ADVANCED CARE PLANNING IN PATIENTS WITH NEUROCOGNITIVE IMPAIRMENT: STARTING THE CONVERSATION EARLY TO RESPECT THEIR CHOICES LATER

Abstract

Alzheimer’s disease is an invariably fatal condition. Many patients, however, die outside of their homes with aggressive, non-terminal care including CPR and feeding tubes. Furthermore, patients with Alzheimer’s disease are less likely to have advanced directives (AD) on admission and undergo fewer goals of care discussions, likely resulting in this undesirable care. Advanced care planning (ACP) should therefore start early in the management process. Chart analysis was conducted of all University of Wisconsin Geriatrics memory clinic initial consultation visits from 9/1/15-11/1/15. Documentation was reviewed for neurocognitive impairment diagnosis, presence of AD before and after clinic visits, and ACP discussion. Data was analyzed to determine percentages of patients presenting to clinic with ADs on file, filing of the ADs after clinic, and discussing ACP during visit. When possible, subsequent brief interviews were conducted with some patients and families regarding barriers to completing ADs and scheduling ACP meetings. There were 101 new Memory Clinic consultations from 9/1/15-11/1/15. 82.2% of patients were diagnosed with neurocognitive impairment. 33.7% of patients diagnosed with neurocognitive impairment had an AD prior to clinic. 9.1% of patients diagnosed with neurocognitive impairment without an AD on file obtained one after leaving the clinic. Three percent of total patients presenting to the Memory Clinic without an AD eventually obtained one. The Memory Clinic discussed ACP with 17.8% of all patients. The most common perceived barriers to obtaining an AD included lack of understanding the forms, lack of time in clinic to fill out forms, and believing they already had one completed at home. Despite evidence for the importance of AD and ACP in patients with dementia, a gap continues to exist in the initiation and implementation of these processes by front line care providers. As this study illustrates, even in a multi-disciplinary university-based memory clinic, it has been difficult to both address ADs and facilitate the ACP process. Based on these results, the Memory Clinic has prepared three simple and efficient interventions that will be implemented to improve ACP rates.