Health Care Power Of Attorney Research Articles

Improve Advance Care Planning: A Brief Report Discussing Goals of Care Interventions to Improve Communication Among Health Care Teams and Patients Maximizing the Use of the Electronic Health Record Tools.

Introduction: A key element of advance care planning (ACP) is the goals of care (GOC) conversation between the provider and the patient. The value of meaningful GOC conversations for the patient, provider, and health care institution is well documented. However, if the GOC documentation is buried in the medical record, not well defined, or poorly documented, that value is squandered. The Improvement Process: Interventions were implemented with oncology physicians and nurse practitioners (NPs). These included education, system reform including improving the ease and consistency of documentation of ACP, and regular feedback. Results: Participants reported increased confidence in communication skills about GOC conversations postworkshops. Data results for the tracked metrics, health care power of attorney, code status, and GOC, all showed improvement. Conclusion: Physicians and NPs recognized the importance of GOC conversations as part of ACP. Considerable progress was made by focusing on GOC conversations, maximizing information technology, participating in coaching, and ongoing data monitoring.

Des directives anticipées aux discussions anticipées sur la fin de vie: From living wills to end-of-life discussions

The Leonetti laws of 2005 and 2016 provide a framework for end-of-life decision-making and strengthen patients’ rights. Living Wills (ADs) enable patients to writing their wishes at the end of life. They share the same aim as the designation of a health care power of attorney whose testimony makes it possible to state what the patient’s wishes would have been. Only a minority of patients use living wills, due to a number of limitations (dealing with the question of worsening, anticipation, written form) encountered by all those involved (doctors, nursing staff and patients).The aim of this review is to clarify the regulatory framework governing end-of-life care, and more specifically that of living wills. It also describes the difficulties of adopting living will France and internationally, as well as their limitations. Numerous studies aimed at evaluating interventions to facilitate their use have led to the development of the notion of advance care planning. This is a clinical process, centered on dialogue between healthcare professionals, patients and their relatives about patients’ values and preferences in the event of worsening and at the end of life. It provides guidelines for anticipating patients’ worsening and identifying their preferences.1877-1203/© 2023 SPLF. Published by Elsevier Masson SAS. All rights reserved.

The association of demographic factors and disease stage on palliative care (PC) referral rates and completion of advanced directives in a lung cancer (LC) patient population.

e24150 Background: Early referral to PC improves quality of life among patients with lung cancer and is associated with improvement in overall survival in patients with stage 4 disease. However, PC utilization remains low. Few studies examined the disparities in PC access and use in real life SCLC and NSCLC patient populations. Objective: To determine the prevalence of PC use among a sample of LC patients and assess the role of PC in facilitating directives and goals of care discussion. Methods: A retrospective cohort analysis was conducted utilizing a randomly selected subset of LC patients treated at the IU Simon Comprehensive Cancer Center between 1/1/18 and 12/31/20. We collected information on advanced directives in the form of designated medical decision maker (Healthcare representative or Healthcare power of attorney) and code status preferences (DNR or POST form). Signed DNR order/POST forms information, demographics (sex, race), LC stage, and LC type were analyzed using descriptive analyses. Chart search identified the dates of first palliative care visit and number of total palliative care visits. Results: Patient characteristics (n = 209): Females 51.7%; White 86.7%; NSCLC 88.5%; stage IV 44.1%. The percentage of total patients who were referred to palliative care was 21.1%. No significant difference in referral rates was found between NSCLC and SCLC patients. 22.3% of male patients and 19.8% of female patients were referred to PC (p = 0.61). No difference was noted in the percentage of white and non-white patients referred to PC (21% and 26.1%, p = 0.97). Palliative referral rates and time from diagnosis to first palliative contact was significantly associated with disease stage, as 27.9% of patients with stage 4 were referred to palliative compared to 15.6% of patients with stages 1-3 (p = 0.036); median time from diagnosis to first palliative contact in stage 4 patients was 355.7 days vs 573.7 days in stages 1-3. Disease stage was associated with the median time from diagnosis to signing POST/DNR forms: 213.6 days in stage 4 patients vs. 409.1 days in stage 1-3 patients. Discussing and signing POST/DNR and HCPOA/HCR forms was associated with palliative care referrals; 53.7% and 63.6% of those referred to palliative signed POST/DNR and HCPOA/HCR forms respectively vs. 11.4% and 16.9% for patients who were never referred to PC. Conclusions: Stage 4 LC was associated with higher likelihood of referral to palliative care than stages 1-3 but PC was underutilized in LC. Demographic factors (race, sex) were not significantly associated with PC referral rates. Patients referred to PC were more likely to address advanced directives than patients who were never offered PC. Strategies to increase palliative care utilization and barriers limiting PC utilization in LC patients need to be further investigated.

Disparities in Advance Directive Documentation for Rural-Dwelling Persons With Lung Cancer.

Purpose: Advance directives (AD) are recommended for persons with lung cancer, yet few studies have investigated AD and healthcare power of attorney (HCPOA) documentation for this population in rural regions of the United States. The purpose of this study was to examine demographic and clinical factors associated with AD and HCPOA documentation for persons with lung cancer in rural eastern North Carolina (ENC). Methods: A cross-sectional retrospective chart review was conducted to collect demographic and clinical data from electronic health records from 2017 to 2021 at a tertiary cancer center and regional satellite sites in ENC. Descriptive statistics and Chi-Square Tests of Independence were used for data analysis. Findings: The sample's mean age was 69.5years (n = 402, SD = 10.5, range = 28 - 92). Most participants were male (58%) and had a smoking history (93%). Consistent with regional population statistics, 32% of persons were black, and 52% lived in rural counties. Just 18.5% of the sample had a documented AD and 26% had a healthcare power of attorney. Black persons had significantly lower AD and HCPOA (P < .001) documentation than white persons. Rural-dwellers had significantly lower HCPOA documentation than urban-dwellers (P = .03). For all other variables, no significant differences were found. Conclusions: These findings suggest that AD and HCPOA documentation are low for persons with lung cancer in ENC, particularly for black persons and rural-dwellers. This disparity highlights the need for enhanced advance care planning (ACP) access to and outreach in the region.

THE RELATIONSHIP BETWEEN PHYSICIAN VISITS AND ADVANCE CARE PLANNING

Abstract Some studies have shown that advance care planning (ACP), discussions about future care given a serious illness, are associated with improved quality of death and better end-of-life care. Studies also have found that physicians play an important role in ACP. In fact, in 2016 CMS began reimbursing physicians for ACP discussions. However, little is known about the relationship between the number of physician visits and engaging in ACP . This study investigated the association between outpatient physician visits and ACP engagement. Only respondents over 65 were included in our study. We conducted logistic regressions using the 2016 Health and Retirement Study. We used ACP engagement (n=9838), advance directive (AD; eg, living will) completion (n=9746), and healthcare power of attorney (e.g., proxy) assignment (n=9724) as outcome variables. In addition to the frequency of physician visits, we controlled for basic demographics (age, gender, marital status, race, and socioeconomic status), number of chronic conditions, and self-rated health in our models. For each additional physician visit, the probability of having an ACP conversation, (p&amp;lt;.001), AD completion (p&amp;lt;.001), and healthcare proxy assignment (p&amp;lt;.001) increased by 1.6%,1.4%, and 1.9% respectively after controlling for covariates. Number of chronic conditions also was independently and positively associated with ACP-related activities. Additionally, greater perceived health was associated with higher odds of AD completion (OR= 1.08, p&amp;lt;.05) and healthcare proxy assignment (OR= 1.07, p&amp;lt;.05). This study found that frequent encounters with physicians are associated with higher rates of ACP engagement even after controlling for health conditions.

Replace the advance directive with a patient activation approach to serious illness communication.

Replace the advance directive with a patient activation approach to serious illness communication.

Patients From Distressed Communities Who Undergo Surgery for Hip Fragility Fractures Are Less Likely to Have Advanced Care Planning Documents in Their Electronic Medical Record.

Patients From Distressed Communities Who Undergo Surgery for Hip Fragility Fractures Are Less Likely to Have Advanced Care Planning Documents in Their Electronic Medical Record.

Medical Orders for Life-Sustaining Treatment in Correctional Settings.

Medical Orders for Life-Sustaining Treatment in Correctional Settings.

Use of a simulated group visit to introduce advance care planning in the primary care setting

Background and objective: When serious illness prevails or when faced with an end-of-life event, nurses should recognize symptoms and support patients with decision-making. By encouraging advance care planning (ACP) in the outpatient setting, patient involvement is enhanced. Objective: A performance improvement plan was used to increase nurse care manager confidence levels with hosting ACP conversations.Methods: Design: Care managers attended a two-hour simulated session to observe how to educate and prepare patients to complete advance directives. The session included a video introduction with two different group activities that encouraged sharing experiences from the peer perspective. Options for care were explored, focusing on selecting a health care power of attorney and promoting an end-of-life values conversation. Setting/Participants: The group visit occurs in the outpatient setting in a small group with five nurse care managers in the first visit and nine nurses in the second visit. Measures: Using a Likert scale, a pre/post-visit survey was given with eight questions to measure confidence levels with ACP in the group visit setting. Follow-up interviews were voluntarily conducted to measure confidence in completing an ACP conversation with a friend or family member.Results: Eight of the fourteen care managers participated in the post-visit interviews. 63% expressed themes of increased comfort in understanding and sharing ACP steps. The overall mean for pre/post survey confidence level increased from 3.77 to 4.33 (S.D. 0.25), with the most significant increase centered around confidence to lead a values conversation to select preferences for care.Conclusions: This performance improvement plan to promote ACP in the outpatient setting aligns with past studies promoting a group visit to educate and prepare patients to complete advance directives. Although findings may have limited generalizability, due to their small sample size, future group visits should be considered as a possible solution to meet busy time constraints in the primary care office.

Chapter 18 - Ethical considerations in the management of poststroke aphasia

From the onset of the first signs of stroke, patients are faced with a chain of events that requires quick decision-making to ensure that lifesaving care is administered. Considering that acute stroke is often associated with altered mental status and changes in cognitive-linguistic abilities, ethical dilemmas may arise when patients are unable to provide input in their own care and must rely on surrogate decision-makers to act on their behalf. Although the most critical, lifesaving decisions are made acutely, for the patients who go on to have residual chronic cognitive-linguistic deficits, loss of language, and/or impaired cognition may mean that a healthcare power of attorney or other proxy is needed to assist with medical decision-making. This chapter discusses ethical concerns surrounding the care of stroke survivors, with a focus on how poststroke cognitive-linguistic deficits can complicate this topic; clinical recommendations are provided.

Building a career in cardiology and palliative care

A 68-year-old man with ischaemic cardiomyopathy presents with acute on chronic systolic heart failure with severe mitral regurgitation. He has a history of coronary artery disease status post-coronary artery bypass...

Reproductive Ethics and Family

Reproductive Ethics and Family

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

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

Improving a Mature Palliative Care Program at a Level I Trauma Center.

Similar to the significant rise in the geriatric population in the United States, trauma centers have seen an increase in geriatric trauma patients. These patients present with additional challenges such as a higher likelihood of undertriage, mortality, and frailty. In addition, the varying presence of advanced directive documentation increases the importance of early palliative care consultations for geriatric trauma patients. In 2018, a Level I trauma center in the Midwest reviewed the American College of Surgeons Trauma Quality Improvement Program's Palliative Care Best Practice Guideline to identify opportunities for improvement to strengthen the collaboration between the palliative care consult service and trauma program. The guideline drove improvements, which included documentation changes (i.e., expansion of palliative care consultation triggers, frailty assessment, advanced directives questions, depression screening, and addition of palliative care consultation section on the performance improvement program form) and training (1-hr lecture on palliative care and 5-hr palliative care simulation training) opportunities. A 3-month manual chart review (March 2019 through May 2019) revealed that by May 2019, 87.2% of admitted geriatric trauma patients received frailty assessments, which surpassed the benchmark (≥85%). In addition, advanced care planning questions (i.e., health care power of attorney, do not resuscitate order, or living will) exceeded the benchmarks set forth by the guideline (≥90%), with all of the questions being asked and documented in 95.7% of those same patient charts by May 2019. This quality improvement project has applicability for trauma centers that treat geriatric trauma patients; using the guidelines can drive changes to meet individual institution needs.

The Role of Health, Social Network, and Race in Advance Care Planning Among Medicare Beneficiaries

Advance care planning (ACP) is linked with high-quality end-of-life outcomes. However, ACP engagement level among older adults varies significantly by demographic, social, and health characteristics. In this study, we sought to identify characteristics associated with informal and formal ACP, in order to inform development of targeted education and outreach efforts that are tailored to diverse groups of older adults. The data came from a nationally representative study of Medicare beneficiaries living in communities, the National Health and Aging Trends Study (Round 8, N= 5,547). Multivariable logistic regressions were conducted to identify individual characteristics (i.e., race/ethnicity, age, gender, income, functional disability, cognitive function, perceived health, and numbers of people in social networks) associated with ACP engagement. Rates of informal ACP (talking to someone), and formal ACP, completing a healthcare power of attorney (HPOA) and a living will (LW), were 56%, 60.5%, and 56% accordingly. Logistic regression showed that individuals who were married or had a larger social network, and had higher functional impairment and health needs were significantly more likely to engage in both informal and formal ACP. However, individuals with memory problems (only informal ACP) and African Americans and Hispanics were significantly less likely to engage in both informal and formal ACP. African Americans without dementia were more likely to have completed HPOA compared with Whites. Findings suggest an important role of social network, and functional and cognitive health in ACP with implications for developing targeted outreach efforts in faith-based or social group settings, and healthcare settings.

Appointment of a Healthcare Power of Attorney Among Older Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) Adults in the Southern United States.

The Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) older adult population may have a heightened need of medical and supportive care while aging. This makes appointment of a healthcare power of attorney (HCPoA) an essential component of end-of-life care to ensure patients' wishes are honored at the end of their lives. The objective of this study was to evaluate the prevalence and preferences for HCPoA appointment among older LGBTQ adults living in the Southern United States. An online survey was distributed to older LGBTQ adults living in the Southern US regarding appointment of a HCPoA between January-March 2018. The survey was completed by 789 older LGBTQ adults from North Carolina, South Carolina, Georgia, Alabama, Mississippi, Louisiana, and Florida in January-March 2018. Overall, 61.6% of respondents had appointed a HCPoA. Respondents with an appointed HCPoA were more likely to be married (aOR = 5.04, p < .001), have larger social networks (aOR = 3.87, p < .001) and be older (aOR = 1.07, p < .001). Gender diverse respondents were less likely to have an appointed HCPoA relative to cisgender respondents (aOR = 0.39, p = .04). Overall, the majority of respondents indicated a spouse or significant other served as their HCPoA (n = 311, 64.5%). Nearly 40% of older LGBTQ adults in the Southern US did not have an appointed HCPoA. Specifically, those who were more socially isolated, single, or who identified as transgender or gender non-binary were less likely to have an appointed HCPoA. These people may benefit from targeted outreach regarding advance care planning.

Home Is Where the Heart Is: The Impact of Home-Based Palliative Care on Patients with Advanced Heart Failure

Introduction There is growing interest in the effect that specialty palliative care (PC) has on outcomes for patients with advanced heart failure (HF). Some evidence suggests that PC may improve quality of life, understanding of prognosis, and documentation of treatment preferences but that it does not affect hospitalization or mortality. Objectives To determine the effect of home-based PC on documentation of treatment preferences and healthcare utilization for patients with advanced HF. Methods A community-based non-profit hospice and PC organization partnered with the heart failure clinic at a general hospital that is a member of a large, state-owned, academic health system. The clinic referred patients with advanced HF to a 30-day program with weekly visits from a PC RN for ongoing physical and symptom assessment, medication reconciliation, advance care planning, home safety evaluation, and psychosocial support. Additional involvement from PC SW, NP, and MD was available as needed. Outcomes included discussion and clarification of code status, discussion and completion of health care power of attorney (HCPOA), and 30-day health care utilization for patients admitted to the program compared to 90 days prior to admission. Results Over 13 months, 40 patients were referred to the program. Of those, 29 agreed to admission, 7 declined admission but enrolled in other services such as hospice, and 4 declined admission and any services. During the 30-day program, code status was discussed with all 29 patients (100%). On admission, code status was “Full” for 23 patients (79%). After 30 days, 11 patients changed their code status to “DNR.” HCPOA completion was discussed with 25 patients (86%). On admission, 15 patients (52%) of patients already had completed a HCPOA. After 30 days, an additional 7 patients completed a HCPOA. On discharge from the program, 17 patients (59%) continued with PC services, 6 (21%) declined follow up, 5 (17%) enrolled in hospice, and 1 (3%) died prior to discharge. Compared to 90 days prior to admission, hospitalizations for the 29 admitted patients decreased 70% from 0.47 hospitalizations per patient per 30 days to 0.14 during the program. Hospitalization length of stay (LOS) decreased 92% from 2.64 days per patient per 30 days to 0.21. Conclusions A 30-day home-based PC program for patients with advanced HF did increase documentation of treatment preferences such as code status and completion of HCPOA. Hospitalizations and hospitalization LOS were reduced during the program when compared to 90 days prior to program admission.

Sidebar: Understanding Medical Orders for Advance Care Planning.

Advance care planning encompasses individual decision-making, conversations with loved ones, and the use of documents to help ensure that a person's treatment wishes are known. The more widely known types of advance care planning documents include health care power of attorney (HCPOA) and living

Advance directives in the emergency department.

Advance directives are documents to convey patients’ preferences in the event they are unable to communicate them. Patients commonly present to the emergency department near the end of life. Advance directives are an important component of patient‐centered care and allow the health care team to treat patients in accordance with their wishes. Common types of advance directives include living wills, health care power of attorney, Do Not Resuscitate orders, and Physician (or Medical) Orders for Life‐Sustaining Treatment (POLST or MOLST). Pitfalls to use of advance directives include confusion regarding the documents themselves, their availability, their accuracy, and agreement between documentation and stated bedside wishes on the part of the patient and family members. Limitations of the documents, as well as approaches to addressing discrepant goals of care, are discussed.

Advance Care Planning in Hematopoietic Stem Cell Transplant Recipients: A Survey of Providers in a Blood &amp; Marrow Transplant Program

Advance care planning (ACP) includes having conversations with loved ones and health care providers regarding health care wishes in various circumstances. It also includes completing advance directives such as a health care power of attorney and living will as well as preparing a will for finances and estate planning. This process helps patients make plans for their future health care goals and is particularly useful when they are unable to make their own medical decisions. ACP in hematopoietic stem-cell transplant (HSCT) recipients can be particularly challenging, given the treatment's significant morbidity and mortality yet curative potential. (Wang, W. S. et al, 2017). Recognizing this challenge, the Cleveland Clinic Blood and Marrow Transplant Program created a multi-disciplinary committee of social workers, physicians, advanced practice providers (APPs), nurse coordinators and nurses to address the gap in ACP for HSCT recipients to improve the overall quality of care provided to patients and families. As part of this initiative, we created a survey to assess perceptions of ACP within the program and comfort level. A confidential, fourteen question survey was created and administered to providers. The survey included questions on: 1) perceptions of the current approach to ACP in our program, 2)the comfort level of the provider in discussing goals of care, prognosis, and code status, 3) provider's current knowledge base and prior training. Open-ended feedback was also elicited. A total of 38 responded to the survey including 15 physicians, 7 APPs, 8 nurse coordinators, 3 social workers, and 3 inpatient nurses. The years of experience ranged from 0.5 to 21 plus years. The majority of providers felt our current approach to ACP was very good (n=11) or good (n=16). While the perception was overall favorable, less than half of the providers (n=14) felt we had adequate training to have goals of care discussions. Only 7 providers report having formal training in goals of care. Despite not having formal training, nearly all (n=37) thought it was important. The survey also assessed comfort level of initiating goals of care discussions, prognosis, and code status. The majority of providers reported feeling comfortable in all these areas: initiating goals of care n=25 (Figure 1), prognosis n=20 (Figure 2), and code status n=22 (Figure 3). Of the 21 who were comfortable initiating goals of care discussions 21 reported initiating these conversations in their clinical practice. Many providers (n= 37) also felt it was appropriate for all members of the team to initiate these discussions. ACP is an important part of HSCT multi-disciplinary care of patients and their families. This survey demonstrates our institution's perceptions of ACP, need for formal training to improve comfort levels, and highlights the need for ACP in HSCT to be approached by a multi-disciplinary team effort.