Honoring Veterans’ Wishes: Efficacy Of An Evidence-Based Shared Decision-Making Tool In Va Icu Goals-Of-Care Discussions, Stephanie Alexander, Anna Astashchanka Md, Venktesh Ramnath Md

Doctor of Nursing Practice Final Manuscripts

Abstract

Introduction: This Doctor of Nursing Practice project aimed to enhance the knowledge and confidence of the San Diego Veterans Health Administration’s (VASD) Intensive Care Unit (ICU) medical providers in goals-of-care discussions (GOCD). Additionally, this project aimed to improve the documentation of these discussions.

Background: Delays in GOCD can lead to futile medical and surgical interventions, inappropriate antibiotic use, and higher rates of mental health conditions in patients and their loved ones. Earlier GOCD are associated with lower ventilation and resuscitation rates, earlier hospice enrollment, reduced ICU admissions, lower financial costs, and better patient and caregiver quality of life. However, …

Education For Primary Care Providers On Advance Care Planning, Lindsey Ward

Doctor of Nursing Practice (DNP) Projects

Background: Advance care planning (ACP) is a discussion of a patient’s end-of-life healthcare wishes. Its purpose is to indicate these wishes clearly should the patient be unable to make their decisions known to providers and family members due to a sudden health decline or medical emergency. Healthcare providers, specifically nurse practitioners, physician assistants, and physicians in the primary care setting, are well-positioned to facilitate these conversations with their older adult patients. However, research states that limited provider knowledge of and confidence in implementing ACP are significant barriers to its application in practice.

Problem: At a primary care clinic in Midtown …

Implementation Of Prognosticator Algorithm For Initiation Of Serious Illness Discussions And Improving The Rate Of Palliative And Hospice Referrals, Joy Isebor

Doctor of Nursing Practice (DNP) Scholarly Projects

Context: Early serious illness conversations related to end-of-life and goals of care with seriously ill patients have been associated with improving patients' outcomes and quality of care (Bernacki et al., 2015). However, initiating these serious illness discussions has been challenging in the home-based primary care setting.

Objectives: To train and support home-based primary care clinicians in integrating best practices in serious illness discussions and decision-making engagement among patients sixty-five and older with serious illnesses, optimize the alignment between patient goals and the medical care they receive, improving their quality of life and the rate of palliative care and hospice referrals. …

Education For Primary Care Providers On Advance Care Planning: A Systematic Literature Review, Lindsey Ward

DNP Qualifying Manuscripts

Background: Healthcare providers in primary care treat patients at various stages of life. As patients age, it becomes necessary for providers to support their older patients throughout the aging process and address patient care even into life’s end stages. Primary care providers (PCPs) are well-positioned to provide this support and can do so through incorporating end-of-life (EOL) conversations in practice. Such discussions are called advance care planning (ACP). Though PCPs can play a crucial role in their patients’ EOL care decisions, providers report their limited knowledge of ACP as a barrier to its application.Consequently, further education for providers on utilizing …

Advance Care Planning: Best Practice Toolkit For Improving Access To Advance Care Planning Using Telehealth Visits, Jae Jackson

Student Scholarly Projects

Advance care planning (ACP) predominately occurs during a life-threatening crisis or during an inpatient admission. The primary care provider (PCP) is generally not the healthcare provider addressing ACP at the time of a crisis or during an inpatient admission. Being proactive in limiting ACP decisions with unfamiliar providers, uncomfortable environments, and increasing access to ACP discussions with PCPs are supportive reasons to utilize an ACP telehealth toolkit in primary care. Patients risk having ACP discussions with random providers, environments that don’t provide comfort when having such personal discussions, or not having the peaceful death they deserve without having an ACP …

Improving Patient Self-Efficacy, Readiness, And Completion Of Advance Care Planning Documents Using Prepare Documents And Advance Care Planning Group Referral, Marie Vassiliadis

Doctor of Nursing Practice Final Manuscripts

Advance Care Planning (ACP) is an ongoing discussion about medical decision making between a provider, patient, and support person. ACP can also include legal documentation in the form of an advance directive (AD). Nationally, only 36.7% of adults complete any form of AD for end-of-life care. Recently, ACP has become an important quality metric that many organizations are prioritizing. The purpose of this evidence-based project is to improve ACP readiness, self-efficacy, and documentation among patients at an internal medicine clinic using the PREPARE program and referral to an ACP group meeting. PREPARE for Your Care is an online program aimed …

Cultural Perspectives In Pain And Palliative Care, Loan Lagué

Master's Projects

Culturally and linguistically diverse (CALD) patients are constantly challenged by the different levels on which lack of cultural competency or bias occurs in healthcare. This literature review focuses on the healthcare providers’ experiences when providing pain and palliative care to CALD populations and explores the challenges that may result in health inequalities. A review of current literature was conducted using PubMed, CINHAL, Sage Journals, Ovid, and Science Direct electronic databases. Sixteen published articles between 2015-2023 were reviewed. Findings from this review identified factors that induce poor quality palliative, pain, and end-of-life (EOL) care among culturally diverse groups. Improving quality of …

Utilization Of Remap Conversation Tool To Improve Advance Care Completion In The Home-Based Palliative Care Community Setting, Gwendolyn Starkey

Doctor of Nursing Practice Projects

Background: The World Health Organization and the American Society of Clinical Oncology guidelines endorses mandatory communication skills training in care goals for seriously ill patients (Back et al., 2019). In one survey of primary care providers (PCP), 68% reported no formal training to discuss advance care planning (Comer et al., 2020). Advance care planning is essential to manage chronic conditions in our growing aging population to provide the best patient care. This manuscript aimed to discuss best practices and techniques in advance care planning and optimize skills to provide patient-centered care conversations that honor patient wishes, reduce unwanted hospitalizations, and …

Factors Associated With Advance Care Planning Engagement In Healthy Young Adults, Pablo J. Vasquez

Dissertations & Theses (Open Access)

Background: Advance care planning (ACP) is a process that supports individuals at any stage of health in understanding and sharing their personal values and goals pertaining current or future medical needs with their families and healthcare providers. Although ACP is applicable to adults of any age and any stage of the health continuum, it is widely associated with older or terminally ill populations, and the need for end-of-life (EOL) planning in healthy young adults is generally found unnecessary. The National Institutes of Health supports the expansion of ACP research in understudied populations. Investigating ACP in healthy young adults support such …

Experiences Of Nurses Who Provide Advance Care Planning In The Dialysis Setting, Sheree Mullen

Walden Dissertations and Doctoral Studies

AbstractPatients diagnosed with end-stage renal disease (ESRD) receiving dialysis experience increased symptom burden and multiple hospitalizations as the disease progresses. Dialysis nurses are charged with involving ESRD patients in decisions regarding their care and advance care planning for end-of- life; however, discussions about end-of-life care do not consistently occur. Providing advance care planning is important to involve the patient in their end-of-life care needs. The purpose of this qualitative descriptive study guided by the theory of planned behavior was to explore the experiences of nurses who provide advance care planning to patients receiving dialysis therapy. Eight participants volunteered to participate …

Measuring Advance Directive Knowledge Gives Rise To Primary Care Nurses' Education Training, Arnell Corethia Kithcart

Walden Dissertations and Doctoral Studies

AbstractPatients have the right to self-determine how and in what manner they desire to make end-of-life decisions. The use of advance directives (AD) is the focus of the Patient Self Determination Act (PSDA). The PSDA permits the use of legal documents to outline the patient’s end-of-life decision when they can no longer communicate to the medical community. Because individuals with chronic diseases are living longer the medical community must stay abreast on current laws and protocols to provide the care needed and address patient’s wishes for end-of-life needs. Nurses would be ideal to provide education on AD to patients upon …

Achieving Advance Care Planning In Diverse Populations Via Teleconferencing With Skilled Nursing Facility Residents, Tania Huezo

Doctor of Nursing Practice Final Manuscripts

Background: Advance care planning (ACP) has always been a priority in healthcare, and even more crucial during the COVID-19 pandemic. It has been extremely challenging for ACP to occur in the skilled nursing facility (SNF) population once social distancing restrictions were put in place to protect residents and staff.

Purpose: The purpose of this evidence-based project was to assess the effectiveness of ACP via teleconferencing with skilled nursing facility (SNF) residents in the hope of increasing completion of high-quality Physician’s Orders for Life-Sustaining Treatment (POLST) forms.

Methods: The San Diego Coalition for Compassionate Care developed an ACP community outreach program …

Technology-Based Advance Care Planning Education For Primary Care Patients, Taryn Achong

Doctor of Nursing Practice (DNP) Projects

Background: Advance Care Planning (ACP) encompasses a multidisciplinary, collaborative process that allows patients to understand their health and make informed decisions in their treatment plans. Considering the COVID-19 pandemic and recent research, ACP is considered imperative for all patients. Evidence-based approaches include supplemental group sessions, case manager interventions, and provision of at-home resources. Within the pandemic, there has also been a rapid shift to telemedicine, restricting most ACP efforts. Therefore, the utilization of technology-based ACP resources and telemedicine is highly supported.

Purpose: This DNP project serves to assist an internal medicine practice located in Hawaii’s metropolitan area. Although the …

Michigan Physician Orders For Scope Of Treatment: Development Of A Nationally Recognized Program, Megan Owens

Doctoral Projects

Background: Advance directives are well intentioned, but fail to promote patient autonomy in emergent situations.

Objective: To develop a sustainable portable medical order program consistent with national standards through an evidence-based toolkit.

Methods: A literature review and policy analysis were conducted to develop toolkit. Interviews were conducted with content experts to validate toolkit.

Results: The final toolkit consisted of five components: educational materials for healthcare providers, a policy brief, strategies for fund development, strategies for quality monitoring, and a cost savings exemplar.

Conclusions: An evidence-based toolkit tailored to state-specific barriers is critical to development of a portable medical order program.

The Role Of Knowledge In End-Of-Life Decision-Making By Older Persons, Laura Van Dyck

Yale Medicine Thesis Digital Library

As physicians, we aim to support our patients to engage in and make end-of-life medical decisions. Ideally, patients engage in advance care planning (ACP) to direct their care if they become incapable of participating in decision-making. For many patients, however, their first encounter with end-of-life care—e.g. code status—occurs at hospital admission. This thesis describes two studies: the ACP Study and Code Status Study. The ACP Study examines ACP knowledge and its relationship to engagement. This study utilizes baseline data from 921 participants age 55 years enrolled in the STAMP randomized controlled trial, including a knowledge scale consisting of 7 questions …

Implementation Of Palliative Care For Interprofessional Dialysis Team: Advance Care Planning Communication Training, Ju Choe

Doctor of Nursing Practice Projects

Palliative care (PC) has become the need of the dialysis population to expedite emotional support, symptom management, and decision-making related to end-of-life situations (Sturgill & Bear, 2019). Under the spectrum of PC, advance care planning (ACP) is essential. The benefits of ACP conversations are largely confirmed in general healthcare (Rietjens et. al, 2017). Utilizing existing interprofessional dialysis teams to deliver the primary level of kidney PC is the most promising way to improve dialysis patients’ quality of life. (Lam et al., 2019; Pfeifer & Head, 2018). The purpose of this project is to provide ACP communication skills training for the …

Perceptions Of Caregivers Of Parkinson's Patients Regarding Using Advance Directives, Meghan Morgan

Walden Dissertations and Doctoral Studies

The increasing focus on end-of-life (EOL) care is influencing the role of advance directive (AD) documents. Difficult conversations among family caregivers and their loved ones are becoming more and more critical. Considering the value of communicating EOL wishes, family caregivers’ perceptions about ADs for their loved ones with Parkinson’s disease (PD) must be examined. Using the theory of planned behavior (TPB) as a foundation, the purpose of this generic qualitative study was to understand family caregivers of PD patients and their perceptions and experiences relating to AD documents. This study involved using purposeful sampling and semi-structured interviews with 11 family …

Improving Nurse Knowledge And Comfort In Advance Care Planning, Hajrudina Brkic, Marisia Young

Nursing DNP Projects

Objectives: The purpose of this project was to increase nurses’ knowledge and comfort level regarding advance care planning (ACP) in patients with a diagnosis of heart failure (HF) in a clinical setting.

Methods: A quasi-experimental design was used with a pre-and-post test administered to nurses prior to the beginning of a four-hour interactive class and immediately following the class. The data was analyzed using a 5-point Likert scale and paired t-tests were used to determine statistical significance. Statistical significance was set at 0.05.

Results: Of the eight nurses who participated in the interactive course, seven were female, one …

Utilization Of Peer-Led Education To Enhance Advance Care Planning And Advance Directive Completion, Jenna Juenger

Doctor of Nursing Practice Final Manuscripts

Background: The integration of advance care planning (ACP) and palliative care (PC) into oncology plays a critical role in symptom management and quality of life. Studies reveal a large subset of oncology patients with unmet needs regarding ACP and advance directive (AD) completion. Successful ACP helps to promote congruent medical treatment with patients’ values and preferences and motivates patients to complete ADs.

Objective: An evidence-based practice project was conducted to assess the effectiveness of peer-led education to nursing staff to improve ACP and AD completion among inpatient oncology and PC patients

Design: A standardized survey created from the …

Increasing Nurses' Knowledge Of Advance Care Planning, Jocelyn K. Allen

UNLV Theses, Dissertations, Professional Papers, and Capstones

Advance care planning (ACP) is a process that seeks to ensure patients receive medical care that is consistent with their values and preferences. The process has proven benefits for patients and their loved ones but is under-utilized in clinical practice. Nurses are capable of successfully supporting patients through ACP; however, they encounter barriers that prevent their engagement in the process. These barriers include a lack of knowledge regarding ACP, poor understanding of their role in the process, and a lack of confidence to embrace the practice.

The purpose of this DNP Project was to create an evidence-based educational intervention to …

Technology-Based End-Of-Life Planning For An Underserved Population, Haley Kirkpatrick

Doctor of Nursing Practice (DNP) Projects

Problem: Research indicates a low-income status and ethnic and racial diversity is a barrier to ACP engagement.

Context: This project took place at a Federally Qualified Heath Center located in Northern California which serves approximately 200,000 diverse and economically disadvantaged patients.

Methods: The primary intervention was dissemination of an email to patients 50 and older, via their health system email account. The email included a direct link to PREPARE, an online advance care planning technology tool. A secondary intervention was a presentation to primary care providers that focused on end-of-life-care planning tools and communication strategies.

Results: The email was distributed …

A Nurse Practitioner-Led Group Advance Care Planning Program In An Independent And Assisted Living Community, Alexander Bustos

DNP Qualifying Manuscripts

It has been well documented that the majority of people want to spend their last days in the comfort of their own homes, free of pain, and off any dependent machine. , However, the majority of people have not documented these wishes or talked with their family or provider about end of life care (Hamel, Wu, & Brodie, 2017). The Patient Self Determination Act (PSDA), which took effect on December 1, 1991, was enacted to raise awareness and promote discussions between patients and providers about end of life (EOL) healthcare decisions. The primary care nurse practitioner is in a prime …

Cultural Aspects Of End Of Life Advance Care Planning For African Americans: An Ethnonursing Study, John Collins

Electronic Theses and Dissertations

Introduction: Advance directive completion rates among the general population are low. Studies report even lower completion rates among African Americans are impacted by demographic variables, cultural distinctives related to patient autonomy, mistrust of the healthcare system, low health literacy, strong spiritual beliefs, desire for aggressive interventions, importance of family-communal decision making, and presence of comorbidities. End of Life (EOL) advance care planning (ACP) promotes patient and family centered care. The purpose of this study was to identify culturally based meanings, expressions, and traditions of EOL ACP and decision making among African Americans, to better understand and provide culturally congruent nursing …

Advance Care Planning Interventions For Racially And Ethnically Diverse Populations: A Literature Review, Haley Kirkpatrick

DNP Qualifying Manuscripts

Background and purpose: Diverse populations are less likely to engage in end-of-life-care-planning. This literature review examined research on end-of-life planning interventions for diverse patient populations.

Methods: This systematic search included Academic Search Complete, Cochrane, CINAHL, and PubMed databases. Results were limited to peer-reviewed articles published in English between 2015 to 2019.

Conclusions: Each intervention was effective at increasing advance care planning (ACP) engagement. Community-based programs are costlier. PREPARE used less resources. If diverse populations are specifically targeted, ACP engagement increases.

Implications for practice: Healthcare institutions and practitioners should employ targeted interventions for ACP engagement of diverse groups.

Keywords: end-of-life-care planning, …

Implementation Of An Advance Care Planning Protocol To Increase Advance Directive Completion Rates, Christine Engle

Evidence-Based Practice Project Reports

Advanced directives (AD) allow an individual to retain autonomy in end-of-life decisions and can prevent unnecessary costs and treatments associated with aggressive life-prolonging measures. As of 2017, only an estimated 36.7% of the United States adult population had a form of advance directive documented (Yadav et al., 2017). The purpose of this evidence-based project was to determine if implementation of an advanced care planning (ACP) protocol would increase ACP discussions, AD completion, and result in a modification in stage of change or behavior. The Transtheoretical Model (TTM) and Stetler Model of evidence-based practice were used as the framework to guide …

A Video Decision Aid To Influence Advance Care Planning, Angela Petry

Graduate Theses, Dissertations, and Problem Reports

The best mechanism to achieve successful advance care planning has yet to be identified. A randomized, controlled, experimental study was performed with a sample of 54 men and women who met inclusion criteria and were randomized into the intervention versus the control group in an outpatient clinical setting in rural West Virginia (WV) from December 2018 to March 2019. Participant mean age was 72.4 years. For those who chose to participate (n=42), the intervention group received the usual standard of care, which was a face to face advance care planning (ACP) discussion with the new intervention of a video decision …

Increasing Post-Acute And Long Term Care Coding For Advance Care Planning In An Outpatient Setting, Emily M. Mccloskey

Doctoral Projects

Today’s healthcare landscape is saturated with an aging U.S. population that is living longer and with more chronic conditions. One way to manage care for this aging population, especially those with chronic conditions, is through advance care planning (ACP). Healthcare providers are capable of engaging patients in these important healthcare discussions, yet use of methods to appropriately document and code for these services are lacking. There are Current Procedural Terminology (CPT) codes in existence that would be applicable for these services; however, they are not widely understood nor routinely used in clinical practice. Administrators at a large Midwestern healthcare organization’s …

The Effectiveness Of Video And Other Electronic Media On Dnr/Dni Decisions Within Advance Care Planning, Peter Seebarg

Theses and Graduate Projects

Advance Care Planning is used to ensure patients’ wishes and preferences for treatment are in line with their medical situation. Its use has increased over the past years, but it has been implemented in a piece wise and unorganized fashion. Changes in provider billing capabilities and a recent consensus definition and implementation strategies of Advance Care Planning have created an opportunity to research and explore best use practices. A key feature of Advance Care Planning is creating autonomy for patients’ decisions. Autonomy is especially important for the use of cardiopulmonary resuscitation (CPR) in the event of a medical crisis.

Research …

Spirituality In Clinical Practice: Recognizing The Importance Of Personal Values And Beliefs In Medical Decision-Making, Katie Lutz

Doctor of Nursing Practice (DNP) Projects

This Doctor of Nursing Practice (DNP) project addresses the importance of values and beliefs in patient’s healthcare decisions. Relying on a holistic theoretical model that accounts for all aspects of the human experience, the focus shifts from standard healthcare delivery to exploration of spiritual values and beliefs. In the past two decades, researchers and healthcare professionals have juxtaposed healthcare and spirituality to broaden the domain of care and enrich the provider and patient experience. Evidence has shown the alliance of spirituality and clinical practice has the potential to improve wellbeing and healthcare outcomes.

Interventions: In a public health setting, a …

Improving Advance Directive Completion Rates Through Advance Care Planning, Erica Shadae Koeppen, Joseph Burkard, Ellen Ward

Doctor of Nursing Practice Final Manuscripts

Purpose: The purpose of this evidence-based practice (EBP) project is to assess the effectiveness of a multimodal intervention to increase advance care planning discussions (ACP) and advance directive (AD) completion rates.

Background: Advance care planning (ACP) and advance directives (AD) is the ongoing discussion and recording of patient preferences and goals of care in the event they lose the capacity to speak for themselves. The Center of Disease Control and Prevention (CDC) estimates that 70% of Americans are without ADs. Centers for Medicare and Medicaid Services (CMS) reimburses for advance care planning consultations. ACP has improved multiple outcomes including higher …