Completion Of Advance Directives Research Articles

Advance Directive Completion Among Older American Couples: A Dyadic Perspective on the Role of Cognitive Function and Other Factors.

Dyadic perspective is scarce in existing advance directive (AD) literature. Particularly, the significance of one's own and/or one's partner's cognitive function on AD remains unknown. This study investigates the relationship of cognitive function and other factors with AD completion within the spousal context. Data from the Health and Retirement Study (2014-2015) were used. Older heterosexual couples (age ≥65) married for 10+ years were asked if they had a living will and/or appointed a durable power of attorney for health care (DPAHC). Structural equation models examined the actor and partner effects of sociodemographic, health, and couple-level characteristics on wife's and husband's AD, respectively. Moderate spousal interdependence was observed in living will (kappa coefficient, κ = .60) and DPAHC (κ = .53). Older age and higher education were related to both spouses having AD. Less household wealth and being racial/ethnic minority were associated with a lower probability of having AD. Notable gender contrasts in actor and partner effects were found. Wife's higher level of cognitive function was associated with husband's AD completion. Contrarily, husband's lower level of cognitive function was associated with wife's AD completion. Retirement status had primarily actor effects for both husbands and wives. More chronic conditions were linked to husband's AD completion. The spousal interdependence of AD warrants practitioner efforts to facilitate family-oriented end-of-life planning. Wives and husbands may have different thoughts regarding their spouse's cognitive capacity to surrogate. Facilitating couple-based discussions may be a feasible approach to promote engagement with AD among older adults.

Advance Care Planning in Pediatric Serious Illness: Centering in the Family Experience.

* Abbreviation: FACE-TC — : Family-Centered Advance Care Planning for Teens with Cancer As advancements enable us to manage increasingly complex pediatric illness, we must be purposeful in ensuring that we meet patient and family goals. In this issue of Pediatrics , Thompkins et al1 examine the impact of an advanced care planning intervention, the Family-Centered Advance Care Planning for Teens with Cancer (FACE-TC), on families’ assessment of their experiences in caregiving and on familial distress. The FACE-TC is a National Cancer Institute–recognized evidence-based intervention developed to foster goals of care discussions and completion of advanced directives between adolescent patients and their families.1,2 The authors conducted a multicentered randomized control trial with adolescents and young adults with cancer, along with their families, over 3 years. Patient-family dyads received either 3 weekly structured sessions through the FACE-TC intervention or treatment as usual. Participants in the FACE-TC intervention had a statistically significant increase in positive estimations of their caregiving, with no notable difference in distress. The authors hope the study results will provide added assurance that this intervention designed to support families has more … Address correspondence to Khaliah A. Johnson, MD, FAAP, Children’s Healthcare of Atlanta, 1001 Johnson Ferry Rd NE, Atlanta, GA 30342. E-mail: khaliah.johnson{at}choa.org

Characterizing advance care planning, palliative care utilization, and location of end-of-life for adult allogeneic hematopoietic stem cell transplant recipients.

7034 Background: The impacts of advance care planning (ACP) on end-of-life (EOL) outcomes in allogeneic hematopoietic stem cell transplant (allo HCT) recipients are not well known. ACP includes advance directive (AD) completion, and palliative care (PC) consultation. Using these two components, we aimed to explore the current state of ACP and its impact on EOL outcomes in allo HCT recipients to provide the groundwork for future prospective studies. Methods: We performed a retrospective study of deceased adult patients who underwent allo HCT between December 2015-December 2019. We summarized patient characteristics, the rate of AD completion, PC consultation, and location of end-of-life (EOL). Univariate and multivariate analyses were performed to evaluate patient characteristics that may be associated with AD completion, PC consultation and assess the impact of these two factors on location of EOL. Results: See Table for summary of patient characteristics. Of the 125 patients included, we found that 66% (n = 82) completed ADs. All patients with ADs completed them prior to undergoing transplant and never modified them. The majority of patients (84%) with an AD expressed the desire to avoid life-sustaining treatment in the event of terminal illness or irreversible coma. PC was consulted for 46% (n = 58) of patients within 6 months prior to time of death (TOD). Regarding location of EOL, 30% of all patients died in the hospital (non-ICU), 20% in the ICU, 38% at home with hospice, and 10% in a hospice facility. Patients with ADs appeared more likely to die outside of the hospital compared to those without (53% vs. 44%, p = 0.4506). By multivariate analysis, there were no significant patient characteristics associated with the presence of an AD or PC consultation. After adjusting for age and comorbidity index, we found that patients with an AD were significantly more likely to die outside of the ICU (OR 3.0, 95% CI 1.2-7.5, p = 0.02), an effect that was further amplified in patients who both had an AD and received PC consultation at any point (n = 30, p = 0.0077). Conclusions: Our findings highlight the importance of ACP for EOL outcomes in the allo HCT population. While the rate of AD completion in our study population is higher than that of prior studies, future prospective studies aimed to improve the rate of ACP are needed.[Table: see text]

Improving end of life care with advance care planning in a rural cancer center.

e18637 Background: We discovered four out of five Medical Oncology patients admitted to the hospital December 2019 and January 2020 were discharged to hospice and died within a week. None of those patients had advance directives. In November and December 2019, all oncology patient charts were reviewed and only 7% (12/174) had advance directives. We believe an established advance directive could have helped avoid unnecessary hospitalization, improved end of life care and reduced wasteful health care costs. This led to the question: Would process changes in a rural cancer center lead to an increase in completion and documentation of Advance Directives, thereby providing more patient goal congruent care? Methods: Data collection and process mapping was performed revealing current processes and overall barriers. This was analyzed and countermeasures were developed leading to process changes and interventions. The interventions included assigning dedicated staff to “own” the advance directives education, follow up and completion, training and certification of staff, and education of the entire Cancer Center on the new process and interventions. The new process included a standardized order set to cue a referral to the dedicated staff, standardized patient education and follow up and documentation consistencies. Results: The initial data collection revealed an advance directive completion rate of 7% in new oncology patients. Process inconsistencies and communication deficiencies, with redundant screening and no follow up, created significant barriers to advance directives. Repeat data collection after creating a position for dedicated staff to educate patients and help with advance directive completion revealed a completion and documentation rate of 6% and thus, was insufficient to lead to change. When a consistent process with formal communication to the dedicated staff was implemented, improvements were noted. Our most recent data collection revealed a 36% completion and documentation rate in advance directives. Conclusions: Lack of effective advance directive programs potentially lead to end of life care incongruent with patients’ wishes and wasteful of health care resources. An advance directive ensures that if a patient is unable to clearly communicate their wishes, these wishes are still honored. In addition, the advance directive can help avoid unnecessary hospitalizations, improve end of life care and reduce wasteful health care costs. As a rural cancer center with a limited service area, we are challenged with a small sample size. Practice will be needed to ensure consistency and efficacy of the current interventions in order to support continued improvement in completion and documentation rates of advance directives. This project will be expanded to address advance directives for all patients.

A Quality Improvement Initiative to Increase Completion and Documentation of Advanced Directives in the ICU at a U.S. Community Teaching Hospital.

Prospective analysis. Urban U.S. community teaching hospital. All patients admitted to the ICU from September 2018 to February 2019. Internal medicine residents in the ICU received a lecture about advance directives and instructions to screen their patients for advance directives. For willing and decisional patients, residents facilitated the creation of a healthcare power of attorney and/or practitioner orders for life-sustaining treatment. Residents were anonymously surveyed at the beginning and end of the ICU rotation about their experience and level of comfort with healthcare power of attorney and practitioner orders for life-sustaining treatment completion. Three-hundred seventy-five patients were admitted to the ICU during the study period. Healthcare power of attorney documents were generated by 34% of all ICU patients without a prior healthcare power of attorney, increased from a baseline rate of 10% (p < 0.001). The number of practitioner orders for life-sustaining treatment documents for patients with code status of "no cardiopulmonary resuscitation" did not increase significantly. The percentage of residents who facilitated completion of a healthcare power of attorney document increased significantly from 56% to 100% (p < 0.001), whereas their practitioner orders for life-sustaining treatment experience did not change significantly by the end of their ICU rotation. On a Likert scale of 0-10, mean resident comfort increased significantly both with healthcare power of attorney documentation, rising from 6.14 to 8.84 (p = 0.005) and with practitioner orders for life-sustaining treatment form completion, increasing from 6.00 to 7.84 (p = 0.008). Training ICU medical residents to routinely screen for and facilitate completion of advance directives significantly increased the percentage of ICU patients with a healthcare power of attorney and significantly improved medical resident comfort with healthcare power of attorney and practitioner orders for life-sustaining treatment form completion.

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

Patients undergoing allogeneic hematopoietic cell transplantation (HCT) are at risk for high morbidity and mortality. Advance directives (AD) allow patients to express wishes regarding their care at the end of life, but these are not completed in the majority of patients undergoing HCT, with only 44% of deceased allogeneic HCT recipients at this institution completing an AD in the past decade. Increasing the AD completion rate can improve the quality of care for allogeneic HCT recipients. Our objective was to evaluate whether an alternative AD instrument can increase AD completion rate and patient satisfaction. We conducted a prospective, randomized controlled study of the traditional California AD versus a novel Letter AD, the Stanford What Matters Most Letter, in adult allogeneic HCT recipients. Patients age ≥18 years undergoing first allogeneic HCT at Stanford University were eligible. Prior to HCT conditioning, enrolled patients were assigned at random to complete either the traditional AD or the Letter AD. The primary endpoint was AD completion. The chi-square test was used to compare the AD completion rate between arms. The Wilcoxon rank-sum test was used to compare uncertainty, satisfaction with decision making, and satisfaction with the AD. Of the 212 patients who were eligible, 126 (59.4%) were enrolled and randomized. The mean age was 53.7 years, 57 (45.2%) were female, and 74 (58.7%) were non-Hispanic white. The overall AD completion rate was 71.4% and did not differ between the traditional and Letter AD arms (70.3% versus 72.6%; P=.78). Of those who completed the Letter AD, 66.7%, 42.2%, and 46.7% of patients wished to die gently/naturally, at home, and/or with hospice, respectively. In the traditional AD arm, 60.0% wished to not prolong life if recovery was unlikely. Opinion surveys did not find differences in levels of satisfaction between the traditional AD and Letter AD. Completion rates of AD on this study were high (71.4%) compared with historically reported completion rates and did not significantly differ based on AD version.

Conducting an advance care planning group among older adults living in residential care homes: An initiative of social workers in Hong Kong.

This study aimed to examine the effects of an advance care planning (ACP) group which was developed by social workers in Hong Kong for older adults. A quasi-experimental study was conducted. Participants were recruited from 14 residential care homes. The ACP intervention group included 59 participants for analyses, and the control group 58. Three major outcomes were measured at two time points: (a) Quality-of-life concerns, (b) End-of-life preference and (c) Advance directive (AD)-related outcomes (awareness of AD, AD completion, willingness to complete AD and communication with family members about AD). Findings indicate that the ACP group enhanced participants' awareness of AD compared with the control group. Participants were also more willing to complete AD, and more participants communicated with family members about AD after participating in the ACP group. No significant difference was found in other outcomes. This study demonstrates the efforts of social workers in promoting ACP in Hong Kong and the effectiveness of an ACP group for enhancing older adults' awareness of AD. Findings support the role of social workers in promoting ACP for deprived groups, like frail older adults. The ACP group could be considered a first step in enhancing older adults' awareness of and willingness to discuss end-of-life issues. Further follow-up is required to develop individualised ACP for older adults.

Advance Directives and Factors Associated with the Completion in Patients with Heart Failure.

Advance directive (AD) has been underutilized among patients with heart failure (HF). This study was performed to explore the ADs and examine factors associated with the completion of an AD survey in patients with HF. In a descriptive, correlational study, data on end-of-life values, treatment directives, and proxy (Korean-Advance Directive (K-AD) questionnaire) and factors associated with K-AD completion were collected among HF patients during outpatient visits. Of 67 patients (age, 67 years; male, 61.2%), 52.2% completed all or part of the K-AD. Among values, comfortable death was the most preferred (n = 15) followed by avoiding family burden (n = 6). In those completers, preferences for hospice care, cardiopulmonary resuscitation, ventilation support, and hemodialysis were 68.6%, 42.9%, 28.6%, and 28.6%, respectively. Female sex (odds ratio (OR) = 0.167), poorer HF prognosis (OR = 0.156), and better functional status (OR = 0.905) were associated with less likelihood of completing the AD survey. The findings suggest that in-depth AD discussion needs to be started earlier in patients with HF to facilitate completion of AD, especially in female patients. Future research should investigate if early discussion of ADs as part of advance care planning with integration into standard care of HF facilitates the documentation of ADs.

Racial Disparities of Possessing Healthcare Power Attorney and Living Will Among Older Americans: Do SES and Health Matter?

ContextMost previous studies considered advance directives (AD) as one outcome, which conceals possible variations of individuals’ decisions on two AD documents—living will (LW) and durable power of attorney for health care (PA). ObjectivesTo address this issue, this study examined how completions of PA and LW are associated with race, and whether SES and health can partially explain the racial disparities of AD possession. MethodsThe sample included 9902 older adults from the 2016 wave of the Health and Retirement Study. AD completion was coded as a four-category variable, including no PA or LW, no PA, no LW, and both PA and LW. Race was categorized as non-Hispanic white, non-Hispanic black, Hispanic, and Asian or Native American. Socioeconomic status (SES) was measured by education and household wealth. Health was indicated by chronic conditions and functional limitations. Multinomial logistic regression models were used to examine the racial effects of AD possession and the effects of SES and health conditions. ResultsOlder adults who only have PA or only have LW significantly differed in racial identity, SES and health. The regression results show that being a racial minority was associated with a lower likelihood to have both ADs and only PA. SES partially buffered racial disparities in AD possession, while the moderation of health was not consistently significant. DiscussionThe findings highlight the importance of examining the completions of two AD documents and indicate the necessity of developing distinct and concrete strategies to promote the completion of PA and LW.

Advance Directives in the Nursing Home Setting: An Initiative to Increase Completion and Reduce Potentially Avoidable Hospitalizations

Advance directive (AD) completion can improve transitions between hospitals and skilled nursing facilities (SNF’s). One Centers for Medicare and Medicaid Services (CMS) Innovations Demonstration Project, The Missouri Quality Initiative (MOQI), focused on improving AD documentation and use in sixteen SNF’s. The intervention included education, training, consultation and improvements to discussion process, policy development, increased AD enactment, and increased community education and awareness activities. An analysis was conducted of data collected from annual chart inventories occurring over four years. Using a logistic mixed model, results indicated statistical significance (p < .001) for increased AD documentation. Greatest gains occurred at project mid-point. The relationship between having an AD and occurrence of transfer to a hospital was tested on a sample of 1,563 residents with length of stays more than 30 days. Residents who did not have an AD were 29% more likely to be transferred. A logistic regression was conducted, and the results were statistically significant (p < .02).

The Effect of Health Literacy on a Brief Intervention to Improve Advance Directive Completion: A Randomized Controlled Study.

ObjectiveCompletion of an advance directive (AD) document is one component of advanced care planning. We evaluated a brief intervention to enhance AD completion and assess whether the intervention effect varied according to health literacy.MethodsA randomized controlled study was conducted in 2 internal medicine clinics. Participants were over 50, without documented AD, no diagnosis of dementia, and spoke English. Participants were screened for health literacy utilizing REALM-SF. Participants were randomized in a 1:1 ratio to the intervention, a 15-minute scripted introduction (grade 7 reading level) to our institution’s AD forms (grade 11 reading level) or to the control, in which subjects were handed blank AD forms without explanation. Both groups received reminder calls at 1, 3, and 5 months. The primary outcome was AD completion at 6 months.ResultsFive hundred twenty-nine subjects were enrolled; half were of limited and half were of adequate health literacy. The AD completion rate was 21.7% and was similar in the intervention vs. the control group (22.4% vs 22.2%, P = .94).More participants with adequate health literacy completed an AD than those with limited health literacy (28.4% vs 16.2%, P = .0008), although the effect of the intervention was no different within adequate or limited literacy groups.ConclusionA brief intervention had no impact on AD completion for subjects of adequate or limited health literacy.Practice ImplicationsOur intervention was designed for easy implementation and to be accessible to patients of adequate or limited health literacy. This intervention was not more likely than the control (handing patients an AD form) to improve AD completion for patients of either limited or adequate health literacy. Future efforts and research to improve AD completion rates should focus on interventions that include: multiple inperson contacts with patients, contact with a trusted physician, documents at 5th grade reading level, and graphic/video decision aids.Trial Registration NumberNCT02702284, Protocol ID IRB201500776

Race and Educational Disparities in Advance Directive Completion: Encouraging Trends in the United States

Advance directives (AD) help to ensure patients’ wishes are honored and contribute to improved end-of- life care. Race and education disparities in advance directive completion have been extensively documented. This study examined five waves of U.S. Health and Retirement Study exit survey data (N = 7,067) to examine to what extent these disparities have expanded or diminished over the past decade. Overall, advance directive completion increased from about 63% among participants who died in 2005-06 to about 73% among those whose deaths occurred between 2015 and 2016. Non-Hispanic whites were almost four times as likely to have advance directives compared to Hispanics or African Americans across this time period (OR=3.90. p<.0001). However, the growth rate in advance directive completion among non-Hispanic whites was significantly slower than for non-whites (OR=.90, p<.01). Compared to those with a high school education or less, those with some college (OR=1.67, p<.0001) and those with at least a college degree (OR=2.02, p<.0001) were significantly more likely to have advance directives across the time period. There were no significant differences in growth rates of advance directive completion for the different educational categories. These results suggest that educational disparities in advance directive completion are fairly stable, but that race disparities may be diminishing.

A Longitudinal Study of Retirement Transition and Advance Directive Completion

Advance directives (AD) help to ensure patients’ wishes are honored and contribute to improved end-of-life care. According to normative life course theory, retirement is a significant role change that signals a transition into the third age and its socially prescribed activities. To the extent that ACP is viewed as something to do when one reaches a more advanced stage in life, retirement may spark recognition that planning for incapacity and the end of life is now personally relevant and appropriate. This study tested whether transitioning from work to retirement prompted AD completion. The sample included Health and Retirement Study participants 65 and older who, in 2012, had no ADs and were not completely retired (N = 919). Retirement was operationalized as both a categorical status and as a multistep process. Three waves of data were analyzed using multinomial logistic regression to test associations between retirement transition and advance directive completion. By 2014, 21% had completed ADs and another 17% completed them by 2016. Those who completely retired between 2012 and 2014 were almost twice as likely to complete ADs between 2014 and 2016. Graduated increase in level of retirement between 2012 and 2014 was associated with higher odds of new AD possession in 2016, but did not reach statistical significance at p < .05. These results suggest the period following retirement may be an optimal time to encourage patients and clients who have not already done so to complete advance directives.

Older Adults’ Persisting Beliefs About the Death Panel Myth and Advance Directives

The political debate preceding passage of the Affordable Care Act included controversy over a bill that some claimed would establish a “death panel” to judge if older adults were worthy of receiving medical care. This claim was false, as the bill would instead incentivize physicians to inform Medicare patients about advanced directives: legal documentation of one’s end-of-life preferences. However, the death panel myth led to the removal of this bill from the Affordable Care Act, and a poll five years later found 41% of Americans still believed in the death panel myth. We investigated the effects believing in this myth had on older adults, hypothesizing that those who believed in the myth would have lower advance directive completion rates and more negative attitudes towards advanced directives. Community-dwelling older adults aged 65 to 102 years (N = 182) in a large city in the southern United States completed an interview survey. No relationship was found between belief in the death panel myth and advanced directive completion; however, older adults who believed in the myth had lower perceived need for advanced directives than those who did not. Surprisingly, 47.1% of older adults who believed in the myth also supported incentivizing doctors to inform patients about advanced directives, suggesting that many older adults who believe in the myth do not know that the controversial bill was about advanced directives. Results suggest that the death panel myth may have long-lasting effects, specifically persistent distrust about policies promoting advance directives.

Determinants of Advance Directive Completion Among Older Chinese Americans

Advance Directive (AD) allows older adults to communicate preferred care at the end of life. Numerous studies reported that ethnic minorities were less likely to complete AD then non-Hispanic Whites. However, determinants of AD completion among older Chinese Americans remain unknown. The present study aims to address this knowledge gap. Data came from a survey of 439 Chinese Americans aged from 51 to 103 living in two metropolitan areas in 2018. Participants’ average year was 75 (SD=9.37). About 63% were women and 93% were born outside the US. Approximately 14% of participants completed an AD. Guided by the Andersen’s Service Use Model, we used logistic regression to examine determinants of AD completion. Results show that older age (OR = 1.06, p < 0.01), being employed (OR = 2.63, p < 0.05), acculturation (OR = 2.09, p < 0.001), having US citizenship (OR = 3.57, p < 0.01), and expectation of intergenerational support (OR = 1.84, p < 0.05), were positively associated with AD completion. Physical and mental health needs were not significantly associated with AD completion. This is among the first studies focusing on AD completion among Chinese Americans, one of the fastest growing older minority populations in the US. Findings highlight the influence of socioeconomic and cultural factors on AD completion and illustrates the importance of developing culturally sensitive interventions to promote end-of-life care decision-making among older Chinese Americans.

Disparities in Palliative and Hospice Care and Completion of Advance Care Planning and Directives Among Non-Hispanic Blacks: A Scoping Review of Recent Literature.

Objectives:Published research in disparities in advance care planning, palliative, and end-of-life care is limited. However, available data points to significant barriers to palliative and end-of-life care among minority adults. The main objective of this scoping review was to summarize the current published research and literature on disparities in palliative and hospice care and completion of advance care planning and directives among non-Hispanc Blacks.Methods:The scoping review method was used because currently published research in disparities in palliative and hospice cares as well as advance care planning are limited. Nine electronic databases and websites were searched to identify English-language peer-reviewed publications published within last 20 years. A total of 147 studies that addressed palliative care, hospice care, and advance care planning and included non-Hispanic Blacks were incorporated in this study. The literature review include manuscripts that discuss the intersection of social determinants of health and end-of-life care for non-Hispanic Blacks. We examined the potential role and impact of several factors, including knowledge regarding palliative and hospice care; healthcare literacy; communication with providers and family; perceived or experienced discrimination with healthcare systems; mistrust in healthcare providers; health care coverage, religious-related activities and beliefs on palliative and hospice care utilization and completion of advance directives among non-Hispanic Blacks.Discussion:Cross-sectional and longitudinal national surveys, as well as local community- and clinic-based data, unequivocally point to major disparities in palliative and hospice care in the United States. Results suggest that national and community-based, multi-faceted, multi-disciplinary, theoretical-based, resourceful, culturally-sensitive interventions are urgently needed. A number of practical investigational interventions are offered. Additionally, we identify several research questions which need to be addressed in future research.

PREPARE-ing South Dakota Farm and Ranch Women for Advance Care Planning

Purpose: Evaluate the impact of an advance care planning (ACP) educational session utilizing PREPARE for Your Care for South Dakota farm and ranch women and its ability to increase engagement in ACP and documentation of medical wishes in the form of an advance directive.&#x0D; Sample: A convenience sample of women (n = 23) represented members of the farm and ranch community in South Dakota who were participating in the Power of Women as AgVocates Conference. Inclusion criteria for this study included being 18 years old or older, female, and conference participation. Exclusion criteria included men and those under the age of 18.&#x0D; Method: This was a cross-sectional investigation, consisting of three phases, and included comparisons of the same sample population before and after an ACP intervention at different time intervals (baseline, 1 week after the educational session and 3 months after the educational session). Increased engagement in ACP was evaluated using a pre-test, post-test design and utilized the 15-item Advance Care Planning Engagement Survey. Demographic information including age and highest level of education completed was collected.&#x0D; Findings: In total, 23 women participated in education session. The median age range was 35-44 years of age. There were statistically significant increases in self-efficacy and readiness to complete ACP reported by participants. The objectives of this education session were met. Per the participants, this was an effective format for ACP. Advance directive completion rates did not increase.&#x0D; Conclusions: The use of PREPARE for Your Care during an education session on ACP can increase self-efficacy and readiness to engage in ACP. The format of this program is appropriate for future use in community settings with the farm and ranch population.&#x0D; Keywords: Advance Care Planning, farm and ranch womenDOI: http://doi.org/10.14574/ojrnhc.v20i2.632

Help and Hindrances to Completion of Psychiatric Advance Directives.

Psychiatric advance directives (PADs) allow service users to participate in their own mental health care in the event that they have a future mental health crisis and are deemed incompetent to make decisions, but few patients complete these documents. This Open Forum reports on factors that have helped or hindered completion of PADs in New Zealand. Perceived barriers to completion include resource limitations, procedural issues, access and storage problems, and mistrust between clinicians and service users regarding implementation. Having management and nursing "champions" of the process and organizing outreach meetings for all interested parties appear to aid completion. Targeted education and training promote creation and use of PADs, address negative attitudes, and assist service users in creating these documents. Information technology support is vital to having PADs uploaded and accessed in medical records.

The impact of an advance care planning intervention for patients hospitalized with acute decompensated heart failure

BackgroundMany patients with heart failure (HF) have not addressed end-of-life planning. ObjectiveEvaluate the impact of an advance care planning (ACP) intervention on patients hospitalized with acute decompensated HF. MethodsA convenience sample of patients hospitalized with HF completed the Advance Directive Attitude Survey (ADAS) before The Conversation Project intervention. Post-intervention scores were collected after 30 days. ResultsAll participants (n = 30) had positive pre-intervention ADAS scores. Post-intervention scores revealed no significant change (p = 0.53). Twenty eight percent completed an advance directive (AD), 64% discussed the AD with a significant other, 40% established a surrogate decision maker, and 12% discussed the AD with a provider. ConclusionsAdvance directive completion rates were low despite participants having positive attitudes regarding their value. Discussion of goals between the patient and significant other is an important factor in end-of-life planning. Further studies are needed on strategies to improve provider discussions and AD completion.

S1072 Integrating Palliative Care in Liver Clinic: It Is Not About Less Aggressive Care

INTRODUCTION: Goals of care are not adequately addressed in patients with severe liver disease. We analyzed the rates of advance directive (AD) and code status completion in patients receiving palliative care (PC) consultation during liver clinic visits. METHODS: This is a retrospective study of patients with decompensated cirrhosis and/or advanced hepatocellular carcinoma (HCC) who had PC consultation. We collected demographics, clinical/laboratory data, and outcomes including AD/code status completion. Associations between categorical predictors and AD/code status completion were analyzed using Pearson’s chi-square test or Fisher’s exact test. Associations between quantitative predictors and AD/code status completion were analyzed using Student’s t-test or the Wilcoxon rank sum test. McNemar’s test was used to assess differences in AD/code status completion before and after PC consult. RESULTS: We identified 61 patients (characteristics described in Table 1). At the PC consult, 79% patients chose full code and 21% Do-Not-Resuscitate (DNR) vs 6.5% DNR prior to PC consult (P = 0.0027), with no differences related to demographics, cirrhosis etiology/decompensations, MELDNa or HCC (Table 1). HCC was inversely associated with switching to a less aggressive code status (Table 2). Only 33% of patients had AD prior to PC consult vs 82% after PC consult (P < 0.0001). Ascites was associated with AD completion, but HCC was inversely associated with AD completion. Patients were followed until death or for at least one year post PC consult. During the first year from PC consult, there were on average 4.9 PC visits/patient, and 10 patients (16%) died. Average time of follow up was 713.4 days, with subsequent changes in the code status. Last documented code status was 70% full code, 20% DNR/Do-Not-Intubate/Do-Not-Treat, 10% DNR but allow other treatments. Higher MELDNa was associated with choosing DNR (P = 0.001, Table 2). CONCLUSION: Integrating palliative care in liver clinic successfully increased the completion of AD and clarification of code status. Among several variables studied, only MELDNa was associated with DNR, and ascites with higher rates of AD completion. Interestingly, our patients with HCC were less likely to complete AD or downgrade their code status. Only a minority of patients (16%) switched to a less aggressive code status after discussions with PC, showing that the focus of PC is documenting patients’ wishes, not “getting the DNR”.Table 1Table 2