Perceptions of physicians and nurses concerning advanced care planning for patients with heart failure in Japan

Abstract

Background: The importance of advance care planning (ACP) has been recognized in the palliative care of patients with heart failure. It is necessary for dissemination of ACP to characterize the perceptions of physicians and nurses towards ACP and to promote mutual understanding. The aim of this study is to investigate the perceptions of physicians and nurses concerning ACP for patients with heart failure.Methods: We conducted a self-administered questionnaire survey with physicians and nurses who belonged to the 427 certified institutions for implantable cardioverter defibrillator (ICD) and/or cardiac resynchronization therapy (CRT) in Japan. The self-administered questionnaire was originally designed based on the guidelines on palliative care or ACP and previous studies on the barriers of ACP. We asked the participants the recognition about condition/timing to implement ACP, Content of care to be implemented in ACP, and barriers against implementing ACP. A Mann-Whitney U test was performed and r value was calculated an effect size (ES) in order to evaluate the characteristic perceptions among physicians and nurses.Results: Valid responses were obtained from 163 physicians (38.2%) and 208 nurses (48.7%). Regarding the condition/timing, nurses tended to recognize that ACP should be implemented from earlier clinical stages than physicians. Regarding the contents of ACP, both physicians and nurses placed emphasis in assessing the patient's perception of disease progression. The biggest difference was found in the item "Ask patient about what has been important in life so far"; 78.6% of physicians but 94.2% of nurses chose "it must/should be implemented" (Cohen's r=0.31). Regarding the barriers, both physicians and nurses recognized the difficulty in prognosis prediction. The biggest differences were found in the items "Medical staff does not know how to implement ACP for patients and their families" (45.6% of physicians and 70.4% of nurses chose "strongly agree/agree", r=0.27), and "There is disagreement regarding care goals among team members of different professions" (18.5% in physicians and 43.3% in nurses, r=0.27). Conclusions:It is suggested that discussions and further studies are necessary concerning the condition/ timing of implementing ACP from early stages, specific manuals/protocols and recommendation on rolesharing within a multidisciplinary team.

Appropriateness rating for the application of optimal medical therapy and multidisciplinary care among heart failure patients

“…On the other hand, we would also like to state that the expert panel consisted of various backgrounds could evaluate the HF management with multiple viewpoints, which might prevent bias in rating the appropriateness from the point of patient‐centred outcome. For example, nurses were more likely to evaluate that ACP should be implemented in the earlier HF clinical stages than physicians 40 . Accordingly, we believe that the expert panel in our study would be one of our advantages for evaluating the appropriateness from multiple viewpoints.…”

“…For example, nurses were more likely to evaluate that ACP should be implemented in the earlier HF clinical stages than physicians. 40 Accordingly, we believe that the expert panel in our study would be one of our advantages for evaluating the appropriateness from multiple viewpoints. Third, as some clinical scenarios will be reconsidered as new data and field experience become available, it will be necessary to assess and update the clinical scenarios and AUC periodically.…”

Realization and personalization by facing fatality: A grounded theory of developing the view of dying in people with heart failure

“…Therefore, advance care planning should ideally be initiated while people's conditions are still stable (Stevenson & O’Donnell, 2015). In some studies, healthcare providers have described some barriers to provide advance care planning for people with heart failure, including: difficulties in predicting their prognosis, missing the timing to initiate advance care planning (De Vleminck et al, 2014; Tokunaga‐Nakawatase et al, 2020), and the fear of taking people's hopes away (De Vleminck et al, 2014; Hjelmfors et al, 2014). Additionally, Wichmann et al, (2018) showed that advance care planning discussions are often initiated when the disease has already reached critical/incurable conditions; logically, it is difficult for healthcare providers to promote a satisfactory discussion and for individuals to share their values/wishes when the latter have critical conditions.…”

“…For example, discussions initiated among care recipients, family members, and healthcare providers about advance care planning are often not focused on the process of dying but on death (Schulz et al, 2017); this may be because healthcare providers are uncertain about the appropriate timing and effective content to discuss the process of dying. Additionally, healthcare providers often think that people are either unaware about or may not receive their prognosis well (De Vleminck et al, 2014; Tokunaga‐Nakawatase et al, 2020). On the other hand, people with heart failure often perceive and change their views of their future through their disease's unpredictable trajectory (Jones et al, 2015).…”

Goals of Care for Patients with Severe Comorbid Illnesses Hospitalized for an Acute Deterioration

“…One Japanese study by Tokunaga-Nakawatase et al did explore and found that nurses had a better predictive ability for death and necessary action plan, in terminally ill cardiac failure patients. 8 …”