Objective To examine the effects of home-based transitional palliative care for patients with end-stage heart failure (ESHF) after hospital discharge. Methods This was a randomised controlled trial conducted in three hospitals in Hong Kong. The recruited subjects were patients with ESHF who had been discharged home from hospitals and referred for palliative service, and who met the specified inclusion criteria. The interventions consisted of weekly home visits/telephone calls in the first 4 weeks then monthly follow-up, provided by a nurse case manager supported by a multidisciplinary team. The primary outcome measures were any readmission and count of readmissions within 4 and 12 weeks after index discharge, compared using χ 2 tests and Poisson regression, respectively. Secondarily, change in symptoms over time between control and intervention groups were evaluated using generalised estimating equation analyses of data collected using the Edmonton Symptom Assessment Scale (ESAS). Results The intervention group (n=43) had a significantly lower readmission rate than the control group (n=41) at 12 weeks (intervention 33.6% vs control 61.0% χ 2 =6.8, p=0.009). The mean number (SE) of readmissions for the intervention and control groups was, respectively, 0.42 (0.10) and 1.10 (0.16) and the difference was significant (p=0.001). The relative risk (CI) for 12-week readmissions for the intervention group was 0.55 (0.35 to 0.88). There was no significant difference in readmissions between groups at 4 weeks. However, when compared with the control group, the intervention group experienced significantly higher clinical improvement in depression (45.9% vs 16.1%, p<0.05), dyspnoea (62.2% vs 29.0%, p<0.05) and total ESAS score (73.0% vs 41.4%, p<0.05) at 4 weeks. There were significant differences between groups in changes over time in quality of life (QOL) measured by McGill QOL (p<0.05) and chronic HF (p<0.01) questionnaires. Conclusions This study provides evidence of the effectiveness of a postdischarge transitional care palliative programme in reducing readmissions and improving symptom control among patients with ESHF. Trial registration number HKCTR-1562; Results.

Background Advance care planning (ACP) is the process of ongoing communication among patients, family and health care professionals regarding what plans for future care are preferred in the event that patients become unable to make their own decisions. Clinicians play an important role in ACP as both initiators and decision coaches. However, lack of training for clinicians has frequently been reported as the reason for low involvement in ACP discussions - hence the present review evaluates the effectiveness of ACP training programs for healthcare professionals to guide the development of novel training programs for them in the future. Methods A literature search for intervention studies was conducted independently by two reviewers in July 2018. Participants included all healthcare professionals working with adult patients suffering from terminal illness. The primary outcomes were the professionals’ knowledge of and attitudes towards ACP, and self-perceived competence in ACP conversations. The Effective Public Health Practice Project appraisal tool was used to examine the quality of the studies included. Results A total of 4025 articles were identified, and ten eligible articles, covering 1081 participants, were included in the review. However, there is a lack of high quality randomized controlled trials of providing ACP training for nurses working in non-palliative care hospital settings. The overall quality of the intervention studies was moderate. All the studies included used instructional sessions in their interventions, while some contained group discussion, role-play and the use of advanced technology. The training programs increased the knowledge, attitudes towards shared decision-making, perceived communication skills, confidence, comfort and experiences concerned with discussing end-of-life (EOL) issues. Patient advocacy, job satisfaction and perceived level of adequate training for EOL care were improved. The use of ‘decision aids’ was rated as acceptable and clinically useful. Conclusions Training for healthcare professionals in ACP has positive effects on their knowledge, attitude and skills. The use of decision aids and advanced technology, instructional sessions with role play, training content focused on ACP communication skills and the needs and experience of patient in the ACP process, and a values-based ACP process are all those factors that made the ACP training programs effective.

Results suggest that a transitional home-based palliative care program is more cost-effective than customary palliative care service. Limitations of the study include small sample size, study confined to one city, clinic consultation costs, and societal costs including patient costs and unpaid care-giving costs were not included.

Introduction. Written narratives are used to develop reflective skills in health care students during clinical education. The purpose of this study was to explore the effectiveness of using a framework in narrative writing to facilitate reflection in physical therapy students during their initial short-term clinical experiences. Subjects. Each of 20 written narratives by physical therapy students was explored during their first clinical short-term experience. Methods. Data analysis was an iterative process consisting of eight individual researchers and cross-group researcher analyses for the development of themes and levels of reflection. Descriptive statistics, percent agreement between pairs of researchers, was calculated based on the number of times the identical rating was assigned to a narrative by pairs of raters. The strength of agreement between researchers was measured using inferential statistics. Results. Five themes emerged; these were patient-centered care, professional role, ethical issues, critical thinking, and student and clinical instructor relationship. Researchers determined that all 20 narratives contained reflection compared with a previous study in which only 64% of the narratives examined contained reflective writing. Analysis showed percent agreement between eight researchers ranged from 60% to 85%, with a mean of 73%. The weighted Kappa scores ranged from fair to substantial agreement, with the exception of one rater who demonstrated poor agreement relative to the consensus. Conclusion. The results of this study support the use of a framework in narrative writing to foster reflection in physical therapy students during their initial clinical experiences. Consistent levels of reflection occur through the use of a model that helps students connect specific experiences with their thoughts and feelings about those experiences. There was moderate agreement among researchers in choosing levels of reflection across narratives.