An Advance Care Planning Group Visit Intervention for Individuals With Mild Cognitive Impairment

Abstract Among older adults without cognitive impairment, a novel advance care planning group visit (ACP-GV) intervention increased ACP documentation and readiness to engage in ACP. A key question is whether an intervention can be adapted to support people with mild cognitive impairment (MCI) and a family care partner. We used a human-centered design process, rapid-cycle prototyping, and qualitative methods to adapt an ACP-GV intervention to individuals with MCI and a study partner. In 2019, we convened a longitudinal cohort of six patient-study partner stakeholders in three focus groups to suggest intervention adaptations. We also conducted a single arm study of four ACP-GV interventions (n=13 dyads total) that were iteratively refined with input from the longitudinal focus groups and intervention participant feedback. Decision tools, resources and videos were used to describe the concept of ACP and flexibility in selecting a medical decision maker. Many ACP-GV participants strongly agreed that the group discussion gave them useful information (81%) and would recommend the ACP-GV to a friend (85%). Pre- and post-ACP readiness surveys indicated that participants were significantly more ready to talk to their medical decision maker about ACP (p=0.028), while study partners perceived their loved ones less ready to speak to their doctor about ACP following the intervention (p=0.031). Use of rapid prototyping allowed testing of different resources and tools aimed at helping individuals with MCI and their study partners discuss ACP. Future work is needed to understand the feasibility of implementing an ACP-GV intervention for individuals with MCI into clinical settings.

food consumption. More in-depth investigations are needed to clarify the sociocultural determinants of dietary behavior and how they relate to different health outcomes among the U.S. Chinese population.

VITAMIN D SUPPLEMENTATION AND MORTALITY IN OLDER ADULTS: A SYSTEMATIC REVIEW AND META-ANALYSIS
Yunli Zhao, 1 Shuli Jia, 2 Meiling Ge, 3 and Birong Dong, 1 1. West China Hospital,Sichuan University,Chengdu,Sichuan,China,2. West China Hospital,Sichuan University,Chengdu,Shanxi,China,3. West China Hospital Sichuan University,Chengdu,Sichuan,China Web of Science, Embase, Medline and Cochrane Central Register of Controlled Trails from their inception to 14 January 2020 were searched in this review. We included randomized controlled trials (RCTs), which compared vitamin D supplementation versus placebo or no intervention and reported mortality as one of outcomes in older adults. Two review authors extracted data independently. Fifty-one articles were included in the analysis, which generated a total pooled sample of 89,977 people and 9813 deaths. These trials were pooled in a meta-analysis, and the outcomes were expressed as risk ratios (RRs) and 95% confidence Intervals (CIs). Across all studies, vitamin D supplementation was not associated with all-cause mortality (RR 0.98, 95%CI 0.92 to 1.04, P=0.48, I2=14%; 89,977 participants; data from 51 trails). Vitamin D supplementation was significantly decreased cancer mortality ( RR 0.85, 95% CI 0.74 to 0.97, P= 0.02, I2=0%; 34364 participants; data from 6 trails). A subgroup analysis showed the associations between the length of vitamin D supplementation more than 3 years and all-cause mortality were statistically significance (RR 0.93, 95%CI 0.88 to 0.98, p = 0.01, I2=0%; 49336 participants; data from 17 trails). Subgroup analyses by vitamin D status, forms of vitamin D (vitamin D3, vitamin D2, alfacalcidol or calcitriol), dose showed no association with all-cause mortality. The evidence from pooled analysis of 51 RCTs undertaken in older adults shows vitamin D supplementation was not associated with all-cause mortality. More long-term trails are need to know weather vitamin D supplementation can decrease all-cause mortality in older adults. Among older adults without cognitive impairment, a novel advance care planning group visit (ACP-GV) intervention increased ACP documentation and readiness to engage in ACP.

ADVANCE CARE PLANNING AND END-OF-LIFE
A key question is whether an intervention can be adapted to support people with mild cognitive impairment (MCI) and a family care partner. We used a human-centered design process, rapid-cycle prototyping, and qualitative methods to adapt an ACP-GV intervention to individuals with MCI and a study partner. In 2019, we convened a longitudinal cohort of six patient-study partner stakeholders in three focus groups to suggest intervention adaptations. We also conducted a single arm study of four ACP-GV interventions (n=13 dyads total) that were iteratively refined with input from the longitudinal focus groups and intervention participant feedback. Decision tools, resources and videos were used to describe the concept of ACP and flexibility in selecting a medical decision maker. Many ACP-GV participants strongly agreed that the group discussion gave them useful information (81%) and would recommend the ACP-GV to a friend (85%). Pre-and post-ACP readiness surveys indicated that participants were significantly more ready to talk to their medical decision maker about ACP (p=0.028), while study partners perceived their loved ones less ready to speak to their doctor about ACP following the intervention (p=0.031). Use of rapid prototyping allowed testing of different resources and tools aimed at helping individuals with MCI and their study partners discuss ACP. Future work is needed to understand the feasibility of implementing an ACP-GV intervention for individuals with MCI into clinical settings.

CLINICIAN DISTRESS: A CONCEPT CLARIFICATION Anessa Foxwell, University of Pennsylvania, Philadelphia, Pennsylvania, United States
In 2017, The National Academy of Medicine created the Action Collaborative on Clinician Well-Being and Resilience given the staggering statistics around distress and burnout, which is particularly high while caring for seriously ill older adults. This distress may be physical, emotional, spiritual, moral, ethical, existential or in degrees and combinations of multiple forms. Many crossover concepts are present in the literature, including moral distress, role stress, compassion fatigue, empathy, emotional labor, post-traumatic stress disorder, vicarious traumatization, and second victim. Because of the number of crossover concepts, we employed the Norris concept clarification method examining similar concepts to create an operational definition, construct a model, and develop possible research hypotheses of clinician distress. Articles were identified through PubMed, CINAHL, PsyhINFO, and SCOPUS with the expert assistance of a nurse librarian. Similar concepts in the literature were compared and contrasted with an emphasis on what encompasses clinician distress. Based on synthesis of the literature and existing concepts, clinician distress is defined as experiencing one or more negative emotions before, during, or after a clinical encounter that impacts the quality of care the clinician is able to provide to the patient. The result of this analysis provides some clarity around clinician distress and its surrogate terms, which presents opportunities for further investigation.

EVALUATING AN ADVANCE CARE PLANNING SKILLS TRAINING FOR MEDICAL, NURSING, AND SOCIAL WORK STUDENTS
Todd Becker, and John Cagle, University of Maryland, Baltimore, Baltimore, Maryland, United States Advance care planning (ACP) helps to ensure future healthcare is congruent with individual preferences. Curricula for health-focused professions rarely include ACP content. This is a repeated measures evaluation of an innovative, interprofessional student training to enhance the ability to lead ACP discussions. Outcomes were measured via selfreport surveys at two timepoints (baseline = T1 [n = 35]; posttraining follow-up = T2 [n = 20]) and included validated measures of communication self-efficacy, ACP self-efficacy, and interprofessional teamwork. Data collection from a third timepoint (T3), following randomized group assignment is currently underway. The matched T1-T2 sample (N = 17) included students from medicine (64.7%), nursing (17.6%), and social work (17.6%). Participants were largely young (M=26 years), non-Hispanic (94.0%), White (59.0%), and female (71.0%). Paired t tests examined change from T1 to T2 for all outcomes. Despite worse communication self-efficacy (Mdiff=1.6, p<.001) and ACP self-efficacy (Mdiff=.92, p<.001), perceptions of interprofessional teamwork improved (Mdiff=3.0, p=.008). These T1-T2 findings mirror results from similar, prior research, which subsequently discovered that both self-efficacy outcomes and their effect sizes for change worsened at T2, but ultimately and substantially improved at T3. These fluctuations suggest participants initially overestimated their self-efficacy related to ACP at T1 and corrected their appraisals at T2. Other studies should account for this self-correction. Further replication is needed to understand the dip that appears to occur before anticipated improvements occur. Previous work has shown that emotional processing as part of diary writing improves well-being during and after stress. The purpose of this study was to determine the feasibility of verbal/audio diaries for home hospice family caregivers (HFCGs). We also describe diary content. As part of an ongoing multi-site, prospective longitudinal study, HFCGs of cancer patients report daily fluctuations in patients' and their own symptoms via an automated telephone system, including a recorded diary entry. HFCGs are randomly assigned instructions to either discuss additional symptoms or discuss their thoughts and feelings. Thirty-six (85.7%) participants to date have completed at least one audio diary. For this preliminary analysis, we selected the 14 longest diary recordings from each condition (n=28) to content analyze using Linguistic Inquiry and Word Count (LIWC) and NVivo 12. Participants are 78.6% female, 53 years of age on average, and most are spouse/partner (46.4%) or adult child (35.7%) caregivers. There was no difference in the overall positivity (23%) or negativity (77%) of words in either condition, but participants asked to express thoughts/ feelings used significantly more anger-related terms (p=0.04) while those asked to describe symptoms used significantly more anxiety-related terms (p = 0.003). Time was the most common theme in both conditions but arose more frequently