Special Issue "Improving Management and Decision-Making Near End of Life"

A special issue of Healthcare (ISSN 2227-9032). This special issue belongs to the section "Nursing".

Deadline for manuscript submissions: closed (31 December 2020).

Special Issue Editor

Dr. Magnolia Cardona
E-Mail Website
Guest Editor
Institute for Evidence-Based Healthcare, Bond University, Gold Coast 4226, Australia
Interests: gerontology and geriatrics; health service evaluation; risk prediction; reducing low-value care; epidemiology

Special Issue Information

Dear Colleagues,

While clinicians are trained to save lives using technology and scientific developments to prevent death, prolonging life at the expense of patient suffering through nonbeneficial interventions is unacceptable. Unfortunately, this is prevalent in many healthcare systems today due to complex system and human issues.

Nonbeneficial treatments are those medical interventions, medications, surgeries, and testing that will not make a difference to the prognosis of dying patients but can potentially harm them. Some nonbeneficial treatments administered when death is inevitable could be prevented if patients and families had discussed care preferences in advance; or if the patient’s risk was anticipated by clinicians to facilitate informed and shared decision-making.  

It is time to reassess current approaches and welcome innovative ways to combat clinical inertia. Evidence-based strategies to improve care at the end of life should not perpetuate unnecessary patient suffering, carry false hope for families, or generate unsustainable care costs for the health system or service consumers. This Special Issue will feature a wide range of research reports bringing evidence-based clinician, health system, and consumer perspectives on how to improve management and decision-making near the end of life.

Asso. Prof. Magnolia Cardona
Guest Editor

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All papers will be peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Healthcare is an international peer-reviewed open access monthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 1600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • End-of-life
  • Intervention
  • Decision-making
  • High-value care

Published Papers (6 papers)

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Research

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Article
Assessing Face Validity of the HexCom Model for Capturing Complexity in Clinical Practice: A Delphi Study
Healthcare 2021, 9(2), 165; https://doi.org/10.3390/healthcare9020165 - 04 Feb 2021
Viewed by 1175
Abstract
Capturing complexity is both a conceptual and a practical challenge in palliative care. The HexCom model has proved to be an instrument with strong reliability and to be valid for describing the needs and strengths of patients in home care. In order to [...] Read more.
Capturing complexity is both a conceptual and a practical challenge in palliative care. The HexCom model has proved to be an instrument with strong reliability and to be valid for describing the needs and strengths of patients in home care. In order to explore whether it is also perceived to be helpful in enhancing coordinated and patient-centred care at a practical level, a methodological study was carried out to assess the face validity of the model. In particular, a Delphi method involving a group of 14 experts representing the full spectrum of healthcare professionals involved in palliative care was carried out. The results show that there is a high level of agreement, with a content validity index-item greater than 0.92 both with regard to the complexity model and the HexCom-Red, HexCom-Basic, and the HexCom-Clin instruments, and higher than 0.85 regarding the HexCom-Figure and the HexCom-Patient instruments. This consensus confirms that the HexCom model and the different instruments that are derived from it are valued as useful tools for a broad range of healthcare professional in coordinately capturing complexity in healthcare practice. Full article
(This article belongs to the Special Issue Improving Management and Decision-Making Near End of Life)
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Article
Evaluation of an End-of-Life Essentials Online Education Module on Chronic Complex Illness End-of-Life Care
Healthcare 2020, 8(3), 297; https://doi.org/10.3390/healthcare8030297 - 25 Aug 2020
Cited by 3 | Viewed by 1168
Abstract
Chronic complex illness/multimorbidity is a leading cause of death worldwide. Many people with chronic complex illnesses die in hospital, with the overall quality of end-of-life care requiring substantial improvement, necessitating an increase in the knowledge of the health professionals caring for them. End-of-Life-Essentials [...] Read more.
Chronic complex illness/multimorbidity is a leading cause of death worldwide. Many people with chronic complex illnesses die in hospital, with the overall quality of end-of-life care requiring substantial improvement, necessitating an increase in the knowledge of the health professionals caring for them. End-of-Life-Essentials (EOLE) offers online education modules for health professionals working in acute hospitals, including one on chronic complex illness. A quantitative pre–post-evaluation analysis was undertaken on data from learners (n = 1489), who completed a questionnaire related to knowledge gained from module completion between December 2018 and November 2019. A qualitative post-evaluation analysis was also conducted using data on learner responses to a question posed between May and November 2019. Results showed a significant positive impact on learners’ knowledge, skill, attitude, and confidence in providing end-of-life care to patients living with chronic complex illness. The majority (82.9%, n = 900) intended to change their practice after module completion. A total of n = 559 qualitative comments were analysed thematically, with three major themes emerging: Patient centred care and care planning, Discussion of prognosis, and Valued communication skills. This evaluation has demonstrated that healthcare professionals could benefit from this education to improve quality of care of the dying. Full article
(This article belongs to the Special Issue Improving Management and Decision-Making Near End of Life)
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Article
Feasibility of Using a Risk Assessment Tool to Predict Hospital Transfers or Death for Older People in Australian Residential Aged Care. A Retrospective Cohort Study
Healthcare 2020, 8(3), 284; https://doi.org/10.3390/healthcare8030284 - 21 Aug 2020
Viewed by 1268
Abstract
Residents of Aged Care Facilities (RACF) experience burdensome hospital transfers in the last year of life, which may lead to aggressive and potentially inappropriate hospital treatments. Anticipating these transfers by identifying risk factors could encourage end-of-life discussions that may change decisions to transfer. [...] Read more.
Residents of Aged Care Facilities (RACF) experience burdensome hospital transfers in the last year of life, which may lead to aggressive and potentially inappropriate hospital treatments. Anticipating these transfers by identifying risk factors could encourage end-of-life discussions that may change decisions to transfer. The aim was to examine the feasibility of identifying an end-of-life risk profile among RACF residents using a predictive tool to better anticipate predictors of hospital transfers, death or poor composite outcome of hospitalisation and/or death after initial assessment. A retrospective cohort study of 373 permanent residents aged 65+ years was conducted using objective clinical factors from records in nine RACFs in metropolitan Sydney, Australia. In total, 26.8% died and 34.3% experienced a composite outcome. Cox proportional hazard regression models confirmed the feasibility of estimating the level of risk for death or a poor composite outcome. Knowing this should provide opportunities to initiate advance care planning in RACFs, facilitating decision making near the end of life. We conclude that the current structure of electronic RACF databases could be enhanced to enable comprehensive assessment of the risk of hospital re-attendance without admission. Automation tools to facilitate the risk score calculation may encourage the adoption of prediction checklists and evaluation of their association with hospital transfers. Full article
(This article belongs to the Special Issue Improving Management and Decision-Making Near End of Life)
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Article
End-of-Life Care in Acute Hospitals: Practice Change Reported by Health Professionals Following Online Education
Healthcare 2020, 8(3), 254; https://doi.org/10.3390/healthcare8030254 - 06 Aug 2020
Cited by 2 | Viewed by 1200
Abstract
Providing quality care for those dying in hospital is challenging for health professionals who receive little training in this. “End of Life Essentials” (EOLE) was developed to address gaps in health professionals’ knowledge, skills and confidence in end-of-life care via the provision of [...] Read more.
Providing quality care for those dying in hospital is challenging for health professionals who receive little training in this. “End of Life Essentials” (EOLE) was developed to address gaps in health professionals’ knowledge, skills and confidence in end-of-life care via the provision of online learning modules and practice resources. This study aimed to determine whether respondents could describe clinical practice change as a result of module completion. Deidentified data were collected between October and November 2018 from learners registered for the online learning modules. Both quantitative and qualitative data were extracted and analysed. The survey design and conduct were reviewed, and ethical approval was obtained. Although the response rate was very low, results from n = 122 learners show improvements in knowledge, skills, awareness and confidence as a result of the undertaking of the learning modules. Two thirds self-reported practice changes (71%, n = 59) following the education, with “communication” cited most commonly (n = 19). The findings suggest that the EOLE education modules can help to improve end-of-life care by increasing health professionals’ awareness of good practice as well as their knowledge, skills and confidence. Online learning has also been reinforced as an appropriate forum for end-of-life education. Following education, implementing what has been learned occurs more easily at a personal level rather than at a team and organisational level. Barriers to and enablers of clinical practice change in hospital are described, including the fact that the organisation may not be responsive to changes or have the relevant resources to support change. Full article
(This article belongs to the Special Issue Improving Management and Decision-Making Near End of Life)

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Commentary
The Motion of the Italian National Bioethics Committee on Aggressive Treatment towards Children with Limited Life Expectancy
Healthcare 2020, 8(4), 448; https://doi.org/10.3390/healthcare8040448 - 01 Nov 2020
Viewed by 660
Abstract
The motion of the Italian National Bioethics Committee entitled “Aggressive treatment or therapeutic obstinacy on young children with limited life expectancy” comprises a premise that rejects therapeutic obstinacy and makes 12 recommendations. Recommendation no. 1 states the general rules: it ascribes a cardinal [...] Read more.
The motion of the Italian National Bioethics Committee entitled “Aggressive treatment or therapeutic obstinacy on young children with limited life expectancy” comprises a premise that rejects therapeutic obstinacy and makes 12 recommendations. Recommendation no. 1 states the general rules: it ascribes a cardinal role to a shared care plan, it supports pain management therapy and pain relief, it opposes ineffective and disproportionate clinical treatment and defensive medicine. The other recommendations are correlated to the enacting of a national law establishing clinical ethics committees in paediatric hospitals; participation of parents and their fiduciaries in the decision-making processes; recourse to courts only as extrema ratio in the event of irremediable disagreement between the medical team and the family members; accompaniment at the end of life also through continuous deep sedation combined with pain therapy; access to palliative care; the need to reinforce research on pain and suffering in children; clinical trials and research studies conducted in children; the training of doctors, healthcare personnel and psychologists, to support parents in emotional and practical terms; the facilitation of the closeness of parents to children in extremely precarious clinical conditions; the relevant role of the associations of parents of sick children. Comments are made, in particular, about the innovative recommendations respectively relating to the adoption of care planning, the establishment, by law, of clinical ethics committees in paediatric hospitals and the limitation of recourse to courts—only as extrema ratio—in the event of irremediable disagreement between the medical team and the family members. Full article
(This article belongs to the Special Issue Improving Management and Decision-Making Near End of Life)
Commentary
Advance Care Planning (ACP) vs. Advance Serious Illness Preparations and Planning (ASIPP)
Healthcare 2020, 8(3), 218; https://doi.org/10.3390/healthcare8030218 - 18 Jul 2020
Cited by 6 | Viewed by 1524
Abstract
COVID-19 has highlighted the reality of an impending serious illness for many, particularly for older persons. Those faced with severe COVID-19 infection or other serious illness will be faced with decisions regarding admission to intensive care and use of mechanical ventilation. Past research [...] Read more.
COVID-19 has highlighted the reality of an impending serious illness for many, particularly for older persons. Those faced with severe COVID-19 infection or other serious illness will be faced with decisions regarding admission to intensive care and use of mechanical ventilation. Past research has documented substantial medical errors regarding the use or non-use of life-sustaining treatments in older persons. While some experts advocate that advance care planning may be a solution to the problem, I argue that the prevailing understanding and current practice of advance care planning perpetuates the problem and results in patients not receiving optimal patient-centered care. Much of the problem centers on the framing of advance care planning around end of life care, the lack of use of decision support tools, and inadequate language that does not support shared decision-making. I posit that a new approach and new terminology is needed. Advance Serious Illness Preparations and Planning (ASIPP) consists of discrete steps using evidence-based tools to prepare people for future clinical decision-making in the context of shared decision-making and informed consent. Existing tools to support this approach have been developed and validated. Further dissemination of these tools is warranted. Full article
(This article belongs to the Special Issue Improving Management and Decision-Making Near End of Life)
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