Patient/ Family Involvement

Background

This project was completed by a team of junior doctors working across two general medical wards at Queen Alexandra Hospital.

Introduction

Due to persistently high bed occupancy, patients are increasingly subject to multiple moves, increasing the risk of missed or delayed communication (Toye C et al, Clin interv aging, 2019, 14, 2223-2237). Importantly, families who receive good communication from staff are more likely to feel satisfied with the care of their loved one (Ersek M et al, J pain symptom manage, 2021, 62(2), 213–222). Our aim was to increase the occurrence and comprehensiveness of documented discussions between next of kin (NOK) and the medical team, especially in vulnerable patients who may be unable to advocate for themselves.

Methods

We conducted a retrospective, cross-sectional analysis of patient notes across two PDSA cycles. NICE guidelines NG27, NG97 and NG96 provided an audit standard. Patients were identified as at-risk of poor communication if diagnosed with dementia, cognitive impairment, addiction, learning difficulties or needing an interpreter. Targeted intervention prior to re-audit included education of the medical team and introduction of a written prompt within the patient's notes.

Results

25/55 patients were identified as at-risk in cycle one, with 39/71 patients at-risk in cycle two. Post-intervention, the number of at-risk patients with a documented NOK discussion increased from 74% to 82%. Patient treatment plan discussions increased from 81% to 97%. Discussions, where applicable, regarding escalation of care, Deprivation of Liberty Safeguards (DoLS), capacity and Mental Health Act (MHA) slightly decreased. Conversations regarding patient consent for data sharing were rarely documented.

Conclusion

Our intervention increased the proportion of documented patient discussions; however, it did highlight the need to improve the frequency of documented conversations surrounding escalation of care, DoLS, capacity and MHA. This has provided impetus for further improvement projects.

Introduction: With the unprecedented population growth of older adults worldwide, higher life-expectancies are creating increasingly more multigenerational interaction. Funded by the General Research Fund of the Research Grant Council in Hong Kong, the study examined the effects of telephone-administered perspective-taking intervention in the context of intergenerational caregiving. The data was collected from 2019 to 2021 in Hong Kong.

Method: Through a cluster-randomized trial, one-hundred seventy-six adult child caregivers of persons living with Alzheimer’s disease (AD) were randomized into two twelve-week interventions: 1) Connecting through Caregiving with intergenerational perspective-taking reappraisals (n=91) and 2) Basic Skill Building (n=85). All interventions are administered via telephone, Both groups receive the basic skills training including 1) monitoring mood and scheduling pleasant events and 2) communication with the care recipient & 3) communication skills with other family member and helping professionals. The CTC group spends less time on basic skills and focused on perspective-taking reappraisals aiming to promote balance between self-care and caring of others. These reappraisals include: 1) connecting with self through enhancing self-awareness, 2) connecting with the care-recipient and 3) connecting with others who can help.

Results: In terms of primary outcomes, as compared to the BSB group, the CTC group reported significantly greater reductions in depressive symptoms and higher levels of psychological well-being. For the secondary outcomes, the CTC group scored higher in emotional and instrumental support and also lower levels of perceived presence  and reaction to behavioral and memory problems of the care recipient. Perspective-taking was found to mediate between intervention effects and reduction of depressive symptoms of the caregiver.

Conclusion: The results provided evidence for the efficacy of the CTC program. The telephone-administered intervention was very useful in supporting caregivers during COVID.  With population aging, there is a rapid increase of people suffering from dementia and those who will provide caregiving. The study contributes towards enhancing sustainability of caregiving in dementia

Introduction The decision to admit an older patient to the intensive care unit (ICU) should reflect shared goals of care. Resource limitations during the Covid-19 pandemic highlighted challenges in selecting candidates for escalation. Patients and next of kin (NoK) who have experienced ICU are well-placed to reflect on whether the admission was right for them. Objective: To explore older patients’ (65 years) and their loved ones’ views on escalation decision making. Methods Qualitative study involving semi-structured interviews with patients, NoK of survivors and NoK of deceased who experienced UK ICU admission with Covid-19 respiratory failure between March 2020 and February 2021. A preliminary questionnaire was used to maximise sample diversity of age, sex, ethnicity, survival, decision regret and impact of event scores. Interview data were collected via video conferencing or telephone. Transcripts were analysed using framework analysis. Results 30 participants were interviewed. Five themes were identified: ‘Inevitability’ - a sense that the illness and its management are out of the control of the patient or their loved one; ‘Disconnect’ - differences between hospital and lay person narratives; challenges to bridging that gap included effective communication aided by technology; ‘Acceptance’ - of the consequences, good or bad, of an intensive care admission as unalterable; ‘Beyond comprehension’ - participants had not contemplated ill health or ICU prior to admission and even with the benefit of hindsight struggled to describe which potential outcomes would be acceptable or unacceptable if they needed to be involved in similar decision-making around escalation in the future; ‘Covid-19’ - unique impact of a pandemic. Conclusion This study, which includes bereaved NoK as well as patients and NoK of survivors, adds perspective to inform decision making regarding treatment escalation of older people.