bluuebunny/crossref_metadata_2025_split huggingface dataset:
‘BUSINESS AS USUAL’: IMPLEMENTATION OF ADVANCE CARE DIRECTIVES IN A RENAL DIALYSIS UNIT
Authors: Larmer A , Battese T , Westgarth F 
Published: April 2013

BackgroundAdvance care directives (ACDs) are designed to empower patients and give them a choice in end of life (EOL) care. According to the NSW Health policy established in 2004, ACDs are to be present in patients' medical records for moments when the patients are unable to make decisions for themselves. In 2009, two incidents highlighted the need to implement ACDs as a standard component of the model of care in our unit.AimTo normalise the establishment of ACDs for patients in our Unit, and to have at least 80% of our renal dialysis patients with up-to-date and easily accessible ACD in place.MethodsProject guidance was provided to the Ballina project team via the ACI Haemodialysis Models of Care Program. The project involved staff training, patient education, development of an ACD Form, and process change within the renal unit and the hospital. The process was adaptable, flexible and responsive, and staff developed confidence in addressing this difficult issue with their patients. Furthermore, a system was developed to include ACD alerts on the patient's electronic medical record (eMR), making this information available at all access points throughout the health district.ResultsACDs have been established as a standard component of the model of dialysis care within our Unit. As a result of the project the proportion of our patients with active ACDs rose from <5% to above 85%. There remain some difficulties broaching this topic with some cultural groups.DiscussionACDs have the ability to prevent overuse of medical resources and decrease family burden during EOL care. During education sessions it was found that staff had difficulty approaching their patients on these very sensitive and challenging issues, and required considerable training to empower them to support their patients' during advance care planning (ACP). The successful implementation was due to the patients perceiving it as a normal process that they themselves should drive, in collaboration with their families and with their clinical carers.ConclusionACP policies require considerable staff training and support to enable successful implementation.
HOW WELL ARE ACUTE HOSPITAL STAFF SETTING TREATMENT GOALS AND IDENTIFYING NEED FOR PALLIATIVE CARE FOR IN-PATIENTS?
Authors: Moran J , Jones D 
Published: April 2013

BackgroundMedical teams in acute hospitals often do not set goals of treatment for patients, especially those who are frail or complex. Hospitals have limitation of treatment policies, but compliance is often poor. The need for palliative care is also under-recognised.AimThis was an observational audit to determine whether patients in a tertiary Melbourne hospital had goals and limitations of treatment documented by the treating team, and the association with length of stay and outcome.MethodOver 2 weeks, the records of hospital inpatients were reviewed. Data included demographics, co-morbidities, goals and limitations of treatment (LOT), need for referral to palliative care and outcomes.Results290 records were reviewed; 55% were male, average age was 67. 60% of patients had no goals of treatment. Ten patients were asked about advance care plans. Of those who should have had LOT according to hospital policy, 55% had no plans. 23 patients were suitable for Palliative Care, but only 9 had been referred. 18% of patients were confused; 60% of these had no record of discussions with family. 9% of patients died, 76% went home and 8% to residential care.DiscussionThere was a lack of setting goals and limitations of treatment and under-referral to palliative care. Patients were more likely to die or go to residential care the longer they stayed in hospital and the greater their co-morbidities.ConclusionThere is potential to improve the practice of setting goals and limitations of treatment in this acute hospital.
CARE PLANNING IN ADVANCE: THE PROCESS OF BRINGING AN IMPOSSIBLE MISSION TO AN INSTITUTIONAL REALITY AT ST VINCENT'S HOSPITAL MELBOURNE
Authors: Boughey M , Hickey B , McDonald L 
Published: April 2013

BackgroundThe development of a systematised advanced care planning process in Catholic faith based institutions has presented challenges that have seen unsustainable unsupported programme. Increasing clinician need, a changing understanding of the role of advanced care planning in routine health care, changing community expectations of the use of advanced care plans and reform in health care quality standards have necessitated a recommitment to develop a sustainable, workable process.AimTo present a narrative of the factors, internal and external to the hospital, that have had to be considered and worked through, to develop a programme in care planning for advanced care at St. Vincent's Hospital Melbourne that has gained acceptance and led to implementation to be embarked upon.MethodsReview of the Advanced care planning working group's meeting minutes actions and document developments taken over 8 month period June 1 to December 2.ResultsThe process demonstrates the key steps in the 18 month timeline that has brought significant points of development to create a workable and viable policy and guidelines, acceptable within a Catholic hospital's ethical and clinical frameworkDiscussionSharing the learning's will be helpful for others developing programmes in comparable institutions to see how important the linking together of key people and committees in an organisation is to develop the acceptable shared understanding and language within the institutions ethical and clinical framework.ConclusionSetting aside historical challenges, it has been possible to develop a system of advanced care planning processes within a Catholic, faith base, tertiary hospital.
MORE THAN JUST LANGUAGE: OLDER DUTCH AND ITALIAN MIGRANTS' VIEWS ON ADVANCE CARE PLANNING
Authors: Smith J , Sinclair C , Touissant Y , Auret K 
Published: April 2013

BackgroundWestern cultural practices and values have largely shaped advance care planning (ACP) policies across the world. In most Western countries utilisation of ACP is typically lower among minority cultural groups (Searight, 2005). Cultural factors may influence attitudes towards ACP (Searight, 2005).AimTo explore perceptions of ACP among older, non-hospitalised first-generation Dutch-Australian and Italian-Australian migrants.MethodsTwenty-nine people participated in individual interviews (N=16) and focus groups (N=13). Average time residing in Australia was 52 years. Most participants were proficient in English; some Italian participants preferred to speak Italian and utilised interpreters. Interviews were recorded, transcribed verbatim and thematically analysed.ResultsPre-migration experiences, reliance on ethnic community support networks and continued contact with the native country contributed to migrant identity, which influenced attitudes towards ACP. Dutch participants typically adopted an individualist approach to medical decision-making, whereas Italian participants associated more with a familial style. Mistrust towards institutions was often associated with less support for ACP. Discussions about ACP elicited unprompted views on euthanasia, particularly among Dutch participants. Participants with poorer English language skills showed similar openness to considering ACP when supported with appropriate language assistance.DiscussionAn individualistic decision making style was associated with openness to ACP. Familial decision making styles and the presence of ethnic community support networks were associated with a view that ACP was redundant.ConclusionEnsuring informed access to ACP for migrant Australians will require appropriate language assistance, understanding the patient's social history and framing benefits of ACP within the broader context of decision-making styles and reliance on ethnic community support networks.
END-OF-LIFE CARE FOR PEOPLE WITH DEMENTIA
Authors: Cartwright C 
Published: April 2013

IntroductionA Diagnosis of Dementia—what does this mean? Receiving a diagnosis of dementia raises many challenges for the person themselves and for their carers and other family members and friends. However, it can also provide opportunities, to plan ahead, to put financial and other affairs in order and, for those who are in the early stages of dementia, to travel or do other things with family and friends.This session will consider some of the issues that need to be addressed at this time. These include: when does a person have capacity to make their own decisions?; the need to undertake Advance Care Planning to appoint a substitute decision-maker and write an Advance Directive; the legally available options that the person may want to include in their Advance Care Plans; an understanding of palliative care; their right to adequate pain relief in terminal illness (and the related issue of what is/is not euthanasia). Issues for Carers of people with dementia will also be covered.Finally, as there is increasing activity in Australia to introduce euthanasia legislation, the special concerns for people with dementia, should such legislation be introduced, will be discussed.
HAVE WE IMPROVED ADVANCE CARE PLANNING FOR DYING RESIDENTIAL AGED CARE PATIENTS PRESENTING TO AN ACUTE TERTIARY HOSPITAL?
Authors: Wilkinson J , Street M , Brean S , Fullerton S 
Published: April 2013

BackgroundThe number of people from Residential Aged Care (RAC) presenting to Emergency Departments (ED) is increasing. The importance of rapid patient-centred decision making highlights the need for Advance Care Plans (ACPs).AimTo investigate trends in ACP completion for the RAC population presenting to ED, by comparing data from 2009 to 2011; the proportion of patients with ACPs in place; whether ACPs were acknowledged and complied with by hospital staff; and whether current strategies have improved ACP implementation and compliance.MethodsA retrospective cohort study of 79 patients from RAC who died during hospital admission in 2011 was compared to a similar group of 90 patients in 2009.ResultsThe median age was 87 for both groups. Time from admission to death was shorter in 2011 (median 3.9 days, IQR=1.3–6.4) compared to 2009 (median 4.3 days, IQR=1.7–8.2). The proportion of patients with ACPs in place had doubled from 13% in 2009 to 29% in 2011 (χ2=5.448, df=1, p=0.02). Improvements were seen in the number of patients for whom ACPs were acknowledged or adhered to. The proportion of patients transferred from RAC who died during that admission was lower in 2011 (6.2%) compared to 2009 (7.3%).DiscussionMore aggressive discharge planning of dying RAC patients by the palliative care team has resulted in fewer than previous deaths of RAC patients in acute beds and shorter length of stay.ConclusionOverall improvement in ACP implementation and compliance has resulted in improved patient outcomes.
HOW OFTEN DOES THE MEDICAL EMERGENCY TEAM IMPLEMENT END OF LIFE CARE? A SYSTEMATIC REVIEW
Authors: Tan L H , Delaney A 
Published: April 2013

BackgroundThe members of Medical Emergency Teams (METs) teams undergo training to deal with medical emergencies. METs also deal with end of life issues arising in the context of acute illness. It is unknown how often METs implement end of life care relative to other interventions and thus what proportion of time should be allocated to training the MET members to deal with end of life issues.AimTo determine the frequency of end of life care relative to other common interventions delivered by METs.MethodsTwo authors independently searched for potentially relevant studies. We included prospective studies that reported activities undertaken by the MET. The suitability of studies for inclusion and validity of studies was assessed independently by two authors. We extracted data on the characteristics of the included studies, the composition of the MET and the activities undertaken by the MET. The primary analysis was descriptive.ResultsPreliminary results are presented. The search identified 2324 abstracts, 99 articles were retrieved for full text review, 32 studies were included. Rates of end of life interventions performed by the MET ranged from 2% to over 20%. These rates are similar to many common interventions performed by METs.DiscussionEnd of life care is an important component of the work carried out by the MET and is carried out at a frequency similar to many interventions that are given more weight in MET training.ConclusionTraining to deal with end of life care should be incorporated into all MET training.
PRACTICALITIES AND SENSITIVITIES AROUND DISCUSSING RESUSCITATION AT THE END OF LIFE: A CLINICAL TOOL
Authors: Herbert A , Irving H 
Published: April 2013

BackgroundThe presence of a resuscitation plan as a clinical indicator in paediatric palliative care and the development of an ‘Acute Resuscitation Plan’ for adult patients in Queensland provided impetus for the development of a resuscitation planning form for children and adolescents in Queensland.AimTo develop a resuscitation planning tool which would facilitate the process of clinical assessment, encourage communication with children and their families and subsequent documentation of mutually agreed upon resuscitation plans.MethodsA working group used the adult ‘Adult Resuscitation Plan’ to determine the key components required for a clinical form which related to the care of patients aged less than 18 years.ResultsThe ‘Paediatric Acute Resuscitation Plan’ (PARP) included the following sections: clinical assessment, resuscitation management plan, consenting details, and clinical authorisation.DiscussionThe resuscitation management plan acknowledges that patients may still benefit from a range of treatments and therapies that contribute to quality end-of-life care. At the same time, the form clearly documents whether cardio-pulmonary resuscitation will or won't be provided. Consent is usually given by the parents who in usual circumstances act in the best interests of their child. The form also encourages discussion and consideration of the views of the Gillick competent child.ConclusionThe development of the Paediatric Acute Resuscitation Plan (PARP) is a clinical form and tool which allows consistency of practice on a statewide level but also allows flexibility to document a unique care plan for each child or young person.
PILOT OF AN END-OF-LIFE CARE PATHWAY IN NON-CANCER PALLIATIVE UNIT IN CHINESE POPULATION
Authors: Wong W M , Chen M&G W T 
Published: April 2013

BackgroundThe End-of-life Care Pathway (ECP) based on the concept used in Liverpool Care Pathway (LCP V.12), was developed, with modification to suit the local needs. It was first applied to non-cancer palliative unit (MPM) in Hong Kong.Table 1ECPNCDAH 2009SettingWard baseHospital baseAudit period1/8/2010–31/12/2010 (4 months)1/10/08–31/12/08 (3 months)Total number of hospitals1155Total Number ECP/LCP applied423893Median number of wards (IQR)2323(15–32)Median number of all deaths occurring in data gathering period (IQR)117227 (180–366)Total percentage of deaths on an ECP/LCP in data gathering period (N)34% (N=40)21%Median age (IQR)80 (75–85)81 (73–87)Female %55% (N=23)55% (N=2141)Median hours in LCP/ECP (IQR)62 (18–103)33 (12–74)Non Cancer79%61%Patient is able to communicate95.4%59%Carer is able to communicate95.2%73%Patient is aware of dying88.9%40%Carer is aware of the patient is dying90.5%76%Carer's contact information updated90.5%73%Carer had a full explanation of the facilities available to them with leaflets88.1%53%Patient's spiritual needs assessed77.3%30%Carer's spiritual needs assessed78.6%50%Anticipated symptom control PRN medications prescribed71.4%90%Patient's current intervention reviewed and unnecessary medications discontinued100%/Artificial nutrition assessed97.6%/Artificial hydration assessed95.2%/Skin integrity assessed92.9%/Full explanation of the pathway to patient83.3%30%Full explanation of the pathway to carer54.8%72%ObjectiveTo identify the quality of care for dying patients as documented in ECP and benchmark our performance with the National Care of the Dying Audit—Hospital (NCDAH) 2009 in UK.MethodsA retrospective audit design was used to gather ECP data from Tuen Mun Hospital from 1st August to 31st December 2010.Results117 deaths occurred in the audit period and 42 ECP was applied. Median Age is 80 (IQR=75–85); 55% are female; 79% are non-cancer patients. The most common diagnosis is end-stage renal failure. The median duration in ECP is 62 h (IQR=18–103). A high percentage of patients and carers can participate in the communication (95.4%, 95.2%), aware the dying status (88.9%, 90.5%), have the current interventions reviewed (100%), and symptoms controlled (range from 85.1% to 90.5%).Relatively low percentage of the patients and cares could discuss about their spiritual needs (77.3%, 78.6%), have the anticipated symptoms control medications prescribed and received (71.4%, 36.7%), pathway explained (83.3%, 54.8%) and physically adjusted environment received (76.2%). The comparison of the results with the NCDAH 2009 was shown in table 1.ConclusionThis audit point out different aspects for improvement of the ECP first applied in non-cancer medical unit in Hong Kong
ADVANCE CARE DIRECTIVES FOR PERSONS WITH MENTAL ILLNESS
Authors: Swartz M , Swanson Jeffrey 
Published: April 2013

The movement toward patient-centred care has fueled considerable interest in Psychiatric Advance Directives (PADs), analogous to medical advance directives and health care proxies, as a possible remedy for loss of patient autonomy in mental healthcare decisions, patient alienation from the treatment process, and associated poor clinical outcomes. Based on the hope for these benefits, 25 US legislatures have adopted PAD statutes and are encouraging the appointment of healthcare proxies, through durable power of attorney, for persons with mental illness. PADs may include three types of anticipatory decision-making: (1) informed consent to future treatment; (2) a forecast of personal values; (3) and the entrusting of someone to act as a proxy decision maker. The role of a healthcare agent (HCA), or proxy decision maker, is to help ensure that the patient's previously expressed wishes are fulfilled; to further interpret what treatment the patient would wish to receive (or not receive); or to act in the patient's best interest and protect the patient's welfare. A recently conducted study in five US communities found that patients have great interest in PADs and supports the idea that people with mental illnesses should write down the type of treatment they would like to receive if they become very ill at some point in the future; 70–83% across sites wished a PAD, but only 4–13% had any form of PAD. In this presentation we will discuss current interest in, barriers to implementing and efforts underway to foster large scale use of PADs.TestimonialThe APCEL conference is an important venue for dissemination of critical information and emerging research on advance care planning. A focus on advance care planning for persons with mental illness will place psychiatric advance directives in the broader context of other types of mechanisms to foster patient-centred healthcare.
Pathological diagnostic criterion of blood and lymphatic vessel invasion in colorectal cancer: a framework for developing an objective pathological diagnostic system using the Delphi method, from the Pathology Working Group of the Japanese Society for Cancer of the Colon and Rectum
Authors: Kojima Motohiro , Shimazaki Hideyuki , Iwaya Keiichi , Kage Masayoshi , Akiba Jun , Ohkura Yasuo , Horiguchi Shinichiro , Shomori Kohei , Kushima Ryoji , Ajioka Yoichi , Nomura Shogo , Ochiai Atsushi 
Published: April 2013

AimsThe goal of this study is to create an objective pathological diagnostic system for blood and lymphatic vessel invasion (BLI).Methods1450 surgically resected colorectal cancer specimens from eight hospitals were reviewed. Our first step was to compare the current practice of pathology assessment among eight hospitals. Then, H&E stained slides with or without histochemical/immunohistochemical staining were assessed by eight pathologists and concordance of BLI diagnosis was checked. In addition, histological findings associated with BLI having good concordance were reviewed. Based on these results, framework for developing diagnostic criterion was developed, using the Delphi method. The new criterion was evaluated using 40 colorectal cancer specimens.ResultsFrequency of BLI diagnoses, number of blocks obtained and stained for assessment of BLI varied among eight hospitals. Concordance was low for BLI diagnosis and was not any better when histochemical/immunohistochemical staining was provided. All histological findings associated with BLI from H&E staining were poor in agreement. However, observation of elastica-stained internal elastic membrane covering more than half of the circumference surrounding the tumour cluster as well as the presence of D2-40-stained endothelial cells covering more than half of the circumference surrounding the tumour cluster showed high concordance. Based on this observation, we developed a framework for pathological diagnostic criterion, using the Delphi method. This criterion was found to be useful in improving concordance of BLI diagnosis.ConclusionsA framework for pathological diagnostic criterion was developed by reviewing concordance and using the Delphi method. The criterion developed may serve as the basis for creating a standardised procedure for pathological diagnosis.
A Linked-Registry Study of Gestational Factors and Subsequent Breast Cancer Risk in the Mother
Authors: Troisi Rebecca , Doody David R. , Mueller Beth A. 
Published: April 2013

Abstract
Background: Women who were younger at their first live birth have a reduced breast cancer risk. Other pregnancy characteristics, including complications, also may affect risk but because they are rare, require large datasets to study.
Methods: The association of pregnancy history and breast cancer risk was assessed in a population-based study including 22,646 cases diagnosed in Washington State 1974 to 2009, and 224,721 controls, frequency matched on parity, age, calendar year of delivery, and race/ethnicity. Information on prediagnosis pregnancies derived from linked birth certificate and hospital discharge databases. Adjusted odd ratios (ORs) and 95% confidence intervals (CI) were calculated.
Results: Multiple gestation pregnancies were associated with decreased breast cancer risk (OR, 0.65; 95% CI, 0.57–0.74) as was prepregnancy obesity (OR, 0.76; 95% CI, 0.65–0.90). Infant birth weight was positively associated (6% per 1,000 g; 95% CI, 3%–9%). The ORs for first trimester bleeding (OR, 3.35; 95% CI, 1.48–7.55) and placental abnormality/insufficiency (OR, 2.24; 95% CI, 1.08–4.67) were increased in women diagnosed at age 50+ years and 15+ years after the index pregnancy. Results were similar in analyses restricted to first pregnancies, those closest to diagnosis, and when excluding in situ disease.
Conclusion: These data suggest that multiple gestation pregnancies are protective, whereas delivering larger infants increases risk for later development of maternal breast cancer. Placental abnormalities that result in bleeding in pregnancy also may reverse the long-term protection in postmenopausal women associated with parity.
Impact: Certain pregnancy characteristics seem to be associated with later maternal breast cancer risk. Cancer Epidemiol Biomarkers Prev; 22(5); 835–47. ©2013 AACR.