxy. How, therefore, can patients be effectively informed? How should they be supported in this process of determining themselves the conditions of their end of life? PMID:26146326

  10. Careful Planning Key to Accurate Fixed Reports Assets.

    ERIC Educational Resources Information Center

    MaRous, Arnold M.

    1986-01-01

    Only with careful planning can school business managers develop fixed asset information and good recordkeeping. Use of a simple inventory system and discussion with school districts already utilizing this system will assist planning. (CJH)

  11. Advanced Education and Technology Business Plan, 2010-13

    ERIC Educational Resources Information Center

    Alberta Advanced Education and Technology, 2010

    2010-01-01

    This paper presents the business plan of the Ministry of Advanced Education and Technology for 2010 to 2013. Advanced Education and Technology supports the advanced learning system by providing funding for advanced learning providers, coordinating and approving programs of study at public institutions, licensing and approving programs at private…

  12. Advanced Planning for Tsunamis in California

    NASA Astrophysics Data System (ADS)

    Miller, K.; Wilson, R. I.; Larkin, D.; Reade, S.; Carnathan, D.; Davis, M.; Nicolini, T.; Johnson, L.; Boldt, E.; Tardy, A.

    2013-12-01

    The California Tsunami Program is comprised of the California Governor's Office of Emergency Services (CalOES) and the California Geological Survey (CGS) and funded through the National Tsunami Hazard Mitigation Program (NTHMP) and the Federal Emergency Management Agency (FEMA). The program works closely with the 20 coastal counties in California, as well as academic, and industry experts to improve tsunami preparedness and mitigation in shoreline communities. Inundation maps depicting 'worst case' inundation modeled from plausible sources around the Pacific were released in 2009 and have provided a foundation for public evacuation and emergency response planning in California. Experience during recent tsunamis impacting the state (Japan 2011, Chile 2010, Samoa 2009) has brought to light the desire by emergency managers and decision makers for even more detailed information ahead of future tsunamis. A solution to provide enhanced information has been development of 'playbooks' to plan for a variety of expected tsunami scenarios. Elevation 'playbook' lines can be useful for partial tsunami evacuations when enough information about forecast amplitude and arrival times is available to coastal communities and there is sufficient time to make more educated decisions about who to evacuate for a given scenario or actual event. NOAA-issued Tsunami Alert Bulletins received in advance of a distant event will contain an expected wave height (a number) for each given section of coast. Provision of four elevation lines for possible inundation enables planning for different evacuation scenarios based on the above number potentially alleviating the need for an 'all or nothing' decision with regard to evacuation. Additionally an analytical tool called FASTER is being developed to integrate storm, tides, modeling errors, and local tsunami run-up potential with the forecasted tsunami amplitudes in real-time when a tsunami Alert is sent out. Both of these products will help

  13. Barriers and Facilitators to Implementing Cancer Survivorship Care Plans

    PubMed Central

    Dulko, Dorothy; Pace, Claire M.; Dittus, Kim L.; Sprague, Brian L.; Pollack, Lori A.; Hawkins, Nikki A.; Geller, Berta M.

    2015-01-01

    Purpose/Objectives To evaluate the process of survivorship care plan (SCP) completion and to survey oncology staff and primary care physicians (PCPs) regarding challenges of implementing SCPs. Design Descriptive pilot study. Setting Two facilities in Vermont, an urban academic medical center and a rural community academic cancer center. Sample 17 oncology clinical staff created SCPs, 39 PCPs completed surveys, and 58 patients (breast or colorectal cancer) participated in a telephone survey. Methods Using Journey Forward tools, SCPs were created and presented to patients. PCPs received the SCP with a survey assessing its usefulness and barriers to delivery. Oncology staff were interviewed to assess perceived challenges and benefits of SCPs. Qualitative and quantitative data were used to identify challenges to the development and implementation process as well as patient perceptions of the SCP visit. Main Research Variables SCP, healthcare provider perception of barriers to completion and implementation, and patient perception of SCP visit. Findings Oncology staff cited the time required to obtain information for SCPs as a challenge. Completing SCPs 3–6 months after treatment ended was optimal. All participants felt advanced practice professionals should complete and review SCPs with patients. The most common challenge for PCPs to implement SCP recommendations was insufficient knowledge of cancer survivor issues. Most patients found the care plan visit very useful, particularly within six months of diagnosis. Conclusions Creation time may be a barrier to widespread SCP implementation. Cancer survivors find SCPs useful, but PCPs feel insufficient knowledge of cancer survivor issues is a barrier to providing best follow-up care. Incorporating SCPs in electronic medical records may facilitate patient identification, appropriate staff scheduling, and timely SCP creation. Implications for Nursing Oncology nurse practitioners are well positioned to create and deliver

  14. 42 CFR 456.381 - Reports of evaluations and plans of care.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: Intermediate Care Facilities Plan of Care § 456.381 Reports of evaluations and plans of care. A written report of each... plan. Utilization Review (UR) Plan: General Requirement...

  15. 42 CFR 456.381 - Reports of evaluations and plans of care.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: Intermediate Care Facilities Plan of Care § 456.381 Reports of evaluations and plans of care. A written report of each... plan. Utilization Review (UR) Plan: General Requirement...

  16. 42 CFR 456.381 - Reports of evaluations and plans of care.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: Intermediate Care Facilities Plan of Care § 456.381 Reports of evaluations and plans of care. A written report of each... plan. Utilization Review (UR) Plan: General Requirement...

  17. 42 CFR 456.381 - Reports of evaluations and plans of care.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: Intermediate Care Facilities Plan of Care § 456.381 Reports of evaluations and plans of care. A written report of each... plan. Utilization Review (UR) Plan: General Requirement...

  18. 42 CFR 456.381 - Reports of evaluations and plans of care.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: Intermediate Care Facilities Plan of Care § 456.381 Reports of evaluations and plans of care. A written report of each... plan. Utilization Review (UR) Plan: General Requirement...

  19. A Planning Guide for Food Service in Child Care Centers.

    ERIC Educational Resources Information Center

    Food and Nutrition Service (USDA), Washington, DC.

    This publication is designed to help child care center directors and other personnel in programs receiving funding through the Child Care Food Program plan their food service. Included are sections on: (1) planning food for a day; (2) meal patterns (information on the necessary food groups, a chart of vegetables and fruits containing vitamin A, C…

  20. Abbreviated Pandemic Influenza Planning Template for Primary Care Offices

    SciTech Connect

    HCTT CHE

    2010-01-01

    The Abbreviated Pandemic Influenza Plan Template for Primary Care Provider Offices is intended to assist primary care providers and office managers with preparing their offices for quickly putting a plan in place to handle an increase in patient calls and visits, whether during the 2009-2010 influenza season or future influenza seasons.

  1. 42 CFR 460.106 - Plan of care.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... Services § 460.106 Plan of care. (a) Basic requirement. The interdisciplinary team must promptly develop a... participants or caregivers, and communications among members of the interdisciplinary team and other providers. (d) Evaluation of plan of care. On at least a semi-annual basis, the interdisciplinary team...

  2. 42 CFR 460.106 - Plan of care.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... Services § 460.106 Plan of care. (a) Basic requirement. The interdisciplinary team must promptly develop a... participants or caregivers, and communications among members of the interdisciplinary team and other providers. (d) Evaluation of plan of care. On at least a semi-annual basis, the interdisciplinary team...

  3. My Cancer Care Plan as a Web-Solution.

    PubMed

    Westman, Bodil; Cornelius, Birgitta

    2016-01-01

    The Swedish National Cancerplan states that patients should be offered an Individual Care Plan (ICP) for the treatment and survivorship care and rehabilitation planning. As there is no web-solution for ICP available, the project aim is to develop a non-commercial web-solution based on communication between the contact nurse and the patient. PMID:27332410

  4. Plan for advanced microelectronics processing technology application

    SciTech Connect

    Goland, A.N.

    1990-10-01

    The ultimate objective of the tasks described in the research agreement was to identify resources primarily, but not exclusively, within New York State that are available for the development of a Center for Advanced Microelectronics Processing (CAMP). Identification of those resources would enable Brookhaven National Laboratory to prepare a program plan for the CAMP. In order to achieve the stated goal, the principal investigators undertook to meet the key personnel in relevant NYS industrial and academic organizations to discuss the potential for economic development that could accompany such a Center and to gauge the extent of participation that could be expected from each interested party. Integrated of these discussions was to be achieved through a workshop convened in the summer of 1990. The culmination of this workshop was to be a report (the final report) outlining a plan for implementing a Center in the state. As events unfolded, it became possible to identify the elements of a major center for x-ray lithography on Lone Island at Brookhaven National Laboratory. The principal investigators were than advised to substitute a working document based upon that concept in place of a report based upon the more general CAMP workshop originally envisioned. Following that suggestion from the New York State Science and Technology Foundation, the principals established a working group consisting of representatives of the Grumman Corporation, Columbia University, the State University of New York at Stony Brook, and Brookhaven National Laboratory. Regular meetings and additional communications between these collaborators have produced a preproposal that constitutes the main body of the final report required by the contract. Other components of this final report include the interim report and a brief description of the activities which followed the establishment of the X-ray Lithography Center working group.

  5. Beyond consumer-driven health care: purchasers' expectations of all plans.

    PubMed

    Lee, Peter V; Hoo, Emma

    2006-01-01

    Skyrocketing health care costs and quality deficits can only be addressed through a broad approach of quality-based benefit design. Consumer-directed health plans that are built around better consumer information tools and support hold the promise of consumer engagement, but purchasers expect these features in all types of health plans. Regardless of plan type, simply shifting costs to consumers is a threat to access and adherence to evidence-based medicine. Comparative and interactive consumer information tools, coupled with provider performance transparency and payment reform, are needed to advance accountability and support consumers in getting the right care at the right time. PMID:17062597

  6. An Incentive Pay Plan for Advanced Practice Registered Nurses: Impact On Provider and Organizational Outcomes.

    PubMed

    Rhodes, Catherine A; Bechtle, Mavis; McNett, Molly

    2015-01-01

    Advanced practice registered nurses (APRNs) are integral to the provision of quality, cost-effective health care throughout the continuum of care. To promote job satisfaction and ultimately decrease turnover, an APRN incentive plan based on productivity and quality was formulated. Clinical productivity in the incentive plan was measured by national benchmarks for work relative value units for nonphysician providers. After the first year of implementation, APRNs were paid more for additional productivity and quality and the institution had an increase in patient visits and charges. The incentive plan is a win-win for hospitals that employ APRNs. PMID:26259336

  7. Clinical Curriculum Reform and Advanced Care Training at the New England College of Optometry.

    ERIC Educational Resources Information Center

    Wilson, Roger

    1998-01-01

    Discusses how the New England College of Optometry has expanded clinical education so graduates are equipped to handle new and advanced clinical and patient-care responsibilities and meet the changing standards of professional entry-level competency. The reform process, third- and fourth-year curriculum components, rotations, and plans for…

  8. The Con Edison Emergency Child Care Plan for Management Employees: Summary Plan Description.

    ERIC Educational Resources Information Center

    Consolidated Edison Co., Brooklyn, NY.

    This summary plan description offers guidelines for participation in a pilot program that provides short-term emergency care for children of Con Edison managers who are under 13 years old. The plan offers professional, in-home child care that can be used when usual arrangements have collapsed. The summary plan description addresses the following…

  9. 42 CFR 460.106 - Plan of care.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 4 2013-10-01 2013-10-01 false Plan of care. 460.106 Section 460.106 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE)...

  10. 42 CFR 460.106 - Plan of care.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 4 2014-10-01 2014-10-01 false Plan of care. 460.106 Section 460.106 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE)...

  11. Concept mapping: reducing clinical care plan paperwork and increasing learning.

    PubMed

    Schuster, P M

    2000-01-01

    The author describes how concept maps were used in place of nursing care plans to reduce care planning paperwork in fundamentals and medical-surgical clinical courses in acute care facilities. In addition to less paperwork, clinical concept mapping enhances students' critical thinking skills and clinical reasoning because students and faculty can clearly and succinctly visualize priorities and identify relationships in clinical patient data. PMID:11052005

  12. Clinician Roles in Early Integrated Palliative Care for Patients with Advanced Cancer: A Qualitative Study

    PubMed Central

    Park, Elyse R.; Greer, Joseph A.; Jackson, Vicki A.; Jacobsen, Juliet C.; Gallagher, Emily R.; Temel, Jennifer S.

    2014-01-01

    Abstract Background: Early palliative care provides better quality of life, increased prognostic awareness, and even improved survival for patients with advanced cancer but how the integrated care model achieves these outcomes has not been completely explained. Methods: To better understand the clinical approach to early outpatient care from the clinicians' perspective, we conducted focus groups with the palliative care clinicians who had participated in a randomized trial of early palliative care for metastatic lung cancer. Results: Clinicians described their role in providing early palliative care as having three distinct roles in the outpatient setting: (1) managing symptoms to improve functional status and as a bridge to other issues; (2) engaging patients in emotional work to facilitate coping, accepting, and planning; and (3) interpreting the oncologist for the patient and the patient for the oncologist. Conclusions: These data lay the foundation for developing training programs for clinicians in early integrated palliative care. PMID:25390467

  13. Health Care Provider Initiative Strategic Plan

    ERIC Educational Resources Information Center

    National Environmental Education & Training Foundation, 2012

    2012-01-01

    This document lays out the strategy for achieving the goals and objectives of NEETF's "Health Care Provider Initiative." The goal of NEETF's "Health Care Provider Initiative" is to incorporate environmental health into health professionals' education and practice in order to improve health care and public health, with a special emphasis on…

  14. Can managed care plans control health care costs?

    PubMed

    Zwanziger, J; Melnick, G A

    1996-01-01

    The health insurance sector has been transformed in the past fifteen years, with managed care replacing indemnity insurance as the norm. This transformation was intended to change the nature of competition in the health care system so that market forces could be used to control costs. Empirical studies have shown that this objective has been met, as areas with high managed care penetration have tended to have much lower rates of increase in their costs. Creating a more efficient health care system will require additional efforts to produce useful measures of quality and to maintain competitive markets. PMID:8690375

  15. Building Choice and Quality into Your Managed Care Plan.

    ERIC Educational Resources Information Center

    Rinaldi, Stephen J.

    1997-01-01

    The challenge of containing health-care costs continues despite a break from cost increases. Most experts would advise school employees to replace existing health plans with a triple-choice HMO plan using $10 copayments. Armed with quality data and a choice-based plan design, school business officials can improve their chances for long-term cost…

  16. CareMAP: Caring for Someone with Advanced Parkinson Disease

    MedlinePlus

    ... and General Health Activities at Home Travel and Transportation Rest and Sleep Changes Around the House Plans ... and General Health Activities at Home Travel and Transportation Rest and Sleep More Videos Changes Around the ...

  17. 42 CFR 495.336 - Health information technology planning advance planning document requirements (HIT PAPD).

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 5 2011-10-01 2011-10-01 false Health information technology planning advance... STANDARDS FOR THE ELECTRONIC HEALTH RECORD TECHNOLOGY INCENTIVE PROGRAM Requirements Specific to the Medicaid Program § 495.336 Health information technology planning advance planning document...

  18. 42 CFR 495.336 - Health information technology planning advance planning document requirements (HIT PAPD).

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 5 2012-10-01 2012-10-01 false Health information technology planning advance... STANDARDS FOR THE ELECTRONIC HEALTH RECORD TECHNOLOGY INCENTIVE PROGRAM Requirements Specific to the Medicaid Program § 495.336 Health information technology planning advance planning document...

  19. 42 CFR 495.336 - Health information technology planning advance planning document requirements (HIT PAPD).

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 5 2013-10-01 2013-10-01 false Health information technology planning advance... STANDARDS FOR THE ELECTRONIC HEALTH RECORD TECHNOLOGY INCENTIVE PROGRAM Requirements Specific to the Medicaid Program § 495.336 Health information technology planning advance planning document...

  20. 42 CFR 495.336 - Health information technology planning advance planning document requirements (HIT PAPD).

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 5 2014-10-01 2014-10-01 false Health information technology planning advance... STANDARDS FOR THE ELECTRONIC HEALTH RECORD TECHNOLOGY INCENTIVE PROGRAM Requirements Specific to the Medicaid Program § 495.336 Health information technology planning advance planning document...

  1. 42 CFR 495.336 - Health information technology planning advance planning document requirements (HIT PAPD).

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 5 2010-10-01 2010-10-01 false Health information technology planning advance... STANDARDS FOR THE ELECTRONIC HEALTH RECORD TECHNOLOGY INCENTIVE PROGRAM Requirements Specific to the Medicaid Program § 495.336 Health information technology planning advance planning document...

  2. Advanced practice nursing in performing arts health care.

    PubMed

    Weslin, Anna T; Silva-Smith, Amy

    2010-06-01

    Performing arts medicine is a growing health care profession specializing in the needs of performing artists. As part of the performing arts venue, the dancer, a combination of athlete and artist, presents with unique health care needs requiring a more collaborative and holistic health care program. Currently there are relatively few advanced practice nurses (APNs) who specialize in performing arts health care. APNs, with focus on collaborative and holistic health care, are ideally suited to join other health care professionals in developing and implementing comprehensive health care programs for the performing artist. This article focuses on the dancer as the client in an APN practice that specializes in performing arts health care. PMID:20644180

  3. Medicaid enrollment choice into managed care health plans.

    PubMed

    Morton, L W

    1998-06-01

    Rural Aid to Families with Dependent Children (AFDC) Medicaid recipients were surveyed to identify factors that influenced their enrollment choice between two managed care health plans and the traditional Medicaid free-for-service plan. Bivariate and logistic regression analyses provided evidence that the Medicaid institutional information structure directly influenced recipient decision to enroll in managed care plans. Current smokers were more likely to choose a managed care plan in this sample. There was no evidence that health status, health service use patterns, marital status, or ethnicity was related to the enrollment decision. Of those who chose the traditional Medicaid fee-for-service plan, 41 percent reported that they did not understand what managed care was. PMID:9615563

  4. Advanced practice roles in the managed care environment.

    PubMed

    Madden, M J; Ponte, P R

    1994-01-01

    The role of the advanced practice nurse is based on expert clinical knowledge and skill and is practiced in multiple settings. As healthcare reform emerges, the context in which healthcare is delivered changes. The authors describe a creative approach to packaging and marketing the services of advanced practice nurses to the customers of the managed care system. PMID:8308561

  5. Advanced Education and Technology Business Plan, 2007-10

    ERIC Educational Resources Information Center

    Alberta Enterprise and Advanced Education, 2007

    2007-01-01

    The Government of Alberta Strategic Business Plan addresses significant opportunities and challenges facing Alberta over the next three years and positions Alberta to make the most of its economic, social and natural advantages. It is a plan to strategically manage growth and plan for a sustainable and secure future. Advanced Education and…

  6. Managed Care Quality of Care and Plan Choice in New York SCHIP

    PubMed Central

    Liu, Hangsheng; Phelps, Charles E; Veazie, Peter J; Dick, Andrew W; Klein, Jonathan D; Shone, Laura P; Noyes, Katia; Szilagyi, Peter G

    2009-01-01

    Objective To examine whether low-income parents of children enrolled in the New York State Children's Health Insurance Program (SCHIP) choose managed care plans with better quality of care. Data Sources 2001 New York SCHIP evaluation data; 2001 New York State Managed Care Plan Performance Report; 2000 New York State Managed Care Enrollment Report. Study Design Each market was defined as a county. A final sample of 2,325 new enrollees was analyzed after excluding those in markets with only one SCHIP plan. Plan quality was measured using seven Consumer Assessment of Health Plans Survey (CAHPS) and three Health Plan Employer Data and Information Set (HEDIS) scores. A conditional logit model was applied with plan and individual/family characteristics as covariates. Principle Findings There were 30 plans in the 45 defined markets. The choice probability increased 2.5 percentage points for each unit increase in the average CAHPS score, and the association was significantly larger in children with special health care needs. However, HEDIS did not show any statistically significant association with plan choice. Conclusions Low-income parents do choose managed care plans with higher CAHPS scores for their newly enrolled children, suggesting that overall quality could improve over time because of the dynamics of enrollment. PMID:19208091

  7. Advanced Education Business Plan 2005-2008

    ERIC Educational Resources Information Center

    Alberta Advanced Education, 2005

    2005-01-01

    In collaboration with learning providers, the advanced education system, industry, communities, government agencies and non-governmental organizations, Advanced Education strives to create accessible, affordable and quality learning opportunities that are responsive to the ongoing learning needs of Albertans. The Ministry's 2005-08 Business Plan…

  8. Do Personality Traits Moderate the Impact of Care Receipt on End-of-Life Care Planning?

    ERIC Educational Resources Information Center

    Ha, Jung-Hwa; Pai, Manacy

    2012-01-01

    Purpose of the Study: This study examines (a) the association between being a care recipient and end-of-life care planning (EOLCP) and (b) the extent to which personality traits moderate the relationship between care receipt and EOLCP. Design and Methods: Data are drawn from the Wisconsin Longitudinal Study, a survey of Wisconsin high school…

  9. Quality of care compliance plans under PPS.

    PubMed

    Dombi, W A

    2001-03-01

    With the onset of Medicare home health Prospective Payment System (PPS), home care agencies must retool their internal compliance efforts to address the new risk areas. PPS presents a reversal of the incentives that existed under previous Medicare reimbursement principles, significantly reducing the risk of non-compliance and fraud in the financing of services while dramatically increasing non-compliance risks in areas related to quality of care and access to services. PMID:11255744

  10. Identifying the Factors That Facilitate or Hinder Advance Planning by Persons With Dementia

    PubMed Central

    Hirschman, Karen B.; Kapo, Jennifer M.; Karlawish, Jason H. T.

    2009-01-01

    We performed semistructured interviews with 30 family members of patients with advanced dementia to identify the factors that facilitate or hinder advance planning by persons with dementia. All interviews were analyzed using qualitative data analysis techniques. The majority (77%) of family members reported that their relative had some form of written advance directive, and at least half reported previous discussions about health care preferences (57%), living situation or placement issues (50%), and finances or estate planning (60%) with the patient. Family members reported some themes that prompted planning and others that were barriers to planning. Events that most often triggered planning were medical, living situation, or financial issues associated with a friend or family member of the patient (57%). Barriers to planning included both passive and active avoidance. The most common form of passive avoidance was not realizing the importance of planning until it was too late to have the discussion (63%). The most common form of active avoidance was avoiding the discussion (53%). These data suggest potentially remediable strategies to address barriers to advance planning discussions. PMID:18580595

  11. Health Care Procedure Considerations and Individualized Health Care Plans

    ERIC Educational Resources Information Center

    Heller, Kathryn Wolff; Avant, Mary Jane Thompson

    2011-01-01

    Teachers need to maintain a safe, healthy environment for all their students in order to promote learning. However, there are additional considerations when students require health care procedures, such as tube feeding or clean intermittent catheterization. Teachers must effectively monitor their students and understand their roles and…

  12. 42 CFR 494.90 - Condition: Patient plan of care.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 5 2013-10-01 2013-10-01 false Condition: Patient plan of care. 494.90 Section 494.90 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) STANDARDS AND CERTIFICATION CONDITIONS FOR COVERAGE FOR END-STAGE RENAL DISEASE FACILITIES Patient Care § 494.90 Condition: Patient...

  13. [Individualised care plan during extracorporeal membrane oxygenation. A clinical case].

    PubMed

    Call Mañosa, S; Pujol Garcia, A; Chacón Jordan, E; Martí Hereu, L; Pérez Tejero, G; Gómez Simón, V; Estruga Asbert, A; Gallardo Herrera, L; Vaquer Araujo, S; de Haro López, C

    2016-01-01

    An individualised care plan is described for a woman diagnosed with pneumonia, intubated, and on invasive mechanical ventilation, who was admitted to the Intensive Care Unit for extracorporeal membrane oxygenation (ECMO). A nursing care plan was designed based on Marjory Gordon functional patterns. The most important nursing diagnoses were prioritised, using a model of clinical reasoning model (Analysis of the current status) and NANDA taxonomy. A description is presented on, death anxiety, impaired gas exchange, decreased cardiac output, dysfunctional gastrointestinal motility, risk for disuse syndrome, infection risk, and bleeding risk. The principal objectives were: to reduce the fear of the family, achieve optimal respiratory and cardiovascular status, to maintain gastrointestinal function, to avoid immobility complications, and to reduce the risk of infection and bleeding. As regards activities performed: we gave family support; correct management of the mechanical ventilation airway, cardio-respiratory monitoring, skin and nutritional status; control of possible infections and bleeding (management of therapies, care of catheters…). A Likert's scale was used to evaluate the results, accomplishing all key performance indicators which were propose at the beginning. Individualised care plans with NNN taxonomy using the veno-venous ECMO have not been described. Other ECMO care plans have not used the same analysis model. This case can help nurses to take care of patients subjected to veno-venous ECMO treatment, although more cases are needed to standardise nursing care using NANDA taxonomy. PMID:27137415

  14. 42 CFR 456.181 - Reports of evaluations and plans of care.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: Mental Hospitals Plan of Care § 456.181 Reports of evaluations and plans of care. A written report of each evaluation... evaluation or plan. Utilization Review (UR) Plan: General Requirements...

  15. 42 CFR 456.181 - Reports of evaluations and plans of care.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: Mental Hospitals Plan of Care § 456.181 Reports of evaluations and plans of care. A written report of each evaluation... evaluation or plan. Utilization Review (UR) Plan: General Requirements...

  16. 42 CFR 456.181 - Reports of evaluations and plans of care.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: Mental Hospitals Plan of Care § 456.181 Reports of evaluations and plans of care. A written report of each evaluation... evaluation or plan. Utilization Review (UR) Plan: General Requirements...

  17. 42 CFR 456.181 - Reports of evaluations and plans of care.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: Mental Hospitals Plan of Care § 456.181 Reports of evaluations and plans of care. A written report of each evaluation... evaluation or plan. Utilization Review (UR) Plan: General Requirements...

  18. 42 CFR 456.181 - Reports of evaluations and plans of care.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... SERVICES (CONTINUED) MEDICAL ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: Mental Hospitals Plan of Care § 456.181 Reports of evaluations and plans of care. A written report of each evaluation... evaluation or plan. Utilization Review (UR) Plan: General Requirements...

  19. Voyager: Perils of advanced planning, 1960 - 1967

    NASA Technical Reports Server (NTRS)

    1984-01-01

    Contract proposals; phased project planning; budgetary problems; Saturn 1 B-Centaur versus Saturn V; mission guidelines and management assignments; and the origins of the Voyager project are discussed.

  20. 42 CFR 456.80 - Individual written plan of care.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 4 2010-10-01 2010-10-01 false Individual written plan of care. 456.80 Section 456.80 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES... and rehabilitative services; (iv) Activities; (v) Social services; (vi) Diet; (4) Plans for...

  1. A Planning and Budget Management System for Day Care.

    ERIC Educational Resources Information Center

    Byers, Bruce B.

    Federal guidelines and pressures for accountability make it essential that more and better planning management information be made available concerning the delivery of day care services. With the existence of a fully developed and operational system, planning and management of resource allocations can be made that can lead to an improved quality…

  2. Planning for Students with Complex Health Care Needs.

    ERIC Educational Resources Information Center

    Lowman, Dianne Koontz

    1997-01-01

    This article discusses the efforts of Virginia school divisions as they prepared for and received students with complex health care needs. Findings from four studies that interviewed early childhood special education teachers and occupational therapies are described. The need for team planning and the development of a Health Services Plan is…

  3. Planning the Menu in the Child Care Center.

    ERIC Educational Resources Information Center

    Bomba, Anne K.; And Others

    1996-01-01

    Preschools provide a large proportion of children's daily food intake. This article guides child care center staff in understanding child nutrition guidelines and translating good nutrition into meal planning. It contains resources for menu planning, cooking, and food safety and includes specific recipes, a weekly meal planner, and contacts for…

  4. 24 CFR 578.39 - Continuum of Care planning activities.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... 24 Housing and Urban Development 3 2013-04-01 2013-04-01 false Continuum of Care planning activities. 578.39 Section 578.39 Housing and Urban Development Regulations Relating to Housing and Urban Development (Continued) OFFICE OF ASSISTANT SECRETARY FOR COMMUNITY PLANNING AND DEVELOPMENT, DEPARTMENT...

  5. 24 CFR 578.39 - Continuum of Care planning activities.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... 24 Housing and Urban Development 3 2014-04-01 2013-04-01 true Continuum of Care planning activities. 578.39 Section 578.39 Housing and Urban Development Regulations Relating to Housing and Urban Development (Continued) OFFICE OF ASSISTANT SECRETARY FOR COMMUNITY PLANNING AND DEVELOPMENT, DEPARTMENT...

  6. End-of-life care in advanced dementia.

    PubMed

    Heron, Christopher R; Simmons, B Brent

    2014-10-01

    In the next 30 years, the average age of the population will continue to increase, as will the prevalence of dementia. The management of advanced dementia requires the careful orchestration of communication, prognostication, patient care, and caregiver education. Understanding the specific tools available to establish prognosis and guide medical management in these complicated medical patients greatly improves patient and caregiver satisfaction at the end of the patient's life. In caring for patients with advanced-stage dementia, providers should be knowledgeable regarding the terminal nature of the condition and its common comorbid diseases, and should be prepared to educate the patients' caregivers, building a structure of support for the patient's benefit and navigating the complexities of end-of-life care. PMID:25414940

  7. Plan for an Advanced Turbine Systems Program

    SciTech Connect

    Bajura, R.A.; Webb, H.A.; Parks, W.P.

    1993-03-01

    A draft version of this paper was presented at the Clemson Clean, affordable, and reliable natural gas utilization technologies will play a growing role in meeting future power generation needs in the United States. The US Department of Energy`s (DOE) National Energy Strategy projected that total demand for natural gas will rise from 18.5 trillion cubic feet (tcf) in 1990 to 24.2 tcf by the year 2000. Much of this increase is attributed to the increased use of natural gas as a fuel for electric power generation. Candidate technologies for gas fired power generation include gas turbine and fuel cell systems. The first workshop on research needs for advanced gas turbine systems for power generation was held on April 8-10, 1991 in Greenville, South Carolina. The goals of the Clemson-I Workshop were to identify research needs which would accelerate the development of advanced gas turbines and to consider new approaches to implement this research. The Clemson-I Workshop focused on advanced gas turbine systems which would have a lower cost of electricity or better environmental performance than systems currently under development. The workshop was cosponsored by the DOE`s Morgantown Energy Technology Center (METC), Clemson University, and the South Carolina Energy Research and Development Center. The proceedings from the workshop have been published. The 75 participants in the Clemson-I Workshop represented a broad spectrum of the gas turbine Research & Development (R&D) community as well as potential users of advanced gas turbines. Gas turbine manufacturers, the electric utility industry, the university community, as well as government and private sector R&D sponsors were represented. Participants in the Clemson-I Workshop concluded that it is technically feasible to develop advanced turbine systems and that Government participation would accelerate the developmental effort. Advanced turbine systems could be operated on natural gas or adapted to coal or biomass firing.

  8. Plan for an Advanced Turbine Systems Program

    SciTech Connect

    Bajura, R.A.; Webb, H.A. ); Parks, W.P. )

    1993-01-01

    A draft version of this paper was presented at the Clemson Clean, affordable, and reliable natural gas utilization technologies will play a growing role in meeting future power generation needs in the United States. The US Department of Energy's (DOE) National Energy Strategy projected that total demand for natural gas will rise from 18.5 trillion cubic feet (tcf) in 1990 to 24.2 tcf by the year 2000. Much of this increase is attributed to the increased use of natural gas as a fuel for electric power generation. Candidate technologies for gas fired power generation include gas turbine and fuel cell systems. The first workshop on research needs for advanced gas turbine systems for power generation was held on April 8-10, 1991 in Greenville, South Carolina. The goals of the Clemson-I Workshop were to identify research needs which would accelerate the development of advanced gas turbines and to consider new approaches to implement this research. The Clemson-I Workshop focused on advanced gas turbine systems which would have a lower cost of electricity or better environmental performance than systems currently under development. The workshop was cosponsored by the DOE's Morgantown Energy Technology Center (METC), Clemson University, and the South Carolina Energy Research and Development Center. The proceedings from the workshop have been published. The 75 participants in the Clemson-I Workshop represented a broad spectrum of the gas turbine Research Development (R D) community as well as potential users of advanced gas turbines. Gas turbine manufacturers, the electric utility industry, the university community, as well as government and private sector R D sponsors were represented. Participants in the Clemson-I Workshop concluded that it is technically feasible to develop advanced turbine systems and that Government participation would accelerate the developmental effort. Advanced turbine systems could be operated on natural gas or adapted to coal or biomass firing.

  9. Later life care planning conversations for older adults and families.

    PubMed

    Stolee, Paul; Zaza, Christine; Sharratt, Michael T

    2014-09-01

    While most older adults have thought about their future care needs, few have discussed their preferences with family members. We interviewed older persons (24), adult children (24), health professionals (23), and representatives of stakeholder associations (3) to understand their views and experiences on later life care (LLC) planning conversations, in terms of (a) their respective roles, and (b) barriers and facilitators that should be taken into account when having these conversations. Roles described included that of information user (older persons), information seeker (family members), and information provider (health care providers). The study identified practical and emotional considerations relevant to LLC planning conversations. This study found strong support for planning for LLC before the need arises, as well as important potential benefits for older adults, family members, and health professionals. There is interest in, and need for, resources to guide families in LLC planning. PMID:24652903

  10. Neonatal ethical issues: viability, advance directives, family centered care.

    PubMed

    Sudia-Robinson, Tanya

    2011-01-01

    Ethical issues in perinatal and NICU settings can arise from a variety of situations. This article focuses on issues surrounding viability and the incorporation of advance directives and family-centered care. Prenatal education about infant viability, probable scenarios, and parental involvement in decision-making are addressed. Considerations for advance directives for complex births and critical decisions at the time of birth are also discussed. Implications for nurses and suggested dialogue strategies are provided. PMID:21407121

  11. Revised Faculty Compensation, Evaluation, and Advancement Plan. March, 1998.

    ERIC Educational Resources Information Center

    May, Joe

    This report provides the revised faculty compensation, evaluation, and advancement plan for Pueblo Community College (PCC) in Colorado. Section 1 contains the PCC three-level salary plan and discusses guidelines for initial appointment and level placement of faculty, initial salary computations, and minimum initial employment requirements. Section…

  12. Implementation of Advanced Health Care Technology into Existing Competency-Based Health Care Program. Final Report.

    ERIC Educational Resources Information Center

    Klemovage, Shirley

    A project was undertaken to develop new curriculum materials that could be incorporated into an existing health assistant program to cover recent advances in health care technology. Area physicians' offices were toured and meetings were held with administrators of local hospitals in order to discover what kinds of advances in health care…

  13. [Part I. End-stage chronic organ failures: a position paper on shared care planning. The Integrated Care Pathway].

    PubMed

    Gristina, Giuseppe R; Orsi, Luciano; Carlucci, Annalisa; Causarano, Ignazio R; Formica, Marco; Romanò, Massimo

    2014-01-01

    In Italy the birth rate decrease together with the continuous improvement of living conditions on one hand, and the health care progress on the other hand, led in recent years to an increasing number of patients with chronic mono- or multi-organ failures and in an extension of their life expectancy. However, the natural history of chronic failures has not changed and the inescapable disease's worsening at the end makes more rare remissions, increasing hospital admissions rate and length of stay. Thus, when the "end-stage" get close clinicians have to engage the patient and his relatives in an advance care planning aimed to share a decision making process regarding all future treatments and related ethical choices such as patient's best interests, rights, values, and priorities. A right approach to the chronic organ failures end-stage patients consists therefore of a careful balance between the new powers of intervention provided by the biotechnology and pharmacology (intensive care), both with the quality of remaining life supplied by physicians to these patients (proportionality and beneficence) and the effective resources rationing and allocation (distributive justice). However, uncertainty still marks the criteria used by doctors to assess prognosis of these patients in order to make decisions concerning intensive or palliative care. The integrated care pathway suggested in this position paper shared by nine Italian medical societies, has to be intended as a guide focused to identify end-stage patients and choosing for them the best care option between intensive treatments and palliative care. PMID:24553592

  14. Implementing nurse sensitive outcomes into care planning at a long-term care facility.

    PubMed

    Cox, R A

    1998-06-01

    This article describes one long-term care facility's efforts to implement standardized language in the care planning process. Federal regulations for long-term care mandate the use of a uniform comprehensive assessment tool. Eighteen Resident Assessment Protocols (RAPs) are identified for data collection. Computer databases were revised for care planning. Appropriate North American Nursing Diagnosis Association (NANDA) diagnoses were linked to each RAP. Nursing-Sensitive Outcomes (NOCs) were linked to each NANDA as goals. Nursing Interventions Classifications (NICs) were linked to NANDA diagnosis and NOC outcomes as approaches. The databases are illustrated, and frequently used NANDAs and NOCs are identified. PMID:9610013

  15. Health Care Consumerism: Lessons My 401(k) Plan Taught Me.

    PubMed

    Steinberg, Allen T

    2015-01-01

    Changes to the U.S. health care system are here. As we think about how individuals will pay for health care--while actively employed and while retired--our experiences with 401(k) plans provide some valuable lessons. In order to support employees in this new health care world--a challenge arguably more daunting than the 401(k) challenge we faced 20 years ago--some very different types of support are needed. Employers should consider providing their employees with the resources to manage health care changes. PMID:26666089

  16. Advanced Technology Applications for Combat Casualty Care

    NASA Technical Reports Server (NTRS)

    Watkins, Sharmila; Baumann, David; Wu, Jimmy

    2010-01-01

    Exploration Medical Capability (ExMC) is an element of NASA s Human Research Program (HRP). ExMC s goal is to address the risk of the "Inability to Adequately Recognize or Treat an Ill or Injured Crewmember." This poster highlights the approach ExMC has taken to address this goal and our current areas of interest. The Space Medicine Exploration Medical Condition List (SMEMCL) was created to identify medical conditions of concern during exploration missions. The list was derived from space flight medical incidents, the shuttle medical checklist, the International Space Station medical checklist, and expert opinion. The conditions on the list were prioritized according to mission type by a panel comprised of flight surgeons, physician astronauts, engineers, and scientists. From the prioritized list, the ExMC element determined the capabilities needed to address the medical conditions of concern. Where such capabilities were not currently available, a gap was identified. The element s research plan outlines these gaps and the tasks identified to achieve the desired capabilities for exploration missions.

  17. Recent advances in topical wound care

    PubMed Central

    Sarabahi, Sujata

    2012-01-01

    There are a wide variety of dressing techniques and materials available for management of both acute wounds and chronic non-healing wounds. The primary objective in both the cases is to achieve a healed closed wound. However, in a chronic wound the dressing may be required for preparing the wound bed for further operative procedures such as skin grafting. An ideal dressing material should not only accelerate wound healing but also reduce loss of protein, electrolytes and fluid from the wound, and help to minimize pain and infection. The present dictum is to promote the concept of moist wound healing. This is in sharp contrast to the earlier practice of exposure method of wound management wherein the wound was allowed to dry. It can be quite a challenge for any physician to choose an appropriate dressing material when faced with a wound. Since wound care is undergoing a constant change and new products are being introduced into the market frequently, one needs to keep abreast of their effect on wound healing. This article emphasizes on the importance of assessment of the wound bed, the amount of drainage, depth of damage, presence of infection and location of wound. These characteristics will help any clinician decide on which product to use and where,in order to get optimal wound healing. However, there are no ‘magical dressings’. Dressings are one important aspect that promotes wound healing apart from treating the underlying cause and other supportive measures like nutrition and systemic antibiotics need to be given equal attention. PMID:23162238

  18. Center for Advanced Energy Studies Program Plan

    SciTech Connect

    Kevin Kostelnik

    2005-09-01

    The world is facing critical energy-related challenges regarding world and national energy demands, advanced science and energy technology delivery, nuclear engineering educational shortfalls, and adequately trained technical staff. Resolution of these issues is important for the United States to ensure a secure and affordable energy supply, which is essential for maintaining U.S. national security, continued economic prosperity, and future sustainable development. One way that the U.S. Department of Energy (DOE) is addressing these challenges is by tasking the Battelle Energy Alliance, LLC (BEA) with developing the Center for Advanced Energy Studies (CAES) at the Idaho National Laboratory (INL). By 2015, CAES will be a self-sustaining, world-class, academic and research institution where the INL; DOE; Idaho, regional, and other national universities; and the international community will cooperate to conduct critical energy-related research, classroom instruction, technical training, policy conceptualization, public dialogue, and other events.

  19. Protein Innovations Advance Drug Treatments, Skin Care

    NASA Technical Reports Server (NTRS)

    2012-01-01

    Dan Carter carefully layered the sheets of tracing paper on the light box. On each sheet were renderings of the atomic components of an essential human protein, one whose structure had long been a mystery. With each layer Carter laid down, a never-before-seen image became clearer. Carter joined NASA s Marshall Space Flight Center in 1985 and began exploring processes of protein crystal growth in space. By bouncing intense X-rays off the crystals, researchers can determine the electron densities around the thousands of atoms forming the protein molecules, unveiling their atomic structures. Cultivating crystals of sufficient quality on Earth was problematic; the microgravity conditions of space were far more accommodating. At the time, only a few hundred protein structures had been mapped, and the methods were time consuming and tedious. Carter hoped his work would help reveal the structure of human serum albumin, a major protein in the human circulatory system responsible for ferrying numerous small molecules in the blood. More was at stake than scientific curiosity. Albumin has a high affinity for most of the world s pharmaceuticals, Carter explains, and its interaction with drugs can change their safety and efficacy. When a medication enters the bloodstream a cancer chemotherapy drug, for example a majority of it can bind with albumin, leaving only a small percentage active for treatment. How a drug interacts with albumin can influence considerations like the necessary effective dosage, playing a significant role in the design and application of therapeutic measures. In spite of numerous difficulties, including having no access to microgravity following the 1986 Space Shuttle Challenger disaster, the image Carter had hoped to see was finally clarifying. In 1988, his lab had acquired specialized X-ray and detection equipment a tipping point. Carter and his colleagues began to piece together albumin s portrait, the formation of its electron densities coalescing on

  20. The web site of the center to advance palliative care.

    PubMed

    Gavrin, Jonathan R

    2004-01-01

    The web site of the Center to Advance Palliative Care is reviewed. This is an excellent resource containing resources that address financial tutorials and customizable Excel worksheets, development and marketing tools, particularly the decision checklists, satisfaction tools, the information on tracking and reporting outcomes, bereavement tools and a press kit. PMID:15760811

  1. A patient-centered longitudinal care plan: vision versus reality

    PubMed Central

    Dykes, Patricia C; Samal, Lipika; Donahue, Moreen; Greenberg, Jeffrey O; Hurley, Ann C; Hasan, Omar; O'Malley, Terrance A; Venkatesh, Arjun K; Volk, Lynn A; Bates, David W

    2014-01-01

    Objective As healthcare systems and providers move toward meaningful use of electronic health records, longitudinal care plans (LCPs) may provide a means to improve communication and coordination as patients transition across settings. The objective of this study was to determine the current state of communication of LCPs across settings and levels of care. Materials and methods We conducted surveys and interviews with professionals from emergency departments, acute care hospitals, skilled nursing facilities, and home health agency settings in six regions in the USA. We coded the transcripts according to the Agency for Healthcare Research and Quality (AHRQ) ‘Broad Approaches’ to care coordination to understand the degree to which current practice meets the definition of an LCP. Results Participants (n=22) from all settings reported that LCPs do not exist in their current state. We found LCPs in practice, and none of these were shared or reconciled across settings. Moreover, we found wide variation in the types and formats of care plan information that was communicated as patients transitioned. The most common formats, even when care plan information was communicated within the same healthcare system, were paper and fax. Discussion These findings have implications for data reuse, interoperability, and achieving widespread adoption of LCPs. Conclusions The use of LCPs to support care transitions is suboptimal. Strategies are needed to transform the LCP from vision to reality. PMID:24996874

  2. Advanced Simulation and Computing Business Plan

    SciTech Connect

    Rummel, E.

    2015-07-09

    To maintain a credible nuclear weapons program, the National Nuclear Security Administration’s (NNSA’s) Office of Defense Programs (DP) needs to make certain that the capabilities, tools, and expert staff are in place and are able to deliver validated assessments. This requires a complete and robust simulation environment backed by an experimental program to test ASC Program models. This ASC Business Plan document encapsulates a complex set of elements, each of which is essential to the success of the simulation component of the Nuclear Security Enterprise. The ASC Business Plan addresses the hiring, mentoring, and retaining of programmatic technical staff responsible for building the simulation tools of the nuclear security complex. The ASC Business Plan describes how the ASC Program engages with industry partners—partners upon whom the ASC Program relies on for today’s and tomorrow’s high performance architectures. Each piece in this chain is essential to assure policymakers, who must make decisions based on the results of simulations, that they are receiving all the actionable information they need.

  3. Establishment of Pediatric Cardiac Intensive Care Advanced Practice Provider Services.

    PubMed

    Gilliland, Jill; Donnellan, Amy; Justice, Lindsey; Moake, Lindy; Mauney, Jennifer; Steadman, Page; Drajpuch, David; Tucker, Dawn; Storey, Jean; Roth, Stephen J; Koch, Josh; Checchia, Paul; Cooper, David S; Staveski, Sandra L

    2016-01-01

    The addition of advanced practice providers (APPs; nurse practitioners and physician assistants) to a pediatric cardiac intensive care unit (PCICU) team is a health care innovation that addresses medical provider shortages while allowing PCICUs to deliver high-quality, cost-effective patient care. APPs, through their consistent clinical presence, effective communication, and facilitation of interdisciplinary collaboration, provide a sustainable solution for the highly specialized needs of PCICU patients. In addition, APPs provide leadership, patient and staff education, facilitate implementation of evidence-based practice and quality improvement initiatives, and the performance of clinical research in the PCICU. This article reviews mechanisms for developing, implementing, and sustaining advance practice services in PCICUs. PMID:26714997

  4. 42 CFR 417.801 - Agreements between CMS and health care prepayment plans.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Agreements between CMS and health care prepayment... MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS Health Care Prepayment Plans § 417.801 Agreements between CMS and health care prepayment plans. (a) General requirement. (1) In order to participate and...

  5. 42 CFR 456.142 - UR plan requirements for medical care evaluation studies.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 4 2013-10-01 2013-10-01 false UR plan requirements for medical care evaluation...: Hospitals Ur Plan: Medical Care Evaluation Studies § 456.142 UR plan requirements for medical care... medical care evaluation studies under paragraph (b)(1) of this section. (b) The UR plan must provide...

  6. 42 CFR 456.242 - UR plan requirements for medical care evaluation studies.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 4 2014-10-01 2014-10-01 false UR plan requirements for medical care evaluation...: Mental Hospitals Ur Plan: Medical Care Evaluation Studies § 456.242 UR plan requirements for medical care... medical care evaluation studies under paragraph (b)(1) of this section. (b) The UR plan must provide...

  7. 42 CFR 456.242 - UR plan requirements for medical care evaluation studies.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 4 2012-10-01 2012-10-01 false UR plan requirements for medical care evaluation...: Mental Hospitals Ur Plan: Medical Care Evaluation Studies § 456.242 UR plan requirements for medical care... medical care evaluation studies under paragraph (b)(1) of this section. (b) The UR plan must provide...

  8. 42 CFR 456.242 - UR plan requirements for medical care evaluation studies.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 4 2013-10-01 2013-10-01 false UR plan requirements for medical care evaluation...: Mental Hospitals Ur Plan: Medical Care Evaluation Studies § 456.242 UR plan requirements for medical care... medical care evaluation studies under paragraph (b)(1) of this section. (b) The UR plan must provide...

  9. 42 CFR 456.142 - UR plan requirements for medical care evaluation studies.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 4 2012-10-01 2012-10-01 false UR plan requirements for medical care evaluation...: Hospitals Ur Plan: Medical Care Evaluation Studies § 456.142 UR plan requirements for medical care... medical care evaluation studies under paragraph (b)(1) of this section. (b) The UR plan must provide...

  10. 42 CFR 456.142 - UR plan requirements for medical care evaluation studies.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 4 2014-10-01 2014-10-01 false UR plan requirements for medical care evaluation...: Hospitals Ur Plan: Medical Care Evaluation Studies § 456.142 UR plan requirements for medical care... medical care evaluation studies under paragraph (b)(1) of this section. (b) The UR plan must provide...

  11. Advancing Alzheimer's disease diagnosis, treatment, and care: recommendations from the Ware Invitational Summit.

    PubMed

    Naylor, Mary D; Karlawish, Jason H; Arnold, Steven E; Khachaturian, Ara S; Khachaturian, Zaven S; Lee, Virginia M-Y; Baumgart, Matthew; Banerjee, Sube; Beck, Cornelia; Blennow, Kaj; Brookmeyer, Ron; Brunden, Kurt R; Buckwalter, Kathleen C; Comer, Meryl; Covinsky, Kenneth; Feinberg, Lynn Friss; Frisoni, Giovanni; Green, Colin; Guimaraes, Renato Maia; Gwyther, Lisa P; Hefti, Franz F; Hutton, Michael; Kawas, Claudia; Kent, David M; Kuller, Lewis; Langa, Kenneth M; Mahley, Robert W; Maslow, Katie; Masters, Colin L; Meier, Diane E; Neumann, Peter J; Paul, Steven M; Petersen, Ronald C; Sager, Mark A; Sano, Mary; Schenk, Dale; Soares, Holly; Sperling, Reisa A; Stahl, Sidney M; van Deerlin, Vivianna; Stern, Yaakov; Weir, David; Wolk, David A; Trojanowski, John Q

    2012-09-01

    To address the pending public health crisis due to Alzheimer's disease (AD) and related neurodegenerative disorders, the Marian S. Ware Alzheimer Program at the University of Pennsylvania held a meeting entitled "State of the Science Conference on the Advancement of Alzheimer's Diagnosis, Treatment and Care," on June 21-22, 2012. The meeting comprised four workgroups focusing on Biomarkers; Clinical Care and Health Services Research; Drug Development; and Health Economics, Policy, and Ethics. The workgroups shared, discussed, and compiled an integrated set of priorities, recommendations, and action plans, which are presented in this article. PMID:22959699

  12. Do Personality Traits Moderate the Impact of Care Receipt on End-of-Life Care Planning?

    PubMed Central

    Ha, Jung-Hwa; Pai, Manacy

    2012-01-01

    Purpose of the Study: This study examines (a) the association between being a care recipient and end-of-life care planning (EOLCP) and (b) the extent to which personality traits moderate the relationship between care receipt and EOLCP. Design and Methods: Data are drawn from the Wisconsin Longitudinal Study, a survey of Wisconsin high school graduates from 1957 to 2004. We used data on EOLCP among older adults in the most recent (2003–2004) wave of this survey. Hierarchical logistic regression models are used to estimate the effects of care receipt and the moderating effects of personality. Results: Compared with their peers who are not receiving care, care recipients are more likely to engage in informal discussion on EOLCP. This association between care receipt and informal EOLCP is strengthened when the individual scores high on openness. Implications: Health practitioners should take into account older adults’ care needs and differing personality traits while helping older adults make successful EOLCP. PMID:22459693

  13. Homecare Nurses' Decision-Making During Admission Care Planning.

    PubMed

    Sockolow, Paulina; Bass, Ellen J; Eberle, Carl L; Bowles, Kathryn H

    2016-01-01

    The re-hospitalization rate of homecare patients within 60 days of hospital discharge is 30%. Enhanced care planning based on better information may reduce this rate. However, very little is known about the homecare admission and care planning processes. The research team collected data during observations of three nursing visits to admit homecare patients in Camden NJ, and conducted thematic content analysis on these data. Human factors methods helped to identify nurse decision-making related to selection of the plan of care problems, non-nursing resources, and the nursing visit pattern. They identified how the electronic health record (EHR) assisted the nurse in visit pattern frequency decisions. Major themes that emerged included reduced efficiency due to use of redundant intra-team communication methods to augment EHR documentation, redundant documentation, and workarounds and reorganization of clinical workflow. PMID:27332156

  14. Solving the Puzzle of Child Care: Report of the Cuyahoga County Child Day Care Planning Project.

    ERIC Educational Resources Information Center

    Child Day Care Planning Project, Cleveland, OH.

    This report describes the Child Day Care Planning Project, which was developed by private and public representatives to meet the needs for child care in Cuyahoga County, Ohio. The project consisted of five major components. The first component, the Data Project, documented the needs and resources of the community. The second component, the Quality…

  15. Experiences of the advanced nurse practitioner role in acute care.

    PubMed

    Cowley, Alison; Cooper, Joanne; Goldberg, Sarah

    2016-05-01

    The aim of the service evaluation presented in this article was to explore the multidisciplinary team's (MDT) experiences and perception of the advanced nurse practitioner (ANP) role on an acute health care of the older person ward. A qualitative case study was carried out comprising semi-structured interviews with members of the MDT, exploring their experiences of the ANP role. An overarching theme of 'Is it a nurse? Is it a doctor? No, it's an ANP' emerged from the data, with three subthemes: the missing link; facilitating and leading holistic care; and safe, high quality care. The ANP role is valued by the MDT working with them and provides a unique skill set that has the potential to enhance care of older patients living with frailty. While there are challenges to its introduction, it is a role worth introducing to older people's wards. PMID:27125941

  16. Advanced systems engineering and network planning support

    NASA Technical Reports Server (NTRS)

    Walters, David H.; Barrett, Larry K.; Boyd, Ronald; Bazaj, Suresh; Mitchell, Lionel; Brosi, Fred

    1990-01-01

    The objective of this task was to take a fresh look at the NASA Space Network Control (SNC) element for the Advanced Tracking and Data Relay Satellite System (ATDRSS) such that it can be made more efficient and responsive to the user by introducing new concepts and technologies appropriate for the 1997 timeframe. In particular, it was desired to investigate the technologies and concepts employed in similar systems that may be applicable to the SNC. The recommendations resulting from this study include resource partitioning, on-line access to subsets of the SN schedule, fluid scheduling, increased use of demand access on the MA service, automating Inter-System Control functions using monitor by exception, increase automation for distributed data management and distributed work management, viewing SN operational control in terms of the OSI Management framework, and the introduction of automated interface management.

  17. Changing workforce demographics necessitates succession planning in health care.

    PubMed

    Collins, Sandra K; Collins, Kevin S

    2007-01-01

    Health care organizations continue to be plagued by labor shortage issues. Further complicating the already existing workforce challenges is an aging population poised to retire en masse within the next few years. With fewer cohorts in the age group of 25 to 44 years (Vital Speeches Day. 2004:71:23-27), a more mobile workforce (Grow Your Own Leaders: How to Identify, Develop, and Retain Leadership Talent, 2002), and an overall reduction in the number of individuals seeking employment in the health care field (J Healthc Manag. 2003:48:6-11), the industry could be faced with an unmanageable number of vacant positions throughout the organization. Bracing for the potential impact of these issues is crucial to the ongoing business continuity of health care organization. Many health care organizations have embraced succession planning to combat the potential labor famine. However, the health care industry as a whole seems to lag behind other industries in terms of succession planning efforts (Healthc Financ Manage. 2005;59:64-67). This article seeks to provide health care managers with a framework for improving the systematic preparation of the next generation of managers by analyzing the succession planning process. The proposition of these models is to initiate and simplify the gap reduction between theoretical concepts and future organizational application. PMID:17992105

  18. Convergence of long-term care planning and retirement planning at the work place.

    PubMed

    Silva, Ajith

    2004-01-01

    There is an increasing expectation that the private-sector should provide needed solutions to pressing problems in long-term care. Long-term care insurance has figured prominently in recent discussions. Within the long-term care insurance market, the potential of the employer in making such insurance available to employees has been discussed extensively. This paper traces the increasing convergence of retirement planning and long-term care planning at the work place. The long-term care insurance market has come a long way, and the employer-sponsored segment of the market has recorded the highest rate of growth in recent times. Furthermore, the employer-sponsored market is beginning to diversify. Low take-up rates still remain a problem. Recent rapid growth of the market coupled with the federal government's involvement as an employer offering long-term care insurance is bound to expand the market further. PMID:15148046

  19. Foreword: planning for the future through advance directive instruments.

    PubMed

    Winick, B J

    1998-09-01

    The Foreword traces the development of advance directive instruments and discusses their legal enforceability and many benefits. Despite their advantages, advance directives remain underused and are frequently ignored by service providers. The contributors to this special issue discuss why this is so and offer and debate a variety of remedial proposals. They analyze the various legal, clinical, ethical, and practical issues presented by the use of advance directives for health and mental health care and examine new directions in their application. The Foreword describes the organization of this special issue, summarizes the articles it contains, and comments on their significance. PMID:12803208

  20. Discharge Planning in Acute Care Hospitals in Israel: Services Planned and Levels of Implementation and Adequacy

    ERIC Educational Resources Information Center

    Auslander, Gail K.; Soskolne, Varda; Stanger, Varda; Ben-Shahar, Ilana; Kaplan, Giora

    2008-01-01

    This study aimed to examine the implementation, adequacy, and outcomes of discharge planning. The authors carried out a prospective study of 1,426 adult patients discharged from 11 acute care hospitals in Israel. Social workers provided detailed discharge plans on each patient. Telephone interviews were conducted two weeks post-discharge. Findings…

  1. [Shared Care Plan: convergence between the educational problematizing perspective and the theory of nursing cultural care].

    PubMed

    Martins, Paula Alvarenga de Figueiredo; Alvim, Neide Aparecida Titonelli

    2012-01-01

    This report is a reflection that marks a change of perspective in the care relation between nurse and client, in the implementation context of the educative process. It emerged a Shared Care Plan as an educational-caring proposal, in the convergence among theorists Paulo Freire and Leininger, regarding the dialogical pedagogy and nursing cultural care. With regard to the elements considered essential to the care, learning together allows the unveiling of a peculiar reality of possibilities for integration and transformation of the reality revealed, by choice of the person. Autonomy planned becomes real, so that customers no longer carry fragmented practices, stemming from traditional pedagogy. The stand-alone client reaches, then, the fullness of the action. PMID:22911423

  2. Application of Transformational Leadership Principles in the Development and Integration of Palliative Care Within an Advanced Heart Failure Program.

    PubMed

    George, Susan; Leasure, A Renee

    2016-01-01

    Heart failure (HF) is a major health problem in United States, and it has reached epidemic proportions. Heart failure is associated with significant morbidity, mortality, and cost. Although the prognosis of HF is worse than many forms of cancer, many patients, families, and clinicians are unaware of the dire prognosis. As the disease progress to advanced HF, patients are faced with many challenges, such as poor quality of life due to worsening symptoms and frequent hospitalizations. Heart failure management adds significant financial burden to the health care system. Palliative care can be integrated into HF care to improve quality of life and symptom management and to address physical, spiritual, and psychosocial needs of patients and families. Palliative care can be used concurrently with or independent of curative or life-prolonging HF therapies. Transformational leadership principles were used to guide the development of a plan to enhance integration of palliative care within traditional advanced HF care. PMID:26836596

  3. Advanced Hybrid Particulate Collector Project Management Plan

    SciTech Connect

    Miller, S.J.

    1995-11-01

    As the consumption of energy increases, its impact on ambient air quality has become a significant concern. Recent studies indicate that fine particles from coal combustion cause health problems as well as atmospheric visibility impairment. These problems are further compounded by the concentration of hazardous trace elements such as mercury, cadmium, selenium, and arsenic in fine particles. Therefore, a current need exists to develop superior, but economical, methods to control emissions of fine particles. Since most of the toxic metals present in coal will be in particulate form, a high level of fine- particle collection appears to be the best method of overall air toxics control. However, over 50% of mercury and a portion of selenium emissions are in vapor form and cannot be collected in particulate control devices. Therefore, this project will focus on developing technology not only to provide ultrahigh collection efficiency of particulate air toxic emissions, but also to capture vapor- phase trace metals such as mercury and selenium. Currently, the primary state-of-the-art technologies for particulate control are fabric filters (baghouses) and electrostatic precipitators (ESPs). However, they both have limitations that prevent them from achieving ultrahigh collection of fine particulate matter and vapor-phase trace metals. The objective of this project is to develop a highly reliable advanced hybrid particulate collector (AHPC) that can provide > 99.99 % particulate collection efficiency for all particle sizes between 0.01 and 50 14m, is applicable for use with all U.S. coals, and is cost-0443competitive with existing technologies. Phase I of the project is organized into three tasks: Task I - Project Management, Reporting, and Subcontract Consulting Task 2 - Modeling, Design, and Construction of 200-acfm AHPC Model Task 3 - Experimental Testing and Subcontract Consulting

  4. Marketing health care to employees: the structure of employee health care plan satisfaction.

    PubMed

    Mascarenhas, O A

    1993-01-01

    Providing cost-contained comprehensive quality health care to maintain healthy and productive employees is a challenging problem for all employers. Using a representative panel of metropolitan employees, the author investigates the internal and external structure of employee satisfaction with company-sponsored health care plans. Employee satisfaction is differentiated into four meaningful groups of health care benefits, whereas its external structure is supported by the traditional satisfaction paradigms of expectation-disconfirmation, attribution, and equity. Despite negative disconfirmation, employees register sufficiently high health care satisfaction levels, which suggests some useful strategies that employers may consider implementing. PMID:10129814

  5. Planning for primary health care: the case of the Sierra Leone National Action Plan.

    PubMed

    Decosas, J

    1990-01-01

    The National Action Plan for Primary Health Care, a planning document of the Sierra Leonean Ministry of Health for the restructuring of the country's rural health services, is analyzed in its social, economic, and historical context. It appears to be an attempt of the national government to gain control over the highly devolved health care delivery system, but the state has neither the political will nor the power to achieve this goal. The utility of the document is therefore in doubt, which raises two important questions: Whose interests does this plan serve, and at whose cost? PMID:2307554

  6. 42 CFR 456.380 - Individual written plan of care.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 4 2010-10-01 2010-10-01 false Individual written plan of care. 456.380 Section 456.380 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN...) Activities; (v) Therapies; (vi) Social services; (vii) Diet; and (viii) Special procedures designed to...

  7. 42 CFR 456.180 - Individual written plan of care.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 4 2010-10-01 2010-10-01 false Individual written plan of care. 456.180 Section 456.180 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN...; (vii) Diet; and (viii) Special procedures recommended for the health and safety of the patient;...

  8. 42 CFR 494.90 - Condition: Patient plan of care.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    .... The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The... achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent...

  9. Evidence Based Order Sets as a Nursing Care Planning System

    PubMed Central

    LaCrosse, Lisa M.; Heermann, Judith; Azevedo, Karen; Sorrentino, Catherine; Straub, Dawn; O'Dowd, Gloria

    2002-01-01

    The process for developing the nursing care planning (NCP) function for integration into a clinical information system (CIS) will be described. This NCP system uses evidence based order sets or interventions that are specific to a problem with associated patient focused goals or outcomes. The problem, order set, goal framework will eventually be used by all disciplines in the patient focused record.

  10. 42 CFR 409.43 - Plan of care requirements.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... skilled nursing, physical therapy, speech-language pathology services, or occupational therapy visit in a... 42 Public Health 2 2010-10-01 2010-10-01 false Plan of care requirements. 409.43 Section 409.43 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES...

  11. Planning for Long-Term Care: Concept, Definition, and Measurement

    ERIC Educational Resources Information Center

    Friedemann, Marie-Luise; Newman, Frederick L.; Seff, Laura R.; Dunlop, Burton D.

    2004-01-01

    Purpose: This study explores the development and testing of an instrument to measure long-term-care planning behavior. Design and Methods: Researchers operationalized proposed constructs and response styles as statements in a questionnaire. A telephone survey involved 150 randomly selected residents of Miami-Dade County, Florida who were between…

  12. 42 CFR 494.90 - Condition: Patient plan of care.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    .... The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The... achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent...

  13. Integrating Palliative Care Into the Care of Patients With Advanced Lung Cancer.

    PubMed

    Kapo, Jennifer M; Akgün, Kathleen M

    2015-01-01

    Lung cancer is the leading cause of death due to malignancy. Although lung cancer mortality has been decreasing in recent years, it remains substantially higher than other causes of cancer death. Median survival for patients with locally advanced non-small cell lung cancer, defined as lung cancer involving regional lymph nodes, is estimated to be approximately 10 to 17 months, and median survival for patients with metastatic disease is only 6 to 9 months. In addition, patients with advanced lung cancer often experience debilitating symptoms and poor quality of life. Pain, dyspnea, and fatigue are most frequently reported and affect at least 65% of patients with advanced lung cancer. Given this burden of symptoms and high mortality, patients and their families facing a diagnosis of advanced lung cancer are in need of support. Palliative care, with its focus on addressing the emotional, physical, and spiritual sources of suffering utilizing the expertise of an interdisciplinary team, can provide this comprehensive support. This review describes the role of supportive and palliative care integrated into the treatment of patients with a diagnosis of advanced lung cancer with sections focused on the evaluation and treatment of pain and dyspnea, approaches to challenging communication tasks, and the support of caregivers who care for patients with advanced lung cancer. PMID:26389769

  14. Understanding the Context for Long-Term Care Planning.

    PubMed

    Broyles, Ila H; Sperber, Nina R; Voils, Corrine I; Konetzka, R Tamara; Coe, Norma B; Van Houtven, Courtney Harold

    2016-06-01

    Evolving family structure and economic conditions may affect individuals' ability and willingness to plan for future long-term care (LTC) needs. We applied life course constructs to analyze focus group data from a study of family decision making about LTC insurance. Participants described how past exposure to caregiving motivated them to engage in LTC planning; in contrast, child rearing discouraged LTC planning. Perceived institutional and economic instability drove individuals to regard financial LTC planning as either a wise precaution or another risk. Perceived economic instability also shaped opinions that adult children are ill-equipped to support parents' LTC. Despite concerns about viability of social insurance programs, some participants described strategies to maximize gains from them. Changing norms around aging and family roles also affected expectations of an active older age, innovative LTC options, and limitations to adult children's involvement. Understanding life course context can inform policy efforts to encourage LTC planning. PMID:26553887

  15. [Municipal planning of care services between competition neutrality and demand planning. An example of care structure planning in Rhineland-Palatinate].

    PubMed

    Klie, T; Pfundstein, T

    2010-04-01

    In times of demographic and social change, it is increasingly important to ensure the availability of care services to cover the growing demand. With the implementation of the German long-term insurance act in 1994, the responsibility of states and municipalities was maintained; however, given the long-term care legislation's market orientation and competition neutrality, the classic instruments for demand planning and supervision of infrastructure developments were lost. This leads to new challenges for states and municipalities: their conventional objective-oriented planning lacks professional and juridical legitimization. Calculations of requirements must relate to methodology and professional expertise. In order to exercise their influence on infrastructure development, instruments of demand planning other than subsidization are required. Using the example of Rheinland-Pfalz (Rhineland-Palatinate) and the newly implemented care structure planning, the concept of care monitoring is introduced, and instruments to influence infrastructure development are outlined. PMID:20383626

  16. 42 CFR 484.18 - Condition of participation: Acceptance of patients, plan of care, and medical supervision.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... a doctor of medicine, osteopathy, or podiatric medicine. (a) Standard: Plan of care. The plan of... in developing the plan of care. (b) Standard: Periodic review of plan of care. The total plan of care... physician to any changes that suggest a need to alter the plan of care. (c) Standard: Conformance...

  17. Advances in Pediatric Asthma in 2013: Coordinating Asthma Care

    PubMed Central

    Szefler, Stanley J.

    2014-01-01

    Last year’s Advances in Pediatric Asthma: Moving Toward Asthma Prevention concluded that: “We are well on our way to creating a pathway around wellness in asthma care and also to utilize new tools to predict the risk for asthma and take steps to not only prevent asthma exacerbations but also to prevent the early manifestations of the disease and thus prevent its evolution to severe asthma.” This year’s summary will focus on recent advances in pediatric asthma on pre- and postnatal factors altering the natural history of asthma, assessment of asthma control, and new insights regarding potential therapeutic targets for altering the course of asthma in children as indicated in Journal of Allergy and Clinical Immunology publications in 2013 and early 2014. Recent reports continue to shed light on methods to understand factors that influence the course of asthma, methods to assess and communicate levels of control, and new targets for intervention as well as new immunomodulators. It will now be important to carefully assess risk factors for the development of asthma as well as the risk for asthma exacerbations and to improve the way we communicate this information in the health care system. This will allow parents, primary care physicians, specialists and provider systems to more effectively intervene in altering the course of asthma and to further reduce asthma morbidity and mortality. PMID:24581430

  18. Unit Planning Grids for Music: Grade 9-12 Advanced.

    ERIC Educational Resources Information Center

    Delaware State Dept. of Education, Dover.

    This unit planning grid outlines the expectations of Delaware high school students for advanced music studies. The grid identifies nine standards for music: (1) students will sing, independently and with others, a varied repertoire of music; (2) students will perform on instruments, independently and with others, a varied repertoire of music; (3)…

  19. Advanced Education and Technology Business Plan, 2009-12. Highlights

    ERIC Educational Resources Information Center

    Alberta Advanced Education and Technology, 2009

    2009-01-01

    Advanced Education and Technology provides strategic leadership for the development of the next generation economy in Alberta through the provision of accessible, affordable and quality learning opportunities for all Albertans and support for a dynamic and integrated innovation system. This paper provides the highlights of the business plan of the…

  20. 45 CFR 95.610 - Submission of advance planning documents.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... contained at §§ 1355.54 through 1355.57, § 307.15 and 42 CFR subchapter C, part 433. (c) Advance Planning... considerations including, where appropriate, the use of service-orientated architecture and a transfer of...

  1. 14 CFR 151.125 - Allowable advance planning costs.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 14 Aeronautics and Space 3 2012-01-01 2012-01-01 false Allowable advance planning costs. 151.125 Section 151.125 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION... as preliminary topographic and soil exploration; (2) Site evaluation; (3) Preliminary...

  2. 14 CFR 151.125 - Allowable advance planning costs.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 14 Aeronautics and Space 3 2013-01-01 2013-01-01 false Allowable advance planning costs. 151.125 Section 151.125 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION... as preliminary topographic and soil exploration; (2) Site evaluation; (3) Preliminary...

  3. 14 CFR 151.125 - Allowable advance planning costs.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... 14 Aeronautics and Space 3 2011-01-01 2011-01-01 false Allowable advance planning costs. 151.125 Section 151.125 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION... as preliminary topographic and soil exploration; (2) Site evaluation; (3) Preliminary...

  4. 14 CFR 151.125 - Allowable advance planning costs.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 14 Aeronautics and Space 3 2014-01-01 2014-01-01 false Allowable advance planning costs. 151.125 Section 151.125 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION... as preliminary topographic and soil exploration; (2) Site evaluation; (3) Preliminary...

  5. 14 CFR 151.125 - Allowable advance planning costs.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 14 Aeronautics and Space 3 2010-01-01 2010-01-01 false Allowable advance planning costs. 151.125 Section 151.125 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION... as preliminary topographic and soil exploration; (2) Site evaluation; (3) Preliminary...

  6. Planning parenthood: Health care providers' perspectives on pregnancy intention, readiness, and family planning.

    PubMed

    Stevens, Lindsay M

    2015-08-01

    A major health care goal in the United States is increasing the proportion of pregnancies that are planned. While many studies examine family planning from the perspective of individual women or couples, few investigate the perceptions and practices of health care providers, who are gatekeepers to medicalized fertility control. In this paper, I draw on 24 in-depth interviews with providers to investigate how they interpret and enact the objective to "plan parenthood" and analyze their perspectives in the context of broader discourses about reproduction, family planning, and motherhood. Interviews reveal two central discourses: one defines pregnancy planning as an individual choice, that is as patients setting their own pregnancy intentions; the second incorporates normative expectations about what it means to be ready to have a baby that exclude poor, single, and young women. In the latter discourse, planning is a broader process of achieving middle-class life markers like a long-term relationship, a good job, and financial stability, before having children. Especially illuminating are cases where a patient's pregnancy intention and the normative expectations of "readiness" do not align. With these, I demonstrate that providers may prioritize normative notions of readiness over a patient's own intentions. I argue that these negotiations of intention and readiness reflect broader tensions in family planning and demonstrate that at times the seemingly neutral notion of "planned parenthood" can mask a source of stratification in reproductive health care. PMID:26151389

  7. ‘Reality and desire’ in the care of advanced chronic kidney disease

    PubMed Central

    Marrón, Belén; Craver, Lourdes; Remón, César; Prieto, Mario; Gutiérrez, Josep Mª; Ortiz, Alberto

    2010-01-01

    There is a long distance between the actual worldwide reality in advanced chronic kidney disease care and the desire of how these patients should be managed to decrease cardiovascular and general morbidity and mortality. Implementation of adequate infrastructures may improve clinical outcomes and increase the use of home renal replacement therapies (RRT). Current pitfalls should be addressed to optimise care: inadequate medical training for nephrological referral and RRT selection, late referral to nephrologists, inadequate patient education for choice of RRT modality, lack of multidisciplinary advanced kidney disease clinics and lack of programmed RRT initiation. These deficiencies generate unintended consequences, such as inequality of care and limitations in patient education and selection-choice for RRT technique with limited use of peritoneal dialysis. Multidisciplinary advanced kidney disease clinics may have a direct impact on patient survival, morbidity and quality of life. There is a common need to reduce health care costs and scenarios increasing PD incidence show better efficiency. The following proposals may help to improve the current situation: defining the scope of the problem, disseminating guidelines with specific targets and quality indicators, optimising medical speciality training, providing adequate patient education, specially through the use of general decision making tools that will allow patients to choose the best possible RRT in accordance with their values, preferences and medical advice, increasing planned dialysis starts and involving all stakeholders in the process. PMID:25984045

  8. SERA - An Advanced Treatment Planning System for Neutron Therapy

    SciTech Connect

    C. A. Wemple; C. L. Albright; D. W. Nigg; D. W. Wessol; F. J. Wheeler; G. J. Harkin; M. B. Rossmeirer; M. T. Cohen; M. W. Frandsen

    1999-06-01

    The technology for computational dosimetry and treatment planning for Boron Neutron Capture Therapy (BNCT) has advanced significantly over the past few years. Because of the more complex nature of the problem, the computational methods that work well for treatment planning in photon radiotherapy are not applicable to BNCT. The necessary methods have, however, been developed and have been successfully employed both for research applications as well as human trials. Computational geometry for BNCT applications can be constructed directly from tomographic medical imagery and computed radiation dose distributions can be readily displayed in formats that are familiar to the radiotherapy community. The SERA system represents a significant advance in several areas for treatment planning. However further improvements in speed and results presentation are still needed for routine clinical applications, particularly when optimizations of dose pattern is required.

  9. End-of-Life Care for Undocumented Immigrants With Advanced Cancer: Documenting the Undocumented.

    PubMed

    Jaramillo, Sylvia; Hui, David

    2016-04-01

    There are approximately 11.1 million undocumented immigrants in the United States, with a majority being Latino. Cancer is now the leading cause of death in Latinos. There is little research guiding providers on how to deliver optimal end-of-life care in this population. We describe a case of an undocumented Latino patient with advanced cancer, and provide a review of the literature on end-of-life care in undocumented immigrants. Our patient encountered many challenges as he navigated through the healthcare system in the last months of life. These included delayed diagnosis, limited social support, financial issues, fear of deportation, and language and cultural barriers, which resulted in significant physical and psychological distress. Within the undocumented patient population, there is often a lack of advance care planning, prognostic understanding, mistrust, religious practices, and cultural beliefs that may affect decision making. Given the growing number of undocumented immigrants in the United States, it is important for clinicians and policy makers to have a better understanding of the issues surrounding end-of-life care for undocumented immigrants, and work together to improve the quality of life and quality of end-of-life care for these disadvantaged individuals. PMID:26681362

  10. AGU governance's decision-making process advances strategic plan

    NASA Astrophysics Data System (ADS)

    McPhaden, Michael; Finn, Carol; McEntee, Chris

    2012-10-01

    A lot has happened in a little more than 2 years, and we want give AGU members an update on how things are working under AGU's strategic plan and governance model. AGU is an organization committed to its strategic plan (http://www.agu.org/about/strategic_plan.shtml), and if you have not read the plan lately, we encourage you to do so. AGU's vision is to be an organization that "galvanizes a community of Earth and space scientists that collaboratively advances and communicates science and its power to ensure a sustainable future." We are excited about the progress we have made under this plan and the future course we have set for the Union. Everything the Board of Directors, Council, and committees put on their agendas is intended to advance AGU's strategic goals and objectives. Together with headquarters staff, these bodies are working in an integrated, effective manner to carry out this plan. The best way to demonstrate the progress made and each group's role is to walk through a recent example: the creation of a new Union-level award (see Figure 1).

  11. Design and analysis of advanced flight planning concepts

    NASA Technical Reports Server (NTRS)

    Sorensen, John A.

    1987-01-01

    The objectives of this continuing effort are to develop and evaluate new algorithms and advanced concepts for flight management and flight planning. This includes the minimization of fuel or direct operating costs, the integration of the airborne flight management and ground-based flight planning processes, and the enhancement of future traffic management systems design. Flight management (FMS) concepts are for on-board profile computation and steering of transport aircraft in the vertical plane between a city pair and along a given horizontal path. Flight planning (FPS) concepts are for the pre-flight ground based computation of the three-dimensional reference trajectory that connects the city pair and specifies the horizontal path, fuel load, and weather profiles for initializing the FMS. As part of these objectives, a new computer program called EFPLAN has been developed and utilized to study advanced flight planning concepts. EFPLAN represents an experimental version of an FPS. It has been developed to generate reference flight plans compatible as input to an FMS and to provide various options for flight planning research. This report describes EFPLAN and the associated research conducted in its development.

  12. Continuity of Care: Sharing the Medication Treatment Plan.

    PubMed

    Spahni, Stéphane

    2016-01-01

    The shared medication treatment plan is a key element for supporting the continuity of care. Indeed a substantial amount of emergency hospitalization is linked to medication - 5% to 10% according to some studies. Methods and tools helping all healthcare providers to have a better knowledge of the complete medication plan are therefore required in order to limit side effects linked to an insufficient knowledge of what the patient is taking. The workshop intends to present various initiatives and open the discussion about the limits, pros and cons of various initiatives. PMID:27332315

  13. Urinary Stone Disease: Advancing Knowledge, Patient Care, and Population Health.

    PubMed

    Scales, Charles D; Tasian, Gregory E; Schwaderer, Andrew L; Goldfarb, David S; Star, Robert A; Kirkali, Ziya

    2016-07-01

    Expanding epidemiologic and physiologic data suggest that urinary stone disease is best conceptualized as a chronic metabolic condition punctuated by symptomatic, preventable stone events. These acute events herald substantial future chronic morbidity, including decreased bone mineral density, cardiovascular disease, and CKD. Urinary stone disease imposes a large and growing public health burden. In the United States, 1 in 11 individuals will experience a urinary stone in their lifetime. Given this high incidence and prevalence, urinary stone disease is one of the most expensive urologic conditions, with health care charges exceeding $10 billion annually. Patient care focuses on management of symptomatic stones rather than prevention; after three decades of innovation, procedural interventions are almost exclusively minimally invasive or noninvasive, and mortality is rare. Despite these advances, the prevalence of stone disease has nearly doubled over the past 15 years, likely secondary to dietary and health trends. The NIDDK recently convened a symposium to assess knowledge and treatment gaps to inform future urinary stone disease research. Reducing the public health burden of urinary stone disease will require key advances in understanding environmental, genetic, and other individual disease determinants; improving secondary prevention; and optimal population health strategies in an increasingly cost-conscious care environment. PMID:26964844

  14. Islam and family planning: changing perceptions of health care providers and medical faculty in Pakistan

    PubMed Central

    Mir, Ali Mohammad; Shaikh, Gul Rashida

    2013-01-01

    ABSTRACT A USAID-sponsored family planning project called “FALAH” (Family Advancement for Life and Health), implemented in 20 districts of Pakistan, aimed to lower unmet need for family planning by improving access to services. To enhance the quality of care offered by the public health system, the FALAH project trained 10,534 facility-based health care providers, managers, and medical college faculty members to offer client-centered family planning services, which included a module to explain the Islamic viewpoint on family planning developed through an iterative process involving religious scholars and public health experts. At the end of the FALAH project, we conducted a situation analysis of health facilities including interviews with providers to measure family planning knowledge of trained and untrained providers; interviewed faculty to obtain their feedback about the training module; and measured changes in women's contraceptive use through baseline and endline surveys. Trained providers had a better understanding of family planning concepts than untrained providers. In addition, discussions with trained providers indicated that the training module on Islam and family planning helped them to become advocates for family planning. Faculty indicated that the module enhanced their confidence about the topic of family planning and Islam, making it easier to introduce and discuss the issue with their students. Over the 3.5-year project period, which included several components in addition to the training activity, we found an overall increase of 9 percentage points in contraceptive prevalence in the project implementation districts—from 29% to 38%. The Islam and family planning module has now been included in the teaching program of major public-sector medical universities and the Regional Training Institutes of the Population Welfare Department. Other countries with sizeable Muslim populations and low contraceptive prevalence could benefit from this module

  15. Contribution of FDOPA PET to radiotherapy planning for advanced glioma

    NASA Astrophysics Data System (ADS)

    Dowson, Nicholas; Fay, Michael; Thomas, Paul; Jeffree, Rosalind; McDowall, Robert; Winter, Craig; Coulthard, Alan; Smith, Jye; Gal, Yaniv; Bourgeat, Pierrick; Salvado, Olivier; Crozier, Stuart; Rose, Stephen

    2014-03-01

    Despite radical treatment with surgery, radiotherapy and chemotherapy, advanced gliomas recur within months. Geographic misses in radiotherapy planning may play a role in this seemingly ineluctable recurrence. Planning is typically performed on post-contrast MRIs, which are known to underreport tumour volume relative to FDOPA PET scans. FDOPA PET fused with contrast enhanced MRI has demonstrated greater sensitivity and specificity than MRI alone. One sign of potential misses would be differences between gross target volumes (GTVs) defined using MRI alone and when fused with PET. This work examined whether such a discrepancy may occur. Materials and Methods: For six patients, a 75 minute PET scan using 3,4-dihydroxy-6-18F-fluoro-L-phynel-alanine (18F-FDOPA) was taken within 2 days of gadolinium enhanced MRI scans. In addition to standard radiotherapy planning by an experienced radiotherapy oncologist, a second gross target volume (GTV) was defined by an experienced nuclear medicine specialist for fused PET and MRI, while blinded to the radiotherapy plans. The volumes from standard radiotherapy planning were compared to the PET defined GTV. Results: The comparison indicated radiotherapy planning would change in several cases if FDOPA PET data was available. PET-defined contours were external to 95% prescribed dose for several patients. However, due to the radiotherapy margins, the discrepancies were relatively small in size and all received a dose of 50 Gray or more. Conclusions: Given the limited size of the discrepancies it is uncertain that geographic misses played a major role in patient outcome. Even so, the existence of discrepancies indicates that FDOPA PET could assist in better defining margins when planning radiotherapy for advanced glioma, which could be important for highly conformal radiotherapy plans.

  16. LGBT people's knowledge of and preparedness to discuss end-of-life care planning options.

    PubMed

    Hughes, Mark; Cartwright, Colleen

    2014-09-01

    Despite the devastating impact of HIV/AIDS, end-of-life care planning among lesbian, gay, bisexual and transgender (LGBT) communities is relatively under-researched, especially in Australia. This paper reports findings of a survey of 305 LGBT people living in New South Wales, which examined their knowledge of and attitudes towards end-of-life care. The focus of this paper is their preparedness to discuss with healthcare providers any end-of-life care plans. The results highlight that while the majority of respondents were aware of three of the four key end-of-life care planning options available in New South Wales--enduring powers of attorney, enduring guardians and person responsible (only a minority had heard of advance healthcare directives)--a much smaller number of people had actually taken up these options. Only a minority of respondents were able to identify correctly who had the legal right to make treatment decisions for a person who is unconscious following a car accident. A small proportion of people had discussed end-of-life care options with general practitioners or another main healthcare provider, and only in very few cases were these issues raised by the practitioners themselves. Those most likely to not feel comfortable discussing these issues with practitioners included younger people, those not fully open about their sexuality to family members, and transgender people and others who do not define their gender as male or female. The paper highlights the importance of education strategies to raise awareness of the end-of-life care planning options among LGBT people, as well as strategies for increasing health providers' preparedness to discuss these issues with LGBT patients. PMID:24935483

  17. Meaningful Use of Data in Care Coordination by the Advanced Practice Registered Nurse: The TeleFamilies Project

    PubMed Central

    Looman, Wendy S.; Erickson, Mary M.; Garwick, Ann W.; Cady, Rhonda G.; Kelly, Anne; Pettey, Carrie; Finkelstein, Stanley M.

    2012-01-01

    Meaningful use of electronic health records to coordinate care requires skillful synthesis and integration of subjective and objective data by practitioners to provide context for information. This is particularly relevant in the coordination of care for children with complex special health care needs. The purpose of this paper is to present a conceptual framework and example of meaningful use within an innovative telenursing intervention to coordinate care for children with complex special health care needs. The TeleFamilies intervention engages an advanced practice nurse in a full-time care coordinator role within an existing hospital-based medical home for children with complex special health care needs. Care coordination is facilitated by the synthesis and integration of internal and external data using an enhanced electronic health record and telehealth encounters via telephone and videoconferencing between the advanced practice nurse and the family at home. The advanced practice nurse’s ability to maintain an updated plan of care that is shared across providers and systems and build a relationship over time with the patient and family supports meaningful use of these data. PMID:22948406

  18. Planning Nurses in Maternity Care: a Stochastic Assignment Problem

    NASA Astrophysics Data System (ADS)

    Phillipson, Frank

    2015-05-01

    With 23 percent of all births taking place at home, The Netherlands have the highest rate of home births in the world. Also if the birth did not take place at home, it is not unusual for the mother and child to be out of hospital in a few hours after the baby was born. The explanation for both is the very well organised maternity care system. However, getting the right maternity care nurse available on time introduces a complex planning issue that can be recognized as a Stochastic Assignment Problem. In this paper an expert rule based approach is combined with scenario analysis to support the planner of the maternity care agency in his work.

  19. Use of advanced technologies across the wound care spectrum: prologue.

    PubMed

    Kirsner, Robert S; Romanelli, Marco

    2016-09-01

    The growing trends of ageing populations and increasing prevalence of diabetes have given rise to an expanding number of problematic acute and chronic wounds. Over the past two decades, the use of negative pressure wound therapy (NPWT) with and without instillation of topical wound solutions has expanded to include treatment of a large variety of wounds. Additionally, the use of NPWT specifically designed for use over closed surgical incisions has been associated with favourable results. The recent introduction of an automated epidermal harvesting system, which neither creates a donor site wound nor requires the use of a surgeon, operating room or anaesthesia, has facilitated the use of epidermal grafting. This supplement highlights some of the advanced wound approaches that have been developed to address challenging wounds and the growing burden of wound care affecting both the patient and the health care system. PMID:27547957

  20. 42 CFR 456.481 - Admission certification and plan of care.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... Individuals Under Age 21: Admission and Plan of Care Requirements § 456.481 Admission certification and plan of care. If a facility provides inpatient psychiatric services to a beneficiary under age 21— (a)...

  1. 42 CFR 456.481 - Admission certification and plan of care.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... Individuals Under Age 21: Admission and Plan of Care Requirements § 456.481 Admission certification and plan of care. If a facility provides inpatient psychiatric services to a beneficiary under age 21— (a)...

  2. 42 CFR 456.481 - Admission certification and plan of care.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... Individuals Under Age 21: Admission and Plan of Care Requirements § 456.481 Admission certification and plan of care. If a facility provides inpatient psychiatric services to a recipient under age 21— (a)...

  3. 42 CFR 456.481 - Admission certification and plan of care.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... Individuals Under Age 21: Admission and Plan of Care Requirements § 456.481 Admission certification and plan of care. If a facility provides inpatient psychiatric services to a beneficiary under age 21— (a)...

  4. 42 CFR 456.481 - Admission certification and plan of care.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... Individuals Under Age 21: Admission and Plan of Care Requirements § 456.481 Admission certification and plan of care. If a facility provides inpatient psychiatric services to a recipient under age 21— (a)...

  5. Self-directed health plans: Web-enabled alternatives to traditional managed care.

    PubMed

    Wiggins, S F; Emery, D W

    2001-01-01

    New approaches for organizing, purchasing, and financing health care services are rapidly emerging as viable alternatives to orthodox managed care. One of the more intriguing approaches, Self-Directed Health Plans (SDHPs), empowers consumers as the agents of change and decision making in the continuing quest for health system reform. Combined with a host of newly evolved Internet support utilities, SDHPs represent a highly advanced paradigm for health insurance. Most importantly, SDHPs promise to genuinely harness the power and dynamism of free-market solutions in ways that are financially and socially sustainable, and to pick up the innovation process where health maintenance organizations left off. Thus, with SDHPs surfaces new hope that the problems facing America's health care system are not intractable to private sector creativity. PMID:11252393

  6. Working with advanced dementia patients in a day care setting.

    PubMed

    Abramowitz, Leah

    2008-01-01

    Alzheimer's disease and most other causes of dementia are regressive by nature. As such one can expect patients with such types of mental impairment to gradually decline in function and ability to participate in day care activities. This paper attempts to show that with the right kind of orientation, staff can "tune into" the more advanced dementia patients, find the key to their personal needs, desires and remaining abilities and design a program that allows them not only to continue to participate in a social and therapeutic framework, but also to gain some meaningful human contact and quality of life despite their cognitive deterioration. PMID:18510188

  7. Care planning and decision-making in teams in Swedish elderly care: a study of interprofessional collaboration and professional boundaries.

    PubMed

    Duner, Anna

    2013-05-01

    In front-line practice, joint working between different professionals in health/social care and rehabilitation is regarded as a means to reach a comprehensive assessment of the needs of the older care recipients, leading to decisions on appropriate care and services. The aim of this study was to examine professional collaboration and professional boundaries in interprofessional care planning teams. Two different care planning teams were studied, one performing care planning in the homes of older individuals and the other performing care planning for older people in hospital wards. The empirical data consisted of audio-recorded care planning meetings and interviews with the professionals in the teams. The integration between the professionals involved was most noticeable in the investigation and assessment phase, while it was lower in the planning phase and almost non-existent in decision-making. The home care planning team tended to work in a more integrated manner than the discharge planning team. The importance of clarifying the roles of all professions concerned with needs assessment and care planning for older people became evident in this study. PMID:23343434

  8. Making twin concerns of family planning and primary health care.

    PubMed

    Wang, Y

    1985-10-01

    The implementation of the Integrated FP/MCH/Parasite Control project by JOICFP in 1984 was envisioned to strengthen international cooperation, promote international exchange of knowledge and expand approaches in the practice of family planning. 2 municipalities in China were selected as pilot project areas. The objectives set in the 3-year plan of the integrated project are: to publicize the advantages of family planning and improve people's knowledge and practice of family planning; to stengthen technical guidance on family planning and control the growth and improve the quality of the population; to improve maternal and child care; and to reduce the infection rate of soil-transmitted helminthiasis. Steering committees on the integrated project at the municipal, county, township and village levels were set up in the pilot areas; the significance of the project has been communicated through film and slide presentations. Training courses for the administrative workers and technicians have been held. As a result of the family planning education activities, the contraceptive rates in the 2 pilot areas remained stable at 85%. Neonatal mortality was reduced significantly. Parasite control has benefitted 52,546 people in the pilot areas. An improvement was noted in environmental hygiene, the proper disposal of waste and the provision of safe drinking water. Further improvement can be achieved by intensifying public health education in the project areas, improving working systems and accomplishing all the tasks that the integrated project has set forth. PMID:12313888

  9. Optimism and Planning for Future Care Needs among Older Adults

    PubMed Central

    Sörensen, Silvia; Hirsch, Jameson K.; Lyness, Jeffrey M.

    2015-01-01

    Aging is associated with an increase in need for assistance. Preparation for future care (PFC) is related to improved coping ability as well as better mental and physical health outcomes among older adults. We examined the association of optimism with components of PFC among older adults. We also explored race differences in the relationship between optimism and PFC. In Study 1, multiple regression showed that optimism was positively related to concrete planning. In Study 2, optimism was related to gathering information. An exploratory analysis combining the samples yielded a race interaction: For Whites higher optimism, but for Blacks lower optimism was associated with more planning. High optimism may be a barrier to future planning in certain social and cultural contexts. PMID:26045699

  10. The Meaning of Parenteral Hydration to Family Caregivers and Patients with Advanced Cancer Receiving Hospice Care

    PubMed Central

    Cohen, Marlene Z; Torres-Vigil, Isabel; Burbach, Beth E.; de Rosa, Allison; Bruera, Eduardo

    2012-01-01

    Context In the U.S., patients with advanced cancer who are dehydrated or have decreased oral intake virtually always receive parenteral hydration in acute care facilities but rarely in the hospice setting. Objectives To describe the meaning of hydration for terminally ill cancer patients in home hospice care and for their primary caregivers. Methods Phenomenological interviews were conducted at two time points with 85 patients and 84 caregivers enrolled in a randomized, double-blind, controlled trial examining the efficacy of parenteral hydration in patients with advanced cancer receiving hospice care in the southern U.S. Transcripts were analyzed hermeneutically by the interdisciplinary research team until consensus on the theme labels was reached. Results Patients and their family caregivers both saw hydration as meaning hope and comfort. Hope was the view that hydration might prolong a life of dignity and enhance quality of life by reducing symptoms such as fatigue and increasing patients’ alertness. Patients and caregivers also described hydration as improving patients’ comfort by reducing pain, enhancing the effectiveness of pain medication, and nourishing the body, mind and spirit. Conclusion These findings differ from traditional hospice beliefs that dehydration enhances patient comfort given that patients and their families in the study viewed fluids as enhancing comfort, dignity and quality of life. Discussion with patients and families about their preferences for hydration may help tailor care plans to meet specific patient needs. PMID:22459230

  11. A Planning Guide for Food Service in Child Care Centers. Revised.

    ERIC Educational Resources Information Center

    Food and Nutrition Service (USDA), Washington, DC.

    This guide provides information to help child care centers and outside-school-hours care centers in the Child Care Food Program plan their food service operations. The guide covers the following topics: (1) guidelines for planning food for a day and daily meal patterns; (2) guidelines for planning menus; (3) suggested menus for young children; (4)…

  12. Advanced skin, scar and wound care centre for children: A new era of care

    PubMed Central

    Burd, Andrew; Huang, Lin

    2012-01-01

    Advanced wound care centres are now a well established response to the growing epidemic of chronic wounds in the adult population. Is the concept transferable to children? Whilst there is not the same prevalence of chronic wounds in children there are conditions affecting the integumentary system that do have a profound effect on the quality of life of both children and their families. We have identified conditions involving the skin, scars and wounds which contribute to a critical number of potential patients that can justify the setting up of an advanced skin, scar and wound care centre for children. The management of conditions such as giant naevi, extensive scarring and epidermolysis bullosa challenge medical professionals and lead to new and novel treatments to be developed. The variation between and within such conditions calls for a customizing of individual patient care that involves a close relationship between research scientists and clinicians. This is translational medicine of its best and we predict that this is the future of wound care particularly and specifically in children. PMID:23162215

  13. End-of-life care policy: An integrated care plan for the dying

    PubMed Central

    Myatra, Sheila Nainan; Salins, Naveen; Iyer, Shivakumar; Macaden, Stanley C.; Divatia, Jigeeshu V.; Muckaden, Maryann; Kulkarni, Priyadarshini; Simha, Srinagesh; Mani, Raj Kumar

    2014-01-01

    Purpose: The purpose was to develop an end-of-life care (EOLC) policy for patients who are dying with an advanced life limiting illness and to develop practical procedural guidelines for limiting inappropriate therapeutic medical interventions and improve the quality of care of the dying within an ethical framework and through a professional and family/patient consensus process. Evidence: The Indian Society of Critical Care Medicine (ISCCM) published its first guidelines on EOLC in 2005 [1] which was later revised in 2012.[2] Since these publications, there has been an exponential increase in empirical information and discussion on the subject. The literature reviewed observational studies, surveys, randomized controlled studies, as well as guidelines and recommendations, for education and quality improvement published across the world. The search terms were: EOLC; do not resuscitate directives; withdrawal and withholding; intensive care; terminal care; medical futility; ethical issues; palliative care; EOLC in India; cultural variations. Indian Association of Palliative Care (IAPC) also recently published its consensus position statement on EOLC policy for the dying.[3] Method: An expert committee of members of the ISCCM and IAPC was formed to make a joint EOLC policy for the dying patients. Proposals from the chair were discussed, debated, and recommendations were formulated through a consensus process. The members extensively reviewed national and international established ethical principles and current procedural practices. This joint EOLC policy has incorporated the sociocultural, ethical, and legal perspectives, while taking into account the needs and situation unique to India. PMID:25249748

  14. Women and managed care: satisfaction with provider choice, access to care, plan costs and coverage.

    PubMed

    Wyn, R; Collins, K S; Brown, E R

    1997-01-01

    This article reports on differences in satisfaction with provider choice, access to care, and plan costs and coverage between women enrolled in fee-for-service and those in managed car plans. It also examines differences in satisfaction, access, and costs and coverage between higher and lower income women and between those in reported fair or poor health and those in excellent or good health, among women in managed care plans. The data for this study are from The Commonwealth Fund's 1994 Managed Care Survey, which included 1,544 women with employer- or union-sponsored insurance in Boston, Los Angeles, and Miami. The study found that women in managed care were less satisfied with provider choice and access to services, but more satisfied with out-of-pocket costs for services and the range of services covered. Both low-income women and those in fair to poor health reported more problems with access barriers than did either higher income women or those in excellent or good health. PMID:9127994

  15. Cohort effects on the need for health care and implications for health care planning in Canada.

    PubMed

    Whittaker, William; Birch, Stephen; MacKenzie, Adrian; Murphy, Gail Tomblin

    2016-01-01

    The sustainability of publicly funded health care systems is an issue for governments around the world. The economic climate limits governments' fiscal capacity to continue to devote an increasing share of public funds to health care. Meanwhile the demands for health care within populations continue to increase. Planning the future requirements for health care is typically based on applying current levels of health service use by age to demographic projections of the population. But changes in age-specific levels of health over time would undermine this 'constant use by age' assumption. We use representative Canadian survey data (Canadian Community Health Survey) covering the period 2001-2012, to identify the separate trends in demography (population ageing) and epidemiology (population health) on self-reported health. We propose an approach to estimating future health care requirements that incorporates cohort trends in health. Overall health care requirements for the population increase as the size and mean age of the population increase, but these effects are mitigated by cohort trends in health-we find the estimated need for health care is lower when models account for cohort effects in addition to age effects. PMID:26586614

  16. Cost accounting, management control, and planning in health care.

    PubMed

    Siegrist, R B; Blish, C S

    1988-02-01

    Advantages and pharmacy applications of computerized hospital management-control and planning systems are described. Hospitals must define their product lines; patient cases, not tests or procedures, are the end product. Management involves operational control, management control, and strategic planning. Operational control deals with day-to-day management on the task level. Management control involves ensuring that managers use resources effectively and efficiently to accomplish the organization's objectives. Management control includes both control of unit costs of intermediate products, which are procedures and services used to treat patients and are managed by hospital department heads, and control of intermediate product use per case (managed by the clinician). Information from the operation and management levels feeds into the strategic plan; conversely, the management level controls the plan and the operational level carries it out. In the system developed at New England Medical Center, Boston, Massachusetts, the intermediate product-management system enables managers to identify intermediate products, develop standard costs, simulate changes in departmental costs, and perform variance analysis. The end-product management system creates a patient-level data-base, identifies end products (patient-care groupings), develops standard resource protocols, models alternative assumptions, performs variance analysis, and provides concurrent reporting. Examples are given of pharmacy managers' use of such systems to answer questions in the areas of product costing, product pricing, variance analysis, productivity monitoring, flexible budgeting, modeling and planning, and comparative analysis.(ABSTRACT TRUNCATED AT 250 WORDS) PMID:3284338

  17. Development and Testing of a Decision Aid on Goals of Care for Advanced Dementia

    PubMed Central

    Einterz, Seth F.; Gilliam, Robin; Lin, Feng Chang; McBride, J. Marvin; Hanson, Laura C.

    2014-01-01

    Objectives Decision aids are effective to improve decision-making, yet they are rarely tested in nursing homes (NHs). Study objectives were to 1) examine the feasibility of a Goals of Care (GOC) decision aid for surrogate decision-makers (SDMs)of persons with dementia; and 2) test its effect on quality of communication and decision-making. Design Pre-post intervention to test a GOC decision aid intervention for SDMs for persons with dementia in NHs. Investigators collected data from reviews of resident health records and interviews with SDMs at baseline and 3-month follow up. Setting Two NHs in North Carolina. Participants 18 residents who were over 65 years of age, had moderate to severe dementia on the Global Deterioration Scale (GDS=5,6,7), and an English-speaking surrogate decision-maker. Intervention 1) GOC Decision Aid video viewed by the SDM, and 2) a structured care plan meeting between the SDM and interdisciplinary NH team Measurements Surrogate knowledge, quality of communication with health care providers, surrogate-provider concordance on goals of care, and palliative care domains addressed in the care plan. Results 89% of the SDMs thought the decision aid was relevant to their needs. After viewing the video decision aid, SDMs increased the number of correct responses on knowledge-based questions (12.5 vs 14.2, P<.001). At 3 months they reported improved quality of communication scores (6.1 vs 6.8, P=.01) and improved concordance on primary goal of care with nursing home team (50% vs 78%, P=.003). The number of palliative care domains addressed in the care plan increased (1.8 vs 4.3, P<.001). Conclusion The decision-support intervention piloted in this study was feasible and relevant for surrogate decision-makers of persons with advanced dementia in nursing homes, and it improved quality of communication between SDM and NH providers. A larger randomized clinical trial is underway to provide further evidence of the effects of this decision aid

  18. Emergency planning and management in health care: priority research topics

    PubMed Central

    Boyd, Alan; Chambers, Naomi; French, Simon; Shaw, Duncan; King, Russell; Whitehead, Alison

    2014-01-01

    Many major incidents have significant impacts on people's health, placing additional demands on health-care organisations. The main aim of this paper is to suggest a prioritised agenda for organisational and management research on emergency planning and management relevant to U.K. health care, based on a scoping study. A secondary aim is to enhance knowledge and understanding of health-care emergency planning among the wider research community, by highlighting key issues and perspectives on the subject and presenting a conceptual model. The study findings have much in common with those of previous U.S.-focused scoping reviews, and with a recent U.K.-based review, confirming the relative paucity of U.K.-based research. No individual research topic scored highly on all of the key measures identified, with communities and organisations appearing to differ about which topics are the most important. Four broad research priorities are suggested: the affected public; inter- and intra-organisational collaboration; preparing responders and their organisations; and prioritisation and decision making. PMID:25013721

  19. A protocol for an exploratory phase I mixed-methods study of enhanced integrated care for care home residents with advanced dementia: the Compassion Intervention

    PubMed Central

    Elliott, Margaret; Harrington, Jane; Moore, Kirsten; Davis, Sarah; Kupeli, Nuriye; Vickerstaff, Victoria; Gola, Anna; Candy, Bridget; Sampson, Elizabeth L; Jones, Louise

    2014-01-01

    Introduction In the UK approximately 700 000 people are living with, and a third of people aged over 65 will die with, dementia. People with dementia may receive poor quality care towards the end of life. We applied a realist approach and used mixed methods to develop a complex intervention to improve care for people with advanced dementia and their family carers. Consensus on intervention content was achieved using the RAND UCLA appropriateness method and mapped to sociological theories of process and impact. Core components are: (1) facilitation of integrated care, (2) education, training and support, (3) investment from commissioners and care providers. We present the protocol for an exploratory phase I study to implement components 1 and 2 in order to understand how the intervention operates in practice and to assess feasibility and acceptability. Methods and analysis An ‘Interdisciplinary Care Leader (ICL)’ will work within two care homes, alongside staff and associated professionals to facilitate service integration, encourage structured needs assessment, develop the use of personal and advance care plans and support staff training. We will use qualitative and quantitative methods to collect data for a range of outcome and process measures to detect effects on individual residents, family carers, care home staff, the intervention team, the interdisciplinary team and wider systems. Analysis will include descriptive statistics summarising process and care home level data, individual demographic and clinical characteristics and data on symptom burden, clinical events and quality of care. Qualitative data will be explored using thematic analysis. Findings will inform a future phase II trial. Ethics and dissemination Ethical approval was granted (REC reference 14/LO/0370). We shall publish findings at conferences, in peer-reviewed journals, on the Marie Curie Cancer Care website and prepare reports for dissemination by organisations involved with end

  20. Quality Nursing Care for Hospitalized Patients with Advanced Illness: Concept Development

    PubMed Central

    Izumi, Shigeko; Baggs, Judith G.; Knafl, Kathleen A.

    2011-01-01

    The quality of nursing care as perceived by hospitalized patients with advanced illness has not been examined. A concept of quality nursing care for this population was developed by integrating the literature on constructs defining quality nursing care with empirical findings from interviews of 16 patients with advanced illness. Quality nursing care was characterized as competence and personal caring supported by professionalism and delivered with an appropriate demeanor. Although the attributes of competence, caring, professionalism, and demeanor were identified as common components of quality care across various patient populations, the caring domain increased in importance when patients with advanced illness perceived themselves as vulnerable. Assessment of quality nursing care for patients with advanced illness needs to include measures of patient perceptions of vulnerability. PMID:20572095

  1. A conceptual framework for advanced practice nursing in a pediatric tertiary care setting: the SickKids' experience.

    PubMed

    LeGrow, Karen; Hubley, Pam; McAllister, Mary

    2010-05-01

    Advanced practice nurses (APNs) at The Hospital for Sick Children (SickKids) are pediatric healthcare providers who integrate principles and theories of advanced nursing with specialty knowledge to provide autonomous, independent, accountable, ethical and developmentally appropriate care in complex, often ambiguous and rapidly changing healthcare environments. Caring for children and adolescents requires culturally sensitive and family-centred approaches to care that incorporate a unique body of knowledge. Family-centred care is an approach to planning, delivery and evaluation of healthcare that is governed by the establishment of mutually beneficial partnerships among APNs, health professionals and children/families. The cornerstone of APN practice at SickKids is the recognition of "family" as the recipients of care. By valuing and developing relationships with families, APNs promote excellence in healthcare across the care continuum to optimize the child's and family's physical, emotional, social, psychological and spiritual well-being. This paper outlines the evolution of advanced practice nursing at SickKids, beginning with the introduction of APN roles in the 1970s and culminating in the current critical mass of APNs who have been integrated throughout the hospital's infrastructure. We describe the process used to create a common vision and a framework to guide pediatric advanced nursing practice. PMID:20530994

  2. Advance directives and nursing home stays associated with less aggressive end-of-life care for patients with severe dementia.

    PubMed

    Nicholas, Lauren H; Bynum, Julie P W; Iwashyna, Theodore J; Weir, David R; Langa, Kenneth M

    2014-04-01

    The number of older adults with cognitive impairment is increasing, and such adults often require a surrogate to make decisions about health care. However, little is known about the aggressiveness of end-of-life care for these people, especially those who reside in the community. We found that cognitive impairment is common among older adults approaching the end of life, whether they live in the community or in a nursing home, and that nearly 30 percent of patients with severe dementia remained in the community until death. Among those patients, having an advance directive in the form of a living will was associated with significantly less aggressive care at the end of life, compared to similar patients without an advance directive-as measured by Medicare spending ($11,461 less per patient), likelihood of in-hospital death (17.9 percentage points lower), and use of the intensive care unit (9.4 percentage points lower). In contrast, advance directives were not associated with differences in care for people with normal cognition or mild dementia, whether they resided in the community or in a nursing home. Timely advance care planning after a diagnosis of cognitive impairment may be particularly important for older adults who reside in the community. PMID:24711329

  3. Place of death: hospital-based advanced home care versus conventional care. A prospective study in palliative cancer care.

    PubMed

    Ahlner-Elmqvist, Marianne; Jordhøy, Marit S; Jannert, Magnus; Fayers, Peter; Kaasa, Stein

    2004-10-01

    The purpose of this prospective nonrandomized study was to evaluate time spent at home, place of death and differences in sociodemographic and medical characteristics of patients, with cancer in palliative stage, receiving either hospital-based advanced home care (AHC), including 24-hour service by a multidisciplinary palliative care team or conventional hospital care (CC). Recruitment to the AHC group and to the study was a two-step procedure. The patients were assigned to either hospital-based AHC or CC according to their preferences. Following this, the patients were asked to participate in the study. Patients were eligible for the study if they had malignant disease, were older than 18 years and had a survival expectancy of 2-12 months. A total of 297 patients entered the study and 280 died during the study period of two and a half years, 117 in the AHC group and 163 in the CC group. Significantly more patients died at home in the AHC group (45%) compared with the CC group (10%). Preference for and referral to hospital-based AHC were not related to sociodemographic or medical characteristics. However, death at home was associated with living together with someone. Advanced hospital-based home care targeting seriously ill cancer patients with a wish to remain at home enable a substantial number of patients to die in the place they desire. PMID:15540666

  4. 25 CFR 1000.52 - What criteria will the Director use to award advance planning grants?

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 25 Indians 2 2010-04-01 2010-04-01 false What criteria will the Director use to award advance... INDIAN SELF-DETERMINATION AND EDUCATION ACT Section 402(d) Planning and Negotiation Grants Advance Planning Grant Funding § 1000.52 What criteria will the Director use to award advance planning...

  5. Advanced High-Level Waste Glass Research and Development Plan

    SciTech Connect

    Peeler, David K.; Vienna, John D.; Schweiger, Michael J.; Fox, Kevin M.

    2015-07-01

    The U.S. Department of Energy Office of River Protection (ORP) has implemented an integrated program to increase the loading of Hanford tank wastes in glass while meeting melter lifetime expectancies and process, regulatory, and product quality requirements. The integrated ORP program is focused on providing a technical, science-based foundation from which key decisions can be made regarding the successful operation of the Hanford Tank Waste Treatment and Immobilization Plant (WTP) facilities. The fundamental data stemming from this program will support development of advanced glass formulations, key process control models, and tactical processing strategies to ensure safe and successful operations for both the low-activity waste (LAW) and high-level waste (HLW) vitrification facilities with an appreciation toward reducing overall mission life. The purpose of this advanced HLW glass research and development plan is to identify the near-, mid-, and longer-term research and development activities required to develop and validate advanced HLW glasses and their associated models to support facility operations at WTP, including both direct feed and full pretreatment flowsheets. This plan also integrates technical support of facility operations and waste qualification activities to show the interdependence of these activities with the advanced waste glass (AWG) program to support the full WTP mission. Figure ES-1 shows these key ORP programmatic activities and their interfaces with both WTP facility operations and qualification needs. The plan is a living document that will be updated to reflect key advancements and mission strategy changes. The research outlined here is motivated by the potential for substantial economic benefits (e.g., significant increases in waste throughput and reductions in glass volumes) that will be realized when advancements in glass formulation continue and models supporting facility operations are implemented. Developing and applying advanced

  6. [Care plan in a patient with spina bifida. Case report].

    PubMed

    González Gancedo, Jacob; Fernández García, Daniel

    2007-01-01

    Spina bifida is a congenital malformation of the lumbar spine. We developed a nursing care plan in a 12-year-old girl with this malformation who attended a special education school. Using Gordon's health patterns, we assessed the patient and identified the following nursing diagnoses: imbalanced nutrition: more than body requirements, urinary incontinence, impaired transfer ability, risk for infection, risk of impaired skin integrity, risk for latex allergy, readiness for enhanced urinary elimination, and readiness for enhanced self-concept. Each nursing diagnosis was individualized, and related factors, risk factors and defining characteristics were identified for each. Likewise, we established the Nursing Outcomes Classification (NOC) outcomes and Nursing Intervention Classification (NIC) interventions, with descriptors and activities, respectively. The use of the nursing process will improve patient care and team work. PMID:17683689

  7. Developing a promotion plan for health care marketing.

    PubMed

    Hallums, A

    1994-07-01

    Promotion of a health care provider's services is essential for communication with its customers and consumers. It is relevant to an organization's marketing strategy and is an element of what is described as the marketing mix. This paper considers the relationship of promotion to the marketing of services and proposes a plan for the promotion of the organization as a whole which can also be applied to an individual service or specialty. Whilst specific reference is made to an National Health Service (NHS) Trust it is also relevant to a Directly Managed Unit. PMID:7952707

  8. Leveraging Standards to Support Patient-Centric Interdisciplinary Plans of Care

    PubMed Central

    Dykes, Patricia C.; DaDamio, Rebecca R.; Goldsmith, Denise; Kim, Hyeon-eui; Ohashi, Kumiko; Saba, Virginia K.

    2011-01-01

    As health care systems and providers move towards meaningful use of electronic health records, the once distant vision of collaborative patient-centric, interdisciplinary plans of care, generated and updated across organizations and levels of care, may soon become a reality. Effective care planning is included in the proposed Stages 2–3 Meaningful Use quality measures. To facilitate interoperability, standardization of plan of care messaging, content, information and terminology models are needed. This degree of standardization requires local and national coordination. The purpose of this paper is to review some existing standards that may be leveraged to support development of interdisciplinary patient-centric plans of care. Standards are then applied to a use case to demonstrate one method for achieving patient-centric and interoperable interdisciplinary plan of care documentation. Our pilot work suggests that existing standards provide a foundation for adoption and implementation of patient-centric plans of care that are consistent with federal requirements. PMID:22195088

  9. 25 CFR 1001.9 - Selection criteria for tribes/consortia seeking advance planning grant funding.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... planning grant funding. 1001.9 Section 1001.9 Indians OFFICE OF THE ASSISTANT SECRETARY, INDIAN AFFAIRS... advance planning grant funding. (a) Who is eligible to apply for a planning grant that will be awarded...-governance tribe and needs advance funding in order to complete the planning phase requirement may...

  10. [Ethics and palliative care in patients with advanced cancer].

    PubMed

    Tenorio-González, Francisco

    2005-01-01

    Recent research in both the biology of cancer and the treatment of patients has increased the life expectancy of cancer patients with recurrence and who have a longer survival rate. Cancer is no longer considered a lethal but a chronic disease. More patients survive, but above all there are more patients with recurrences thus increasing the need for physical or psychological treatment of patients with longer lives. The American Cancer Society reported in 1992 that in the U.S. more than 8 million people survived between 4 and 5 years. This produces both an ethical and medical challenge for treatment of cancer patients. This paper reviews the actual criteria for palliative care: treatment for pain and the ethical and psychological treatment of advanced cancer patients and their families. PMID:16454965

  11. Experimental area plans for an advanced hadron facility

    SciTech Connect

    Hoffman, E.W.; Macek, R.J.; Tschalear, C.

    1986-01-01

    A brief overview is presented of the current plans for an experimental area for a new advanced hadron facility for the exploration of nuclear and particle physics. The facility, LAMPF II, is presently visualized as consisting of the LAMPF linac sending 800 MeV protons to a 6 GeV booster ring followed by a 45 GeV main ring. Two experimental areas area planned. The first is intended to provide neutrinos via a pair of pulsed focusing horns. The other is designed to accommodate secondary beams that span the range of useful energies up to GeV/c. Beam specification goals are discussed with respect to source brightness, beam purity, and beam-line acceptance and length. The various beam lines are briefly described. Production cross sections and rates are estimated for antiproton production. Problems of thermal energy deposition in both components and targets and of effectiveness of particle separators are discussed. 9 refs. (LEW)

  12. Knowledge Management Platform in Advanced Product Quality Planning

    NASA Astrophysics Data System (ADS)

    Chiliban, Bogdan; Baral, Lal Mohan; Kifor, Claudiu

    2014-12-01

    Knowledge is an essential part of organizational competitiveness. This vital resource must be managed correctly within organizations in order to achieve desired performance levels within all undertakings. The process of managing knowledge is a very difficult one due to the illusive nature of the resource itself. Knowledge is stored within every aspect of an organization starting from people and ending with documents and processes. The Knowledge Management Platform is designed as a facilitator for managers and employees in all endeavours knowledge related within the Advanced Product Quality Planning Procedure

  13. A Renewal Plan for the Advanced Photon Source

    SciTech Connect

    Fischetti, Robert F.; Fuoss, Paul H.; Gerig, Rodney E.; Maclean, John F.; Mills, Dennis M.; Srajer, George; Keane, Denis T.; Neumann, Dan A.

    2010-06-23

    With coordination from the APS Renewal Steering Committee (the members of which are the co-authors of this paper), staff and users of the U.S. Department of Energy's Advanced Photon Source (APS) at Argonne National Laboratory are in the process of developing a renewal plan for the facility. The renewal is a coordinated upgrade of the accelerator, beamlines, and associated technical structure that will enable users of the APS to address key scientific challenges in the coming decades. The cost of the renewal is estimated to be from $300M to $400M and to take approximately six years from start to finish.

  14. Coordination of care for individuals with advanced progressive conditions: a multi-site ethnographic and serial interview study

    PubMed Central

    Mason, Bruce; Epiphaniou, Eleni; Nanton, Veronica; Donaldson, Anne; Shipman, Cathy; Daveson, Barbara A; Harding, Richard; Higginson, Irene; Munday, Dan; Barclay, Stephen; Boyd, Kirsty; Dale, Jeremy; Kendall, Marilyn; Worth, Allison; Murray, Scott A

    2013-01-01

    Background Coordination of care for individuals with advanced progressive conditions is frequently poor. Aim To identify how care is coordinated in generalist settings for individuals with advanced progressive conditions in the last year of life. Design and setting A mixed methods study of three UK generalist clinical settings producing three parallel case studies: an acute admissions unit in a regional hospital, a large general practice, and a respiratory outpatient service. Method Ethnographic observations in each setting, followed by serial interviews of patients with advanced progressive conditions and their family carers in the community. A spectrum of clinicians and healthcare workers were also interviewed. Results Ethnographic observations were conducted for 22 weeks. A total of 56 patients, 25 family carers and 17 clinicians yielded 198 interviews. Very few participants had been identified for a palliative approach. Rapid throughput of hospital patients and time pressures in primary care hindered identification of palliative care needs. Lack of care coordination was evident during emergency admissions and discharges. Patient, families, and professionals identified multiple problems relating to lack of information, communication, and collaboration at care transitions. Family carers or specialist nurses, where present, usually acted as the main care coordinators. Conclusion Care is poorly coordinated in generalist settings for patients in the last year of life, although those with cancer have better coordinated care than other patients. A model to improve coordination of care for all individuals approaching the end of life must ensure that patients are identified in a timely way, so that they can be assessed and their care planned accordingly. PMID:23972199

  15. Hospital-based discharge planning: the beginning of home care for many.

    PubMed

    Luken, P C

    1991-01-01

    Discharge planning can be viewed as the first step in home care for many individuals. This article examines the process through the discussion of the stages of discharge planning, and a study of discharge planning in an acute-care hospital. Several recommendations are made that would strengthen the role of home care providers in the process, who are encouraged to work for a more active role in discharge planning. PMID:10109300

  16. Advanced Launch System advanced development oxidizer turbopump program: Technical implementation plan

    NASA Technical Reports Server (NTRS)

    Ferlita, F.

    1989-01-01

    The Advanced Launch Systems (ALS) Advanced Development Oxidizer Turbopump Program has designed, fabricated and demonstrated a low cost, highly reliable oxidizer turbopump for the Space Transportation Engine that minimizes the recurring cost for the ALS engines. Pratt and Whitney's (P and W's) plan for integrating the analyses, testing, fabrication, and other program efforts is addressed. This plan offers a comprehensive description of the total effort required to design, fabricate, and test the ALS oxidizer turbopump. The proposed ALS oxidizer turbopump reduces turbopump costs over current designs by taking advantage of design simplicity and state-of-the-art materials and producibility features without compromising system reliability. This is accomplished by selecting turbopump operating conditions that are within known successful operating regions and by using proven manufacturing techniques.

  17. Advancing critical care: time to kiss the right frog

    PubMed Central

    2013-01-01

    The greatest advances in critical care over the past two decades have been achieved through doing less to the patient. We have learnt through salutary experience that our burgeoning Master-of-the-Universe capabilities and the oh-so-obvious stratagems instilled in us from youth were often ineffective or even deleterious. This re-education process, however, is far from complete. We are now rightly agonizing over the need for better characterization of pathophysiology, earlier identification of disease processes and a more directed approach to therapeutic intervention. We need to delineate the point at which intrinsic and protective adaptation ends and true harmful pathology begins, and how our iatrogenic meddling either helps or hinders. We need to improve trial design in the heterogeneous populations we treat, and to move away from syndromic fixations that, while offering convenience, have generally proved counterproductive. Importantly, we need to discover a far more holistic approach to patient care, evolving from the prevailing overmedicalized, number-crunching perspective towards a true multidisciplinary effort that embraces psychological as well as physiological well-being, with appropriate pharmacological minimization or supplementation. Complacency, with an unfair apportion of blame on the patient for not getting better, is the biggest threat to continued improvement. PMID:23514321

  18. Transition Planning for Adolescents with Special Health Care Needs and Disabilities: A Guide for Health Care Providers.

    ERIC Educational Resources Information Center

    Porter, Stephanie; Freeman, Linda; Griffin, Lynne Reeves

    Designed for Massachusetts health care providers, this booklet provides information on transition planning for adolescents with special health care needs and disabilities. It includes resources and strategies to guide interventions with families and to focus their attention on four key facets of adulthood: health care, education, employment, and…

  19. Cancer Pharmacogenomics: Integrating Discoveries in Basic, Clinical and Population Sciences to Advance Predictive Cancer Care

    Cancer.gov

    Cancer Pharmacogenomics: Integrating Discoveries in Basic, Clinical and Population Sciences to Advance Predictive Cancer Care, a 2010 workshop sponsored by the Epidemiology and Genomics Research Program.

  20. [Advanced nursing practice: a must for the quality of care and mental health services].

    PubMed

    Ricard, Nicole; Page, Claire; Laflamme, France

    2014-01-01

    supported the development of new models of advanced practice in mental health. These developments have been particularly significant in the United States and Australia. In United States, during the 1990s, at least four models of advanced practice in mental health nursing have been developed leading to wide variations in the roles, education, job titles, scope of practice and legal authorizations. Consequently, a consensus model of uniform standards of practice, accreditation and education has been proposed. This LACE model (Licensure, Accreditation, Certification, Education) will be in effect in 2015. Australia has adopted a more systematic approach, unified and progressive to facilitate the development of advanced mental health nursing practice. Australia who, through their many publications, retains more attention since a clear definition of the role of the nurse practitioner in mental health and a legal framework has been adopted at the national level. The Australian experience and the finding from studies suggest that mental health nurse practitioners and nurses who are specialized in mental health have the potential to make a significant contribution to enhancing access to and quality of mental health care through flexible an innovative approaches. So there are more and more evidence and indications that Quebec should invest in enhancing the skills of mental health nurses through the development of advanced nursing practice and integration of this new model in primary care. In addition, researches, funded by the Canadian Services Research Foundation (CHSRF, 2010), shows that the contribution of advanced nursing practice has never been stronger and there is a broad consensus to its value for the Canadian health care system (Dicenso.et Lukosius-Briant, 2010). The implementation of advanced practice nursing role in mental health is part of best practices required to improve care and mental health services and should be taken into account in future Action Plan 2014

  1. Pragmatic diabetes management in nursing homes: individual care plan.

    PubMed

    Benetos, Athanase; Novella, Jean-Luc; Guerci, Bruno; Blickle, Jean-Frederic; Boivin, Jean-Marc; Cuny, Pierre; Delemer, Brigitte; Gabreau, Thierry; Jan, Philippe; Louis, Jacques; Passadori, Yves; Petit, Jean-Michel; Weryha, Georges

    2013-11-01

    Although the management of diabetes as a simple entity has been extensively developed, there is a dearth of evidence in elderly, frail patients with multiple comorbidities and polymedication. This population represents a large proportion of the residents of nursing homes (NHs). As a multidisciplinary group of French experts (geriatricians, endocrinologists, diabetologists, and general practitioners) with practical experience in this area, which is growing in magnitude throughout the world, we convened to compile pragmatic, simple advice on the management of elderly, frail diabetic patients. Given demands on NH personnel (manager, medical coordinator, nurses, and, at the front line of care provision, the undertrained and overworked carers), coupled with the quasiconstant of high staff turnover, the foundation stone of a patient's diabetes management is an Individual Care Plan (ICP) expressed in layman's language. This document that is opened on the patient's admission aims to make sure that the prescriptions established at admission are followed, notably to ensure correct treatment and adapted, regular monitoring with dates and times when examinations and tests are due. This includes monitoring of the diabetes control (HbA1c and, if necessary, blood and urine glucose) and its complications (cardiovascular disease, hypoglycemia, ocular problems, foot disorders, malnutrition, peripheral neuropathy, kidney failure). A necessary corollary is the training of staff to understand the specificities of caring for a frail patient with diabetes, on what to do in a potential emergency, and how to keep the ICP up to date for consultation by doctors and nurses. PMID:24113629

  2. Center for Advanced Energy Studies (CAES) Strategic Plan

    SciTech Connect

    Kevin Kostelnik; Keith Perry

    2007-07-01

    Twenty-first century energy challenges include demand growth, national energy security, and global climate protection. The Center for Advanced Energy Studies (CAES) is a public/private partnership between the State of Idaho and its academic research institutions, the federal government through the U.S. Department of Energy (DOE) and the Idaho National Laboratory (INL) managed by the Battelle Energy Alliance (BEA). CAES serves to advance energy security for our nation by expanding the educational opportunities at the Idaho universities in energy-related areas, creating new capabilities within its member institutions, and delivering technological innovations leading to technology-based economic development for the intermountain region. CAES has developed this strategic plan based on the Balanced Scorecard approach. A Strategy Map (Section 7) summarizes the CAES vision, mission, customers, and strategic objectives. Identified strategic objectives encompass specific outcomes related to three main areas: Research, Education, and Policy. Technical capabilities and critical enablers needed to support these objectives are also identified. This CAES strategic plan aligns with and supports the strategic objectives of the four CAES institutions. Implementation actions are also presented which will be used to monitor progress towards fulfilling these objectives.

  3. What's the Plan? Needing Assistance with Plan of Care Is Associated with In-Hospital Death for ICU Patients Referred for Palliative Care Consultation.

    PubMed

    Kiyota, Ayano; Bell, Christina L; Masaki, Kamal; Fischberg, Daniel J

    2016-08-01

    To inform earlier identification of intensive care unit (ICU) patients needing palliative care, we examined factors associated with in-hospital death among ICU patients (N=260) receiving palliative care consultations at a 542-bed tertiary care hospital (2005-2009). High pre-consultation length of stay (LOS, ≥7 days) (adjusted odds ratio (aOR)=5.0, 95% confidence interval (95% CI)=2.5-9.9, P<.01) and consultations for assistance with plan of care (aOR=11.6, 95% CI=5.6-23.9, P<.01) were independently associated with in-hospital death. Patients with both consultation for plan of care and high pre-consult LOS had the highest odds of in-hospital death (aOR=36.3, 95% CI=14.9-88.5, P<.001), followed by patients with consultation for plan of care and shorter pre-consult LOS (aOR=9.8, 95% CI=4.3-22.1, P<.001), and patients with long pre-consult LOS but no consultation for plan of care (aOR=4.7, 95% CI=1.8-12.4, P=.002). Our findings suggest that ICU patients who require assistance with plan of care need to be identified early to optimize end-of-life care and avoid in-hospital death. PMID:27563500

  4. What's the Plan? Needing Assistance with Plan of Care Is Associated with In-Hospital Death for ICU Patients Referred for Palliative Care Consultation

    PubMed Central

    Kiyota, Ayano; Bell, Christina L; Masaki, Kamal

    2016-01-01

    To inform earlier identification of intensive care unit (ICU) patients needing palliative care, we examined factors associated with in-hospital death among ICU patients (N=260) receiving palliative care consultations at a 542-bed tertiary care hospital (2005–2009). High pre-consultation length of stay (LOS, ≥7 days) (adjusted odds ratio (aOR)=5.0, 95% confidence interval (95% CI)=2.5–9.9, P<.01) and consultations for assistance with plan of care (aOR=11.6, 95% CI=5.6–23.9, P<.01) were independently associated with in-hospital death. Patients with both consultation for plan of care and high pre-consult LOS had the highest odds of in-hospital death (aOR=36.3, 95% CI=14.9–88.5, P<.001), followed by patients with consultation for plan of care and shorter pre-consult LOS (aOR=9.8, 95% CI=4.3–22.1, P<.001), and patients with long pre-consult LOS but no consultation for plan of care (aOR=4.7, 95% CI=1.8–12.4, P=.002). Our findings suggest that ICU patients who require assistance with plan of care need to be identified early to optimize end-of-life care and avoid in-hospital death. PMID:27563500

  5. Employer strategies to combat health care plan fraud.

    PubMed

    Pflaum, B B; Rivers, J S

    1991-01-01

    Each year health care fraud drains millions of dollars from employer-sponsored health plans. Historically, employers have taken a rather tolerant view of fraud. As the pressure to manage health plan costs increases, however, many employers are beginning to see the detection and prosecution of fraud as an appropriate part of a cost management program. Fraud in medical insurance covers a wide range of activities in terms of cost and sophistication--from misrepresenting information on a claim, to billing for services never rendered, to falsifying the existence of an entire medical organization. To complicate matters, fraudulent activities can emanate from many, many sources. Perpetrators can include employees, dependents or associates of employees, providers and employees of providers--virtually anyone able to make a claim against a plan. This article addresses actions that employers can take to reduce losses from fraud. The first section suggests policy statements and administrative procedures and guidelines that can be used to discourage employee fraud. Section two addresses the most prevalent form of fraud--provider fraud. To combat provider fraud, employers should set corporate guidelines and should enlist the assistance of employees in identifying fraudulent provider activities. Section three suggests ways to improve fraud detection through the claims payment system--often the first line of defense against fraud. Finally, section four discusses the possibility of civil and criminal remedies and reviews the legal theories under which an increasing number of fraud cases have been prosecuted. PMID:10116952

  6. Advanced Reactor Technology -- Regulatory Technology Development Plan (RTDP)

    SciTech Connect

    Moe, Wayne Leland

    2015-05-01

    This DOE-NE Advanced Small Modular Reactor (AdvSMR) regulatory technology development plan (RTDP) will link critical DOE nuclear reactor technology development programs to important regulatory and policy-related issues likely to impact a “critical path” for establishing a viable commercial AdvSMR presence in the domestic energy market. Accordingly, the regulatory considerations that are set forth in the AdvSMR RTDP will not be limited to any one particular type or subset of advanced reactor technology(s) but rather broadly consider potential regulatory approaches and the licensing implications that accompany all DOE-sponsored research and technology development activity that deal with commercial non-light water reactors. However, it is also important to remember that certain “minimum” levels of design and safety approach knowledge concerning these technology(s) must be defined and available to an extent that supports appropriate pre-licensing regulatory analysis within the RTDP. Final resolution to advanced reactor licensing issues is most often predicated on the detailed design information and specific safety approach as documented in a facility license application and submitted for licensing review. Because the AdvSMR RTDP is focused on identifying and assessing the potential regulatory implications of DOE-sponsored reactor technology research very early in the pre-license application development phase, the information necessary to support a comprehensive regulatory analysis of a new reactor technology, and the resolution of resulting issues, will generally not be available. As such, the regulatory considerations documented in the RTDP should be considered an initial “first step” in the licensing process which will continue until a license is issued to build and operate the said nuclear facility. Because a facility license application relies heavily on the data and information generated by technology development studies, the anticipated regulatory

  7. Patient Care Planning Discussions for Patients at the End of Life: An Evidence-Based Analysis

    PubMed Central

    Baidoobonso, S

    2014-01-01

    Background Ontario spends about 9% of its health budget on care for people at the end of life (EoL), most of whom die from chronic, prolonged conditions. For many people, patient care planning discussions (PCPDs) can improve the quality and reduce the cost of care. Objectives This evidence-based analysis aimed to examine the effectiveness of PCPDs in achieving better patient-centred outcomes for people at the EoL. Data Sources A systematic literature search was conducted in MEDLINE, Embase, CINAHL, and EBM Reviews to identify relevant literature published between January 1, 2004, and October 9, 2013. Review Methods Peer-reviewed reports from randomized controlled trials (RCTs) and observational studies were examined. Outcomes included quality of life (QoL), satisfaction, concordance, advance care planning (ACP), and health care use. Quality of evidence was assessed using GRADE. Results While the effects of PCPDs on QoL are unclear, single-provider PCPDs were associated with family members being very satisfied with EoL care (odds ratio [OR]: 5.17 [95% CI: 1.52, 17.58]), improved concordance between patients’ and families’ wishes (OR: 4.32, P < 0.001), fewer episodes of hospital care (mean difference [MD]: −0.21, P = 0.04), spending fewer days in hospital (MD: −1.8, P = 0.03), and receiving hospice care (OR: 5.17 [95% CI: 2.03, 13.17]). Team-based PCPDs were associated with greater patient satisfaction (standardized mean difference [SMD]: 0.39 [95% CI: 0.17, 0.60]) and fewer outpatient visits (MD: −5.20 [95% CI: −9.70, −0.70]). Overall, PCPDs were associated with more ACP and more optimal health care use. Limitations Most of the RCTs were unblinded, intervention was measured or described inadequately in some studies, and the term “usual care” was often undefined. Conclusions Patients at the EoL and their families benefited from PCPDs. Furthermore, PCPDs occurring earlier in the course of illness were associated with better outcomes than those

  8. Advances in laparoscopy for acute care surgery and trauma

    PubMed Central

    Mandrioli, Matteo; Inaba, Kenji; Piccinini, Alice; Biscardi, Andrea; Sartelli, Massimo; Agresta, Ferdinando; Catena, Fausto; Cirocchi, Roberto; Jovine, Elio; Tugnoli, Gregorio; Di Saverio, Salomone

    2016-01-01

    The greatest advantages of laparoscopy when compared to open surgery include the faster recovery times, shorter hospital stays, decreased postoperative pain, earlier return to work and resumption of normal daily activity as well as cosmetic benefits. Laparoscopy today is considered the gold standard of care in the treatment of cholecystitis and appendicitis worldwide. Laparoscopy has even been adopted in colorectal surgery with good results. The technological improvements in this surgical field along with the development of modern techniques and the acquisition of specific laparoscopic skills have allowed for its utilization in operations with fully intracorporeal anastomoses. Further progress in laparoscopy has included single-incision laparoscopic surgery and natural orifice trans-luminal endoscopic surgery. Nevertheless, laparoscopy for emergency surgery is still considered challenging and is usually not recommended due to the lack of adequate experience in this area. The technical difficulties of operating in the presence of diffuse peritonitis or large purulent collections and diffuse adhesions are also given as reasons. However, the potential advantages of laparoscopy, both in terms of diagnosis and therapy, are clear. Major advantages may be observed in cases with diffuse peritonitis secondary to perforated peptic ulcers, for example, where laparoscopy allows the confirmation of the diagnosis, the identification of the position of the ulcer and a laparoscopic repair with effective peritoneal washout. Laparoscopy has also revolutionized the approach to complicated diverticulitis even when intestinal perforation is present. Many other emergency conditions can be effectively managed laparoscopically, including trauma in select hemodynamically-stable patients. We have therefore reviewed the most recent scientific literature on advances in laparoscopy for acute care surgery and trauma in order to demonstrate the current indications and outcomes associated with a

  9. Advances in laparoscopy for acute care surgery and trauma.

    PubMed

    Mandrioli, Matteo; Inaba, Kenji; Piccinini, Alice; Biscardi, Andrea; Sartelli, Massimo; Agresta, Ferdinando; Catena, Fausto; Cirocchi, Roberto; Jovine, Elio; Tugnoli, Gregorio; Di Saverio, Salomone

    2016-01-14

    The greatest advantages of laparoscopy when compared to open surgery include the faster recovery times, shorter hospital stays, decreased postoperative pain, earlier return to work and resumption of normal daily activity as well as cosmetic benefits. Laparoscopy today is considered the gold standard of care in the treatment of cholecystitis and appendicitis worldwide. Laparoscopy has even been adopted in colorectal surgery with good results. The technological improvements in this surgical field along with the development of modern techniques and the acquisition of specific laparoscopic skills have allowed for its utilization in operations with fully intracorporeal anastomoses. Further progress in laparoscopy has included single-incision laparoscopic surgery and natural orifice trans-luminal endoscopic surgery. Nevertheless, laparoscopy for emergency surgery is still considered challenging and is usually not recommended due to the lack of adequate experience in this area. The technical difficulties of operating in the presence of diffuse peritonitis or large purulent collections and diffuse adhesions are also given as reasons. However, the potential advantages of laparoscopy, both in terms of diagnosis and therapy, are clear. Major advantages may be observed in cases with diffuse peritonitis secondary to perforated peptic ulcers, for example, where laparoscopy allows the confirmation of the diagnosis, the identification of the position of the ulcer and a laparoscopic repair with effective peritoneal washout. Laparoscopy has also revolutionized the approach to complicated diverticulitis even when intestinal perforation is present. Many other emergency conditions can be effectively managed laparoscopically, including trauma in select hemodynamically-stable patients. We have therefore reviewed the most recent scientific literature on advances in laparoscopy for acute care surgery and trauma in order to demonstrate the current indications and outcomes associated with a

  10. 42 CFR 456.401 - State plan UR requirements and options; UR plan required for intermediate care facility services.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... care facility services. (a) The State plan must provide that— (1) UR is performed for each ICF that furnishes inpatient services under the plan; (2) Each ICF has on file a written UR plan that provides for review of each recipient's need for the services that the ICF furnishes him; and (3) Each written ICF...

  11. Improving Transitions of Care With an Advanced Practice Nurse: A Pilot Study.

    PubMed

    Hsueh, Martha; Dorcy, Kathleen

    2016-06-01

    Gaps in complex oncology care coordination between inpatient and outpatient settings can result in treatment and monitoring delays and omissions, which can negatively affect patient outcomes. Gaps also exist for patients facing complex treatment modalities and collaborations between multiple care teams working at geographically distant sites. A pilot advanced practice nurse care coordinator 
(APNCC) role to coordinate these complex care transitions and implement processes for safer and more efficient care has shown promise.
. PMID:27206289

  12. Advance directives in action in a regional palliative care service: "road testing" the provisions of the Medical Treatment Act 1988 (VIC).

    PubMed

    Brown, Margaret; Fisher, John W; Brumley, David J; Ashby, Michael A; Milliken, Jan

    2005-11-01

    In order to explore the usefulness and acceptability of the provisions of the Medical Treatment Act 1988 (Vic) for palliative care patients in a rural region in Victoria, Australia, between July and December 2004 patients were given information explaining the Act and the opportunity to discuss it with the research officer. Grounded theory methodology was used to evaluate client responses. Findings suggested that palliative care patients are willing to engage in advance care planning but they have to be well enough and need skilled, practical, face-to-face assistance to complete the required legal forms. Written materials alone are not adequate, but provide the opportunity for medical staff to have conversations about death and dying. Doctors and nurses should understand the provisions of the Act to assist patients and families. It is recommended that advance care planning, appropriate to the jurisdiction, be an integral part of the palliative care assessment process. PMID:16304759

  13. Palliative care and pulmonary rehabilitation.

    PubMed

    Janssen, Daisy J A; McCormick, James R

    2014-06-01

    Numerous barriers exist to the timely introduction of palliative care in patients with advanced chronic obstructive pulmonary disease (COPD). The complex needs of patients with advanced COPD require the integration of curative-restorative care and palliative care. Palliative care and pulmonary rehabilitation are both important components of integrated care for patients with chronic respiratory diseases. Pulmonary rehabilitation provides the opportunity to introduce palliative care by implementing education about advance care planning. Education about advance care planning addresses the information needs of patients and can be an effective strategy to promote patient-physician discussion about these issues. PMID:24874135

  14. Alberta's acute care funding plan: update to December 1994.

    PubMed

    Jacobs, P; Hall, E M; Plain, R H

    1995-01-01

    From 1990 until 1994 Alberta Health adjusted the acute care portion of hospital budgets based on a case mix index, initially called the Hospital Performance Index (HPI). The HPI formula method was a temporary measure; in November 1993, Alberta Health announced that, commencing in 1994, hospitals would be funded on a prospective basis, although they would still use the core of the HPI in the setting of funding rates. The creation of 17 health regions in June 1994 created the need for a new system of funding which would supplant the modified prospective system. In this paper we review the evolution of the HPI plan and its individual components-patient data, patient classification, funding weights, inpatient costs and adjustment factors. PMID:10144217

  15. Theory of planned behavior, self-care motivation, and blood pressure self-care.

    PubMed

    Peters, Rosalind M; Templin, Thomas N

    2010-01-01

    The theory of planned behavior (TPB) was integrated within the theory of self-care (SCT) to explore the predictive value of extending TPB to measure attitudes and beliefs regarding a behavioral goal, and determine the ability of goal beliefs to predict engagement in the combined, multiple behaviors necessary to control BP. The hypothesized model was evaluated in a sample of 306 community-dwelling African Americans between 21 and 65 years of age. Scales developed for the study achieved acceptable reliability (alpha = .68-.95). Structural equation modeling analysis resulted in a second-order factor structure with attitude, subjective norm, perceived behavioral control, and intention modeled as indicators of a construct representing goal beliefs related to keeping BP within normal limits. This latent construct was conceptualized within the theory of self-care as "self-care motivation," and predicted 18% of the variance in self-care behaviors necessary for BP control. The model achieved acceptable fit (CMIN/df = 2.32; CFI = .95; RMSEA = .066). Final assessment of fit was done using multi-group SEM and bootstrapping techniques. In this extension of the TPB attitudes and beliefs regarding the goal of keeping BP within normal limits were found to determine one's motivation to engage in the multiple behaviors necessary for BP control. PMID:20949834

  16. Dx for a careful approach to moving dual-eligible beneficiaries into managed care plans.

    PubMed

    Neuman, Patricia; Lyons, Barbara; Rentas, Jennifer; Rowland, Diane

    2012-06-01

    Policy makers are moving rapidly to develop and test reforms aimed at doing a better job of managing the costs and care for people dually eligible for Medicare and Medicaid. This commentary underscores the importance of pursuing new initiatives to address care coordination and spending concerns. It then focuses on key issues raised by proposals that would shift dual-eligible beneficiaries into managed care plans. The paper describes the heterogeneity and complexity of this population, emphasizing the need for approaches closely tied to the needs of particular subgroups of dual-eligible beneficiaries. It warns against moving too quickly, noting the time and resources required to build capacity to serve patients, secure provider networks, and develop an infrastructure for integrating and managing both Medicare and Medicaid services. The commentary cautions that optimistic savings assumptions might not materialize, raises questions about how savings will be allocated, and highlights the need for accountability as new models are being developed and tested to improve care for a population with complex needs. PMID:22665830

  17. 78 FR 15553 - Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health Plans...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-03-11

    ... Care Act; Establishment of Exchanges and Qualified Health Plans; Proposed Rule, 76 FR 41866 (July 15...) Requirements Under the Patient Protection and Affordable Care Act; Interim Final Rule, 75 FR 74864, 74918-20... of the Patient Protection and Affordable Care Act and the Health Care and Education...

  18. CARES: Carbonaceous Aerosol and Radiative Effects Study Operations Plan

    SciTech Connect

    Zaveri, RA; Shaw, WJ; Cziczo, DJ

    2010-07-12

    The CARES field campaign is motivated by the scientific issues described in the CARES Science Plan. The primary objectives of this field campaign are to investigate the evolution and aging of carbonaceous aerosols and their climate-affecting properties in the urban plume of Sacramento, California, a mid-size, mid-latitude city that is located upwind of a biogenic volatile organic compound (VOC) emission region. Our basic observational strategy is to make comprehensive gas, aerosol, and meteorological measurements upwind, within, and downwind of the urban area with the DOE G-1 aircraft and at strategically located ground sites so as to study the evolution of urban aerosols as they age and mix with biogenic SOA precursors. The NASA B-200 aircraft, equipped with the High Spectral Resolution Lidar (HSRL), digital camera, and the Research Scanning Polarimeter (RSP), will be flown in coordination with the G-1 to characterize the vertical and horizontal distribution of aerosols and aerosol optical properties, and to provide the vertical context for the G-1 and ground in situ measurements.

  19. States, Congress confront abortion services under Medicaid, health care plan.

    PubMed

    1994-01-13

    Abortion coverage under various health care reform proposals has dominated the political reproductive rights debate, while poor women's access to abortion under Medicaid presents a current practical concern. Under the Clinton administration's proposed Health Security Act, abortion would be covered under "services for pregnant women," and Medicaid would eventually be incorporated into the national health plan. A final version is a long way off. For now, the Hyde amendment, limiting Medicaid coverage of abortion, controls the issue. Congress has made only negligible progress in freeing federal funds for Medicaid abortions: only in situations of life endangerment, rape, or incest. States are required to cover abortions that are medically necessary under the new guidelines, which now include pregnancy arising from rape and incest. The federal policy defers to state law on the definition of rape and incest, allowing for reasonable reporting or documentation requirements, while disallowing unduly burdensome regulations by allowing the treating physician reimbursement when the physician certifies that the patient was unable for physical or psychological reasons to comply with the requirement. States disagreeing with the new abortion policy immediately registered their opposition. Utah's health department, which has a "life only" law, has pledged not to implement the new federal policy until there is further clarification. The Health Care Financing Administrator responded by writing that "the decision to implement this policy nationwide was not discretionary." Congress chose not to add statutory language deferring to the states, and under U.S. Constitutional law, where state law or policy conflicts with federal law, federal law takes precedence. The next battle will certainly center on attempts to amend the Hyde amendment itself as well as health care legislation along the "states' option" lines. PMID:12345518

  20. Advancing asthma care: the glass is only half full!!

    PubMed Central

    Szefler, Stanley J.

    2011-01-01

    Summary Over the past 20 years there has been a concerted effort in the United States to reduce morbidity related to chronic disease including asthma. Attention was initially directed towards asthma in response to the recognition that asthma mortality was increasing and that the burden of disease was significant. These efforts to address asthma mortality led to many new initiatives to develop clinical practice guidelines, implement the asthma guidelines into clinical practice, conduct research to fill the gaps in the guidelines, and to continuously revise the asthma guidelines as more information became available. An assessment of our progress shows significant accomplishments in relation to reducing asthma mortality and hospitalizations. Consequently, we are now at a crossroads in asthma care. Although we have recognized some remarkable accomplishments in reducing asthma mortality and morbidity, the availability of new tools to monitor disease activity, including biomarkers and epigenetic markers, along with information technology systems to monitor asthma control hold some promise in identifying gaps in disease management. These advances should prompt the evolution of new strategies and new treatments to further reduce disease burden. It now becomes imperative to continue a focus on ways to further reduce the burden of asthma and prevent its onset. PMID:21798579

  1. Advances in the care of patients with mucinous colorectal cancer.

    PubMed

    Hugen, Niek; Brown, Gina; Glynne-Jones, Robert; de Wilt, Johannes H W; Nagtegaal, Iris D

    2016-06-01

    The majority of colorectal cancers (CRCs) are classified as adenocarcinoma not otherwise specified (AC). Mucinous carcinoma (MC) is a distinct form of CRC and is found in 10-15% of patients with CRC. MC differs from AC in terms of both clinical and histopathological characteristics, and has long been associated with an inferior response to treatment compared with AC. The debate concerning the prognostic implications of MC in patients with CRC is ongoing and MC is still considered an unfavourable and unfamiliar subtype of the disease. Nevertheless, in the past few years epidemiological and clinical studies have shed new light on the treatment and management of patients with MC. Use of a multidisciplinary approach, including input from surgeons, pathologists, oncologists and radiologists, is beginning to lead to more-tailored approaches to patient management, on an individualized basis. In this Review, the authors provide insight into advances that have been made in the care of patients with MC. The prognostic implications for patients with colon or rectal MC are described separately; moreover, the predictive implications of MC regarding responses to commonly used therapies for CRC, such as chemotherapy, radiotherapy and chemoradiotherapy, and the potential for, and severity of, metastasis are also described. PMID:26323388

  2. Anticipatory care planning and integration: a primary care pilot study aimed at reducing unplanned hospitalisation

    PubMed Central

    Baker, Adrian; Leak, Paul; Ritchie, Lewis D; Lee, Amanda J; Fielding, Shona

    2012-01-01

    Background Anticipatory care for older patients who are frail involves both case identification and proactive intervention to reduce hospitalisation. Aim To identify a population who were at risk of admission to hospital and to provide an anticipatory care plan (ACP) for them and to ascertain whether using primary and secondary care data to identify this population and then applying an ACP can help to reduce hospital admission rates. Design and setting Cohort study of a service intervention in a general practice and a primary care team in Scotland. Method The ACP sets out patients’ wishes in the event of a sudden deterioration in health. If admitted, a proactive approach was taken to transfer and discharge patients into the community. Cohorts were selected using the Nairn Case Finder, which matched patients in two practices for age, sex, multiple morbidity indexes, and secondary care outpatient and inpatient activity; 96 patients in each practice were studied for admission rate, occupied bed days and survival. Results Survivors from the ACP cohort (n = 80) had 510 fewer days in hospital than in the 12 months pre-intervention: a significant reduction of 52.0% (P = 0.020). There were 37 fewer admissions of the survivors from that cohort post-intervention than in the preceding 12 months, with a significant reduction of 42.5% (P = 0.002). Mortality rates in the two cohorts were similar, but the number of patients who died in hospital and the hospital bed days used in the last 3 months of life were significantly lower for the decedents with an ACP than for the controls who had died (P = 0.007 and P = 0.045 respectively). Conclusion This approach produced statistically significant reductions in unplanned hospitalisation for a cohort of patients with multiple morbidities. It demonstrates the potential for providing better care for patients as well as better value for health and social care services. It is of particular benefit in managing end-of-life care. PMID:22520788

  3. Space Station Freedom advanced photovoltaics and battery technology development planning

    NASA Astrophysics Data System (ADS)

    Brender, Karen D.; Cox, Spruce M.; Gates, Mark T.; Verzwyvelt, Scott A.

    1993-05-01

    Space Station Freedom (SSF) usable electrical power is planned to be built up incrementally during assembly phase to a peak of 75 kW end-of-life (EOL) shortly after Permanently Manned Capability (PMC) is achieved in 1999. This power will be provided by planar silicon (Si) arrays and nickel-hydrogen (NiH2) batteries. The need for power is expected to grow from 75 kW to as much as 150 kW EOL during the evolutionary phase of SSF, with initial increases beginning as early as 2002. Providing this additional power with current technology may not be as cost effective as using advanced technology arrays and batteries expected to develop prior to this evolutionary phase. A six-month study sponsored by NASA Langley Research Center and conducted by Boeing Defense and Space Group was initiated in Aug. 1991. The purpose of the study was to prepare technology development plans for cost effective advanced photovoltaic (PV) and battery technologies with application to SSF growth, SSF upgrade after its arrays and batteries reach the end of their design lives, and other low Earth orbit (LEO) platforms. Study scope was limited to information available in the literature, informal industry contacts, and key representatives from NASA and Boeing involved in PV and battery research and development. Ten battery and 32 PV technologies were examined and their performance estimated for SSF application. Promising technologies were identified based on performance and development risk. Rough order of magnitude cost estimates were prepared for development, fabrication, launch, and operation. Roadmaps were generated describing key issues and development paths for maturing these technologies with focus on SSF application.

  4. Space Station Freedom advanced photovoltaics and battery technology development planning

    NASA Technical Reports Server (NTRS)

    Brender, Karen D.; Cox, Spruce M.; Gates, Mark T.; Verzwyvelt, Scott A.

    1993-01-01

    Space Station Freedom (SSF) usable electrical power is planned to be built up incrementally during assembly phase to a peak of 75 kW end-of-life (EOL) shortly after Permanently Manned Capability (PMC) is achieved in 1999. This power will be provided by planar silicon (Si) arrays and nickel-hydrogen (NiH2) batteries. The need for power is expected to grow from 75 kW to as much as 150 kW EOL during the evolutionary phase of SSF, with initial increases beginning as early as 2002. Providing this additional power with current technology may not be as cost effective as using advanced technology arrays and batteries expected to develop prior to this evolutionary phase. A six-month study sponsored by NASA Langley Research Center and conducted by Boeing Defense and Space Group was initiated in Aug. 1991. The purpose of the study was to prepare technology development plans for cost effective advanced photovoltaic (PV) and battery technologies with application to SSF growth, SSF upgrade after its arrays and batteries reach the end of their design lives, and other low Earth orbit (LEO) platforms. Study scope was limited to information available in the literature, informal industry contacts, and key representatives from NASA and Boeing involved in PV and battery research and development. Ten battery and 32 PV technologies were examined and their performance estimated for SSF application. Promising technologies were identified based on performance and development risk. Rough order of magnitude cost estimates were prepared for development, fabrication, launch, and operation. Roadmaps were generated describing key issues and development paths for maturing these technologies with focus on SSF application.

  5. Review of Planning for uncertainty: living wills and other advance directives for you and your family, 2nd edition by David John Doukas, M.D., and William Reichel, M.D

    PubMed Central

    Bernal, Ellen W

    2008-01-01

    Advance directives are useful ways to express one's wishes about end of life care, but even now most people have not completed one of the documents. David Doukas and William Reichel strongly encourage planning for end of life care. Although Planning for Uncertainty is at times fairly abstract for the general reader, it does provide useful background and practical steps.

  6. Complex Care Options for Patients With Advanced Heart Failure Approaching End of Life.

    PubMed

    Wordingham, Sara E; McIlvennan, Colleen K; Dionne-Odom, J Nicholas; Swetz, Keith M

    2016-02-01

    Care for patients with advanced cardiac disease continues to evolve in a complex milieu of therapeutic options, advanced technological interventions, and efforts at improving patient-centered care and shared decision-making. Despite improvements in quality of life and survival with these interventions, optimal supportive care across the advanced illness trajectory remains diverse and heterogeneous. Herein, we outline challenges in prognostication, communication, and caregiving in advanced heart failure and review the unique needs of patients who experience frequent hospitalizations, require chronic home inotropic support, and who have implantable cardioverter-defibrillators and mechanical circulatory support in situ, to name a few. PMID:26829929

  7. A Cost Sharing Plan: Solutions for the Child Care Crisis.

    ERIC Educational Resources Information Center

    Delaware Valley Child Care Council, Philadelphia, PA.

    This booklet discusses the current child care crisis and suggests a solution to the crisis. The gap between the cost of child care and parents' ability to pay is restricting the expansion and availability of child care services and undercutting the quality of child care. The average cost of full-day child care in the Delaware Valley, Pennsylvania,…

  8. Advanced Platform Systems Technology study. Volume 4: Technology advancement program plan

    NASA Technical Reports Server (NTRS)

    1983-01-01

    An overview study of the major technology definition tasks and subtasks along with their interfaces and interrelationships is presented. Although not specifically indicated in the diagram, iterations were required at many steps to finalize the results. The development of the integrated technology advancement plan was initiated by using the results of the previous two tasks, i.e., the trade studies and the preliminary cost and schedule estimates for the selected technologies. Descriptions for the development of each viable technology advancement was drawn from the trade studies. Additionally, a logic flow diagram depicting the steps in developing each technology element was developed along with descriptions for each of the major elements. Next, major elements of the logic flow diagrams were time phased, and that allowed the definition of a technology development schedule that was consistent with the space station program schedule when possible. Schedules show the major milestone including tests required as described in the logic flow diagrams.

  9. Development of Advanced Multi-Modality Radiation Treatment Planning Software

    SciTech Connect

    Nigg, D W; Hartmann Siantar, C

    2002-02-19

    The Idaho National Engineering and Environmental Laboratory (INEEL) has long been active in development of advanced Monte-Carlo based computational dosimetry and treatment planning methods and software for advanced radiotherapy, with a particular focus on Neutron Capture Therapy (NCT) and, to a somewhat lesser extent, Fast-Neutron Therapy. The most recent INEEL software product system of this type is known as SERA, Simulation Environment for Radiotherapy Applications. SERA is at a mature level in its life cycle, it has been licensed for research use worldwide, and it has become well established as a computational tool for research. However, along with its strengths, SERA also has some limitations in its structure and computational methodologies. More specifically, it is optimized only for neutron-based applications. Although photon transport can be computed with SERA, the simplified model that is used is designed primarily for photons produced in the neutron transport process. Thus SERA is not appropriate for applications to, for example, standard external-beam photon radiotherapy, which is by far more commonly used in the clinic than neutron based therapy.

  10. Plans for an Upgrade of the Advanced Photon Source

    NASA Astrophysics Data System (ADS)

    Mills, Dennis; APS-U Project Team

    2011-03-01

    We are presently developing plans for an upgrade of the Advanced Photon Source facility. Science has formally issued Critical Decision 0 and approved the Mission Need Statement in April of 2010, authorizing the APS to develop a conceptual design for the APS Upgrade (APS-U) project. The proposed upgrade will include enhancements to the accelerator, beamlines, and facility infrastructure. The high brilliance x-ray beams at high photon energy (e.g. > 25 keV) provided by the APS Upgrade will have strong impact on research in energy, the environment, new or improved materials, and biological studies. High-energy x-rays can penetrate into a wide range of realistic and/or extreme environments and allow imaging of structures and processes in unprecedented detail on picosecond time scales and nanometer length scales. The presentation will include some of the essential goals of the APS-U and proposed strategies to attain those goals. The Advanced Photon Source at Argonne National Laboratory is supported by the U. S. Department of Energy, Office of Science, Office of Basic Energy Sciences, under Contract No. DE-AC02-06CH11357.

  11. Fuel qualification plan for the Advanced Neutron Source Reactor

    SciTech Connect

    Copeland, G.L.

    1995-07-01

    This report describes the development and qualification plan for the fuel for the Advanced Neutron Source. The reference fuel is U{sub 3}Si{sub 2}, dispersed in aluminum and clad in 6061 aluminum. This report was prepared in May 1994, at which time the reference design was for a two-element core containing highly enriched uranium (93% {sup 235}U) . The reactor was in the process of being redesigned to accommodate lowered uranium enrichment and became a three-element core containing a higher volume fraction of uranium enriched to 50% {sup 235}U. Consequently, this report was not issued at that time and would have been revised to reflect the possibly different requirements of the lower-enrichment, higher-volume fraction fuel. Because the reactor is now being canceled, this unrevised report is being issued for archival purposes. The report describes the fabrication and inspection development plan, the irradiation tests and performance modeling to qualify performance, the transient testing that is part of the safety program, and the interactions and interfaces of the fuel development with other tasks.

  12. Advanced Stirling Convertor Durability Testing: Plans and Interim Results

    NASA Technical Reports Server (NTRS)

    Meer, David W.; Oriti, Salvatore M.

    2012-01-01

    The U.S. Department of Energy (DOE), Lockheed Martin Corporation (LM), and NASA Glenn Research Center (GRC) have been developing the Advanced Stirling Radioisotope Generator (ASRG) for use as a power system for space science missions. In support of this program, GRC has been involved in testing Stirling convertors, including the Advanced Stirling Convertor (ASC), for use in the ASRG. This testing includes electromagnetic interference/compatibility (EMI/EMC), structural dynamics, advanced materials, organics, and unattended extended operation. The purpose of the durability tests is to experimentally demonstrate the margins in the ASC design. Due to the high value of the hardware, previous ASC tests focused on establishing baseline performance of the convertors within the nominal operating conditions. The durability tests present the first planned extension of the operating conditions into regions beyond those intended to meet the product spec, where the possibility exists of lateral contact, overstroke, or over-temperature events. These tests are not intended to cause damage that would shorten the life of the convertors, so they can transition into extended operation at the conclusion of the tests. This paper describes the four tests included in the durability test sequence: 1) start/stop cycling, 2) exposure to constant acceleration in the lateral and axial directions, 3) random vibration at increased piston amplitude to induce contact events, and 4) overstroke testing to simulate potential failures during processing or during the mission life where contact events could occur. The paper also summarizes the analysis and simulation used to predict the results of each of these tests.

  13. Advanced Stirling Convertor Durability Testing: Plans and Interim Results

    NASA Technical Reports Server (NTRS)

    Meer, Dave; Oriti, Sal

    2012-01-01

    The U.S. Department of Energy (DOE), Lockheed Martin Corporation (LM), and NASA Glenn Research Center (GRC) have been developing the Advanced Stirling Radioisotope Generator (ASRG) for use as a power system for space science missions. In support of this program, NASA?s Glenn Research Center (GRC) has been involved in testing Stirling convertors, including the Advanced Stirling Convertor (ASC), for use in the ASRG. This testing includes electromagnetic interference/compatibility (EMI/EMC), structural dynamics, advanced materials, organics, and unattended extended operation. The purpose of the durability tests is to experimentally demonstrate the margins in the ASC design. Due to the high value of the hardware, previous ASC tests focused on establishing baseline performance of the convertors within the nominal operating conditions. The durability tests present the first planned extension of the operating conditions into regions beyond those intended to meet the product spec, where the possibility exists of lateral contact, overstroke, or over-temperature events. These tests are not intended to cause damage that would shorten the life of the convertors, so they can transition into extended operation at the conclusion of the tests. This paper describes the four tests included in the durability test sequence: 1) start/stop cycling, 2) exposure to constant acceleration in the lateral and axial directions, 3) random vibration at increased piston amplitude to induce contact events, and 4) overstroke testing to simulate potential failures during processing or during the mission life where contact events could occur. The paper also summarizes the analysis and simulation used to predict the results of each of these tests.

  14. Community care management across the continuum. Study results from a Medicare health maintenance plan.

    PubMed

    Quinn, J L; Prybylo, M; Pannone, P

    1999-01-01

    A large national health plan piloting a community care management (CCM) model for its high-risk, chronically ill, Medicare population has demonstrated a significant reduction in overall medical costs for its participants. The key elements include: the proactive identification and risk stratification of members; assignment of advanced practice nurses to physicians with high-volume high-risk members; and ongoing clinical management across the continuum, establishing a continuous relationship with the member. The results are derived from a retrospective study comparing 6 months of claim data prior to the member entering CCM, with 6 months of claim data while participants received community, care management. Members in the pilot study experienced both a 42% reduction in institutional days and a 53% reduction in admissions to acute care settings. In addition, physician and specialists fees were reduced by 37%. This resulted in a 6-month net savings of $3,602 per participant. To be extremely conservative, the savings were reduced by 50% to reflect the possible impact of regression to the mean. Even accounting for this, the program's projected cost savings are $1,801 per participant in 6 months. The total projected savings for community care managed members in a fully implemented program divided by the entire enrolled population of 27,000 is $6.60 per member per month (PM/PM). The results of this study of care management across the continuum signal a new approach for medical management at a time when health care and the needs of the population are changing. PMID:10879209

  15. Consensus statement on advancing research in emergency department operations and its impact on patient care.

    PubMed

    Yiadom, Maame Yaa A B; Ward, Michael J; Chang, Anna Marie; Pines, Jesse M; Jouriles, Nick; Yealy, Donald M

    2015-06-01

    The consensus conference on "Advancing Research in Emergency Department (ED) Operations and Its Impact on Patient Care," hosted by The ED Operations Study Group (EDOSG), convened to craft a framework for future investigations in this important but understudied area. The EDOSG is a research consortium dedicated to promoting evidence-based clinical practice in emergency medicine. The consensus process format was a modified version of the NIH Model for Consensus Conference Development. Recommendations provide an action plan for how to improve ED operations study design, create a facilitating research environment, identify data measures of value for process and outcomes research, and disseminate new knowledge in this area. Specifically, we call for eight key initiatives: 1) the development of universal measures for ED patient care processes; 2) attention to patient outcomes, in addition to process efficiency and best practice compliance; 3) the promotion of multisite clinical operations studies to create more generalizable knowledge; 4) encouraging the use of mixed methods to understand the social community and human behavior factors that influence ED operations; 5) the creation of robust ED operations research registries to drive stronger evidence-based research; 6) prioritizing key clinical questions with the input of patients, clinicians, medical leadership, emergency medicine organizations, payers, and other government stakeholders; 7) more consistently defining the functional components of the ED care system, including observation units, fast tracks, waiting rooms, laboratories, and radiology subunits; and 8) maximizing multidisciplinary knowledge dissemination via emergency medicine, public health, general medicine, operations research, and nontraditional publications. PMID:26014365

  16. Completion of advanced care directives is associated with willingness to donate.

    PubMed Central

    Thornton, J. Daryl; Curtis, J. Randall; Allen, Margaret D.

    2006-01-01

    OBJECTIVES: A useful framework for initiating organ donation discussions in the primary care setting may help increase willingness to donate and thereby increase the frequency of organ transplantation. Given the lower willingness to donate among African Americans and that a higher proportion of African Americans die while waiting for an organ transplant, this is an important group to consider in such an approach. We examined the association among completion of a living will and willingness to donate and the influence of race in this relationship. METHODS: A nationwide telephone interview survey using random digit dialing of households in high- and low-density African-American census blocks. Results: One hundred-eighty-eight adults participated (41% cooperation rate). In a multivariate model, factors associated with willingness to donate included having signed a living will (OR=2.43, 95% CI=1.13-5.23), talking with a physician about organ donation (OR=3.04, 95% CI=1.07-8.67) and white race (OR=2.5, 95% CI=1.23-5). CONCLUSION: The public is generally supportive of organ donation although African Americans remain less willing to donate after controlling for confounding variables. Physicians interested in increasing donation rates should consider incorporating organ donation into discussions of advance care planning and end-of-life care. PMID:16775911

  17. The role of Advanced Practice Providers in interdisciplinary oncology care in the United States.

    PubMed

    Reynolds, Rae Brana; McCoy, Kimberly

    2016-06-01

    Advanced Practice Registered Nurses (APRNs) and Physician Assistants (PAs), generally referred to as Advanced Practice Providers (APPs), are fundamental to interdisciplinary oncology care. As the projected demand for oncology services is anticipated to outpace the supply of oncologists, APPs will become increasingly vital in the delivery of oncology care and services. The training, education, and scope of practice for APPs gives the interdisciplinary care team professionals that deliver high-quality clinical services and provide valuable contributions and leadership to health care quality improvement initiatives. Optimizing the integration of APPs in oncology care offers immense advantages towards improvement of clinical outcomes. PMID:27197514

  18. Bioinformatics Methods and Tools to Advance Clinical Care

    PubMed Central

    Lecroq, T.

    2015-01-01

    Summary Objectives To summarize excellent current research in the field of Bioinformatics and Translational Informatics with application in the health domain and clinical care. Method We provide a synopsis of the articles selected for the IMIA Yearbook 2015, from which we attempt to derive a synthetic overview of current and future activities in the field. As last year, a first step of selection was performed by querying MEDLINE with a list of MeSH descriptors completed by a list of terms adapted to the section. Each section editor has evaluated separately the set of 1,594 articles and the evaluation results were merged for retaining 15 articles for peer-review. Results The selection and evaluation process of this Yearbook’s section on Bioinformatics and Translational Informatics yielded four excellent articles regarding data management and genome medicine that are mainly tool-based papers. In the first article, the authors present PPISURV a tool for uncovering the role of specific genes in cancer survival outcome. The second article describes the classifier PredictSNP which combines six performing tools for predicting disease-related mutations. In the third article, by presenting a high-coverage map of the human proteome using high resolution mass spectrometry, the authors highlight the need for using mass spectrometry to complement genome annotation. The fourth article is also related to patient survival and decision support. The authors present datamining methods of large-scale datasets of past transplants. The objective is to identify chances of survival. Conclusions The current research activities still attest the continuous convergence of Bioinformatics and Medical Informatics, with a focus this year on dedicated tools and methods to advance clinical care. Indeed, there is a need for powerful tools for managing and interpreting complex, large-scale genomic and biological datasets, but also a need for user-friendly tools developed for the clinicians in their

  19. Using a Question Prompt List As a Communication Aid in Advanced Cancer Care

    PubMed Central

    Yeh, Jonathan C.; Jennifer Cheng, M.; Chung, Christine H.; Smith, Thomas J.

    2016-01-01

    Purpose Oncologists and patients often avoid discussing prognosis, treatment failure, and end-of-life planning. Thus, many patients still overestimate their prognosis and possibility of cure, impairing decision making. We piloted a question prompt list (QPL) covering these issues to determine whether it would affect patient anxiety and how it would be used and received by new oncology patients. Materials and Methods A one-page checklist of common questions surrounding cancer care, quality of life, and end of life was created from previous instruments. A total of 30 patients with advanced or metastatic head and neck cancer were recruited from outpatient clinics. Patients received the QPL before their initial consultation. Patient anxiety, satisfaction, and information/decision-making preferences were assessed using validated instruments. Patient opinions regarding the QPL were solicited through Likert-scale items. Results During their visit, 27 patients (90%) used the QPL, but notably, none shared it directly with their oncologist. Most participants felt that the QPL was relevant and helpful (90%) and recommended that more physicians use this sort of list (90%) while disagreeing that the QPL made them feel anxious (80%). Generally, participants were highly satisfied with the consultation, and their anxiety decreased during the visit (P < .005). Conclusion A simple, one-page QPL addressing cancer treatment, prognosis, quality of life, and end-of-life issues was well received by new oncology patients and did not affect patient anxiety or physician workflow. Follow-up studies will determine whether use of the QPL increases knowledge, facilitates decision making, and improves advance-care planning. PMID:24594680

  20. Care planning at home: a way to increase the influence of older people?

    PubMed Central

    Berglund, Helene; Dunér, Anna; Blomberg, Staffan; Kjellgren, Karin

    2012-01-01

    Introduction: Care-planning meetings represent a common method of needs assessment and decision-making practices in elderly care. Older people’s influence is an important and required aspect of these practices. This study’s objective was to describe and analyse older people’s influence on care-planning meetings at home and in hospital. Methods: Ten care-planning meetings were audio-recorded in the older people’s homes and nine were recorded in hospital. The study is part of a project including a comprehensive continuum-of-care model. A qualitative content analysis was performed. Results: Care-planning meetings at home appeared to enable older people’s involvement in the discussions. Fewer people participated in the meetings at home and there was less parallel talking. Unrelated to the place of the care-planning meeting, the older people were able to influence concerns relating to the amount of care/service and the choice of provider. However, they were not able to influence the way the help should be provided or organised. Conclusion: Planning care at home indicated an increase in involvement on the part of the older people, but this does not appear to be enough to obtain any real influence. Our findings call for attention to be paid to older people’s opportunities to receive care and services according to their individual needs and their potential for influencing their day-to-day provision of care and service. PMID:23593048

  1. Economic Impact of an Advanced Illness Consultation Program within a Medicare Advantage Plan Population

    PubMed Central

    Colaberdino, Vincent; Marshall, Colleen; DuBose, Paul; Daitz, Mitchell

    2016-01-01

    Abstract Background: In the United States the quality and cost associated with medical treatment for individuals experiencing an advanced illness is highly variable and is often misaligned with the patient's and family's quality of life values and priorities. Many of the obstacles that stand in the way of aligning the care that an individual receives with their priorities are well understood in the context of behavioral science. Through employing behavioral based approaches to improve the quality of communication and shared decision making processes among patients, providers and families it is possible to enhance the efficiency of delivering care which is also more highly aligned with the individual's preferences. Objectives: The study objectives were to measure the economic impact of a proprietary advanced illness behavioral consultation program, the Vital Decisions Living Well Consultation Program (LWCP), on the cost of care delivered during the last six and three months of life for enrolled members in a Medicare Advantage plan. Study design: Retrospective matched case control analysis examined medical, pharmaceutical, and capitation expenses after an offset by premium revenue. Methods: The treatment population consisted of participating members of the LWCP who died between October 1, 2011 and March 31, 2013 (N = 1755). The control population consisted of plan members who died between July 1, 2008 and June 1, 2011, prior to the introduction of the LWCP (N = 5560). Criteria used to match treatment subjects with one or more control subjects were diagnosis, age at death, and health care costs incurred prior to the time under examination. A paired t-test evaluated the significance of differences between the matched treatment and control members. Results: The mean cost reduction during the last six months of life for treatment members compared to matched control group members was $13,956 (p < 0.001) during the last six months of life and $9,285 (p < 0

  2. A Plan of Action for Recruitment and Evaluation of the Child Care Credential Training Program for Child Care Professionals.

    ERIC Educational Resources Information Center

    Whaley, Deborah W.

    This practicum project was designed to formulate and initiate a plan of action to promote and evaluate a community college Child Care Credential (CCC) training program. A pre-implementation survey indicated that few child care professionals in the community knew of the program or its characteristics. A media campaign was designed to promote the…

  3. Type of Plan and Provider Network (Affordable Care Act)

    MedlinePlus

    ... health insurance plan Email Print Health insurance plan & network types: HMOs, PPOs, and more 3 things to ... deductible & out-of-pocket costs Health insurance plan & network types: HMOs, PPOs, and more START HERE See ...

  4. Professional perspectives on service user and carer involvement in mental health care planning: A qualitative study

    PubMed Central

    Bee, Penny; Brooks, Helen; Fraser, Claire; Lovell, Karina

    2015-01-01

    Background Involving users/carers in mental health care-planning is central to international policy initiatives yet users frequently report feeling excluded from the care planning process. Rigorous explorations of mental health professionals’ experiences of care planning are lacking, limiting our understanding of this important translational gap. Objectives To explore professional perceptions of delivering collaborative mental health care-planning and involving service users and carers in their care. Design Qualitative interviews and focus groups with data combined and subjected to framework analysis. Setting UK secondary care mental health services. Participants 51 multi-disciplinary professionals involved in care planning and recruited via study advertisements. Results Emergent themes identified care-planning as a meaningful platform for user/carer involvement but revealed philosophical tensions between user involvement and professional accountability. Professionals emphasised their individual, relational skills as a core facilitator of involvement, highlighting some important deficiencies in conventional staff training programmes. Conclusions Although internationally accepted on philosophical grounds, user-involved care-planning is poorly defined and lacks effective implementation support. Its full realisation demands greater recognition of both the historical and contemporary contexts in which statutory mental healthcare occurs. PMID:26253574

  5. NIH Research: Children Research Volunteers Receive Care and Help Advance Knowledge | NIH MedlinePlus the Magazine

    MedlinePlus

    ... of this page please turn Javascript on. NIH Research: Children Research Volunteers Receive Care and Help Advance Knowledge Past ... NIH Clinical Center. Photo: NIH Clinical Center Children research volunteers receive care and help advance knowledge I ...

  6. Plan for advanced microelectronics processing technology application. Final report

    SciTech Connect

    Goland, A.N.

    1990-10-01

    The ultimate objective of the tasks described in the research agreement was to identify resources primarily, but not exclusively, within New York State that are available for the development of a Center for Advanced Microelectronics Processing (CAMP). Identification of those resources would enable Brookhaven National Laboratory to prepare a program plan for the CAMP. In order to achieve the stated goal, the principal investigators undertook to meet the key personnel in relevant NYS industrial and academic organizations to discuss the potential for economic development that could accompany such a Center and to gauge the extent of participation that could be expected from each interested party. Integrated of these discussions was to be achieved through a workshop convened in the summer of 1990. The culmination of this workshop was to be a report (the final report) outlining a plan for implementing a Center in the state. As events unfolded, it became possible to identify the elements of a major center for x-ray lithography on Lone Island at Brookhaven National Laboratory. The principal investigators were than advised to substitute a working document based upon that concept in place of a report based upon the more general CAMP workshop originally envisioned. Following that suggestion from the New York State Science and Technology Foundation, the principals established a working group consisting of representatives of the Grumman Corporation, Columbia University, the State University of New York at Stony Brook, and Brookhaven National Laboratory. Regular meetings and additional communications between these collaborators have produced a preproposal that constitutes the main body of the final report required by the contract. Other components of this final report include the interim report and a brief description of the activities which followed the establishment of the X-ray Lithography Center working group.

  7. Palliative care and end-of-life planning in Parkinson's disease.

    PubMed

    Walker, Richard William

    2013-04-01

    In Parkinson's disease (PD) typical "palliative care" type symptoms, such as pain, nausea, weight loss and breathlessness can occur throughout the condition, but become more prevalent in later disease stages. Pain may be specifically related to PD, e.g. dystonic pain with wearing off, but is more commonly due to other conditions. The cause can usually be elicited by a careful history and examination, and this guides intervention, both non-pharmaceutical, and pharmaceutical. For example, dystonic pain will respond best to appropriate changes to dopaminergic medication. In later disease stages people have increasing problems with swallowing, and also cognitive impairment. Impaired swallowing may lead to aspiration pneumonia, which is a common cause of hospital admission, and also death. Decisions about interventions towards the end of life, such as insertion of percutaneous endoscopic gastrostomy (PEG) tube for nutrition, can be very challenging, particularly if, as in most cases, the person with PD has not previously expressed their views upon this while they still maintained capacity to make decisions. Advance care planning (ACP) in PD should be encouraged in relation to interventions such as PEG tubes. It may also cover issues such as preferred place of death. Over recent years lower proportions of people have been dying at home, and this is especially true for PD, but home may well be where they would have preferred to die. However, there is little evidence to guide health professionals about how, when, and by whom, ACP should be approached. PMID:23328948

  8. Family planning and maternal health care in Egypt.

    PubMed

    El-mouelhy, M T

    1990-01-01

    The Government of Egypt is introducing policies to reduce the mortality of women of reproductive age. However, family planning and maternal-child health care programs are unlikely to have the desired impact without corresponding improvements in the status of Egyptian women. Women's status in the areas of education, health, poverty, employment, the family, government, and the community is a crucial determinant of their willingness and ability to accept a smaller family size ideal and become contraceptive users. At present, only 6% of Egyptian women are a part of the work force and 60% are illiterate. In a society in which women are valued on the basis of the number of children they produce for their husbands, those practice birth control risk abandonment and isolation. The powerlessness and insecurity that lead Egyptian women to have an average of at least 5 children impeded national development and thus delay creation of the socioeconomic conditions that could liberate women from their domestic role. Equal opportunities in education and employment would represent a first step toward improving women's status by giving them a source of income and increased independence. Also needed are modifications in archaic marriage, divorce, and custody laws. PMID:12317075

  9. [Necessary changes for advancing nursing as caring science].

    PubMed

    de Pires, Denise Elvira Pires

    2013-09-01

    The article aimed to reflect upon the challenges involved in strengthening Nursing as a caring science. It is founded on the sociological theory, connecting three approaches: the historical-dialectic materialism perspective about the working process in health care and nursing; the sociology of professions from a critical perspective; and the philosophy of science. The discussion is organized considering the aspects of Nursing as a discipline, work and health care profession. It sustains that knowledge production should be driven both by the purpose of Nursing work which is providing care to human beings with health needs and to advocate for the indispensable work conditions to a safe and responsible practice. It concludes that to strengthening Nursing it is necessary to produce knowledge to support nursing care and the political actions defending safe work conditions, the universal right to health as well safe and high quality care. PMID:24092308

  10. Manager's leadership is the main skill for ambulatory health care plan success.

    PubMed

    Marin, Gustavo Horacio; Silberman, Martin; Colombo, Maria Virginia; Ozaeta, Belen; Henen, Jaime

    2015-01-01

    To demonstrate effectiveness of ambulatory health care plan implementation among institutions and variables associated with the differences observed. Randomized selection of primary health care (PHC) centers was done. Leadership ability of the plan manager was explored. Univariate/bivariate analyses were performed to observe correlation between variables. Two groups of PHC centers were established according to the efficacy of plan implementation: high and low performance. Differences between groups were observed (592%-1023% more efficacy in controls and practices; P < .001). Leadership was responsible for the main differences observed. Leadership of manager for implementation of the health care plan was the major important variable to reach the best efficacy standards. PMID:25469579

  11. Razing a Tower of Babel: a taxonomy for managed care and health insurance plans.

    PubMed

    Weiner, J P; de Lissovoy, G

    1993-01-01

    To many, the U.S. health care system has become an unintelligible alphabet soup of three-letter health plans. There is little agreement about which characteristics distinguish one type of plan from another. In this article we chip away at what has become a Tower of Babel of managed care and health insurance terminology. We review past and current trends in the market for nontraditional health benefit plans and propose a taxonomy, or system of classification, that will aid in understanding how managed care plans differ from conventional health insurance and from one another. Also included is a comprehensive glossary of terms. PMID:8320444

  12. Advancing Design-for-Assembly: The Next Generation in Assembly Planning

    SciTech Connect

    Calton, T.L.

    1998-12-09

    At the 1995 IEEE Symposium on Assembly and Task Planning, Sandia National Laboratories introduced the Archimedes 2 Software Tool [2]. The system was described as a second-generation assembly planning system that allowed preliminmy application of awembly planning for industry, while solidly supporting further research in planning techniques. Sandia has worked closely with indust~ and academia over the last four years. The results of these working relationships have bridged a gap for the next generation in assembly planning. Zke goal of this paper is to share Sandia 's technological advancements in assembly planning over the last four years and the impact these advancements have made on the manufacturing communip.

  13. Social Work Discharge Planning in Acute Care Hospitals in Israel: Clients' Evaluation of the Discharge Planning Process and Adequacy

    ERIC Educational Resources Information Center

    Soskolne, Varda; Kaplan, Giora; Ben-Shahar, Ilana; Stanger, Varda; Auslander, Gail. K.

    2010-01-01

    Objective: To examine the associations of patients' characteristics, hospitalization factors, and the patients' or family assessment of the discharge planning process, with their evaluation of adequacy of the discharge plan. Method: A prospective study. Social workers from 11 acute care hospitals in Israel provided data on 1426 discharged…

  14. Advanced Test Reactor Capabilities and Future Irradiation Plans

    SciTech Connect

    Frances M. Marshall

    2006-10-01

    The Advanced Test Reactor (ATR), located at the Idaho National Laboratory (INL), is one of the most versatile operating research reactors in the Untied States. The ATR has a long history of supporting reactor fuel and material research for the US government and other test sponsors. The INL is owned by the US Department of Energy (DOE) and currently operated by Battelle Energy Alliance (BEA). The ATR is the third generation of test reactors built at the Test Reactor Area, now named the Reactor Technology Complex (RTC), whose mission is to study the effects of intense neutron and gamma radiation on reactor materials and fuels. The current experiments in the ATR are for a variety of customers--US DOE, foreign governments and private researchers, and commercial companies that need neutrons. The ATR has several unique features that enable the reactor to perform diverse simultaneous tests for multiple test sponsors. The ATR has been operating since 1967, and is expected to continue operating for several more decades. The remainder of this paper discusses the ATR design features, testing options, previous experiment programs, future plans for the ATR capabilities and experiments, and some introduction to the INL and DOE's expectations for nuclear research in the future.

  15. Advanced Coal Conversion Process Demonstration Project. Environmental Monitoring Plan

    SciTech Connect

    Not Available

    1992-04-01

    Western Energy Company (WECO) was selected by the Department of Energy (DOE) to demonstrate the Advanced Coal Conversion Process (ACCP) which upgrades low rank coals into high Btu, low sulfur, synthetic bituminous coal. As specified in the Corporate Agreement, RSCP is required to develop an Environmental Monitoring Plan (EMP) which describes in detail the environmental monitoring activities to be performed during the project execution. The purpose of the EMP is to: (1) identify monitoring activities that will be undertaken to show compliance to applicable regulations, (2) confirm the specific environmental impacts predicted in the National Environmental Policy Act documentation, and (3) establish an information base of the assessment of the environmental performance of the technology demonstrated by the project. The EMP specifies the streams to be monitored (e.g. gaseous, aqueous, and solid waste), the parameters to be measured (e.g. temperature, pressure, flow rate), and the species to be analyzed (e.g. sulfur compounds, nitrogen compounds, trace elements) as well as human health and safety exposure levels. The operation and frequency of the monitoring activities is specified, as well as the timing for the monitoring activities related to project phase (e.g. preconstruction, construction, commissioning, operational, post-operational). The EMP is designed to assess the environmental impacts and the environmental improvements resulting from construction and operation of the project.

  16. Proceedings: Advanced motors and drives R D planning forum

    SciTech Connect

    McCleer, P.J. )

    1992-12-01

    With motors consuming nearly 70% of the total US electric power generation, there is a growing need for in-depth user information and comparison data on drive technology. Adjustable-speed drive technology offers opportunities for improving the productivity, energy conservation, and cost-effectiveness of motor operation. Recommendations from an EPRI R D motors and drives forum are organized into an assessment of research needs in areas of circuits, controls, power devices, motor design, and materials. EPRI's Advanced Motors and Drives R D Planning Forum was held June 21--22, 1990, in Monterey, California. More than 110 representatives from relevant economic sectors met in four sessions, each emphasizing a different aspect of motor technology and use. Session 1 reviewed the status of newer motor systems, such as permanent magnet (PM) and reluctance motors as well as associated power electronics. Session 2 reviewed motor and drive requirements in several key application areas such as heating, ventilating, and air conditioning (HVAC); refrigeration; petrochemicals; machine tools and appliances; motion control and robotics; and electric vehicle and automobile systems. Session 3 addressed issues involving motor materials, manufacturing, and marketing. Session 4's open discussions examined other motor and drive application needs and technology issues, while identifying and prioritizing R D areas.

  17. Planning Manual for School-Age Child Care in New Mexico.

    ERIC Educational Resources Information Center

    Rainhart, Dolly

    This manual was designed to assist concerned individuals and organizations within communities in New Mexico to develop and plan effective school-age child care programs. Emphasized are the first steps in initiating and implementing school-age child care in a community. Chapter I discusses the need for school-age child care programs and the…

  18. Nutrition and Meal Planning in Child-Care Programs: A Practical Guide.

    ERIC Educational Resources Information Center

    Edelstein, Sari

    Designed to assist child care center managers in planning nutritious meals for children in centers or licensed home day care programs, this guide presents information on the nutritional requirements of infants and children, sample menus for child care centers, and resources for further information. The first part of the guide details the…

  19. 42 CFR 418.56 - Condition of participation: Interdisciplinary group, care planning, and coordination of services.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 3 2010-10-01 2010-10-01 false Condition of participation: Interdisciplinary group, care planning, and coordination of services. 418.56 Section 418.56 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM HOSPICE CARE Conditions of Participation: Patient Care...

  20. Not-so-strange bedfellows: models of interaction between managed care plans and public health agencies.

    PubMed

    Halverson, P K; Mays, G P; Kaluzny, A D; Richards, T B

    1997-01-01

    Alliances between managed care plans and public health agencies are a growing phenomenon in local health care markets, with profound implications for health care quality, cost, and accessibility. A typology of interorganizational relations between managed care plans and local public health agencies is drawn from observations of over 60 public health jurisdictions. Relations are described along three dimensions corresponding to the strategic intent, functional operation, and structural design of each alliance type. The identified models of interaction reveal the motivations for forming alliances, the mechanics of their operation, and the possible outcomes. These alliances suggest that a wide range of interorganizational strategies is possible in order to pursue the shared interests of local public health agencies and managed care plans. Nonetheless, public health agencies may face challenges in forging managed care alliances that benefit community-wide populations and that are open to participation by the full spectrum of health care providers in the community. PMID:9063302

  1. Recent advances in the treatment of advanced renal cell carcinoma: towards multidisciplinary personalized care.

    PubMed

    Bex, Axel; Gore, Martin; Mulders, Peter; Sternberg, Cora N

    2012-11-01

    What's known on the subject? and What does the study add? With recent improvements in the prognosis for patients with metastatic renal cell carcinoma (mRCC), focus is now shifting towards maximising clinical benefit from targeted therapies. Factors other than efficacy data are increasingly being considered when selecting a treatment strategy, with a view towards optimising clinical outcomes. This review examines the development and efficacy of targeted agents for the management of mRCC and discusses the potential factors, including resistance mechanisms, sequential therapy, prognostic and predictive markers of response, and adverse event management, that may contribute to successful individually tallored treatment of patients with this disease. • Targeted agents have substantially improved outcomes for patients with metastatic renal cell carcinoma (mRCC). • Treatment focus is now shifting towards achieving a continuum of care such that long-term benefit and extended survival may be achieved through the optimal use of targeted agents. • To achieve this goal, a number of factors which impact on treatment selection and outcomes need to be considered when treating patients with mRCC, such as the optimal sequence of targeted therapies (and the related issue of resistance mechanisms). • Recent advances are also likely to impact on the future treatment of mRCC. Examples include the identification of predictive biomarkers as well as a consideration of patient risk profiles or the safety profile of the selected targeted agent. In addition, attention is focusing on re-defining the role of surgery for the treatment of RCC in the context of targeted therapies. • This review examines the recent and future advances that offer the potential for personalizing treatment by selecting the most appropriate treatment for each patient with a view towards optimizing clinical outcomes. PMID:22624610

  2. Democratic Citizenship and Service Learning: Advancing the Caring Self.

    ERIC Educational Resources Information Center

    Rhoads, Robert A.

    2000-01-01

    Discusses how service learning can promote the development of a "caring self" in college students by drawing on the ideas of John Dewey, George Herbert Mead, and contemporary critical theorists. Links this caring self to democratic citizenship and uses students' narratives to illustrate how it develops through service learning contexts. (DB)

  3. The Clintons stump for health care reform plan as details slowly emerge.

    PubMed

    1993-10-01

    In September 1993, in the US, Hillary Rodham Clinton, testified before 5 key congressional committees on President Clinton's plan to reform health care. Most of the money needed to finance the plan would come from elimination of waste in the current system. The administration has not yet formally sent the proposal to Congress. Family planning services are part of the proposed mandated benefit package, but the draft document does not provide details on family planning coverage while it discusses other mandated services in detail. Further, the draft document mentions neither family planning supplies (e.g., pills, IUDs, or diaphragms) nor whether family planning services will be considered preventive care, thereby exempting them from copayments or deductibles. It specifies prenatal care, periodic examinations, and screening test for children and adults (e.g., well-baby care and immunizations) as preventive services. The plan covers pregnancy-related care, but, other than exclusion of in vitro fertilization, this is not defined. The plan has a conscientious exemption option, but it is not clear as to whether the administration plans to continue the standing policy granting conscientious exemption to individuals and medical facilities or to expand it to include entire health plans. The administration emphasizes that, even though the plan covers abortion. The Health Insurance Association of America opposes the plan while the American Medical Association (AMA) neither supports nor opposes it. The AMA does object, however, to the plans provisions on malpractice and limits on annual premium increases. Families USA strongly favors the plan. The Congressional Caucus on Women's Issues asks the President to include all reproductive health services. The National Black Women's Health Project appreciates the Administration's commitment and the plan's coverage of preventive care and reproductive health, but stresses that it must improve access to poor women, most of whom are black

  4. 25 CFR 1001.9 - Selection criteria for tribes/consortia seeking advance planning grant funding.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... participate in self-governance. (e) Can tribes/consortia that receive advance planning grants also apply for a..., DEPARTMENT OF THE INTERIOR SELF-GOVERNANCE PROGRAM § 1001.9 Selection criteria for tribes/consortia seeking...-governance tribe and needs advance funding in order to complete the planning phase requirement may...

  5. 25 CFR 1001.9 - Selection criteria for tribes/consortia seeking advance planning grant funding.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... participate in self-governance. (e) Can tribes/consortia that receive advance planning grants also apply for a..., DEPARTMENT OF THE INTERIOR SELF-GOVERNANCE PROGRAM § 1001.9 Selection criteria for tribes/consortia seeking...-governance tribe and needs advance funding in order to complete the planning phase requirement may...

  6. 25 CFR 1001.9 - Selection criteria for tribes/consortia seeking advance planning grant funding.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... participate in self-governance. (e) Can tribes/consortia that receive advance planning grants also apply for a..., DEPARTMENT OF THE INTERIOR SELF-GOVERNANCE PROGRAM § 1001.9 Selection criteria for tribes/consortia seeking...-governance tribe and needs advance funding in order to complete the planning phase requirement may...

  7. 45 CFR 307.20 - Submittal of advance planning documents for computerized support enforcement systems.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... prescribed in 45 CFR part 95, subpart F. ... 45 Public Welfare 2 2011-10-01 2011-10-01 false Submittal of advance planning documents for... § 307.20 Submittal of advance planning documents for computerized support enforcement systems. The...

  8. 45 CFR 307.20 - Submittal of advance planning documents for computerized support enforcement systems.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... prescribed in 45 CFR part 95, subpart F. ... 45 Public Welfare 2 2014-10-01 2012-10-01 true Submittal of advance planning documents for... § 307.20 Submittal of advance planning documents for computerized support enforcement systems. The...

  9. 45 CFR 307.20 - Submittal of advance planning documents for computerized support enforcement systems.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... prescribed in 45 CFR part 95, subpart F. ... 45 Public Welfare 2 2012-10-01 2012-10-01 false Submittal of advance planning documents for... § 307.20 Submittal of advance planning documents for computerized support enforcement systems. The...

  10. 45 CFR 307.20 - Submittal of advance planning documents for computerized support enforcement systems.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... prescribed in 45 CFR part 95, subpart F. ... 45 Public Welfare 2 2010-10-01 2010-10-01 false Submittal of advance planning documents for... § 307.20 Submittal of advance planning documents for computerized support enforcement systems. The...

  11. 45 CFR 307.20 - Submittal of advance planning documents for computerized support enforcement systems.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... prescribed in 45 CFR part 95, subpart F. ... 45 Public Welfare 2 2013-10-01 2012-10-01 true Submittal of advance planning documents for... § 307.20 Submittal of advance planning documents for computerized support enforcement systems. The...

  12. 14 CFR 151.123 - Procedures: Offer; amendment; acceptance; advance planning agreement.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 14 Aeronautics and Space 3 2013-01-01 2013-01-01 false Procedures: Offer; amendment; acceptance; advance planning agreement. 151.123 Section 151.123 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION... Planning and Engineering Proposals § 151.123 Procedures: Offer; amendment; acceptance; advance...

  13. 14 CFR 151.123 - Procedures: Offer; amendment; acceptance; advance planning agreement.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 14 Aeronautics and Space 3 2014-01-01 2014-01-01 false Procedures: Offer; amendment; acceptance; advance planning agreement. 151.123 Section 151.123 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION... Planning and Engineering Proposals § 151.123 Procedures: Offer; amendment; acceptance; advance...

  14. Uneasy alliances: managed care plans formed by safety-net providers.

    PubMed

    Sparer, M S; Brown, L D

    2000-01-01

    Health care providers that have traditionally served the poor are forming their own managed care plans, often in alliance with local safety-net peers. These alliances make it easier to raise needed capital, increase the pool of likely enrollees, and enable plans to benefit from efficiencies of scale. At the same time, however, the alliances often are undermined by conflicts of interest among the different sponsors and between the sponsors and the plan. This paper suggests that these plans are most likely to do well when the state makes special efforts to help and when plans have the leadership and financial reserves to take advantage of their supportive state policies. PMID:10916958

  15. A dynamic care pathway to coordinate the use of advanced therapy in diabetic foot ulceration.

    PubMed

    Chadwick, P; Haycocks, S; Bielby, A; Milne, J

    2009-10-01

    The non-coordinated use of advanced therapies is not clinically or cost effective. A care pathway for the sequential use of these interventions on complex wounds provides a more restructured approach, and helped improve patient outcomes. PMID:19816383

  16. Advanced Education and Technology Business Plan, 2010-13. Highlights

    ERIC Educational Resources Information Center

    Alberta Advanced Education and Technology, 2010

    2010-01-01

    The Ministry of Advanced Education and Technology envisions Alberta's prosperity through innovation and lifelong learning. Advanced Education and Technology's mission is to lead the development of a knowledge-driven future through a dynamic and integrated advanced learning and innovation system. This paper presents the highlights of the business…

  17. Reporting and Charting Residents' Behaviors and Care in an Adult Residential Care Home. Adult Residential Care Home 12, Lesson Plan No. 2.

    ERIC Educational Resources Information Center

    Basuel, Terry

    Designed as part of a 40-hour course on adult residential care homes (ARCH's), this lesson plan was developed to explain the importance of and correct procedures for charting (i.e., keeping a written record of observations and care of ARCH residents). The objectives of the 50-minute lesson are to enable students to: (1) list reasons why the…

  18. [A study on the development of standardized nursing care plans for computerized nursing service].

    PubMed

    Kim, C J; Chun, C Y; Lim, Y S; Park, J W

    1990-12-01

    A central issue in the development of nursing practice is to describe the phenomenon with which nursing is concerned. To identify the health problems which can be diagnosed and managed by the nurse is the first step to organize and ensure the development of nursing science. Therefore the academic world has been discussing the application of the nursing diagnosis in nursing practice as a means of improving quality of care. The objectives of this study were to develop a standardized nursing care plan for ten selected nursing diagnoses to form a database for computerized nursing service. The research approach used in the study was (1) the selection of the ten nursing diagnoses which occur most frequently on medical-surgical wards, (2) the development of a standardized nursing care plan for the ten selected nursing diagnoses, (3) application of the plan to hospitalized patients and evaluation of the content validity by the nurses, and (4) evaluation of the clinical effects after the use of the standardized nursing care plans. The subjects were 56 nurses and 395 hospitalized patients on two medical and two surgical unit. The results of this study were as follows: 1) The ten selected nursing diagnoses for the development of the standardized nursing care plans were "PAIN, SLEEP DISTURBANCE, ALTERED HEALTH MAINTENANCE, ALTERATION IN NUTRITION, ANXIETY, CONSTIPATION, ALTERED PATTERNS OF URINARY ELIMINATION, DISTURBANCE IN BODY IMAGE, POTENTIAL FOR ACTIVITY INTOLERANCE AND ACTIVITY INTOLERANCE". 2. The developed standardized nursing care plans included the nursing diagnosis, definition, defining characteristics, etiologic or related factors that contribute to the condition, recording pattern, desired outcomes and nursing orders (nursing interventions). 3. The plan was used with hospitalized patients on medical-surgical wards to test for content validity. The patient's satisfaction with the nursing care and nurses' job satisfaction were investigated to evaluate the clinical

  19. Family-centered care for children with cerebral palsy: conceptual and practical considerations to advance care and practice.

    PubMed

    King, Gillian; Chiarello, Lisa

    2014-08-01

    This article focuses on conceptual and practical considerations in family-centered care for children with cerebral palsy and their families. In the last 5 years, there have been important advances in our understanding of the components of family-centered care, and initial attempts to understand the client change processes at play. Recent research elaborates on family-centered care by delving into aspects of family-provider partnership, and applying family-centered principles to organizational service delivery to bring about organizational cultures of family-centered care. Recent research has also begun to consider mediators of client change, and new practice models have been proposed that embrace family-centered principles and illustrate the "art" of practice. Future research directions are discussed, including explorations of causal relationships between family-centered care principles, elements of caregiving practice, client change processes, and child and family outcomes. The meaning of the recent literature for pediatric neurology practice is considered. PMID:24810084

  20. Conservative Management and Planned Surgery for Periviable Advanced Extrauterine Abdominal Pregnancy with Favorable Outcome: Report of Two Cases

    PubMed Central

    Harirah, Hassan M.; Smith, J. Michael; Dixon, C. Luke; Hankins, Gary D. V.

    2016-01-01

    Advanced abdominal pregnancy is an extremely rare condition that poses diagnostic and management challenges. A high index of suspicion and careful assessment of the patient's symptoms, supplemented with obstetric ultrasound, and magnetic resonance imaging, are crucial for timely diagnosis and management to prevent life-threatening complications. The presence of periviable fetuses in advanced abdominal pregnancies increases the challenge to achieve a balance between maternal and fetal benefits and risks. Early diagnosis and management decisions via a multidisciplinary approach and planned delivery are of paramount importance to minimize complications and achieve favorable maternal and fetal outcomes. Even in the setting of oligohydramnios and suspected preterm premature rupture of membranes, in-patient conservative management and an individualized planned surgical approach that includes removing or leaving the placenta in place are appropriate for managing the periviable abdominal pregnancy. PMID:27595049

  1. Conservative Management and Planned Surgery for Periviable Advanced Extrauterine Abdominal Pregnancy with Favorable Outcome: Report of Two Cases.

    PubMed

    Harirah, Hassan M; Smith, J Michael; Dixon, C Luke; Hankins, Gary D V

    2016-07-01

    Advanced abdominal pregnancy is an extremely rare condition that poses diagnostic and management challenges. A high index of suspicion and careful assessment of the patient's symptoms, supplemented with obstetric ultrasound, and magnetic resonance imaging, are crucial for timely diagnosis and management to prevent life-threatening complications. The presence of periviable fetuses in advanced abdominal pregnancies increases the challenge to achieve a balance between maternal and fetal benefits and risks. Early diagnosis and management decisions via a multidisciplinary approach and planned delivery are of paramount importance to minimize complications and achieve favorable maternal and fetal outcomes. Even in the setting of oligohydramnios and suspected preterm premature rupture of membranes, in-patient conservative management and an individualized planned surgical approach that includes removing or leaving the placenta in place are appropriate for managing the periviable abdominal pregnancy. PMID:27595049

  2. Integrating Compassionate, Collaborative Care (the "Triple C") Into Health Professional Education to Advance the Triple Aim of Health Care.

    PubMed

    Lown, Beth A; McIntosh, Sharrie; Gaines, Martha E; McGuinn, Kathy; Hatem, David S

    2016-03-01

    Empathy and compassion provide an important foundation for effective collaboration in health care. Compassion (the recognition of and response to the distress and suffering of others) should be consistently offered by health care professionals to patients, families, staff, and one another. However, compassion without collaboration may result in uncoordinated care, while collaboration without compassion may result in technically correct but depersonalized care that fails to meet the unique emotional and psychosocial needs of all involved. Providing compassionate, collaborative care (CCC) is critical to achieving the "triple aim" of improving patients' health and experiences of care while reducing costs. Yet, values and skills related to CCC (or the "Triple C") are not routinely taught, modeled, and assessed across the continuum of learning and practice. To change this paradigm, an interprofessional group of experts recently recommended approaches and a framework for integrating CCC into health professional education and postgraduate training as well as clinical care. In this Perspective, the authors describe how the Triple C framework can be integrated and enhance existing competency standards to advance CCC across the learning and practice continuum. They also discuss strategies for partnering with patients and families to improve health professional education and health care design and delivery through quality improvement projects. They emphasize that compassion and collaboration are important sources of professional, patient, and family satisfaction as well as critical aspects of professionalism and person-centered, relationship-based high-quality care. PMID:26717505

  3. Financial Performance of Health Plans in Medicaid Managed Care

    PubMed Central

    McCue, Mike

    2012-01-01

    Objective This study assesses the financial performance of health plans that enroll Medicaid members across the key plan traits, specifically Medicaid dominant, publicly traded, and provider-sponsored. Data and Methods National Association of Insurance Commissioners (NAIC) financial data, coupled with selected state financial data, were analyzed for 170 Medicaid health plans for 2009. A mean test compared the mean values for medical loss, administrative cost, and operating margin ratios across these plan traits. Medicaid dominant plans are plans with 75 percent of their total enrollment in the Medicaid line of business. Findings Plans that are Medicaid dominant and publicly traded incurred a lower medical loss ratio and higher administrative cost ratio than multi-product and non-publicly traded plans. Medicaid dominant plans also earned a higher operating profit margin. Plans offering commercial and Medicare products are operating at a loss for their Medicaid line of business. Policy Implications Health plans that do not specialize in Medicaid are losing money. Higher medical cost rather than administrative cost is the underlying reason for this financial loss. Since Medicaid enrollees do not account for their primary book of business, these plans may not have invested in the medical management programs to reduce inappropriate emergency room use and avoid costly hospitalization. PMID:24800142

  4. Doing the right thing: a geriatrician's perspective on medical care for the person with advanced dementia.

    PubMed

    Gillick, Muriel R

    2012-01-01

    Developing a reasonable approach to the medical care of older people with dementia will be essential in the coming decades. Physicians are the locus of decision making for persons with dementia. It is the responsibility of the physician to assure that the surrogate understands the nature and trajectory of the disease and then to elicit the desired goal of care. Physicians need to ascertain whether any advance directives are available, and if so, whether they apply to the situation of advanced dementia. Finally, physicians should help surrogates understand how the goals of care are best translated into practice. When the goal is comfort, this is achieved by assuring dignity, minimizing suffering, and promoting caring. In general, comfort should be the default goal of care, best implemented through palliative care or hospice. PMID:22458462

  5. Advanced practice in neurocritical care: an innovative orientation and competency model.

    PubMed

    Vicari-Christensen, Michele

    2014-02-01

    The advanced registered nurse practitioner (ARNP) began in the 1960s as an alternative provider to meet the demands of an escalating healthcare resource deficit. As the role evolved and ARNPs demonstrated safe and effective care, these providers began to appear in critical care settings. It is believed that in the specialty of Neurocritical Care, about half the providers are ARNPs. Hiring and training practitioners for this complex environment is daunting. At the University of Florida & Shands Jacksonville, an innovative orientation and competency model for ARNPs hired for the newly opened Neurocritical Care unit was developed and implemented. The program contains a roadmap for knowledge base and skill acquisition as well as competency training and maintenance. Experience with appropriate hiring and screening standards, internally developed training tools, and identification of necessary advanced classes are discussed. This model may be used as a guideline for Neurocritical Care ARNP training as well as adapted for all other critical care settings. PMID:24399169

  6. Health Care Professionals' Death Attitudes, Experiences, and Advance Directive Communication Behavior

    ERIC Educational Resources Information Center

    Black, Kathy

    2007-01-01

    The study surveyed 135 health care professionals (74 nurses, 32 physicians, and 29 social workers) to examine their personal death attitudes and experiences in relation to their reported advance directive communication practice behavior. Negative correlations were found between collaborating with other health care professionals regarding the…

  7. Digital Story Analysis Utilizing the Advancing Care Excellence for Seniors Framework

    ERIC Educational Resources Information Center

    Bassell, Kellie

    2013-01-01

    The purpose of this study was to explore the effectiveness of using digital storytelling as an end of rotation assignment, in a long-term care setting, for pre-licensure nursing students as a means to demonstrate an understanding of the Advancing Care Excellence for Seniors (ACES) framework. The research sought to explore the relationship between…

  8. The Care Needs of Community-Dwelling Seniors Suffering from Advanced Chronic Obstructive Pulmonary Disease

    ERIC Educational Resources Information Center

    Wilson, Donna M.; Ross, Carolyn; Goodridge, Donna; Davis, Penny; Landreville, Alison; Roebuck, Kim

    2008-01-01

    Aim: This study was undertaken to determine the care needs of Canadian seniors living at home with advanced chronic obstructive pulmonary disease (COPD). Background: COPD is a leading cause of morbidity and mortality worldwide. Although hospitalizations for illness exacerbations and end-stage care may be common, most persons with COPD live out…

  9. The Role and Timing of Palliative Care in Supporting Persons with Intellectual Disability and Advanced Dementia

    ERIC Educational Resources Information Center

    McCarron, Mary; McCallion, Philip; Fahey-McCarthy, Elizabeth; Connaire, Kevin

    2011-01-01

    Aim: To better describe the role and timing of palliative care in supporting persons with intellectual disabilities and advanced dementia (AD). Background: Specialist palliative care providers have focused mostly on people with cancers. Working with persons with intellectual disabilities and AD offers opportunities to expand such palliative care…

  10. Perceptions of palliative care among patients with advanced cancer and their caregivers

    PubMed Central

    Zimmermann, Camilla; Swami, Nadia; Krzyzanowska, Monika; Leighl, Natasha; Rydall, Anne; Rodin, Gary; Tannock, Ian; Hannon, Breffni

    2016-01-01

    Background: Early palliative care is increasingly recommended but seldom practised. We sought to examine perceptions of palliative care among patients with advanced cancer and their caregivers. Methods: After conducting a cluster randomized controlled trial of early palliative care versus standard care for patients with advanced cancer, we approached patients and their caregivers to participate in semistructured interviews seeking to assess, qualitatively, their attitudes and perceptions about palliative care. We used the grounded theory method for data collection and analysis. Results: A total of 48 patients (26 intervention, 22 control) and 23 caregivers (14 intervention, 9 control) completed interviews. Participants’ initial perceptions of palliative care in both trial arms were of death, hopelessness, dependency and end-of-life comfort care for inpatients. These perceptions provoked fear and avoidance, and often originated from interactions with health care professionals. During the trial, those in the intervention arm developed a broader concept of palliative care as “ongoing care” that improved their “quality of living” but still felt that the term itself carried a stigma. Participants in the intervention group emphasized the need for palliative care to be reframed and better explained by health care professionals. Participants in the control group generally considered it pointless to rename palliative care, but many in the intervention group stated emphatically that a different name was necessary in the early outpatient setting. Interpretation: There is a strong stigma attached to palliative care, which may persist even after positive experiences with an early palliative care intervention. Education of the public, patients and health care providers is paramount if early integration of palliative care is to be successful. PMID:27091801

  11. Effectiveness of Advanced Illness Care Teams for Nursing Home Residents with Dementia

    ERIC Educational Resources Information Center

    Chapman, Dennis G.; Toseland, Ronald W.

    2007-01-01

    This study evaluated the effectiveness of advanced illness care teams (AICTs) for nursing home residents with advanced dementia. The AICTs used a holistic approach that focused on four domains: (1) medical, (2) meaningful activities, (3) psychological, and (4) behavioral. The authors recruited 118 residents in two nursing homes for this study and…

  12. Advanced lung cancer patients' experience with continuity of care and supportive care needs.

    PubMed

    Husain, Amna; Barbera, Lisa; Howell, Doris; Moineddin, Rahim; Bezjak, Andrea; Sussman, Jonathan

    2013-05-01

    As cancer care becomes increasingly complex, the ability to coordinate this care is more difficult for health care providers, patients and their caregivers alike. Despite the widely recognized need for improving continuity and coordination of care, the relationship of continuity of care with patient outcomes has yet to be elucidated. Our study's main finding is that the Continuity and Coordination subscale of the widely used Picker System of Ambulatory Cancer Care Survey is able to distinguish between lung cancer patients with unmet supportive care needs and those without. Specifically, this study shows a new association between this widely implemented continuity and coordination survey and the 'psychological needs' domain, as well as the 'health system and information' domains of supportive care needs. The finding provides support for the idea that interventions to improve continuity may impact tangible indicators of patient care such as supportive care needs being met. The study focuses attention on continuity of care as an important aspect of optimizing outcomes in cancer care. PMID:23274923

  13. Advancing nursing leadership in long-term care.

    PubMed

    O'Brien, Jennifer; Ringland, Margaret; Wilson, Susan

    2010-05-01

    Nurses working in the long-term care (LTC) sector face unique workplace stresses, demands and circumstances. Designing approaches to leadership training and other supportive human-resource strategies that reflect the demands of the LTC setting fosters a positive work life for nurses by providing them with the skills and knowledge necessary to lead the care team and to address resident and family issues. Through the St. Joseph's Health Centre Guelph demonstration site project, funded by the Nursing Secretariat of Ontario's Ministry of Health and Long-Term Care, the Excelling as a Nurse Leader in Long Term Care training program and the Mentor Team program were developed to address these needs. Evaluation results show that not only have individual nurses benefitted from taking part in these programs, but also that the positive effects were felt in other parts of the LTC home (as reported by Directors of Care). By creating a generally healthier work environment, it is anticipated that these programs will also have a positive effect on recruitment and retention. PMID:20463447

  14. Brazilian public policies for reproductive health: family planning, abortion and prenatal care.

    PubMed

    Guilhem, Dirce; Azevedo, Anamaria Ferreira

    2007-08-01

    This study is an ethical reflection on the formulation and application of public policies regarding reproductive health in Brazil. The Integral Assistance Program for Women's Health (PAISM) can be considered advanced for a country in development. Universal access for family planning is foreseen in the Brazilian legislation, but the services do not offer contraceptive methods for the population in a regular and consistent manner. Abortion is restricted by law to two cases: risk to the woman's life and rape. This reality favors the practice of unsafe abortion, which is the third largest cause of maternal death in Brazil. Legal abortion is regulated by the State and the procedure is performed in public health centers. However, there is resistance on the part of professionals to attend these women. Prenatal care is a priority strategy for promoting the quality of life of these women and of future generations. Nonetheless, it is still difficult for these women to access the prenatal care services and to have the required number of consultations. Moreover, managers and health professionals need to be made aware of the importance of implementing the actions indicated by the public policies in the area of sexual and reproductive health, favoring respect for autonomy in a context of personal freedom. PMID:17614992

  15. Discovering the nature of advanced nursing practice in high dependency care: a critical care nurse consultant's experience.

    PubMed

    Fairley, Debra

    2005-06-01

    This paper describes how a critical care nurse consultant's clinical role has evolved within a surgical high dependency unit (SHDU) in a large teaching hospitals trust. In order to provide some background to role development, an overview of the research exploring the nature of advanced nursing practice in the context of critical care will be presented. From the outset, advanced nursing practice was not perceived as the acquisition and application of technical procedures usually undertaken by doctors, but possibly an integration of medicine and nursing where holistic nursing assessment is combined with symptom-focused physical examination. A reflective account of practical problems encountered relating to role integration, professional autonomy, legal and consent issues, non-medical prescribing, and role evaluation will be presented. A model of working that can be applied to high dependency units, integrating the role of the advanced nurse practitioner within the clinical team, will be described. PMID:15907666

  16. Does Multidisciplinary Care Enhance the Management of Advanced Breast Cancer?: Evaluation of Advanced Breast Cancer Multidisciplinary Team Meetings

    PubMed Central

    Chirgwin, Jacquie; Craike, Melinda; Gray, Christine; Watty, Kathy; Mileshkin, Linda; Livingston, Patricia M.

    2010-01-01

    Purpose: To assess the contribution of the advanced breast cancer (ABC) multidisciplinary team meetings (MDMs) to patient care and clinical outcomes. Methods: Members of ABC MDMs at two health services completed questionnaires in November 2007. The questionnaire asked about the performance of the MDMs and their contribution to improvement in patient care in five domains: medical management, psychosocial care, palliative care, care in the community, and benefits for team members. A final section covered the perceived value and importance of the MDM in patient management. Descriptive statistics (frequencies, mean, and standard deviation) were used to summarize the performance, improvement, and importance scores. Results: A total of 27 multidisciplinary team members (73%) completed the questionnaire. The MDM performed best in medical management (mean performance score out of 5 [M] = 3.78) and palliative care (M = 3.77). These were also the areas that were most improved through the MDM. Benefits to team members and care in the community (both M = 3.05) ranked lowest by both measures. The MDM provided the most benefit for patient management in the areas of “awareness of services available” (M = 4.32), “efficiency of referrals” (M = 4.27) and “supportive care for patients” (M = 4.27). “Awareness of services available,” “psychological care for patients,” and “continuity of care” were considered the most important (M = 4.64). Conclusion: The study provides evidence that MDMs make an important contribution to the logistical and medical management of patients with advanced breast cancer. PMID:21358959

  17. Predictors of practice patterns for lymphedema care among oncology advanced practice nurses.

    PubMed

    Ryan, Joanne C; Cleland, Charles M; Fu, Mei R

    2012-09-01

    Lymphedema, a debilitating and chronic condition, is considered to be one of the most distressing adverse effects of cancer treatment. The purpose of this study was to understand the practice patterns in lymphedema care and identify predictors influencing those patterns among oncology nurses, with a focus on advanced practice nurses. Random and purposive sampling was utilized to recruit 238 oncology nurses who completed the Web-based study. Participants included advanced practice nurses (nurse practitioners and clinical nurse specialists), nurse navigators/case managers, staff nurses, and directors/managers/coordinators. Data focused on perceived knowledge of and perceived competence in risk reduction, treatment, and self-management of lymphedema and practice patterns in lymphedema care. Actual knowledge of lymphedema care was evaluated. Descriptive, comparative, and regression analyses were performed. The study showed that perceived knowledge and perceived competence were highly correlated. Perceived competence was a predictor of practicing lymphedema care. Advanced practice nurses scored in the midrange for perceived knowledge and perceived competence in risk reduction and self-management, but obtained lower scores in perceived knowledge and perceived competence for treatment. The odds of advanced practice nurses delivering lymphedema care were less than those of staff nurses. This study identifies gaps and opportunities for advanced practice nurses to play an important role in providing lymphedema care, an essential aspect of cancer survivorship. PMID:25031960

  18. Predictors of Practice Patterns for Lymphedema Care Among Oncology Advanced Practice Nurses

    PubMed Central

    Ryan, Joanne C.; Cleland, Charles M.; Fu, Mei R.

    2012-01-01

    Lymphedema, a debilitating and chronic condition, is considered to be one of the most distressing adverse effects of cancer treatment. The purpose of this study was to understand the practice patterns in lymphedema care and identify predictors influencing those patterns among oncology nurses, with a focus on advanced practice nurses. Random and purposive sampling was utilized to recruit 238 oncology nurses who completed the Web-based study. Participants included advanced practice nurses (nurse practitioners and clinical nurse specialists), nurse navigators/case managers, staff nurses, and directors/managers/coordinators. Data focused on perceived knowledge of and perceived competence in risk reduction, treatment, and self-management of lymphedema and practice patterns in lymphedema care. Actual knowledge of lymphedema care was evaluated. Descriptive, comparative, and regression analyses were performed. The study showed that perceived knowledge and perceived competence were highly correlated. Perceived competence was a predictor of practicing lymphedema care. Advanced practice nurses scored in the midrange for perceived knowledge and perceived competence in risk reduction and self-management, but obtained lower scores in perceived knowledge and perceived competence for treatment. The odds of advanced practice nurses delivering lymphedema care were less than those of staff nurses. This study identifies gaps and opportunities for advanced practice nurses to play an important role in providing lymphedema care, an essential aspect of cancer survivorship. PMID:25031960

  19. Discussing the Evidence for Upstream Palliative Care in Improving Outcomes in Advanced Cancer.

    PubMed

    LeBlanc, Thomas W; Nickolich, Myles S; El-Jawahri, Areej; Temel, Jennifer S

    2016-01-01

    Palliative care has received increasing attention at the American Society of Clinical Oncology (ASCO) Annual Meeting since the publication of its provisional clinical opinion on the topic in 2012. Despite frequent discussion, palliative care remains a source of some controversy and confusion in clinical practice, especially concerning who should provide it, what it encompasses, and when and how it can help patients and their families. In this article, we provide a formal definition of palliative care and review the state of the science of palliative care in oncology. Several randomized controlled trials now show that palliative care improves important outcomes for patients with cancer. Related outcome improvements include a reduction in symptoms, improved quality of life, better prognostic understanding, less depressed mood, less aggressive end-of-life care, reduced resource utilization, and even prolonged survival. As such, ASCO recommends early integration of palliative care into comprehensive cancer care for all patients with advanced disease and/or significant symptom burden. Our aim is that this summary will facilitate greater understanding about palliative care and encourage further integration of palliative care services into cancer care. More research is needed to illuminate the mechanisms of action of palliative care and to improve the specificity of palliative care applications to unique scenarios and populations in oncology. PMID:27249764

  20. What is Family-Centered Care for Nursing Home Residents With Advanced Dementia?

    PubMed Central

    Lopez, Ruth Palan; Mazor, Kathleen M.; Mitchell, Susan L.; Givens, Jane L.

    2014-01-01

    To understand family members’ perspectives on person- and family-centered end-of-life care provided to nursing home (NH) residents with advanced dementia, we conducted a qualitative follow-up interview with 16 respondents who had participated in an earlier prospective study, Choices, Attitudes, and Strategies for Care of Advance Dementia at End of Life (CASCADE). Family members of NH residents (N = 16) with advanced dementia participated in semistructured qualitative interviews that inquired about overall NH experience, communication, surrogate decision making, emotional reaction, and recommendations for improvement. Analysis identified 5 areas considered important by family members: (1) providing basic care; (2) ensuring safety and security; (3) creating a sense of belonging and attachment; (4) fostering self-esteem and self-efficacy; and (5) coming to terms with the experience. These themes can provide a framework for creating and testing strategies to meet the goal of person- and family-centered care. PMID:24085250