Discussion Of Advance Directives Research Articles

Using Preanesthesia Clinic Visits to Improve Advance Directives Completion: An Interrupted Time Series Analysis.

Advance directives documentation can increase the likelihood that patient's wishes are respected if they become incapacitated. Unfortunately, completion rates are suboptimal overall, and disparities may exist, especially for vulnerable groups. We assessed whether implementing an initiative to standardize advance directives discussions during preanesthesia visits was associated with changes in rates of advance directives completion over time, and whether the association depends on race, insurance type, or income. We conducted a before-after interrupted time series evaluation between January 1, 2015 and June 30, 2019 in a single-center, outpatient preanesthesia clinic. Participants were adults who visited the preanesthesia clinic at Cleveland Clinic and had >1 comorbidity before a noncardiac surgery of either medium or high risk. The intervention in March of 2017 consisted of training staff to help patients complete and witness advance directives documents during visits. We measured advance directives completion, by race, payor, and income (using the 2019 Federal Poverty Line). We assessed the confounder-adjusted association between intervention (pre versus post) and proportion of patients completing advanced directives over time using segmented regression to compare slopes between periods and assess changes at start of the intervention. We used similar models to assess whether changes depended on race, insurance type, or income level. We included 26,368 visits from 22,430 patients. We analyzed financial status for 16,788 visits from 14,274 patients who had address data. There were 11,242 (43%) visits preintervention and 15,126 (57%) visits postintervention. Crude completion rates for advance directives increased from 29% to 78%, with odds of completion an estimated 18 times higher than preintervention (odds ratio [95% CI] of 18 [16-21]; P < 0.001). Regarding race, Black patients had lower completion rates preintervention than White patients, although the gap steadily closed after the intervention (P = .001). Postintervention, both race groups immediately increased, with no difference in amount of increase (P = .17) or postintervention change in slope difference (P = .17). Regarding insurance, patients with Medicaid had lower preintervention completion rates than those with private. Intervention was associated with increases in both groups, but the difference in slopes (P = .43) or proportions (P = .23) between the groups did not change after intervention. Regarding the Federal Poverty Line, the completion rate gap between those below (<100%) and above (139%-400%) narrowed by approximately half (0.51: 95% CI, 0.27-0.98; P = .04). Standardizing advance directives discussions during preanesthesia visits was associated with more patients completing advance directives, particularly in vulnerable patient groups.

"Advancing" Advance Care Planning to Veterans in the Veterans Health Administration.

The completion rate of Advance Directive (ADs) in the Veterans Health Administration (VHA) is unknown. There is substantial literature on the need for effective Advance Care Planning (ACP) that leads to an AD to ensure that health care preferences for patients are known. Advance Directive are essential to consider since ACP, which explains and plans Advance Directive, does not reach all individuals. Health inequities, such as those experienced in rural areas, continue to exist. While ACP may disproportionately affect rural-residing veterans and their providers, a VHA program was specifically designed to increase ACP engagement with rural veterans and to address several systemic barriers to ACP. This descriptive analysis seeks to identify patient, provider, and geographic characteristics associated with higher rates of ACP participation in VHA. An observational examination of the profile of veterans and the types of ACP (e.g., individual or in groups) using administrative data for all beneficiaries receiving VHA health care services in federal fiscal year (FY) 2020 was conducted as part of a national program evaluation. The measures include patient-level data on demographics (e.g., race, ethnicity, gender), unique patient identifiers (e.g., name, social security number), geographic characteristics of patient's location (e.g., rurality defined as Rural-Urban Commuting Areas [RUCA]), VHA priority group; provider-level data (e.g., type of document definition, clinic stop codes, visit date used to verify Advance Care Planning via Group Visits [ACP-GV] attendance; data not shown), and electronic health record note titles that indicated the presence of ACP in VHA (e.g., "Advance Directive [AD] Discussion" note title, "ACP-GV CHAR 4 code"). Pearson's chi-square statistics were used for between-group comparisons based on a two-sided test with a significance level of 0.05. The overall rate of AD discussions among unique VHA users in FY2020 was 5.2% (95% CI: 5.2%-5.2%) and for Advance Care Planning via Group Visits, which targets rural veterans using groups, it was 1.8% (95% CI: 1.8%-1.9%). Advance Directive discussions in VHA are more successful at reaching middle age (M = 64; SD = 16), African Americans, males, veterans living in urban areas, and veterans with a VA disability (Priority Group 1-4). Advance Care Planning delivered in groups is reaching slightly younger veterans under the age of 75 years (M = 62; SD = 15), African Americans, females, disabled veterans (e.g., Priority Group 1-4), and more veterans residing in rural communities compared to the national population of VHA users. Advance Directive discussion rates are low across VHA, yet intentional efforts with ACP via group visits are reaching veterans who are considered underserved owing to residing in rural areas. Advance Care Planning needs to be a well-informed clinical priority for VHA to engage with the entire veteran population and to support the completion of ADs.

A Community Engagement Model to Drive Advance Directive Discussion and Completion

Background Advance directives (ADs) describe individuals’ preferences for life-sustaining treatments and/or surrogate decision-makers, to help avoid unwanted, burdensome treatments at the end-of-life. However, only 36.7% of adults have completed an AD. There is growing interest in adopting a public health approach to end-of-life care, including ADs. We describe the experience of Honoring Choices Tennessee (HCT) which developed a pilot program, Advance Directives at Work in Tennessee (AD@WorkTN), to enhance AD completion by the general public workforce. Methods The AD@WorkTN initiative targeted adults in the Tennessee workforce by engaging human resource (HR) leaders in educational presentations. Each workshop provided resources to employers to integrate ADs into the employee orientation and benefits enrollment process. Educational materials, web tools, podcasts, AD forms, and a demonstration of how to complete an AD were included. Participants were directed to the HCT website which contains the state advance directive documents and with detailed instructions, as well as the co-branded MyDirectives app (MYD), to securely upload completed ADs. In April 2021 a HCT sponsored PBS documentary on advance care planning was produced with statewide distribution. Results Over a 2-year period, 58 workshops were conducted for 260 human resources leaders representing 958 businesses. As a result, 23 businesses have included ADs as part of the employee benefit process. Additionally, a 2-year multifaceted public outreach campaign between 2019-21 has reached 2,950 employees and 958 businesses. Approximately 81,500 Tennessee viewers have seen the Public Broadcasting Service (PBS) documentary on advance care planning. There have been 2,954 visits to the HCT website and 411 visits to the co-branded MyDirectives site. Conclusion AD@WorkTN is a promising model to promote integration of ADs into the employee orientation and benefits enrollment processes. Enhanced discussion and completion of ADs among employed individuals and enhanced public discourse such as podcasts and television productions may encourage intergenerational conversations about end-of-life care and documentation in healthcare records.

An Ethically Justified Approach That Integrates Advance Directives Discussions With Care of the Patient With Cancer.

Although the frequency of advance directives discussions may be increasing, there is a need to improve the quality of these discussions. In a range of advanced medical illnesses, including cancer, poor outcomes with advanced cardiopulmonary life support (ACLS) have been well documented. However, when speaking to patients at the end-of-life, physicians frequently withhold evidence-based information and guidance about prognosis or outcomes of ACLS. Tools and models developed to facilitate communication at the end-of-life do not explicitly include recommendations on advance directives and specifically do not discuss the available evidence on ACLS outcomes in the seriously ill. Here, we review the current literature on outcomes of ACLS and current tools and communications for end-of-life discussions. A majority of patients have a preference for truth-telling and guidance. We advocate an approach that integrates individual goals and preferences with a shared understanding of prognosis and appropriate management options, as judged and recommended by the disease experts, in order to reach an evidence-based decision on advance directives. This pragmatic and ethically justified approach emphasizes active empathic communication to prioritize the care of the patient over the mechanical details of ACLS, thereby aligning end-of-life discussions with current practices in other domains of medicine.

Promoting Advance Directive Discussions

Promoting Advance Directive Discussions

Utilizing Shared Medical Appointments to Increase Advance Directives Discussion and Documentation (QI607)

Utilizing Shared Medical Appointments to Increase Advance Directives Discussion and Documentation (QI607)

Improving residents’ skills and confidence on advance directive discussion: a quality improvement project

ABSTRACTBackground: Advance directives have been established as a legal document that ensures patients’ wishes are followed if/when they cannot make medical decisions for themselves. The concept, advance directive, is rooted in the ethical principle of patient’s autonomy. New York State recognizes three types of advance directives: New York State Health Care Proxy, Living Wills, and Do Not Resuscitate (DNR) order. A common misnomer in healthcare is the idea that advance directives are for the elderly or patients with terminal illness. As per New York State statutes, everyone older than 18-years-old should have an advance directive to avoid conflicts in times of crisis. It has been shown that most patients believe it is their physician’s responsibility to initiate an advance directive discussion and residents are at the forefront of most health facilities.Objective: To assess the knowledge and attitude of internal medicine residents towards advance directive and to improve residents’ skills and confidence on advance directive discussion.Design: We carried out a prospective study to assess the knowledge and attitude of the internal medicine residents towards advance directive to validate the need to implement didactic sessions and simulations.Results: Fifty out of the 75 internal medicine residents of Harlem Hospital Center participated in the study. Most of the responders indicated that they lacked sufficient knowledge in advance directive discussion and indicated that they were interested in didactic sessions and simulations related to how to help patients with advance directives.Conclusion: Our study showed that most of the residents lacked sufficient knowledge in advance directives discussions and the importance of its incorporation into residency training education.

“Life Support”: A Play about Palliative Care (FR476)

•Identify factors that lead to effective patient-provider communication.•Discuss how complex psychosocial issues affect patient care.•Reflect on a patient’s journey through illness. For this session, we propose a unique educational strategy: combining live theater with a talkback/reflective exercise. First, we will perform “Life Support”, a 90-minute play about palliative care. “Life Support” tells the story of a complicated patient who transitions to hospice. After the play, attendees will have an opportunity to debrief through a facilitated discussion. Goals of this session are: to teach communication skills, promote self-reflection, and highlight complex psychosocial issues. According to the literature, theater can enhance empathy [1], improve case presentation skills [2], and facilitate discussions about “hot button” issues [3]. For example, at AAHPM 2016, Ms. Elaine Magree presented a play about the AIDS crisis. The play “Life Support”, by Madeline Leong, was presented at Johns Hopkins Hospital in April 2016. It received substantial press and excellent reviews. Technical requirements are simple. For more information about the play, please contact the primary author. In “Life Support”, the characters participate in several goals of care discussions, including a discussion of Advance Directives and what it means to receive hospice care. These topics are especially relevant given the known benefit of early palliative care and advance care planning and the public’s frequent misconception of these phrases. During the talkback, attendees will discuss the patient-provider communication in the play. Attendees will also have the option to fill out a one-page survey about the play. The purpose of the reflective exercise is to act as an interactive adjunct to the inherent educational value of the play. Yasmina Reza wrote, “Theater is a mirror.” In this session, we hope to use theater as a mirror to demonstrate the nuances of patient-provider communication and the importance of the words we choose and how we speak them. We also hope to create a unique educational experience that contributes to clinician wellness and burnout prevention.

The Ethical Imperative of Healthy Paternalism in Advance Directive Discussions at the End of Life.

The Ethical Imperative of Healthy Paternalism in Advance Directive Discussions at the End of Life.

It isn’t like this on TV: Revisiting CPR survival rates depicted on popular TV shows

BackgroundPublic perceptions of cardiopulmonary resuscitation (CPR) can be influenced by the media. Nearly two decades ago, a study found that the rates of survival following CPR were far higher in popular TV shows than actual rates. In recent years, major strides toward enhanced education and communication around life sustaining interventions have been made. This study aimed to reassess the accuracy of CPR portrayed by popular medical TV shows. Additionally, we sought to determine whether these shows depicted discussions of care preferences and referenced advance directives. MethodsThree trained research assistants independently coded two leading medical dramas airing between 2010 and 2011, Grey's Anatomy and House. Patient characteristics, CPR survival rates, and goals of care discussions were recorded. ResultsCPR was depicted 46 times in the 91 episodes, with a survival rate of 69.6%. Among those immediately surviving following CPR, the majority (71.9%) survived to hospital discharge and 15.6% died before discharge. Advance directive discussions only occurred for two patients, and preferences regarding code status (8.7%), intubation (6.5%) and feeding (4.3%) rarely occurred. ConclusionsBoth popular TV shows portrayed CPR as more effective than actual rates. Overall, the shows portrayed an immediate survival rate nearly twice that of actual survival rates. Inaccurate TV portrayal of CPR survival rates may misinform viewers and influence care decisions made during serious illness and at end of life.

Treatment preference discussion in oncology outpatient clinic.

106 Background: Often end of life discussions are either not held in a timely manner or remain poorly communicated when outpatients are transferred to hospital care. This leads to unwarranted and costly interventions. Methods: In an academic oncology clinic we developed an electronic medical record (EMR) template that listed important information for management decisions, including life expectancy, goals of management and specific patient treatment preferences (ventilator support, tube feedings, transfusions, do-not-resuscitate (DNR) wishes, etc.). The completed note was placed in an easily retrievable location in patients’ electronic charts. Clinic charts were reviewed one week ahead of visits to identify patients who were within the last year of life and a pop up reminder for the treating physician was placed in the EMR. The physicians who admitted our patients to the hospital were educated on utilization of the template notice. We compared the percentage of patients with advanced directives or treatment preference notes before the intervention with the percentage 1½ years after the intervention was begun. We utilized a cross-sectional, self-administered survey to compare in-patient physician responses before and after implementation of the intervention to evaluate the in-hospital utility of the intervention. Results: Easily accessible treatment preference or advanced directive discussions with patients in their last year of life increased from 32% to 55% (p =0.004) with the intervention. Results of the survey also showed improved understanding of patient’s wishes for DNR status (26.9% vs 52.6%, p = 0.08) among admitting physicians. Conclusions: The development of an easily utilized EMR template to record the treatment preferences of patients near the end of life, with an EMR accountability instrument, improved both documentation of discussion and physician understanding of patient treatment preferences when patients were transferred from outpatient to inpatient care. We hypothesize that this intervention will lead to a decline in costly and unwanted interventions for patients near the end of life, and plan to test this hypothesis with further outcomes measures.

Developing an Educational Intervention for Advance Directives Discussion and Documentation in a Nursing and Rehabilitation Center

Appropriate discussion and documentation of advance directives (AD) are important aspects of medical care and a responsibility of all members of the interdisciplinary team. AD are particularly important in the long term and sub-acute care settings as these populations tend to have poorer overall prognoses. While most nursing homes (NH) make AD a priority, there are often opportunities to improve both the rate and quality of AD completion which may vary among facilities.

Do residents need end-of-life care training?

As medical education evolves, emphasis on chronic care management within the medical curriculum becomes essential. Because of the consistent lack of appropriate end-of-life care training, far too many patients die without the benefits of hospice care. This study explores the association between physician knowledge, training status, and level of comfort with hospice care referral of terminally ill patients. In 2011, anonymous surveys were distributed to physicians in postgraduate years 1, 2, and 3; fellows; hospital attending physicians; specialists; and other healthcare professionals in five hospitals of a large health system in New York. Demographic comparisons were performed using χ2 and Fisher's exact tests. Spearman correlations were calculated to determine if professional status and experience were associated with comfort and knowledge discussing end-of-life topics with terminal patients. The sample consisted of 280 participants (46.7% response rate). Almost a quarter (22%) did not know key hospice referral criteria. Although 88% of respondents felt that knowledge of hospice care is an important competence, 53.2% still relinquished advance directives discussion to emergency room (ER) physicians. Fear of patient/family anger was the most frequently reported hospice referral barrier, although 96% of physicians rarely experienced reprisals. Physician comfort level discussing end-of-life issues and hospice referral was significantly associated with the number of years practicing medicine and professional status. Physicians continue to relinquish end-of-life care to ER staff and palliative care consultants. Exploring unfounded and preconceived fears associated with hospice referral needs to be integrated into the curriculum, to prepare future generations of physicians. Medical education should focus on delivering the right amount of end-of-life care training, at the right time, within the medical school and residency curriculum.

Training Mid-level Providers on Palliative Care

Palliative care services are not available in most outpatient oncology practices. A program training 11 mid-level providers from oncology practices on advanced directive discussions and supportive symptom assessment and management performed by palliative care specialists was completed. A follow-up session 9 months later identified barriers to implementation. Of the 11 mid-level providers, 8 participated in the follow-up session, and 9 of the 11 providers implemented advanced directive’s discussions and symptom assessment and management for patients with metastatic cancer. Main barriers included uncertainties about reimbursement, patients’ lack of knowledge about palliative care, and lack of access to supportive services. This program successfully promoted advanced directive discussions and supportive/palliative care symptom assessment and management to community oncology practices, which will hopefully translate into improved quality of life for patients with metastatic cancer.

Non-Renal Hospice Eligibility in the Dialysis Population: Utilization and Barriers (S764)

retained 60% of their improvement at 6 months. All expressed increased comfort with opioid usage, communicating bad news, goals-of-care, and advanced directive discussions. Implications for Research, Policy, or Practice. Anesthesiologists are expected to be pain specialists. Improving knowledge and skill utilizing goals-of-care and non-invasive pain management may lead to improved care management of both acute and chronic pain. Further research will look at any changes in attitudes toward perioperative DNR decisions in those with and without palliative medicine rotations.

Nursing Home Physicians and the Credibility Gap

Transitions between care venues tend to bring out the very worst in our health system. This is particularly true for patients discharged from acute care hospitals to nursing homes (NH), as evidenced by the embarrassingly high 30-day readmission rate of Medicare patients in the United States.1 Many of these readmissions are avoidable, invariably linked to miscommunication between care providers, lack of patient and family education, poor or inadequate documentation, and avoidance of advanced directive discussions. Dr Miles, in the “Psychophysics of Transition to Long Term Care,” dissects these and other factors to more fully describe the underpinnings of mistrust between physician, patient, and family.2 Dr Miles is to be commended for the presentation of a novel typology that lends itself to a proactive and rational approach to care delivery in the NH and that ultimately will serve to enhance quality of life for our patients. The mistrust encountered by NH physicians can be traced, in part, to the expectations imparted to patients and families by acute care providers on discharge to the NH. Because few hospitalists have spent any meaningful time in a NH setting, they carry with them a number of misperceptions concerning medical care delivery in the NH, an environment characterized by significant regulatory and resource constraints. It is no wonder then that patients often arrive in the NH, specifically those admitted for short-term rehabilitation, expecting daily physician visits and an intensity of care equal to that of the hospital. Expectations are often set at a level that is unattainable and counter to regulatory guidelines, leaving it to the NH provider to bring the patient and patient’s family back to reality. Establishing a trusting relationship in such a circumstance is challenging, to say the least. Hospitalists are now recognizing the need for education and training in “postacute care” and are looking to organizations, such as the American Medical Directors Association (AMDA), to fill in the gaps.3 If false expectations were not enough, the quality of information accompanying the patient on transfer is also a major concern. In our experience, albeit anecdotal, the electronic medical record has become an ideal vehicle in which inaccurate information becomes codified and passed on as gospel from one venue to another. Although medication reconciliation theoretically addresses pharmacologic missteps, it often is given short shrift by harried clinicians and frequently does not accurately account for prehospitalization medication regimens.4 Advance directives are also often neglected and at

Advance Directive Discussions: Lost in Translation or Lost Opportunities?

Previous studies have shown that minority populations have low rates of documented advance directives and express preferences for more life-prolonging interventions at the end of life. We sought to determine the impact of Latino ethnicity on patients' self-report of having an advance directive discussion and having a completed advance directive in the medical record at an index hospitalization for serious medical illness. This was a prospective observational cohort study of 458 adults admitted to the general medical services of a safety net hospital, an academic medical center, and a Veterans' Affairs (VA) hospital. Patients were asked if they had discussed advance directives, and we reviewed medical records for documented advance directives. Overall, 45% of patients reported having had a discussion about advance directives (29% of Latinos compared with 54% of Caucasians, p=0.0002) and 24% of patients had a completed advance directive in their medical record (25% Latinos and 26% of Caucasians, p=not significant [ns]). Using logistic regression modeling and adjusting for socioeconomic status (SES), education level, and language spoken, Latinos (odds ratio [OR] 0.42, confidence interval [CI] 0.24-0.75) were less likely to report having advance directive discussions compared with Caucasians (referent). However, modeling of a completed advance directive in the medical record showed no significant difference between Latinos (OR 1.44, CI 0.73-2.85) and Caucasians (referent). The unexpected discrepancy we found highlights the need for more effective communication in advance care planning that includes education that is culturally sensitive and accessible to persons with low health literacy.

“They're going to unplug grandma”: Advance directive discussions and documentation do not decrease survival in patients at baseline lower risk of death

To determine the effect of having advance directive (AD) discussions or having an AD in the medical record on patient survival. Prospective observational cohort study. Three Colorado area hospitals: a large academic tertiary referral center, a Veteran's Affairs medical center, and an urban safety net hospital. Four hundred fifty-eight adults admitted to the general internal medicine service interviewed about AD discussions. A concurrent chart review documented the presence of an AD in the medical record. Participants were stratified into low, medium, and high risk of death within 1 year based on validated prognostic criteria. Kaplan-Meier survival plots were estimated for those at low and medium risk of death. No significant differences in survival for participants at low and medium risk of death who reported having had an AD discussion and those who had not (Wilcoxon low risk, P = 0.97; medium risk, P = 0.28; and log-rank low risk, P = 0.82; medium risk, P = 0.45), and for those who had an AD in the medical record vs those who did not (Wilcoxon low risk, P = 0.84; medium risk, P = 0.78; and log-rank low risk, P = 0.86; medium risk, P = 0.69). There is no evidence that AD discussions or documentation result in increased mortality. In regards to the current national debate about the merits of advance care planning, this study suggests that honoring patients' wishes to engage in AD discussions and documentation does not lead to harm.

Resident Sign-Out and Patient Hand-Offs: Opportunities for Improvement

Background: Inpatient care is characterized by multiple transitions of patient care responsibilities. In most residency programs trainees manage transitions via verbal, written, or combined methods of communication termed “sign-out.” Often sign-out occurs without standardization or supervision. Purpose: The purpose was to assess daily sign-out with a goal of identifying aspects of this process most in need of improvement. Methods: This was a prospective, observational cohort study of interns’ sign-out conducted by industrial engineering students. Daily sign-out was analyzed for inclusion of multiple criteria and scored on organization (on a scale of 0–4) based on how effectively written information was conveyed. Results: We observed 124 unique verbal and written sign-outs. We found that 99% of sign-outs included a general hospital course. Sign-outs were well organized with a mean of 3.1, though substantial variation was noted (SD = 0.8). Directions for anticipated patient events were included in only 42% of sign-outs. Do Not Resuscitate (DNR) or advanced directive discussions were reported in only 11% of sign-outs. Only 50% of successive daily sign-outs were updated. Conclusions: We found variability in the content and organization of interns’ sign-out, possibly reflecting a lack of instruction and supervision. Standardization of sign-out content, and education on good sign-out skills are increasingly important as patient hand-offs become more frequent.

A theoretical decision model to help inform advance directive discussions for patients with COPD

BackgroundAdvance directives (AD) may promote preference-concordant care yet are absent in many patients with Chronic Obstructive Pulmonary Disease (COPD). In order to begin to inform AD discussions between clinicians and COPD patients, we constructed a decision tree to estimate the impact of alternative AD decisions on both quality and quantity of life (quality adjusted life years, QALYs).MethodsTwo aspects of the AD were considered, Do Not Intubate (DNI; i.e., no invasive mechanical ventilation) and Full Code (i.e., may use invasive mechanical ventilation). Model parameters were based on published estimates. Our model follows hypothetical patients with COPD to evaluate the effect of underlying COPD severity and of hypothetical patient-specific preferences (about long-term institutionalization and complications from invasive mechanical ventilation) on the recommended AD.ResultsOur theoretical model recommends endorsing the Full Code advance directive for patients who do not have strong preferences against having a potential complication from intubation (ETT complications) or being discharged to a long-term ECF. However, our model recommends endorsing the DNI advance directive for patients who do have strong preferences against having potential complications of intubation and are were willing to tradeoff substantial amounts of time alive to avoid ETT complications or permanent institutionalization. Our theoretical model also recommends endorsing the DNI advance directive for patients who have a higher probability of having complications from invasive ventilation (ETT).ConclusionsOur model suggests that AD decisions are sensitive to patient preferences about long-term institutionalization and potential complications of therapy, particularly in patients with severe COPD. Future work will elicit actual patient preferences about complications of invasive mechanical ventilation, and incorporate our model into a clinical decision support to be used for actual COPD patients facing AD decisions.