Factors Associated with Successful Intervention to Facilitate Completion of Advance Medical Directives: A Cross-Sectional Study.

The purposes of the present study were (1) to explore the completion rate of advance directives (ADs) in a sample of Asian Americans and (2) to examine the direct and moderating effects of knowledge of AD, education, and acculturation in predicting AD completion. Education and acculturation were conceptualized as moderators in the link between knowledge and completion of ADs. Using data from 2609 participants in the 2015 Asian American Quality of Life survey (aged 18-98), logistic regression analyses on AD completion were conducted, testing both direct and moderating effects. The overall AD completion rate in sample was about 12%. The AD knowledge and acculturation independently predicted AD completion. No direct effect of education was found; however, it interacted with AD knowledge. The AD knowledge was more likely to be translated into completion in the group with higher education. The AD completion rate observed in the present sample of Asian Americans was much lower than that of the US general population (26%-36%). The interactive role of education helps to explain the gap between AD knowledge and completion and suggests intervention strategies.

Purpose: The purpose of this study was to identify factors related to the completion of advance directives by community-dwelling older adults.Methods: This descriptive correlational study used a cross-sectional survey of 236 older adults recruited from a welfare center in Jungnang gu Seoul, South Korea. Data collection was done from June 1 to August 20, 2021. A self-administered questionnaire was used to measure advance directives' self-efficacy and intentions and the completion of advance directives. The data were analyzed with the SPSS 23.0 and SPSS Process Macro program.Results: Advance directives' self-efficacy indirectly had a significant positive effect on the completion of advance directives and fully mediated advance directives' intentions, and its explanatory power was confirmed to be 21%.Conclusion: The result of this study suggests developing education programs to improve the completion of advance directives in community-dwelling older adults. Further research is needed with more elderly populations in extended areas.

Setting Trends in the Preoperative Care Setting: Advance Care Planning (SA510A)

ObjectivesTo compare outpatients from private practices and outpatients from a university clinic regarding the determinants of completion of advance directives (AD) in order to generalise results of studies from one...

BackgroundAn advance directive (AD) is a written or verbal document that legally stipulates a person’s health care preference while they are competent to make decisions for themselves and is used to guide decisions on life-sustaining treatment in the event that they become incapacitated. AD can take the form of a living will, a limitation of care document, a do-not-resuscitate order, or an appointment of a surrogate by durable power of attorney. The completion rate of AD varies from region to region, and it is influenced by multiple factors. The objectives of this study were to determine the proportion of terminally ill patients with AD and to identify the factors that influence the completion of AD amongst terminally ill patients at a tertiary hospital in Kenya.MethodsThe study was a retrospective survey. All available records of terminally ill patients seen at Aga Khan University Hospital, Nairobi, between July 2010 and December 2015, and that met the inclusion criteria were included in the study.ResultsIn total, 216 records of terminally ill patients were analyzed: 89 records were of patients that had AD and 127 records were of patients that did not have AD. The proportion of terminally ill patients that had completed AD was 41.2%. The factors that were associated with the completion of AD on bivariate analysis were history of ICU admission, history of endotracheal intubation, functional status of the patient, the medical specialty taking care of the patient, patient’s caregiver discussing the AD with the patient, and a palliative specialist review. On multivariate regression analysis, discussion of AD with a caregiver and patient’s functional impairment were the factors with statistically significant association with completion of AD.ConclusionsThe proportion of terminally ill patients that had AD in their medical records was significant. However, most terminally ill patients did not have AD. Our data, perhaps the first on the subject in East Africa, suggest that most of the factors associated with AD completion mirrored those seen in other regions of the world. Discussion between patient and their physician and patient’s functional impairment were the factors independently associated with completion of AD. Therefore, physicians need to be aware of the importance of discussions of AD with their patients.

The purposes of the study were to assess awareness and prevalence of advance directives (ADs) among patients with advanced cancer undergoing active outpatient care and to determine factors associated with AD completion before and after the diagnosis of cancer. Patients with advanced solid tumor malignancy receiving treatment at the Chemotherapy Day Unit were approached for recruitment. They completed an onsite questionnaire about completion and timing of ADs, demographic information, and perceived health; a review of their medical records was conducted to document their cancer care and co-morbidities. Multinomial logistic regression analysis identified factors associated with the timing of AD completion (pre-cancer, post-cancer, or not at all). Two hundred patients were enrolled, with 193 surveys available for analysis. ADs were completed in 55 % (106/193) of patients, including a living will in 33 % (63/193), a power of attorney in 49 % (95/193), and a do-not-resuscitate (DNR) designation in 18 % (35/193). Most patients (53 %) had completed an AD before being diagnosed with cancer. Higher income (p=0.02) and age (p=0.004) were associated with AD completion pre-cancer diagnosis; discussion of end-of-life care (p=0.02) and palliative care referral (p<0.0001) were associated with AD completion post-cancer diagnosis. This study demonstrates that different factors may influence the completion of ADs before and after a diagnosis of cancer and highlights the potential for early palliative care to impact the completion of ADs in patients with advanced cancer who are undergoing active cancer treatment.

1 Background: Advance care planning (ACP), which includes advance directive (AD) completion, ensures that patients receive care that is consistent with their beliefs and preferences. ACP is particularly important to patients with cancer as they have high rates of hospitalization and mortality. However, AD completion rates for oncology patients have been reported to be as low as 10%. We sought to evaluate barriers and improve AD completion rates in hospitalized oncology patients in our institution. Methods: 63 patients with cancer admitted to our inpatient oncology unit were surveyed. A multi-disciplinary team, consisting of resident physicians and social workers, was constituted to educate patients and provide assistance with AD completion. Barriers to AD completion were identified and AD completion and filing rates on patients’ discharge were calculated. Results: Most patients were female (66.6%) with mean age of 63.8 years. Majority of patients had stage IV cancer (71.4%) and were receiving palliative treatment (80.9%). Only 9.5% (6/63) of the patients had completed AD on file. However, 92% of the patients had previously heard about AD. After intervention, the AD filing rate improved to 41.2% (26/63). Some of the patient-reported barriers were needing more time to discuss with family (28.5%), wanting to file in clinic (23.8%), too sick to make decision (6.3%) and did not think they needed it (4.7%). Conclusions: AD completion rate in hospitalized oncology patients in our institute was lower than anticipated. We identified the barriers and improved the AD filing rate, however there is room for further improvement. While AD discussion and filing should ideally be done in clinic, hospitalization is an opportunity that should not be missed to educate and assist completion of AD. [Table: see text]

The 1.7 million older adults receiving long-term services often do not receive end of life care consistent with their wishes. Advance directives (ADs) can help, yet only one-third of Americans have completed ADs. The limited effectiveness of traditional interventions to increase AD completion may be because they do not address the behavioral aspects of advance care planning. Behavioral Design is an innovative approach that combines design thinking and behavioral economics to identify predictable behavioral bottlenecks and create real-time solutions. This study used Behavioral Design to address low AD completion rates of long-term care residents. Consistent with the Behavioral Design process, an interdisciplinary team compiled evidence from 10 diverse data sources to identify behavioral bottlenecks to AD completion. These barriers were analyzed using the cognitive bias codex to determine behavioral levers for intervention. Informed by these findings, the study team designed multicomponent interventions to address behavioral aspects of AD completion. Four behavioral bottlenecks incorporating ten behaviorally mediated causes for lack of AD completion were identified. For example, AD completion is affected by complexity mediated by hassle factor, choice overload, and ambiguity effect. Three interventions were designed to address these behaviorally mediated causes. For example, the intervention HeAD Start would provide a simple, easy to read AD (addressing choice overload) to residents upon admission (addressing hassle factor) with scheduled follow-up by trained staff (addressing ambiguity effect). Behavioral Design incorporates design thinking and leverages behavioral economic principles to create behaviorally mediated AD interventions. Next steps include testing behaviorally informed designs in practice.

20 Background: Advance Care Planning (ACP) is a central component of patient-centered care, helping ensure patient values and preferences guide clinical decisions. Patient navigators have been utilized effectively in healthcare for numerous roles, and more recently for ACP. At City of Hope National Medical Center (COH), an ACP-focused navigator was hired to support patients, families, and staff with Advance Directive (AD) notarization and primary ACP conversations. Methods: The Department of Supportive Care Medicine at COH with significant institutional collaboration and administrative support created a patient-centered ACP program and marketing campaign, called “Plan Today for Tomorrow.” In 2016, an ACP navigator joined the team to facilitate AD completion. Referral to the ACP navigator occurred either through staff endorsement and/or the institution’s technological screening platform deployed in a majority of COH outpatient clinics. Staff referrals came from physicians, clinical social workers, nurses, or from the Sheri &amp; Les Biller Patient and Family Resource Center. Prior to the ACP navigator, all referrals were addressed by Clinical Social Workers (CSWs). Results: In a review of 14 months of data, the ACP navigator followed up on 1,125 referrals, 574 were from staff, while 551 were from the institutional tablet-based screening platform. Follow-up on staff referrals resulted in an 86% AD completion rate. Follow-up on tablet-based screening resulted in a 23% AD completion rate. Conclusions: The presence of an available onsite ACP-focused navigator was more effective in facilitating AD completion of staff generated AD referrals as compared to AD completion of tablet-based patient screening AD referrals. The presence of the ACP navigator to facilitate AD completion decreased workload for CSWs, creating increased opportunity for CSWs to work at the top of their professional license. Further work is needed to increase the effectiveness of AD completion from tablet-based screening referrals.

Introduction: Advance care planning (ACP) aims to provide care at the end of life (EOL) that is consistent with a patient’s wishes, but it is infrequently performed in patients with decompensated cirrhosis. We implemented a quality improvement (QI) initiative in a hepatology fellows clinic at a major tertiary medical center with the goal of increasing advance directive (AD) completion among patients with decompensated cirrhosis. The goal of this analysis is to describe factors related to successful AD completion and preliminary effects of AD completion on EOL outcomes. Methods: The QI intervention, consisting of provider education, electronic health record templates, and standardized workflows, was conducted between November 2018 and March 2021. We performed a retrospective chart review of adult patients with decompensated cirrhosis seen during this period. We collected data on whether an AD was successfully completed and type of AD (first completed, if multiple). We also assessed location of death and receipt of hospice care among decedent patients. Descriptive statistics and univariate logistic regression were performed using STATA 14.2. Results: A total of 120 patients with decompensated cirrhosis were seen during the QI intervention. Our cohort was mostly male (62%), Latino (55%), Medicaid-insured (70%) and non-transplant candidates (86%). AD completion improved from 8% (N=10) to 44% (N=53) by the end of the study period. Most ADs were completed in the outpatient setting (N=38, 72%) and were healthcare proxy designation forms (N=41, 77%). A diagnosis of NASH (OR: 4.25, 95% CI: 1.11-16.2) and divorced marital status (OR: 10.23, CI: 2.04-51.3) were the only factors associated with successful AD completion. Seventeen (14%) patients died during the study period, of which 12 (71%) had an AD. Decedents with an AD were more likely overall to receive hospice (67% vs. 20%) and die under hospice care (42% vs. 20%). Conclusion: Following our QI intervention, 44% of patients with decompensated cirrhosis had an AD, which were largely health care proxy forms completed in the outpatient setting. No significant disparities in AD completion by age, gender, or race were observed from our intervention. AD completion was associated with higher rates of receiving hospice among decedents. These findings suggest benefits of AD completion on EOL care in this population.Table 1.: AD=advance directive, SD=standard deviation, LT=liver transplant, MOLST=medical order for life-sustaining treatment, DNR=do-not-resuscitate order.

Background Despite many benefits of end-of-life (EOL) planning, only 1 in 3 adults has EOL documentation, with low rates in resident primary care clinics as well. Objective To increase clinic completion of life-sustaining treatment (LST) notes and advance directives (AD) for veterans at highest risk for death. Methods The setting was a Veterans Affairs (VA) internal medicine primary care clinic. All clinic residents in the 2021-2022 academic year and all clinic patients identified through a VA risk-stratification tool as highest risk for death were included. Baseline AD and LST completion rates were determined through manual chart review. Our interventions included 2 hours of teaching to increase resident knowledge of EOL planning and a systematic process improvement to complete EOL planning appointments. Outcomes assessed included anonymous resident pre- and post-surveys of self-assessed knowledge and comfort with EOL conversations, as well as rates of LST and AD completion determined through serial chart review. Results In the 2021-2022 academic year, 22 residents (100%) and 54 patients were included. Post-intervention surveys (n=22, 100%) showed improved self-assessed knowledge of EOL concepts and comfort with patient discussions (median Likert increase 3 to 4). The number of residents who completed an EOL planning visit increased from 9 of 22 (41%) to 15 (68%). LST completion increased from 9 of 54 (17%) to 29 (54%), and AD completion increased from 18 of 54 (33%) to 33 (61%). Conclusions A brief teaching intervention to prepare residents for comprehensive EOL visits combined with process improvement to offer EOL planning visits improved self-reported knowledge and comfort and completion of EOL visits.

Do Older Adults with Completed Advance Directives Really Understand Them? (704)

Prospective Randomized Study of Advance Directives in Allogeneic Hematopoietic Cell Transplant Recipients

Part 2: Ethical Aspects of CPR and ECC

e13511 Background: Advance directives (ADs) are an important part of life care planning in patients with cancer. There is a lack of effective interventions that increase AD rates in breast cancer patients prior to surgery. In this quality improvement project, we implemented a 4R Oncology intervention in a community-based cancer center within an integrated health care system. 4R (Right Info / Care / Patient / Time) is a novel care planning and delivery model, which enables patients and care teams to manage complex time-sensitive care with a multi-modality 4R Care Sequence plan, coupled with follow-up workflows. Methods: Patients with newly diagnosed non-metastatic breast cancer who attended a multidisciplinary clinic and underwent definitive surgery at one facility were included in the study. Patients received usual care from 10/1/19 to 9/30/20 (usual care cohort). From 10/1/20 to 9/30/21 (intervention cohort), patients were provided a 4R Care Sequence, which included AD completion prior to surgery, and those without AD were referred for follow-up with a health educator to discuss AD completion. Demographics, NCCN thermometer distress scores, and AD completion rates were compared between the usual care and intervention cohorts using descriptive statistics. Results: Characteristics of age, gender, race/ethnicity, language interpreter usage, Elixhauser Comorbidity Index, NCCN distress scores &gt; 4, surgery type, tumor grade, ER/PR/HER-2 status were similar between the usual care (N=140) and intervention cohorts (N=141). The intervention improved AD completion rates in a time-sensitive fashion prior to surgery between usual care and intervention cohorts, both in total (15% vs 74%, p&lt;.01), and in 3 of the 5 race/ethnicity groups (Table). AD completion rates increased in patients of all races/ethnicities, but increases were not statistically significant for Hispanic patients, likely due to low numbers of these patients in both cohorts. Patients with higher distress scores completed ADs at similar rates to those with lower distress scores. Conclusions: Delivery of 4R Care Sequences, coupled with a health educator follow-up can significantly increase rates of time-sensitive AD completion, regardless of patients’ distress score. Patients across race/ethnicity groups benefited from the intervention, but further efforts are needed to understand the impact of this intervention in patients who are Hispanic. Through an effective care delivery model, patients can be provided with standardized equitable care. [Table: see text]