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Managing clinical uncertainty in older people towards the end of life: a systematic review of person-centred tools
BACKGROUND: Older people with multi-morbidities commonly experience an uncertain illness trajectory. Clinical uncertainty is challenging to manage, with risk of poor outcomes. Person-centred care is essential to align care and treatment with patient priorities and wishes. Use of evidence-based tools...
Autores principales: | , , , , , |
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Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
BioMed Central
2021
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Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8532380/ https://www.ncbi.nlm.nih.gov/pubmed/34674695 http://dx.doi.org/10.1186/s12904-021-00845-9 |
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author | Ellis-Smith, Clare Tunnard, India Dawkins, Marsha Gao, Wei Higginson, Irene J. Evans, Catherine J. |
author_facet | Ellis-Smith, Clare Tunnard, India Dawkins, Marsha Gao, Wei Higginson, Irene J. Evans, Catherine J. |
author_sort | Ellis-Smith, Clare |
collection | PubMed |
description | BACKGROUND: Older people with multi-morbidities commonly experience an uncertain illness trajectory. Clinical uncertainty is challenging to manage, with risk of poor outcomes. Person-centred care is essential to align care and treatment with patient priorities and wishes. Use of evidence-based tools may support person-centred management of clinical uncertainty. We aimed to develop a logic model of person-centred evidence-based tools to manage clinical uncertainty in older people. METHODS: A systematic mixed-methods review with a results-based convergent synthesis design: a process-based iterative logic model was used, starting with a conceptual framework of clinical uncertainty in older people towards the end of life. This underpinned the methods. Medline, PsycINFO, CINAHL and ASSIA were searched from 2000 to December 2019, using a combination of terms: “uncertainty” AND “palliative care” AND “assessment” OR “care planning”. Studies were included if they developed or evaluated a person-centred tool to manage clinical uncertainty in people aged ≥65 years approaching the end of life and quality appraised using QualSyst. Quantitative and qualitative data were narratively synthesised and thematically analysed respectively and integrated into the logic model. RESULTS: Of the 17,095 articles identified, 44 were included, involving 63 tools. There was strong evidence that tools used in clinical care could improve identification of patient priorities and needs (n = 14 studies); that tools support partnership working between patients and practitioners (n = 8) and that tools support integrated care within and across teams and with patients and families (n = 14), improving patient outcomes such as quality of death and dying and satisfaction with care. Communication of clinical uncertainty to patients and families had the least evidence and is challenging to do well. CONCLUSION: The identified logic model moves current knowledge from conceptualising clinical uncertainty to applying evidence-based tools to optimise person-centred management and improve patient outcomes. Key causal pathways are identification of individual priorities and needs, individual care and treatment and integrated care. Communication of clinical uncertainty to patients is challenging and requires training and skill and the use of tools to support practice. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12904-021-00845-9. |
format | Online Article Text |
id | pubmed-8532380 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2021 |
publisher | BioMed Central |
record_format | MEDLINE/PubMed |
spelling | pubmed-85323802021-10-25 Managing clinical uncertainty in older people towards the end of life: a systematic review of person-centred tools Ellis-Smith, Clare Tunnard, India Dawkins, Marsha Gao, Wei Higginson, Irene J. Evans, Catherine J. BMC Palliat Care Research BACKGROUND: Older people with multi-morbidities commonly experience an uncertain illness trajectory. Clinical uncertainty is challenging to manage, with risk of poor outcomes. Person-centred care is essential to align care and treatment with patient priorities and wishes. Use of evidence-based tools may support person-centred management of clinical uncertainty. We aimed to develop a logic model of person-centred evidence-based tools to manage clinical uncertainty in older people. METHODS: A systematic mixed-methods review with a results-based convergent synthesis design: a process-based iterative logic model was used, starting with a conceptual framework of clinical uncertainty in older people towards the end of life. This underpinned the methods. Medline, PsycINFO, CINAHL and ASSIA were searched from 2000 to December 2019, using a combination of terms: “uncertainty” AND “palliative care” AND “assessment” OR “care planning”. Studies were included if they developed or evaluated a person-centred tool to manage clinical uncertainty in people aged ≥65 years approaching the end of life and quality appraised using QualSyst. Quantitative and qualitative data were narratively synthesised and thematically analysed respectively and integrated into the logic model. RESULTS: Of the 17,095 articles identified, 44 were included, involving 63 tools. There was strong evidence that tools used in clinical care could improve identification of patient priorities and needs (n = 14 studies); that tools support partnership working between patients and practitioners (n = 8) and that tools support integrated care within and across teams and with patients and families (n = 14), improving patient outcomes such as quality of death and dying and satisfaction with care. Communication of clinical uncertainty to patients and families had the least evidence and is challenging to do well. CONCLUSION: The identified logic model moves current knowledge from conceptualising clinical uncertainty to applying evidence-based tools to optimise person-centred management and improve patient outcomes. Key causal pathways are identification of individual priorities and needs, individual care and treatment and integrated care. Communication of clinical uncertainty to patients is challenging and requires training and skill and the use of tools to support practice. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12904-021-00845-9. BioMed Central 2021-10-22 /pmc/articles/PMC8532380/ /pubmed/34674695 http://dx.doi.org/10.1186/s12904-021-00845-9 Text en © The Author(s) 2021 https://creativecommons.org/licenses/by/4.0/Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ (https://creativecommons.org/licenses/by/4.0/) . The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/ (https://creativecommons.org/publicdomain/zero/1.0/) ) applies to the data made available in this article, unless otherwise stated in a credit line to the data. |
spellingShingle | Research Ellis-Smith, Clare Tunnard, India Dawkins, Marsha Gao, Wei Higginson, Irene J. Evans, Catherine J. Managing clinical uncertainty in older people towards the end of life: a systematic review of person-centred tools |
title | Managing clinical uncertainty in older people towards the end of life: a systematic review of person-centred tools |
title_full | Managing clinical uncertainty in older people towards the end of life: a systematic review of person-centred tools |
title_fullStr | Managing clinical uncertainty in older people towards the end of life: a systematic review of person-centred tools |
title_full_unstemmed | Managing clinical uncertainty in older people towards the end of life: a systematic review of person-centred tools |
title_short | Managing clinical uncertainty in older people towards the end of life: a systematic review of person-centred tools |
title_sort | managing clinical uncertainty in older people towards the end of life: a systematic review of person-centred tools |
topic | Research |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8532380/ https://www.ncbi.nlm.nih.gov/pubmed/34674695 http://dx.doi.org/10.1186/s12904-021-00845-9 |
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