Completion Of Advance Directives Research Articles

Cultural Aspects of End-of-Life Advance Care Planning for African Americans: An Ethnonursing Study.

Advance directive completion rates among the general population are low, with even lower completion rates among African Americans (AAs). This study's purpose was to identify culturally based meanings, expressions, and traditions of end-of-life (EOL) advance care planning (ACP) and decision making in order to promote culturally congruent nursing care among African Americans. Leininger's Culture Care Theory and Ethnonursing Research Method guided the study. A convenience sample of 21 informants were interviewed in community settings. Data analysis was guided using Leininger's phases of ethnonursing data analysis for qualitative data. Three themes emerged that affect EOL decision making: (a) faith in God and belief in life after death, (b) a strong matriarchal family structure, and (c) fear of talking about death and mistrust of the U.S. health care system. AA culture, beliefs, and traditions influence EOL ACP and practices, and must be considered while providing culturally congruent care.

The Association of Spanish Language Preference with Advance Directive Completion.

Hispanics have lower advance directive (AD) completion than non-Hispanic Whites. Few studies have assessed the role of language preference in end-of-life planning. We investigated whether language preference and needing an interpreter affected AD completion among older adults in an integrated health system. Retrospective cohort investigation of electronic medical records. Northern California integrated health system. A total of 620,948 Hispanic and non-Hispanic White patients, aged 55 years and older, between January 1, 2013, and December 31, 2017. Descriptive statistics and bivariate analysis were performed to compare AD completion among non-Hispanic Whites, Hispanics, and Hispanic subgroups by language preference (English speaking, Spanish speaking, and needed interpreter). We conducted multivariable logistic regression to determine the relationship between language preference and having an AD while controlling for demographic, clinical, and utilization factors. We found 20.3% of non-Hispanic Whites (n = 512,577) and 10.9% of Hispanics (n = 108,371) had completed an AD. Among Hispanics, after controlling for demographic, clinical, and utilization factors, compared with Spanish speakers requiring an interpreter, English speakers had nearly two-fold increased odds of completing an AD (adjusted odds ratio (aOR) = 2.6; 95% confidence interval (CI) = 2.4-2.9), whereas Spanish speakers not requiring an interpreter had 20% increased odds (aOR = 1.2; 95% CI = 1.1-1.3). Additional predictors of successful AD completion were being female, being older, having more comorbidities, having more hospital and emergency department visits, and having higher socioeconomic status. There were no differences associated with primary care provider characteristics. These findings indicate the need for a tailored outreach to Hispanics, particularly among those subgroups who require the need of an interpreter, to reduce AD completion disparities.

Nurse-led patient-centred intervention to increase written advance directives for outpatients in early-stage palliative care: study protocol for a randomised controlled trial with an embedded explanatory qualitative study

IntroductionDiscussing the evolution of life-threatening diseases and end-of-life issues remains difficult for patients, relatives and professionals. Helping people discuss and formalise their preferences in end-of-life care, as planned in the...

Advance Care Planning and Advance Directives Completion of Elderly Patients at a Rural Health Clinic on a Regional Medical Campus

Advance care planning is the shared decision-making process between physicians, patients, and families regarding the patient’s preferences for end of life care. These conversations increase compliance with patient wishes, decrease hospitalizations, increase deaths in patient’s preferred location, and decrease depression in surviving family members3. Even though there is proven benefit from advance care planning, these discussions are often overlooked. The purpose of this study is to evaluate rates of advance care planning and advance directive completion rate of 245 geriatric patients at our rural health clinic training site. We searched the electronic medical record to determine the number of patients who were asked about advance directives, stated they had a living will or medical power of attorney (MPOA), and had a living will or MPOA scanned into their chart. Out of the study population, 45% of patients stated they had some form of advanced directives. Of these patients, 22% and 25% had a living will and MPOA scanned into their chart, respectively. This study demonstrates the need for detailed discussion about advanced care planning with patients and additional follow-up to ensure documentation is readily available.

Advance Directive Completion and Its Associated Factors Among Older Chinese Americans

ObjectivesTo examine the factors of advance directive (AD) completion among older Chinese Americans. DesignCross-sectional survey. Setting and ParticipantsData came from 435 Chinese Americans aged 55 years and older living in 2 metropolitan areas through self-administered questionnaires and research assistant–administered interviews in 2018. Participants' average age was 75 years (standard deviation = 9.4). MethodsLogistic regression was used to examine factors associated with AD completion. ResultsApproximately 14% of participants completed an AD. Older age [odds ratio (OR) 1.07, 95% confidence interval (CI) 1.02-1.12], higher level of acculturation (OR 2.15, 95% CI 1.39-3.33), higher expectation for intergenerational support (OR 1.52, 95% CI 1.02-2.27), and having US citizenship (OR 3.02, 95% CI 1.26-7.23) were positively associated with AD completion. Physical and mental health needs were not significantly associated with AD completion. Conclusions and ImplicationsThis study is among the first focusing on AD completion among Chinese Americans, one of the fastest-growing older minority populations in the United States. Findings highlight the influence of socioeconomic and cultural factors on AD completion and illustrate the importance of developing culturally sensitive interventions to promote end-of-life care decision making among older Chinese Americans.

Completion of Advance Directives and Documented Care Preferences During the Coronavirus Disease 2019 (COVID-19) Pandemic

Fewer than one-third of US residents have completed an advance directive (AD) to guide care when seriously ill.1 Clinician-focused efforts to increase AD completion, such as Medicare payments for advance care planning (ACP), have been ineffective.2 In contrast, patient-facing interventions that enable independent completion of ADs show early promise.3 Self-service platforms also reveal changes in demand for ADs and preferences for future care. We sought to quantify changes in patient completion of ADs and expressed preferences during the coronavirus disease 2019 (COVID-19) pandemic by monitoring users of a web-based AD platform from January 2019 to April 2020.

Association of Palliative Care Consultation with Advance Directive Completion for Patients Admitted with an Acute Heart Failure Exacerbation

Association of Palliative Care Consultation with Advance Directive Completion for Patients Admitted with an Acute Heart Failure Exacerbation

Introducing a Supportive Care Team for Advance Directive Education in a Neurological and Neurosurgical Patient Population.

Background:Patient-centered care includes delineation of patient treatment values (ie, advance care planning [ACP]). Advance care planning often includes advance directive (AD) completion and is underutilized, particularly among neurology and neurosurgery patients. Implementation of a supportive care team (SCT) in outpatient clinic settings may offer opportunities for AD education and completion.Objective:This study assesses the effectiveness of an integrative SCT composed of hospice volunteers and undergraduate quality improvement interns in their efforts to provide ACP education in neurological and neurosurgical outpatient clinics. Assessment includes a description of different types of SCT-patient encounters, as well as patient interest in and completion of ADs after interacting with the SCT.Results:Across the data collection period, 2770 encounters were initiated. The majority of encounters resulted in patient ACP education. Some patients completed ADs during their SCT encounter (3.45%) or after their SCT encounter (10.18%).Conclusion:The SCT effectively enhances ACP education in this patient population. The utilization of trained interns to assist with ACP is beneficial and practical in clinic workflow.

Effects of Advance Care Planning on End-of-Life Decision Making: A Systematic Review and Meta-Analysis.

The purpose of this systematic review and meta-analysis was to investigate the effects of advance care planning on end-of-life decision-making. Databases including RISS, KISS, KMbase, KoreaMed, PubMed (MEDLINE), Embase, and CINAHL were searched for studies that examined the effects of advance care planning interventions. The inclusion criteria were original studies in English or Korean; adults ≥18 years of age (population); advance care planning (intervention); completion of advance directives (AD) or advance care planning (ACP) (outcomes); and randomized or non-randomized controlled trials (RCTs and non-RCTs, respectively) (design). Study quality was measured using the checklists of the Joanna Briggs Institute. Meta-analyses were conducted with the Comprehensive Meta-Analysis program. Nine RCTs and nine non-RCTs were selected for the final analysis. The effect sizes (ES) of the outcome variables in nine RCTs were meta-analyzed, and found to range from 0.142 to 0.496 for the completion of AD and ACP (ES=0.496, 95% CI: 0.157~0.836), discussion of end-of-life care (ES=0.429, 95% CI: -0.027~0.885), quality of communication (ES=0.413, 95% CI: 0.008~0.818), decisional conflict (ES=0.349, 95% CI: -0.059~0.758), and congruence between preferences for care and delivered care (ES=0.142, 95% CI: -0.267~0.552). ACP interventions had a positive effect on the completion of AD and ACP. To apply AD or ACP in Korea, it is necessary to develop ACP interventions that reflect aspects of Korean culture.

Geriatric assessment-driven intervention (GAIN) on chemotherapy toxicity in older adults with cancer: A randomized controlled trial.

12010 Background: Geriatric assessment (GA) can predict chemotherapy (chemo) toxicity in older adults (age ≥65) with cancer. However, evidence regarding the effect of GA-driven intervention (GAIN) on the incidence of chemo toxicity has been limited. Therefore, we conducted a randomized controlled trial evaluating the impact of GAIN vs. standard of care (SOC) on chemo toxicity in older adults with cancer. Methods: Patients (pts) age ≥65, diagnosed with a solid malignancy, and starting a new chemo regimen at City of Hope were eligible (NCT02517034). In a 2:1 ratio, 600 pts were randomly assigned to either GAIN (n = 398) or SOC (n = 202) arms. All pts completed a baseline GA prior to chemo. In the GAIN arm, a multidisciplinary team led by a geriatric oncologist, nurse practitioner, social worker, physical/occupation therapist, nutritionist, and pharmacist, reviewed GA results and implemented interventions based on predefined triggers built into the GA’s various domains. In the SOC arm, GA results were sent to treating oncologists to use at their discretion. Pts were followed until either end of chemo or 6 months after start of chemo, whichever occurred first. The primary endpoint was incidence of grade 3-5 chemo-related toxicity (NCI CTCAE v.4.0). Secondary endpoints included advance directive (AD) completion, emergency room (ER) visits, hospitalizations, and average length of stay (ALOS). Chi-square and Fisher’s exact tests were used to compare the categorical outcomes, and Kruskal-Wallis test was used to compare the ALOS between arms. Results: Pt characteristics were balanced between arms. Median age was 71 (range 65-91). Cancer types included: 33% gastrointestinal, 23% breast, 16% lung, 15% genitourinary, and 13% other. Most (71%) had stage IV disease. The incidence of grade 3-5 chemo-related toxicity was 50.5% (95% CI: 45.6-55.4%) in the GAIN arm and 60.4% (95% CI: 53.7-67.1%) in the SOC arm (p = 0.02). Compared to SOC, the GAIN arm had a reduction of 9.9% (95% CI: 1.6-18.2%) in chemo-related toxicity. At the end of study, AD completion increased 24.1% in the GAIN arm vs. 10.4% in the SOC arm (p < 0.001). No significant differences in ER visits (27.4% vs. 30.7%), hospitalizations (22.1% vs. 19.3%), or ALOS (median 4.8 vs. 5.0 days) were observed between the GAIN and SOC arms, respectively. Conclusions: Integration of multidisciplinary GA-driven interventions reduced grade 3-5 chemo-related toxicity and improved AD completion in older adults with cancer. GA-driven interventions should be included as a part of cancer care for all older adults. Clinical trial information: NCT02517034 .

A randomized trial of a palliative care intervention for patients on phase I studies.

12001 Background: The purpose of this study was to test a Palliative Care Intervention for patients with solid tumors enrolled in phase I therapeutic trials. Methods: This randomized trial compared patients accrued to phase I Clinical Trials in groups of Usual Care compared to a Palliative Care Intervention (PCI) in two comprehensive cancer centers. The PCI included assessment of quality of life (QOL) and symptoms, an interdisciplinary meeting to discuss the care plan, including goals of care, and two nurse-delivered teaching sessions. Subjects (n=479) were followed for 24 weeks, with 12 weeks as the primary outcome point. Results: Outcomes revealed that relative to Usual Care, PCI subjects showed less Psychological Distress (1.9 in Intervention and 1.2 in Control pts, p=0.03) and a trend toward improved QOL (3.7 versus 1.6, p=0.07), with differences between sites. We observed high rates of symptom-management admissions (41.3%) and low rates of Advance Directive completion (39%), and use of supportive care services including hospice (30.7%, for only1.2 months duration), despite a median survival for all patients in both groups of 10.1 months from initiating a phase 1 study until death. Patient satisfaction with oncology care was already high at baseline, and we did not see clinically significant changes in those scores by week 12. Conclusions: Palliative care interventions can improve QOL outcomes and distress for patients participating in phase 1 trials. Greater integration of PC is needed to provide quality care to these patients and to support transitions from treatment to supportive care, especially at the end of life. Clinical trial information: NCT01828775 .

Effect of FAmily CEntered (FACE®) Advance Care Planning on Longitudinal Congruence in End-of-Life Treatment Preferences: A Randomized Clinical Trial.

Trial tested effect of advance care planning on family/surrogates' understanding of patients' end-of-life treatment preferences longitudinally. A multisite, assessor-blinded, intent-to-treat, parallel-group, randomized controlled clinical trial in five hospital-based HIV clinics enrolled 449 participants aged 22 to 77years during October 2013-March 2017. Patients living with HIV/family dyads were randomized at 2:1 ratio to 2 weekly ~ 60-min sessions either ACP (n = 155 dyads)-(1) ACP facilitated conversation, (2) Advance directive completion; or Control (n = 68 dyads)-(1) Developmental/relationship history, (2) Nutrition/exercise tips. ACP families/surrogates were more likely to accurately report patients' treatment preferences at Time 1 (T1) and 12months post-intervention (T2) compared to controls, experiencing high congruence longitudinally (high→high transition), [63·6% vs 37·7% (difference = 25·9%, 95% CI: 11·3%, 40·4%, χ2 = 11·52, p = 0·01)], even as patients' preferences changed over time. ACP families/surrogates had eight times the odds of controls of having an excellent understanding of patients' treatment preferences (Adjusted Odds Ratio 7.91, 95%CI: 3.08, 20.3). Conversations matter.

Worry as a Mechanism to Motivate Information Seeking about Protective End-of-Life Communication Behaviors

Making known one’s end-of-life (EOL) care wishes via the processes of advance care planning (ACP) and advance directive (AD) completion is associated with many positive outcomes for patients including lower healthcare costs, greater patient-provider relationship satisfaction, increased quality of life, and more. Despite these benefits, fewer than 30% of patients in the United States engage in ACP or complete ADs. These low numbers are most likely due to several causes, including low self-efficacy and low motivation to engage in the process. Several researchers have examined the persuasive power of using worry to motivate patients to engage in preventive health behaviors. The present study expands upon this body of literature by examining patient intentions to seek information related to ACP and AD after being exposed to stimuli intended to arouse differing levels of worry regarding bad EOL outcomes. Participants (N = 804) were randomly assigned to either the high worry, low worry, or control group and asked to complete a questionnaire examining beliefs and information seeking intentions regarding ACP and AD completion. Additionally, to control for participants’ level of trait worry, each participant completed the Penn State Worry Questionnaire, which was treated as a covariate in the final analysis. A repeated measures MANCOVA found a statistically significant increase for the worrying conditions on the participants’ intention to seek information about ACP and ADs from time 1 to time 2 for those in the worry experimental conditions. However, those in the control group did not show a statistically significant increase. Additionally, exposure to the high worry condition was predictive of engaging in actual information seeking behavior about EOL care. Results of the experiment indicate worry is associated with greater motivation to engage in information seeking about ACP and AD. This study contributes to the literature on worry as a persuasive mechanism to motivate patients to engage in important preventative health behaviors.

Group-based educational intervention for advance care planning in primary care: a quasi-experimental study in Japan

Background: Older adults who have health conditions with good prognoses typically fall outside the scope of efforts encouraging advance care planning. We developed group and individual versions of an advance care planning program for use in primary care.
 Methods: We conducted a quasi-experimental trial in a rural family clinic in Japan. Medically stable patients aged ≥65 years were invited to watch an educational video on advance care planning, followed by an individual (n=46) or group-based (n=63) discussion. Advance directive completion was tracked over four months. Participants completed baseline and follow-up questionnaires and reported occurrence of family discussions about advance care planning and attitudes toward advance care planning. Group discussions were recorded and thematically analyzed to identify barriers and facilitators to engaging in advance care planning.
 Results: Advance directive completion rates were high for both intervention versions but did not significantly differ between arms (85.7% vs. 80.4%, p=0.45). Only one-fifth of patients in both arms discussed advance care planning with their family after the intervention (20.7% and 21.7%, p=0.89). Patients in the group arm rated their experience slightly higher than those in the individual arm (4.2 and 3.9 out of 5, p=0.023). Qualitative analysis of group discussions revealed that patients were affected by their perceptions of societal norms that prioritize family consensus over patient autonomy; however, these perceptions influenced advance care planning behaviors in inconsistent ways.
 Conclusions: Group-based advance care planning intervention among medically stable older patients is as effective as an individually-focused discussion in promoting advance directive completion. Future research is needed on ways to enhance patients’ ability to discuss advance care planning with their family members.

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

Background Advance directives (AD) offer the opportunity for goal-concordant care at the end of life (EOL). However, fewer than half of HCT recipients have a documented AD. We hypothesized that the use of a novel AD-the Stanford What Matters Most Letter (Letter AD)-developed to assess patients' values, goals, and EOL wishes would result in a greater proportion of AD completion among HCT recipients. We therefore conducted a prospective, randomized, controlled study of the traditional California AD vs. the Letter AD in adult allogeneic HCT recipients. Methods Patients >= 18 years old undergoing first allogeneic HCT at Stanford University were eligible. Prior to HCT conditioning, enrolled patients were randomly assigned to complete either the traditional California AD or the Letter AD, and all patients received a sociodemographic survey and a survey evaluating their opinions regarding the AD form they received. Patients were asked to return all research forms at the time of their transplant admission; a research assistant placed a reminder call to each patient prior to scheduled transplant. The primary endpoint was AD completion; secondary endpoints included EOL wishes as documented on the AD and patient preferences and opinions regarding the AD version they received. Results Between March 2017 and August 2018, 212 patients were eligible, of whom 126 (59.4%) were enrolled and randomized. Among the 84 who declined, the primary reason was already having an AD (N=34). The median age was 57 years (IQR 45-64); 54.8% were male; 58.7% were non-Hispanic White; and 72.3% had AML/MDS. There were no statistically significant differences in baseline socio-demographics between study arms. The overall AD completion rate was 71.6% and did not differ between the Traditional and Letter AD study arms (70.3% vs 72.6%, P=0.78). Preferences for EOL among responders are described in Table 1. The Letter AD uncovered that 66.7%, 42.2%, and 46.7% of patients actively wished to die gently/naturally, at home, and/or with hospice, respectively, whereas the traditional AD found that 62.2% wished to not prolong life if recovery was unlikely. Figure 1 portrays participant responses to the AD opinion survey; non-significant trends suggested that patients found the Letter AD favorable in terms of identifying what matters most to them, describing medical preferences to family, and stimulating thinking about the topic. Conclusion Completion rates of AD amongst allogeneic HCT recipients on this study were high and did not differ based upon AD version. Most patients wish to die naturally/do not wish to prolong care at EOL. Non-significant trends favored the Letter AD over the Traditional AD across several domains of patient preference.

Evaluation of the national implementation of the VA Diffusion of Excellence Initiative on Advance Care Planning via Group Visits: protocol for a quality improvement evaluation

BackgroundTraditionally, system leaders, service line managers, researchers, and program evaluators hire specifically dedicated implementation staff to ensure that a healthcare quality improvement effort can “go to scale.” However, little is known about the impact of hiring dedicated staff and whether funded positions, amid a host of other delivered implementation strategies, are the main difference among sites with and without funding used to execute the program, on implementation effectiveness and cost outcomes.Methods/designIn this mixed methods program evaluation, we will determine the impact of funding staff positions to implement, sustain, and spread a program, Advance Care Planning (ACP) via Group Visits (ACP-GV), nationally across the entire United States Department of Veterans Affairs (VA) healthcare system. In ACP-GV, veterans, their families, and trained clinical staff with expertise in ACP meet in a group setting to engage in discussions about ACP and the benefits to veterans and their trusted others of having an advance directive (AD) in place. To determine the impact of the ACP-GV National Program, we will use a propensity score-matched control design to compare ACP-GV and non-ACP-GV sites on the proportion of ACP discussions in VHA facilities. To account for variation in funding status, we will document and compare funded and unfunded sites on the effectiveness of implementation strategies (individual and combinations) used by sites in the National Program on ACP discussion and AD completion rates across the VHA. In order to determine the fiscal impact of the National Program and to help inform future dissemination across VHA, we will use a budget impact analysis. Finally, we will purposively select, recruit, and interview key stakeholders, who are clinicians and clinical managers in the VHA who offer ACP discussions to veterans, to identify the characteristics of high-performing (e.g., high rates or sustainers) and innovative sites (e.g., unique local program design or implementation of ACP) to inform sustainability and further spread.DiscussionAs an observational evaluation, this protocol will contribute to our understanding of implementation science and practice by examining the natural variation in implementation and spread of ACP-GV with or without funded staff positions.

Improving Care for Patients with Advanced Kidney Disease: More, Earlier and Better Conversations Using the Serious Illness Conversation Guide (QI639)

•Describe the deficits in advance care planning and goals of care conversations among patients with advanced kidney disease.•Measure the impact of implementing the Serious Illness Conversation & Care Planning Program among a group of nephrologists.•Disseminate lessons learned and future directions for ongoing implementation of the Serious Illness Conversation & Care Planning Program within a nephrology practice. Despite growing evidence citing benefits, advance care planning (ACP) conversations and advance directive (AD) completion remain low in patients with advanced kidney disease. This quality improvement project aimed to improve quality of conversations and AD completion in this patient population at a large healthcare system. Baylor Scott & White Health (BSWH), in partnership with Ariadne Labs (AL), is implementing the Serious Illness Conversation and Care Planning Program (SICP). Physicians and Advance Practice Professionals are trained to use the Serious Illness Conversation Guide (SIG) through a training program created by AL and taught by trained faculty at BSWH. We collected baseline data prior to training. Data is collected from the conversation guide which was built into multiple electronic medical record (EMR) systems. Review of aggregate data is ongoing for implementation process improvement. Approximately 1% of patients within a nephrology practice had ADs retrievable in the EMR in 2015. Information about patient preferences for care were unable to be obtained from the documentation, therefore timing of conversations before death could not be calculated. As of June 2018, 21 nephrologists have been trained and 51 conversations documented across all CKD clinics in system. Of these, 35 (68%) included answers to the understanding question, shared prognosis and made a recommendation. Conversations led to creating a new AD in 14 patients (27%). To date, four patients died (7%) and four were admitted to hospice (7%). The average time from conversation to death was 158.5 days. Approximately 15 nephrologists are scheduled for training in the next 3 months. Evaluations of the course revealed nephrologists found the training useful and recommend it to others. After completing SIG training, nephrologists engaged in more and earlier conversations and completed more ADs. Nephrologists found the training helpful and would recommend to others.

Association of Palliative Care Consultations with Goals of Care Conversations and Advance Directive Completion for Patients Admitted with Acute Exacerbations of COPD (S727)

Association of Palliative Care Consultations with Goals of Care Conversations and Advance Directive Completion for Patients Admitted with Acute Exacerbations of COPD (S727)

Advance Directives for Blood and Marrow Transplantation Recipients

Topic Significance & Study Purpose/Background/Rationale Blood and Marrow Transplantation (BMT) is a potentially curative therapy, but despite clinical advancements it continues to be associated with significant morbidity and mortality. Advance Directives (AD) ensure that patients receive the care that is consistent with their values, goals, and preferences at end of life (EOL). Yet, fewer than a quarter of BMT recipients at this Academic Medical Center have a documented AD. This leads to an increase in unnecessary treatments, care escalations, and discrepancy of care expectations which heightens distress for the patient, family, and provider. In May 2019, a nurse driven interprofessional team was assembled to conduct a performance improvement project. Methods, Intervention, & Analysis The goal was to increase the percent of completed AD for BMT recipients at this Center before transplant (Day 0), from 21% to 40% by September 2019. Through team-based problem solving, analyzation of possible causes for gaps in practice related to AD completion was performed. The identified key focus areas included: the absence of AD discussions in both the clinic and inpatient settings, lack of staff training and education, and no standard workflow for AD completion or collection. These findings were addressed in June 2019, by implementing a standard operating procedure within the BMT program for AD completion, delivery, and submission into the electronic health record. Training was also developed and provided to all BMT interprofessional teams. Findings & Interpretation Between July 2019 and September 2019, 74 patients received a transplant at this center, of those patients 30 had an AD completed by Day 0. The overall AD completion rate was 40.5% (Table 1). Furthermore, an increase in patients providing their Social Workers with a completed AD in the clinic setting was identified as well as the referrals to inpatient Spiritual Care services for assistance with AD completion. Discussion & Implications Early completion of AD offers the opportunity for goal-concordant care at EOL, and the BMT population can greatly benefit from this care. This has the potential to reduce hospitalization at the EOL, decrease ICU utilization and costly invasive interventions, increase utilization of hospice services, and promote a higher satisfaction with the quality of care.

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. This study tested whether transitioning from work to retirement prompted AD completion. The sample included Health and Retirement Study participants who, in 2012, had no ADs and were not completely retired (N = 919). 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. The period following retirement may be an optimal time to encourage patients and clients who have not already done so to complete advance directives.