Advance Healthcare Directives Research Articles

Implementing advance directives-An international literature review of important considerations for nurses.

To review the global literature on the implementation of advance health care directives to date, and the experiences of the health care professionals who must initiate the discussions around advance care planning, as well as support patients' ultimate decisions. Ireland's Assisted Decision-Making (Capacity) Act 2015 legalizes advance health care directives. It promotes the autonomy of the person and enables them to have treatment in accordance with their will and preferences. However, there is professional uncertainty on how to support and integrate assisted decision-making. 16 studies featuring the views of health care professionals are included and evaluated using a framework of 'benefits versus challenges'. Four themes clearly emerge during the review process: the concept of capacity and who decides; autonomy versus paternalism-conflict among the health care professional/patient/family caregiver triad; barriers to advance directives; and timing issues. Significant benefits of advance health care directives exist for all parties including less stress for patients and families alike, less burden and less residual guilt for surviving relatives, and an over-arching prevention of 'crisis' decision-making. This review highlights the central role of the nurse in empowering patients to express their wills and preferences, supporting patients' capacity to make decisions about their own care, initiating end-of-life care discussions and advocating to have advance health care directives acknowledged. Moreover, it identifies the challenges ahead for all nurse managers in implementing this new mandate.

Conscientious Objections during COVID-19 Pandemic

Globally evolving COVID-19 pandemic has raised major questions which may have catastrophic implications like absence of universal facemask use, misunderstanding implications of SARS-CoV-2 test results, ventilator related mortality, cytokine reduction technology and anti-viral treatments being in their infancy still, failure to update advanced healthcare directives during pandemic, and overlooked home hospice options for COVID-19 patients when terminally ill. Moreover, there are inquisitive and interesting avenues worth exploring and innovating during COVID19 pandemic like “cold” viruses such as SARS-CoV-2 uniquely choosing airways which normally and naturally have temperatures much lower than core body temperatures, potential therapeutic role (if any) of facemask usage, potential role of natural disinfection by sunlight and its component ultraviolet-C which is used for artificial cleansing, potential bimodal immune response against SARS-CoV-2, and exploration into BCG vaccination based non-specific protection against intracellular pathogens with SARS-CoV-2 itself being an intracellular pathogen. Summarily, I am praying that the natural delays in establishing reproducible evidence during COVID-19 pandemic should not turn the humanity as we know today into a historical evidence.

Knowledge and attitudes of Spanish mental health professionals towards advance healthcare directives.

WHAT IS KNOWN ON THE SUBJECT?: AHDs in mental health are fundamental tools in advance care planning processes. It is an important method for involving mental healthcare users in clinical decisions and in providing effective healthcare based around user preferences. AHDs can be applied in situations in which the person may forfeit their legal capacity, according to the Convention on the Rights of Persons with Disabilities. However, the use of AHDs as described above is not yet a reality in Spain. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The present study surveys the knowledge and attitudes of mental healthcare providers towards AHDs in clinical practice. Although providers had a moderate-low level of knowledge about AHDs, they presented positive attitudes towards them. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The use of AHDs in mental healthcare practice poses challenges to the Spanish mental healthcare system. Acquiring up-to-date data on the knowledge and attitudes of providers towards AHDs allows organizations to address aspects of their service that require reinforcement. This data could also be used by other countries just starting to use AHDs, as an initial step towards supporting the implementation of a multistage intervention process. More in-depth training for providers would help improve their competence to implement or honour the statements set out in AHDs, the related legal and ethical issues, and liability issues related to their implementation. The Spanish mental healthcare system requires structural changes so that providers can embrace new ways of relating to users and to organize partnerships and a continuity of care centred on user preferences. ABSTRACT: Introduction Advance healthcare directives (AHDs) in mental health offer important information regarding service users' preferences. However, whether AHDs are truly understood by providers is questionable. Aim To survey the knowledge and attitudes of mental health professionals towards AHDs and examine any associations with sociodemographic and occupational variables. Method We cross-sectionally surveyed the knowledge and attitudes of 113 mental health professionals by using two validated questionnaires. Results Participants showed very positive attitudes and high levels of knowledge about the conceptual definition and application of AHDs in clinical practice but their knowledge of the legalities, procedure and registration of AHDs was poor. Working in a community, having a career specializing in mental health or having personally signed an AHD was associated with enhanced knowledge about them. Moreover, female sex or employment as an auxiliary nursing-care technician was associated with stronger positive attitudes. Discussion Legal and structural changes will be needed to implement AHDs in Spain and to promote competence among healthcare providers in order to include AHDs in everyday practice. Implications for practice The Spanish mental healthcare system requires legal and structural changes and must improve healthcare providers' competence in AHDs before they are implemented.

Advanced Health Care Directives in Nebraska: Health Care Power of Attorney and Living Wills

Advanced Health Care Directives in Nebraska: Health Care Power of Attorney and Living Wills

Advance Healthcare Directives: Binding or Informational Value?

Advance directives entail a refusal expressed by a still-healthy patient. Three consequences stem from that fact: (a) advance refusal is unspecific, since it is impossible to predict what the patient's conditions and the risk-benefit ratio may be in the foreseeable future; (b) those decisions cannot be as well informed as those formulated while the disease is in progress; (c) while both current consent and refusal can be revoked as the disease unfolds, until the treatment starts out, advance directives become effective when the patient becomes incapable or unconscious; such decisions can therefore not be revoked at any stage of the disease. Therefore, advance directives are binding for doctors only at the stage of advance treatment planning, i.e., only if they refer to an illness already in progress.

Acceptance of and factors influencing attitudes towards post-mortem organ donation in Germany : Analysis of representative cross-sectional studies between 2010 and 2016

The German post-mortem organ donation rate has been low, since transplantation scandals attracted media attention in 2012. Therefore, the objective of this article is to address the willingness to document attitudes (e.g., organ donor card) towards organ donation, factors influencing the willingness to document the individual will and knowledge of organ donation among the German public. Data of surveys on attitudes towards organ and tissue donation in Germany conducted between 2010 and 2016 by the Federal Centre for Health Education (Bundeszentrale für gesundheitliche Aufklärung) were analysed. Using binary logistic regression, factors influencing the method for documenting the individual will were identified. In the 2016 survey, 35.7% of all respondents had documented their will in the form of an organ donor card or an advance health care directive. Female gender, younger age, higher level of education, discussion of organ donation with next-of-kin/friends, grasping the concept of death and knowledge of organ donation increase the likelihood of possessing an organ donor card. Being male increases the likelihood of documenting the individual will using an electronic health insurance card. Older respondents or respondents with lower level of education lack knowledge about organ donation. Persons with extensive knowledge are more likely to possess an organ donor card and to consent to donate organs of next-of-kin. Further measures to increase knowledge of organ donation among the general public should be discussed. The influence of gender on the willingness to use different methods to document attitudes needs to be evaluated.

IMPACT OF GERIATRIC INTERPROFESSIONAL TRAINING ON ADVANCE CARE PLANNING IN GERIATRIC PRIMARY CARE

Currently, an important measure of Advance Care Planning (ACP), Advance Health Care Directives (AHCD) documentation rate, is at 33% for older adults in the United States. To address this disparity, geriatric faculty in an academic geriatric primary care practice aimed to train geriatrics fellows and other interprofessional (IP) learners to engage patients in ACP. As part of a Geriatric Workforce Enhancement Program funded by the Health Resources and Services Administration, geriatrics faculty and the Medical Legal Partnership for Seniors based at University of California Hastings College of Law provided ACP training to fellows and IP learners, including social work interns. In practice, the fellows and social work interns collaborated to incorporate ACP into patient visits and follow-up telephone calls. To monitor ACP progress, research staff reviewed patients’ electronic health records and performed descriptive analysis of the data. In 21 months, 4 geriatrics fellows built a panel of 59 patients who on average had 3 office visits and 7 telephone calls per person. Prior to clinic enrollment, 12 (20.3%) patients had preexisting AHCD, and 47 lacked AHCD documentation. After ACP intervention, 42 of 47 patients without AHCD documentation engaged in ACP discussion. Of those who engaged in ACP discussion, 24 completed AHCD, raising AHCD completion rate to 61%, or 36 patients in the panel of 59. ACP is a complex process that benefits from skilled communication among interprofessional providers and patients. Findings underscore the potential advantages of IP training and engaging patients in ACP discussion in an academic primary care setting.

Advance healthcare directives in mental health: A qualitative analysis from a Spanish healthcare professional's viewpoint.

WHAT IS KNOWN ON THE SUBJECT?: Advance care planning (ACP) in mental health is a useful tool to avoid human rights violations in mental health settings. However, ACP is not yet a reality in the Spanish context. The advance healthcare directive (AHD) is a document reflecting healthcare preferences, drafted within the framework of the ACP process, to be applied in situations in which an individual's legal capacity may be questionable. No study has explored the viewpoint of Spanish mental healthcare professionals towards AHDs in the mental health field. Considering their extensive use, further study of providers' knowledge and attitudes is warranted. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: The study adds knowledge about the viewpoint of Spanish mental healthcare professionals towards the implementation of AHDs in their clinical practices. This study illuminates the prevailing paternalistic provider-user relationship as the main barrier surrounding AHD management in terms of decision-making. Our findings support the need for broader awareness, staff training regarding the documentation, the conversation process and communication skills, and personalized assistance in the mental health services to implement AHDs in everyday practice. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Advance healthcare directives are a recovery tool that offers major information regarding mental health user preferences. Although they pose challenges for clinical practice, AHDs should be incorporated into interventional mental health care. Obtaining up-to-date perspectives held by mental healthcare professionals regarding AHDs allows the administration to determine the aspects requiring reinforcement. The implementation of AHDs in the Spanish mental health system requires macro- and micro-changes, both ethically and structurally, so that mental healthcare professionals relinquish their paternalistic approach and embrace new ways of relating to users. Abstract Introduction An advance healthcare directive (AHD) is a written document that contains a patient-in-care's will and preferences concerning the treatment options available to them, should they lack decision-making capacity. AHDs are completed within a broader framework known as advance care planning. No study has explored the viewpoint of Spanish mental healthcare professionals towards AHDs. Aim To explore the viewpoint of mental health professionals towards the implementation of AHDs in mental health. Method A qualitative study was conducted using semi-structured interviews that were thematically analysed. Findings Three main themes were identified: care planning culture; barriers for the practical management of AHDs; and reasons to not honour patient-in-care AHDs. Discussion Professionals find it pragmatically difficult to stop applying traditional paternalistic practices. To implement AHDs, improving the knowledge and awareness of AHDs and management of non-technical skills through training is required. Such training should include users and families and allow for compliance with United Nations requirements. Implications for practice Advance healthcare directives offer important information regarding user preferences, although they pose challenges for practices. Acquiring an up-to-date perspective on the attitudes of professionals towards AHDs allows organizations to attend to particular aspects that require reinforcement. Wider awareness, staff training and new ways of relating to users are necessary to implement AHDs in Spanish context. Relevance statement A better understanding of the attitudes of Spanish mental health professionals towards AHDs was achieved. Despite the implementation of AHDs being an important and potentially beneficial initiative, mental health professionals find many pragmatic issues that need addressing before AHDs become a reality in their clinical practice. Wider awareness, staff training, personalized assistance and new ways of relating to users are required to implement AHDs in everyday practice.

Factors Associated with Having a Will, Power of Attorney, and Advanced Healthcare Directive in Patients Presenting to a Rural and Remote Memory Clinic.

A Will, Power of Attorney, and Advanced Healthcare Directive are critical to guide decision-making in patients with dementia. We identified characteristics that are associated with the existence of these documents in patients who presented to a rural and remote memory clinic (RRMC). Ninety-five consecutive patients were included in this study. Patients and caregivers completed questionnaires on initial presentation to the RRMC and patients were asked if they had legal documents. Patients also completed neuropsychological testing. Statistical analysis (t-test and χ2 test) was performed to identify significant variables. Seventy (73.7%) patients had a Will, 62 (65.3%) had a Power of Attorney, and 21 (22.1%) had an Advanced Healthcare Directive. Having a Will was associated with good quality of life (p = 0.001), living alone or with a spouse or partner only (p = 0.034), poor verbal fluency (p = 0.055), and European ethnicity (p = 0.028). Factors associated with having a Power of Attorney included good quality of life (p = 0.031), living alone or with a spouse or partner only (p = 0.053), and poor verbal fluency (p = 0.015). Old age (p = 0.015), poor verbal fluency (p = 0.023), and greater severity of cognitive and functional impairment (p = 0.023) were associated with having an Advanced Healthcare Directive. Our results indicate that poor quality of life, good performance on verbal fluency, Indigenous ethnicity, and living with others are associated with a lower likelihood of legal documents in patients with dementia. These factors can help physicians identify patients at risk of leaving their legal affairs unattended to. Physicians should discuss the creation of legal documents early on in patients with signs of dementia.

Ireland's Assisted Decision Making Capacity Act-the potential for unintended effects in critical emergencies: a cross-sectional study of Advanced Paramedic decision making.

Irish legislation on Advance Healthcare Directives (Assisted Decision Making Capacity Act 2015, ADMC) proposes to change the basis of decision making from acting in the patient's best interests to following the expressed will and intentions of the patient. Refusal of life-saving care can occur, without sound reasons. The implications for care in life-threatening emergencies have not been explored among clinicians. An anonymous questionnaire survey of Advanced Paramedics (AP) covering awareness of the legislation, attitudes to and experience of refusal of care and potential actions in emergency scenarios now and if the legislation were in force. The scenarios covered end-of-life and deliberate self-harm situations potentially requiring resuscitation. All 482 graduates of the Advanced Paramedic Training Programme were invited to take part. Overall, 85/389 (21.9%) valid contacts responded, with demographic characteristics similar to the overall population. Attitudes ranged from highly positive to highly negative in relation to the potential impact of the legislation on professional and operational responsibilities. Respondents described marked changes in whether they would offer resuscitation if the ADMC were in place. Irish legislation which changes the traditional basis of medical practice away from the best interests of the patient may affect the resuscitation practices of Advanced Paramedics in life-threatening situations. It has significant implications for medical education, professional practice and clinician-patient interactions. This legislation and similar planned legislation may have implications for other EU jurisdictions.

Approaches and reflexions on advance healthcare directives in Brazil.

to explain the approaches and discussions about the Advance Healthcare Directives spread among health professionals, lawyers and society. bibliographic search in the databases SciELO, LILACS, BDENF, in Portuguese, carried out from December 2017 to January 2018. 22 articles were considered for analysis with interviews and testimonies of physicians, intensivists and geriatricians, nurses, technicians and Nursing auxiliaries, Medical students, lawyers and Law students. there is a small number of papers on the Advance Healthcare Directives in Brazil, and a wide range of approaches that have not yet been clarified. The theme is not widely spread and little clarified in its essence.

Assessing knowledge gaps regarding end-of-life issues in patients admitted to the hospital through the emergency department

Introduction: United States law requires hospitals to document advanced directives for patients on admission with no provision for assessment of their understanding. Aim: We sought to assess patients' knowledge gaps regarding end-of-life care, including do-not-resuscitate and do-not-intubate orders, physician orders for life-sustaining treatment, outcomes after cardiopulmonary resuscitation, and preferences regarding end-of-life care Methods: This is a cross-sectional survey-based study of adult patients aged 55 and older who were being admitted to a large community hospital from the emergency department (ED). Patients were not excluded based on acuity or reason for admission. The survey questioned patients regarding age, primary care provider status, ED visits and hospitalization within the prior year, prior discussions with family, primary care, or inpatient care physicians regarding advanced medical directives, prior completion of advanced medical directives paperwork, knowledge of outcomes after cardiac arrest, and general attitudes regarding priorities related to a “good death”. Results: Although 98% of patients had primary care physicians, only one-fourth recalled discussing advanced directives with their doctors. About half of patients had discussed their wishes with their families, and 52% had signed advanced directive paperwork. Patients overestimated survival after cardiac arrest. The most common elements reported by patients as being important to a “good death” were the absence of pain (26%), the presence of family (24%), and death at home (16%). Conclusion: Patients have clear ideas for what makes a good death but have inadequate knowledge regarding resuscitative outcomes and do not make use of advanced directives. Physicians miss opportunities to educate patients and assist with these difficult decisions. Closing the gap between providers' understanding of patients' desires, and patients' understanding of end-of-life care is an opportunity for improvement. The following core competencies are addressed in this article: Patient care and procedural skills and Systems-based practice.

Ethical Justification in Medical Futility and Advanced Medical Directive from The Islamic Perspective

Introduction: Medical futility and advanced medical directive are related issues in end-of-life medical decisions that present challenge to doctors and patients in terminal condition and to doctors and family members of patients who are critically ill in the ICU. Materials and Methods: A qualitative study comprises of literature search and an in-depth interview of experts was carried out to determine the clinical situations in medical futility and the ethical considerations from the Islamic perspective that justify forgoing medical treatment and also the practice of advanced medical directives in the country. Results: In such scenarios, clinical data must be interpreted alongside patient values, as well as the physicians’ ethical commitments. From the Islamic perspective, doctors are the authorised person to diagnose medical futility and forgo medical treatment. Forgoing treatment is permissible as long as it conforms to the maqasid and qawaid al-shariah principles that guide the decision-making process. The practice of advanced medical directive is still at its infancy in this country. From the Islamic perspective, upon considering the maqasid and qawaid al-shariah principles, it should be permissible and its practice should be encouraged as it assists the doctors and the surrogate decision-maker to decide to the withdrawal of treatment. Conclusion: Ethical justification on medical futility conforms to the maqasid and qawaid al-shariah principles and forgoing medical treatment is permissible in Islam. Advanced medical directive assists in the decision-making of forgoing treatment in the presence of utility and thus its practice should be promoted.

Nonstandard Advance Health Care Directives in Emergency Departments: Ethical and Legal Dilemma or Reality: A Narrative Review.

People have tattooed themselves for thousands of years, and it remains popular with various groups across mainstream society. Although many people choose tattoos that express their life philosophy, epic events in their life, or their personal mantra, the use of tattooing in medicine such as a "do not resuscitate" tattoo is increasingly becoming more common (; ). As these tattoos do not meet the legal requirements for an advance health directive, they are at best a guide to the person's wishes and at worst a useless, painful exercise. New technology such as "talking tattoos" or implantable microchips could conceivably be used to record either an audible advance health directive or directions for emergency responders to access an individual's advance health directive. This article discusses the ethical and legal implications of nonstandard advance health directive tattoos in emergency treatment situations.

Conocimientos y actitudes sobre voluntades anticipadas en profesionales sanitarios

Background and objectiveThe advanced healthcare directive is a new style of health care relationship, based on the respect of the patientś autonomous decisions: as well as a valuable tool that enables a proper management of the decisions made at the end of life. The objective of this study was to explore the knowledge and attitudes of the health care professionals regarding the advance directives, as well as the resources for advanced care planning in a municipality of Madrid during 2016-2017. Material and methodsA cross-sectional descriptive study was carried out on a population of Health care professionals of Primary and Specialised Care. The knowledge and attitudes questionnaire about the advance directives was used. Sociodemographic and knowledge variables related to resources for the advanced care planning. Statistical-descriptive analysis was performed. ResultsA total of 431 professionals were included, with a mean age of 44.55 years (SD: 11.1). As regards knowledge about advance directives, the mean score was 5.08 (SD 2.4), with statistically significant differences being found between professional groups. A small percentage (4.6%) of the professionals had their document of Advance directives ready, and 42% of professionals did not know if they were regulated by the Community of Madrid. Less than half (41.5%) of the professionals knew the palliative resources of their institution. ConclusionsThe health care professional's knowledge about advance directives, as well as the resources for the advanced care planning, show deficiencies at training and information level. Almost half of the professionals did not know if these are regulated in the Community of Madrid. They also believe that it would be useful to plan, and very useful to have the Advance directives document ready.

P.001 Factors associated with having a will, power of attorney and advanced healthcare directive in patients presenting to a rural and remote memory clinic

Background: A will, power of attorney and advanced healthcare directive are critical to guide decision-making in people with cognitive decline. We identified characteristics that are associated with the existence of these documents in patients who presented to a rural and remote memory clinic (RRMC). Methods: 95 consecutive patients were included in this study. Patients and caregivers completed questionnaires on initial presentation to the RRMC and patients were asked if they have legal documents. Patients also completed neuropsychological testing. Statistical analysis (t-test and χ2 test) was performed to identify significant variables. Results: 70 patients had a will, 62 had a power of attorney and 21 had an advanced healthcare directive. Having a will was associated with good quality of life (p=0.001), living alone (p=0.034), poor verbal fluency (p=0.055) and European ethnicity (p=0.028). Factors associated with having a power of attorney included good quality of life (p=0.031), living alone (p=0.053) and poor verbal fluency (p=0.015). Old age (p=0.015), poor verbal fluency (p=0.023) and severity of cognitive and functional impairment (p=0.023) were associated with having an advanced healthcare directive. Conclusions: Our results indicate that poor quality of life, good verbal fluency, non-European ethnicity and living with others are associated with a lower likelihood of creating legal documents in patients with cognitive decline

Les directives anticipées à l’hôpital : l’affaire de tous ?

IntroductionIn France, Leonetti and Claeys-Leonetti laws relating to patients’ rights and end-of-life practice have introduced the advance healthcare directives (ADs). Although family doctor's role is important in initiating discussions regarding AD, hospital healthcare professionals should also be concerned by the health care planning laws. MethodsA descriptive, quantitative and qualitative study was conducted in Paris Saint-Joseph hospital to evaluate the knowledge of nursing personnel regarding ADs. Among healthcare professionals present on 02/06/2016 and agreeing to participate, 50 non-medical caregivers and 50 doctors were randomly selected and took part in this survey. Three trainee lawyers conducted interviews, recorded and anonymized them. The Nvivo software analyzed the qualitative part of the results. ResultsOnly 10% of healthcare professionals knew these legal and ethical issues in health care. Most caregivers were not in favor of informing all patients admitted to a hospital (hospitalized patients or patients received consultations). For 44%, only hospitalized end-of-life patients should be informed about ADs. For 76% of the people questioned, family doctor has a unique position to guide the patient on the preparation and registration of living wills. In hospital stay, the nurse was proposed by 52% of the staff as the preferred caregiver for AD communication, as part of an interdisciplinary healthcare team approach. Finally, the clear majority of caregivers (85%), called for discussions and documentation about ADs, and end-of-life training. ConclusionAdvance directives remain poorly known in the hospital, 12 years after the first Leonetti law. The attitude of professionals about ADs is not homogenous but interest for the subject is obvious in the vast majority of caregivers. The results of this survey highlighted that discussions and documentation about ADs as well as training on end-of-life patient care are essential.

Law on advance health care directives: a medical perspective.

The paper's authors aim to elaborate on law22 dicembre 2017, n. 219, designed to regulate informed consent practices and advance health care directives", which has sparked a passionate debate centered on the substantial innovation achieved over the past decades in bio-medical science and at the same time, the noteworthy accomplishments made in enforcing human and personal rights. Within the paper, article three is delved into, which covers the creation of the so-called DAT ("Disposizioni anticipate di trattamento", advance health care directives), by which patients, in light of possible future incapacity to choose, can express their convictions and decisions on how to be treated and their consent or dissent to undergo treatments and procedures, including artificial nutrition and hydration. The authors peruse the new law's provisions through a medical perspective, and observe how they are heavily tilted towards patient choice, thus making doctors little more than mere tools of such decisions.

Guidance for healthcare staff: Advance Care Planning and Advance Healthcare Directives with People with Dementia

Introduction: Dementia is a progressive life limiting illness. People with dementia value planning ahead. It allows them to express wishes and preferences and reduces anxiety. Description: With the enactment of The Assisted Decision Making (Capacity) Act 2015 guidance in relation to advance care planning and advance healthcare directives with people with dementia is required by health and social care professionals in all care settings. Aim: To develop guidance for health and social care professionals with regard to advance care planning and advance healthcare directives with people with dementia Population and Stakeholders: This work involves health and social care professionals, people with dementia and family members Timeline: This work took place over a 9 month period Highlights: People with dementia were involved in the development of the guidance document The document has been well received within Ireland and other countries across Europe. Sustainability: Advice is offered on use of the document, to carry out information sessions, use as a reference and hosts up to date information with regard to new Irish legislation that will have a long term impact. Transferability: The document is written for the Irish context but as it is in keeping with European legislation and promotes best practice with regard to advance care planning and advance healthcare directives the information and guidance can be applied in other countries. Result: A guidance document and accompanying factsheet have been developed. Conclusion: The document and factsheet are published and available for use. Discussion: More research is needed to indicate the impact of the document on practice and for people with dementia. Lessons Learned: People with dementia can participate in the development of resources that impact them. Collaboration is key when carrying out work that reaches across all care settings.

PREDICTing Mortality in the Emergency Department: External Validation and Derivation of a Clinical Prediction Tool.

The Choosing Wisely campaign has called for better engagement of palliative and hospice care services for patients in the emergency department (ED). PREDICT is a clinical prediction tool that was derived in an Australian ED cohort. It assesses a patient's risk of mortality at 1year to select those who would benefit from advanced care planning. Such goals-of-care discussion can improve patients' ability to communicate what they want out of their healthcare and, in cases of end of life, potentially reduce the number of futile interventions. Using a cutoff of 13 points, PREDICT had a reported 95.3% specificity and 53.9% sensitivity for 1-year mortality. We externally validated PREDICT and derived a simpler modified PREDICT tool to systematically identify high-risk patients eligible for goals-of-care discussions and palliative care consultation in the ED. This was an observational cohort study of a random sample of 927 patients aged 55+ seen in the ED in 2014. We identified advance healthcare directives (AHDs) on file. We summarized diagnostic accuracy of the clinical tool to predict 1-year mortality using sensitivity, specificity, and area under the curve (AUC). We refined PREDICT using multivariable modeling. We followed reporting guidelines including STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) for cohort studies and Standards for Reporting of Diagnostic Accuracy (STARD). A total of 927 patients were included: 55.0% were male, 63 (7.0%) were nursing home residents, 389 (42.0%) patients had an AHD in their medical record at the time of ED visit, and 245 (26.4%) were deceased at 1year. Of the 780 patients with PREDICT scores<13, a total of 164 (21.0%; 95% confidence interval [CI]= 18.3-24.1) were deceased at 1year, and of the 147 patients with PREDICT scores ≥ 13, a total of 81 (55.1%; 95% CI= 46.7-63.2) were deceased at 1year. The AUC of the PREDICT score was 0.717 (95% CI= 0.680-0.754), sensitivity was 33.1% (95% CI= 27.3-39.4), and specificity was 90.3% (95% CI= 87.8-92.4) to predict 1-year mortality. The modified PREDICT tool resulted in an AUC of 0.709 (95% CI= 0.671-0.747). We decided to select this model as the preferred model, as the variable of intensive care unit (ICU) admission with multiorgan failure can be difficult to assess in the ED and may delay advanced care planning. Reweighting the score did not improve fit or the AUC, so points assigned to each variable were not adjusted. PREDICT is an easy tool to administer to be able to identify patients who are at high risk of 1-year mortality and who could benefit from AHDs, goals-of-care discussion, and when appropriate in the context of an end-of-life setting, palliative medicine consultation. External validation of PREDICT was successful in our population. We simplified PREDICT and derived a new tool, the modified PREDICT minus ICU tool, without significantly altering the sensitivity, specificity, and AUC for death at 1year. The next steps include external validation of the newly derived rule and prospective implementation.