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There is widespread agreement that clinicians should talk to seriously ill patients and their families about their illnesses. However, advance directives as a quality metric have been called into question because of the lack of data that these conversations lead to goal-concordant care. The controversy has led many to reexamine the purpose of conversations with seriously ill patients and what should be discussed in ambulatory visits. In this Controversies in Palliative care, experts in palliative care review the literature and suggest both how it influences their clinical practice and what research needs to be done to clarify the controversy. While there is not a single outcome that the experts agree on, they posit a variety of different ways to assess these conversations. [ABSTRACT FROM AUTHOR]

1. Recognize five distinct trajectories of serious illness communication among patients admitted to a long-term acute care hospital. 2. Discuss the qualitative differences that help to distinguish these serious illness communication trajectories. Through novel qualitative longitudinal analysis of SIC notes, this study identified five SIC trajectories that culminated along a continuum from reluctance to acceptance. Incorporating intentional starting points, purposeful inclusion of conversation participants, modifying expectations, and addressing discord offer ways to enhance communication across SIC encounters to facilitate informed healthcare decision-making. Little is known about how serious illness communication (SIC) evolves over time to influence healthcare decision-making among chronic critically ill patients in the long-term acute care hospital (LTACH) setting.1,2,3 To characterize trajectories of SIC among patients admitted to an LTACH. A qualitative methodology for understanding longitudinal care processes—trajectory analysis—was conducted for a subset of patient cases where three or more SIC notes were documented between 2019 to 2020.4 This involved a time-ordered matrix to organize and code SIC notes by patient case according to time. Within each patient case, themes were identified with respect to the evolution of the patient's (and caregiver's) orientation toward decision-making across SIC encounters. Patterns among themes defined the trajectories. Across 125 patient cases, 28 patients had three or more SIC notes. Mean age was 70 years. Patients were predominantly White (71%), female sex (68%), admitted with respiratory failure for an average of 38 days. Five SIC trajectories were identified: (1) maintain clinical course (n=3); (2) in-limbo: focus on all possible treatments (n=10); (3) de-escalation of treatment: reactive (n=3); (4) in-limbo: contemplating comfort (n=7); (5) de-escalation of treatment: proactive (n=5). Overall, trajectories began from a place of stagnation and culminated along a continuum from reluctance to acceptance. Several features distinguished trajectories (e.g., role of the patient's voice, code status preferences, and presence of discord), which may have served as key drivers of the conversation evolution. These findings underscore the importance of the collective impact of SIC over time and the need for clinicians to leverage factors during conversations that will help build on prior interactions to engage in informed healthcare decision-making. This study adds insight into the features of SIC that may help conversations evolve over time and avoid conversations that solely recapitulate prior interactions and stagnate decision-making. [ABSTRACT FROM AUTHOR]

1. Utilizing a case-based approach, participants will articulate the process of implementing an evidence-based advance care planning educational intervention in the faith-based community in the underserved rural population. 2. Utilizing a case-based approach, participants will describe the impact of a culturally sensitive faith-based community educational intervention on advance care planning knowledge and engagement in the underserved rural population. There is a need to increase Advance Care Planning (ACP) knowledge and engagement, making ACP culturally sensitive and accessible to underserved rural populations. This presentation describes implementing and evaluating an evidence-based ACP educational workshop in a rural faith-based community to address the gap in limited public awareness and participation. Advance Care Planning (ACP) facilitates high-quality, person-centered end-of-life care. Yet only 30% of Americans have engaged in ACP. The problem of limited public awareness and participation in ACP can lead to unnecessary healthcare interventions that are not preference-matched—poorly impacting patients' quality of life and patients' and caregivers' experiences of distress at the end of life. This project is a response to the growing demand to bring ACP outside the walls of healthcare facilities. Opportunity exists for hospice and palliative care professionals to partner with faith-based communities to provide culturally sensitive community-based education to enhance ACP knowledge and engagement in underserved rural populations. The purpose of this project is to 1) implement an evidence-based ACP educational workshop hosted in a rural faith-based community, and 2) evaluate its impacts on ACP knowledge and engagement. This project utilizes a pre- and post-test design to examine the impact of the workshop on ACP knowledge and engagement. Three self-contained workshops will utilize the ACP educational materials developed by PREPARE (prepareforyourcare.org) and be offered in a faith-based community in rural northwest Ohio. The workshops will be open to adults aged 18 and older in the surrounding communities. ACP knowledge and engagement will be measured using a validated ACP Knowledge Questionnaire and ACP Engagement Survey before and after the education. In-progress results will be presented, based on data from the planned delivery of the ACP educational workshop in September, October, and November 2023. Anticipated outcomes include increased ACP knowledge and engagement among an underserved rural faith-based community, representing steps toward improved high-quality, person-centered end-of-life care for all. If the results show promise, this approach to ACP education offers an exemplar for continued work in promoting access to and awareness of ACP in this largely untapped setting for facilitating community-based ACP. Shared Decision Making / Advance Care PlanningCommunication [ABSTRACT FROM AUTHOR]

Background: National oncology guidelines recommend early integration of palliative care for patients with cancer. However, drivers for this integration remain understudied. Understanding illness concerns at the time of cancer treatment may help facilitate integration earlier in the cancer illness trajectory. Objective: To describe cancer patients' concerns while undergoing cancer treatment, and determine if concerns differ among African Americans and Whites. Methods: A 1-time, semi-structured qualitative interview was conducted with a purposive subsample of cancer patients participating in a larger study of illness concerns. Eligible patients were undergoing cancer treatments and had self-reported moderate-to-severe pain in the last week. Analysis encompassed a qualitative descriptive approach with inductive thematic analysis. Results: Participants (16 African American, 16 White) had a median age of 53 and were predominantly females (72%) with stage III/IV cancer (53%). Illness concerns were largely consistent across participants and converged on 3 themes: symptom experience (pain, options to manage pain), cancer care delivery (communication, care coordination and care transitions), and practical concerns (access to community and health system resources, financial toxicity). Conclusions: The findings extend the scope of factors that could be utilized to integrate palliative care earlier in the cancer illness trajectory, moving beyond the symptoms- and prognosis-based triggers that typify current referrals to also consider diverse logistical concerns. Using this larger set of concerns aids anticipatory risk mitigation and planning (e.g. care transitions, financial toxicity), helps patients receive a larger complement of support services, and builds cancer patients' capacity toward a more patient-centered treatment and care experience. [ABSTRACT FROM AUTHOR]

Parenting stress is common and may lead to worsening health, particularly in the context of other risk factors such as mental disorders or a history of abuse. This study investigated how parenting-related stress impacts the effect of abuse experiences on health among mothers with mental health disorders. Survey data was analyzed from 172 predominantly Hispanic mothers receiving outpatient behavioral health services. Most (80.2%) mothers had experienced abuse. Those reporting childhood abuse had 3.82 greater odds of experiencing abuse in adulthood. Findings demonstrated worse health outcomes among those experiencing abuse in both childhood and adulthood and those with a greater number of abuse experiences. Caregiving load intensified the relationship between abuse and anxiety and sleep disturbance. Parenting self-agency intensified the relationship between abuse and cigarette use. These findings have important implications for mental health nursing practice by identifying parenting-stress as an important target for interventions to improve health among women with histories of abuse and mental health disorders. [ABSTRACT FROM AUTHOR]

Context: Prolonged management of critical illnesses in long-term acute care hospitals (LTACH) makes serious illness communication (SIC), a clinical imperative. SIC in LTACH is challenging as clinicians often lack training and patients are typically unable to participate-making caregivers central., Objectives: This qualitative descriptive study characterized caregiver engagement in SIC encounters, while considering influencing factors, following the implementation of Ariadne Labs' SIC training at a LTACH in the Northeastern United States., Methods: Clinicians' documented SIC notes (2019-2020) were analyzed using directed content analysis. Codes were grouped into four categories generated from two factors that influence SIC-evidence of prognostic understanding (yes/no) and documented preferences (yes/no)-and caregiver engagement themes identified within each category., Results: Across 125 patient cases, 251 SIC notes were analyzed. In the presence of prognostic understanding and documented preferences, caregivers acted as upholders of patients' wishes (29%). With prognostic understanding but undocumented preferences, caregivers were postponers of healthcare decision-making (34%). When lacking prognostic understanding but having documented preferences, caregivers tended to be searchers, intent on identifying continued treatment options (13%). With poor prognostic understanding and undocumented preferences, caregivers were strugglers, having difficulty with the clinicians or family unit over healthcare decision-making (21%)., Conclusion: The findings suggest that two factors-prognostic understanding and documented preferences-are critical factors clinicians can leverage in tailoring SIC to meet caregivers' SIC needs in the LTACH setting. Such strategies shift attention away from SIC content alone toward factors that influence caregivers' ability to meaningfully engage in SIC to advance healthcare decision-making., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.