The Effect of Advance Care Planning on Heart Failure: a Systematic Review and Meta-analysis.

BACKGROUND: Advance care planning is widely advocated to improve outcomes in end-of-life care for patients suffering from heart failure. But until now, there has been no systematic evaluation of the impact of advance care planning (ACP) on clinical outcomes. Our aim was to determine the effect of ACP in heart failure through a meta-analysis of randomized controlled trials (RCTs). METHODS: We searched CINAHL, Cochrane Central Register of Controlled Trials, Database of Systematic Reviews, Embase, ERIC, Ovid MEDLINE, Science Citation Index and PsycINFO (inception to July 2018). We selected RCTs including adult patients with heart failure treated in a hospital, hospice or community setting. Three reviewers independently screened studies, extracted data, assessed the risk of bias (Cochrane risk of bias tool) and evaluated the quality of evidence (GRADE tool) and analysed interventions according to the Template for Intervention Description and Replication (TIDieR). We calculated standardized mean differences (SMD) in random effects models for pooled effects using the generic inverse variance method. RESULTS: Fourteen RCTs including 2924 participants met all of the inclusion criteria. There was a moderate effect in favour of ACP for quality of life (SMD, 0.38; 95% CI [0.09 to 0.68]), patients' satisfaction with end-of-life care (SMD, 0.39; 95% CI [0.14 to 0.64]) and the quality of end-of-life communication (SMD, 0.29; 95% CI [0.17 to 0.42]) for patients suffering from heart failure. ACP seemed most effective if it was introduced at significant milestones in a patient's disease trajectory, included family members, involved follow-up appointments and considered ethnic preferences. Several sensitivity analyses confirmed the statistically significant direction of effect. Heterogeneity was mainly due to different study settings, length of follow-up periods and compositions of ACP. CONCLUSIONS: ACP improved quality of life, patient satisfaction with end-of-life care and the quality of end-of-life communication for patients suffering from heart failure and could be most effective when the right timing, follow-up and involvement of important others was considered.This research did not receive any funding

Implementing advance care planning in heart failure : a qualitative study of primary healthcare professionals

Background: Advance care planning (ACP) can improve the quality of life of patients suffering from heart failure (HF). However, primary care healthcare professionals (HCPs) find ACP difficult to engage with and patient care remains suboptimal. Aim: To explore the views of primary care HCPs on how to improve their engagement with ACP in heart failure. Design and Setting: A qualitative interview study with GPs and primary care nurses in England. Method: Semi-structured interviews were conducted with a purposive sample of 24 primary HCPs. Data were analysed using reflexive thematic analysis. Results: Three main themes were constructed from the data: ACP as integral to holistic care in HF; potentially limiting factors to the doctor-patient relationship; approaches to improve professional performance. Many HCPs saw the benefits of ACP as synonymous with providing holistic care and improving patients’ quality of life. However, some feared that initiating ACP could irrevocably damage their doctor-patient relationship. Their own fear of death and dying, a lack of disease specific communication skills and uncertainty about the right timing were significant barriers to ACP. To optimise their engagement with ACP in HF, HCPs recommended better clinician-patient dialogue through question prompts, enhanced shared decision-making approaches, synchronising ACP across medical specialities, and disease specific training. Conclusion: GPs and primary care nurses are vital to deliver ACP for patients suffering from HF. HCPs highlighted important areas to improve their practice and the urgent need for investigations into better clinician-patient engagement with ACP

Palliative care after stroke: A review.

BACKGROUND: Palliative care is an integral aspect of stroke unit care. In 2016, the American Stroke Association published a policy statement on palliative care and stroke. Since then there has been an expansion in the literature on palliative care and stroke. AIM: Our aim was to narratively review research on palliative care and stroke, published since 2015. RESULTS: The literature fell into three broad categories: (a) scope and scale of palliative care needs, (b) organization of palliative care for stroke, and (c) shared decision making. Most literature was observational. There was a lack of evidence about interventions that address specific palliative symptoms or improve shared decision making. Racial disparities exist in access to palliative care after stroke. There was a dearth of literature from low- and middle-income countries. CONCLUSION: We recommend further research, especially in low- and middle-income countries, including research to explore why racial disparities in access to palliative care exist. Randomized trials are needed to address specific palliative care needs after stroke and to understand how best to facilitate shared decision making

Economic predictors of differences in interview faking between countries : economic inequality matters, not the state of economy

Many companies recruit employees from different parts of the globe, and faking behavior by potential employees is a ubiquitous phenomenon. It seems that applicants from some countries are more prone to faking compared to others, but the reasons for these differences are largely unexplored. This study relates country-level economic variables to faking behavior in hiring processes. In a cross-national study across 20 countries, participants (N = 3839) reported their faking behavior in their last job interview. This study used the random response technique (RRT) to ensure participants anonymity and to foster honest answers regarding faking behavior. Results indicate that general economic indicators (gross domestic product per capita [GDP] and unemployment rate) show negligible correlations with faking across the countries, whereas economic inequality is positively related to the extent of applicant faking to a substantial extent. These findings imply that people are sensitive to inequality within countries and that inequality relates to faking, because inequality might actuate other psychological processes (e.g., envy) which in turn increase the probability for unethical behavior in many forms

Optimising the implementation of advance care planning in heart failure

Clinicians are hesitant to talk to patients suffering from heart failure about their care preferences should they become seriously ill. Similarly, patients suffering from heart failure lack the tools to help them identify their care needs and communicate these to their healthcare professionals. This process is also known as advance care planning (ACP). Some studies show that ACP can improve the quality of life in life-threatening illnesses like heart failure. Patients expect their clinicians to initiate conversations about ACP. But as a result of clinicians’ hesitance, ACP rarely takes place and patient care is affected. The overall aim of this thesis is to develop a behaviourally informed intervention targeting clinicians to engage with ACP for patients suffering from heart failure. The different stages of the project were informed by the Medical Research Council’s framework for the development and evaluation of complex interventions. The early development phase of the intervention started with an exploration of the evidence base for the impact of ACP on heart failure. The literature suggested that this led to an improved quality of life, better patient satisfaction with end-of-life care and an improved quality of communication between clinicians and patients. This was followed by a component analysis to identify interventions which had the greatest potential in changing clinicians’ behaviour to engage with ACP. Patient-mediated interventions, reminders systems, educational meetings and academic detailing were among the most promising intervention categories. A subsequent literature review analysed the barriers and facilitators for ACP in heart failure leading to the design of an early model of the intervention. Findings from a clinician interview series advanced the early model and shaped the prototype of the intervention based on the Theoretical Domains Framework and Behaviour Change Techniques. The findings from a focus group study including patients and carers refined the final version of the intervention consisting of: 1. A patient-led Question Prompt List 2. A shared decision-making tool in the form of a Choices of Care Table 3. A clinician-owned ACP Reminder Sheet 4. An ACP Practice-Based Training Session A detailed protocol for a feasibility cluster randomised controlled trial was developed to address issues surrounding the feasibility and acceptability of delivering the intervention in clinical practice. Finally, the results from this thesis informed a model for the involvement of the intervention in the clinical management of heart failure. </p

Optimising the implementation of advance care planning in heart failure

Clinicians are hesitant to talk to patients suffering from heart failure about their care preferences should they become seriously ill. Similarly, patients suffering from heart failure lack the tools to help them identify their care needs and communicate these to their healthcare professionals. This process is also known as advance care planning (ACP). Some studies show that ACP can improve the quality of life in life-threatening illnesses like heart failure. Patients expect their clinicians to initiate conversations about ACP. But as a result of cliniciansâ hesitance, ACP rarely takes place and patient care is affected. The overall aim of this thesis is to develop a behaviourally informed intervention targeting clinicians to engage with ACP for patients suffering from heart failure. The different stages of the project were informed by the Medical Research Councilâs framework for the development and evaluation of complex interventions. The early development phase of the intervention started with an exploration of the evidence base for the impact of ACP on heart failure. The literature suggested that this led to an improved quality of life, better patient satisfaction with end-of-life care and an improved quality of communication between clinicians and patients. This was followed by a component analysis to identify interventions which had the greatest potential in changing cliniciansâ behaviour to engage with ACP. Patient-mediated interventions, reminders systems, educational meetings and academic detailing were among the most promising intervention categories. A subsequent literature review analysed the barriers and facilitators for ACP in heart failure leading to the design of an early model of the intervention. Findings from a clinician interview series advanced the early model and shaped the prototype of the intervention based on the Theoretical Domains Framework and Behaviour Change Techniques. The findings from a focus group study including patients and carers refined the final version of the intervention consisting of: 1. A patient-led Question Prompt List 2. A shared decision-making tool in the form of a Choices of Care Table 3. A clinician-owned ACP Reminder Sheet 4. An ACP Practice-Based Training Session A detailed protocol for a feasibility cluster randomised controlled trial was developed to address issues surrounding the feasibility and acceptability of delivering the intervention in clinical practice. Finally, the results from this thesis informed a model for the involvement of the intervention in the clinical management of heart failure. </p

Clinician barriers and facilitators to heart failure advance care plans : a systematic literature review and qualitative evidence synthesis

Background Clinicians hesitate to engage with advance care planning (ACP) in heart failure. We aimed to identify the disease-specific barriers and facilitators for clinicians to engage with ACP. Methods We searched Medline, Embase, CINAHL, PubMed, Scopus, the British Nursing Index, the Cochrane Library, the EPOC register, ERIC, PsycINFO, the Science Citation Index and the Grey Literature from inception to July 2018. We conducted the review according to Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guidelines. Two reviewers independently assessed original and empirical studies according to Critical Appraisal Skills Programme criteria. The SURE framework and thematic analysis were used to identify barriers and facilitators. Results Of 2308 articles screened, we reviewed the full text of 42 studies. Seventeen studies were included. The main barriers were lack of disease-specific knowledge about palliative care in heart failure, high emotional impact on clinicians when undertaking ACP and lack of multidisciplinary collaboration between healthcare professionals to reach consensus on when ACP is indicated. The main facilitators were being competent to provide holistic care when using ACP in heart failure, a patient taking the initiative of having an ACP conversation, and having the resources to deliver ACP at a time and place appropriate for the patient. Conclusions Training healthcare professionals in the delivery of ACP in heart failure might be as important as enabling patients to start an ACP conversation. This twofold approach may mitigate against the high emotional impact of ACP. Complex interventions are needed to support clinicians as well as patients to engage with ACP

The Effect of Advance Care Planning on Heart Failure: a Systematic Review and Meta-analysis

Abstract: Background: Advance care planning is widely advocated to improve outcomes in end-of-life care for patients suffering from heart failure. But until now, there has been no systematic evaluation of the impact of advance care planning (ACP) on clinical outcomes. Our aim was to determine the effect of ACP in heart failure through a meta-analysis of randomized controlled trials (RCTs). Methods: We searched CINAHL, Cochrane Central Register of Controlled Trials, Database of Systematic Reviews, Embase, ERIC, Ovid MEDLINE, Science Citation Index and PsycINFO (inception to July 2018). We selected RCTs including adult patients with heart failure treated in a hospital, hospice or community setting. Three reviewers independently screened studies, extracted data, assessed the risk of bias (Cochrane risk of bias tool) and evaluated the quality of evidence (GRADE tool) and analysed interventions according to the Template for Intervention Description and Replication (TIDieR). We calculated standardized mean differences (SMD) in random effects models for pooled effects using the generic inverse variance method. Results: Fourteen RCTs including 2924 participants met all of the inclusion criteria. There was a moderate effect in favour of ACP for quality of life (SMD, 0.38; 95% CI [0.09 to 0.68]), patients’ satisfaction with end-of-life care (SMD, 0.39; 95% CI [0.14 to 0.64]) and the quality of end-of-life communication (SMD, 0.29; 95% CI [0.17 to 0.42]) for patients suffering from heart failure. ACP seemed most effective if it was introduced at significant milestones in a patient’s disease trajectory, included family members, involved follow-up appointments and considered ethnic preferences. Several sensitivity analyses confirmed the statistically significant direction of effect. Heterogeneity was mainly due to different study settings, length of follow-up periods and compositions of ACP. Conclusions: ACP improved quality of life, patient satisfaction with end-of-life care and the quality of end-of-life communication for patients suffering from heart failure and could be most effective when the right timing, follow-up and involvement of important others was considered

Data for "Ammonia Dry Deposition in an Alpine Ecosystem Traced to Agricultural Emission Hotpots"

Download the README.txt file for a detailed description of this dataset's content.Elevated reactive nitrogen (Nr) deposition is a concern for alpine ecosystems, and dry NH3 deposition is a key contributor. Understanding how emission hotspots impact downwind ecosystems through dry NH3 deposition provides opportunities for effective mitigation. However, direct NH3 flux measurements with sufficient temporal resolution to quantify such events are rare. Here, we measured NH3 fluxes at Rocky Mountain National Park (RMNP) during two summers and analyzed transport events from upwind agricultural and urban sources in northeastern Colorado. We deployed open-path NH3 sensors on a mobile laboratory and an eddy covariance tower to measure NH3 concentrations and fluxes. Our spatial sampling illustrated an upslope event that transported NH3 emissions from the hotspot to RMNP. Observed NH3 deposition was significantly higher when backtrajectories passed through only the agricultural region (7.9 ng m-2 s-1) versus only the urban area (1.0 ng m-2 s-1) and both urban and agricultural areas (2.7 ng m-2 s-1). Cumulative NH3 fluxes were calculated using observed, bidirectional modeled, and gap-filled fluxes. More than 40% of the total dry NH3 deposition occurred when air masses were traced back to agricultural source regions. More generally, we identified that 10 (25) more national parks in the U.S. are within 100 (200) km of an NH3 hotspot, and more observations are needed to quantify the impacts of these hotspots on dry NH3 depositions in these regions