Medical Durable Power Of Attorney Research Articles

Findings on Loneliness, Telehealth, and Advance Care Planning From the National Poll on Healthy Aging

The University of Michigan National Poll on Healthy Aging (NPHA) taps into the perspectives of older adults to inform health care policy and practice using a nationally representative sample of more than 2,000 adults age 50-80. Questions about lack of companionship and feelings of loneliness were tracked over three time points; 34% expressed feelings of loneliness in October 2018, 41% in June 2020, and 37% in January 2021. The NPHA also found that use of telehealth increased from 4% in May 2019 to 30% in June 2020 to 43% in January 2021. Finally, the NPHA found that 37% have completed both medical durable power of attorney and advance directive with 7% completing at least one of these documents in the first three months of the COVID-19 pandemic. These poll results can be used to inform actions by coalitions and organizations to advance state and federal policy.

Increasing Medical Power of Attorney Completion for Hospitalized Patients During the COVID Pandemic: A Social Work Led Quality Improvement Intervention

BackgroundThe high risk of mechanical ventilation with COVID hospitalizations requires health-care systems to rapidly innovate advance care planning (ACP) delivery for hospitalized patients to promote goal-concordant care. MeasuresAssess the impact of a social work and care management intervention on the proportion of admitted patients each week with a Medical Durable Power of Attorney (MDPOA). InterventionSocial workers were consulted to assist with identification of a surrogate decision maker and completion of MDPOA forms for hospitalized patients. This intervention utilized change management strategies and was implemented between April and June 2020. OutcomesFrom a baseline average of 30.1%, the weekly percentage of admitted patients with MDPOA forms rose to 42.8% with correlating evidence of nonrandom special cause variation. Lessons LearnedUse of change management strategies resulted in rapid implementation of an effective ACP initiative. Ongoing needs include focusing on intervention sustainability and education of interprofessional providers about ACP processes.

Advance Care Planning Among Users of a Patient Portal During the COVID-19 Pandemic: Retrospective Observational Study.

BackgroundAdvance care planning is the process of discussing health care treatment preferences based on patients’ personal values, and it often involves the completion of advance directives. In the first months of 2020, a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), began circulating widely in the American state of Colorado, leading to widespread diagnosis of coronavirus disease (COVID-19), hospitalizations, and deaths. In this context, the importance of technology-based, non–face-to-face methods to conduct advance care planning via patient portals has increased.ObjectiveThe aim of this study was to determine the rates of use of a web-based advance care planning tool through a health system–based electronic patient portal both before and in the early months of the COVID-19 pandemic.MethodsIn 2017, we implemented web-based tools through the patient portal of UCHealth’s electronic health record (EHR) for patients to learn about advance care planning and complete an electronically signed medical durable power of attorney (MDPOA) to legally appoint a medical decision maker. Patients accessing the portal can complete and submit a legally valid MDPOA, which becomes part of their medical record. We collected data on the patients’ date of MDPOA completion, use of advance care planning messaging, age, sex, and geographic location during the early phase of the COVID-19 pandemic (December 29, 2019, to May 30, 2020).ResultsOver a 5-month period that includes the early phase of the COVID-19 pandemic in Colorado, total monthly use of the advance care planning portal tool increased from 418 users in January to 1037 users in April and then decreased slightly to 815 users in May. The number of MDPOA forms submitted per week increased 2.4-fold after the stay-at-home order was issued in Colorado on March 26, 2020 (P<.001). The mean age of the advance care planning portal users was 47.7 years (SD 16.1), and 2206/3292 (67.0%) were female. Women were more likely than men to complete an MDPOA, particularly in younger age groups (P<.001). The primary use of the advance care planning portal tools was the completion of an MDPOA (3138/3292, 95.3%), compared to sending an electronic message (148/3292, 4.5%). Over 50% of patients who completed an MDPOA did not have a prior agent in the EHR.ConclusionsUse of a web-based patient portal to complete an MDPOA increased substantially during the first months of the COVID-19 pandemic in Colorado. There was an increase in advance care planning that corresponded with state government shelter-in-place orders as well as public health reports of increased numbers of COVID-19 cases and deaths. Patient portals are an important tool for providing advance care planning resources and documenting medical decision makers during the pandemic to ensure that medical treatment aligns with patient goals and values.

Use of an Ambulatory Patient Portal for Advance Care Planning Engagement.

Primary care clinics need sustainable, population-based approaches to engage patients in advance care planning (ACP). Patient portal-based ACP tools may provide an option for patient engagement. To increase ACP outcomes by engaging older adults through portal-based ACP tools, including an electronic Medical Durable Power of Attorney (MDPOA) form. Geriatric clinic pilot of a multi-modal population-based outreach strategy for portal-based ACP tools. Outreach was to patients (n = 105) who were 65 years and older with an active portal account, no cognitive impairment, and no MDPOA on file. Patients received a motivational message via the portal and, if not read within 2 weeks, a mailed postcard about the portal-based ACP tools. Primary outcome was composite of any ACP action at 1-year including 1) new advance directive (AD) in the electronic health record, 2) use of portal-based ACP tools, or 3) documented ACP discussion with a provider. Sixty-five older adults read the electronic message at 12 months. Seventeen (16%) engaged in at least 1 ACP action. Fourteen of 17 engaged by adding an AD to their record. More patients completed an AD on article or brought a previously completed AD to clinic, compared with choosing to complete an electronic MDPOA via the portal. Brief motivational messages about ACP via a patient portal is feasible and may increase ACP outcomes for older adults in primary care. Future studies should evaluate population-based portal outreach strategies in combination with team-based workflows to enhance patient engagement in ACP.

Patient Perspectives on Advance Care Planning via a Patient Portal.

Patient portals can offer patients an opportunity to engage in the advance care planning (ACP) process outside of clinical visits. To describe patient perspectives on use of patient portal-based ACP tools. Interviews with patients who used portal-based ACP tools. The tools included an electronic Medical Durable Power of Attorney (MDPOA) form to designate a medical decision maker, a patient-centered educational web page, online messaging, and patient access to completed advance directives stored in the electronic health record (EHR). Regional health-care system with a common EHR. Semistructured interviews with purposefully sampled patients who used the ACP tools. Questions explored motivations for using the tools and perceptions about how the tools fit into ACP. Analysis followed a grounded hermeneutic editing approach. From 46 patients (mean age: 49, 63% female), 4 key themes emerged: (1) individualized explorations of the ACP tools, (2) personal initiation and engagement with ACP tools through the portal, (3) value of connecting ACP portal tools to clinical care, and (4) practicality of the ACP tools. Patients described benefits of communicating with health-care team members who referred them to online ACP tools, as well as having the electronic MDPOA form connected to clinical care. Patients considered the portal-based ACP tools to be practical and feasible to use within the scope of their own ACP experiences. Further study is needed to understand whether portal-based ACP tools increase the quality and quantity of ACP conversations and documentation that is available to inform medical decision-making.

An invitation to complete: Making advance directives part of the new patient process.

7 Background: In Colorado, there is no legal designation as to who is authorized to make healthcare decisions for an adult unable to make decisions for themselves. Completing an advance directive is increasingly associated with better end-of-life outcomes. Failure to complete an advance directive leads to fewer days on hospice and expensive, end-of-life care. It was hypothesized that patients who completed a Medical Durable Power of Attorney (MDPOA) document early may have higher adoption of advance care planning and earlier hospice at end-of-life. Methods: The Rocky Mountain Cancer Centers (RMCC) is the largest private oncology group in Colorado with multiple offices across the state. The RMCC-Pueblo clinic developed and piloted a new patient process where, at registration, all new patients were invited to complete a MDPOA while also completing other new patient forms. The Medical Durable Power of Attorney (MDPOA) is a document that appoints a healthcare decision maker (“healthcare agent”). Data on 4,441 patients from Nov. 1, 2017, to June 30, 2018, were extracted from the electronic health record (EHR), including code status, advance care planning counseling appointment, advance directive completion, and outcomes. Results: During this pilot, advance directive capture within the EHR rose from 15.4% to 21.4%. While the number of patients who elected hospice enrollment at the end of life was about the same, the length of hospice stay increased from an average of 14 to over 20 days, a 50% improvement. Conclusions: A MDPOA as a routine part of the new patient intake process is feasible and scalable. It opens the door to future ACP discussions and improved hospice utilization. Because of these findings, we are currently expanding this process to all RMCC practice sites. The results suggest that early completion of an Advance Directive lead to ongoing and healthy discussions about the patient’s end-of-life preferences for care, including appropriate hospice enrollment.

Evaluation of a multi-disciplinary, systematic approach to palliative care for patients undergoing active treatment for head and neck cancer.

91 Background: Patients who receive concurrent chemoradiation therapy for head and neck cancer (H&amp;N CA) commonly experience a range of symptoms, including dysphagia, weight loss, and dehydration, which may impact their treatment and prognosis. Treatment of patients with H&amp;N CA often involves multiple specialties, including Surgery, Medical, and Radiation Oncology, and Palliative Care. In January 2017, Kaiser Permanente Colorado (KPCO) began providing early, integrated palliative care for all H&amp;N CA patients (stages I-IV) starting chemoradiation at a single clinic site. This quality improvement program was subsequently evaluated for ease of implementation and, secondarily, to discern impacts on patient care. Methods: Retrospective chart review was performed for patients undergoing treatment in 2017 for H&amp;N CA with concurrent chemoradiation therapy who also received integrated palliative care (n = 16) compared to standard care patients (n = 32) from 2015-2017. Data on rates of unplanned hospitalizations and feeding tube placement, completion of Medical Durable Power of Attorney (MDPOA) and Edmonton Symptom Assessment Scale (ESAS) were extracted from the electronic health record. Descriptive and inferential statistics were used to review data. Assessment of implementation occurred by interviews with the clinical teams. Results: Implementation of the program required intentional work between departments to define roles and reduce unwanted overlap. Standardized nursing assessments of symptom burden were developed. Patients followed in an integrated fashion had increased MDPOA and ESAS completion (38% vs 6%) and decreased hospital admissions (19% vs 53%) and unplanned PEG tube insertions (13% vs 34%). Differences were statistically significant for hospitalizations (p = 0.022) and ESAS completion (p = 0.006). Conclusions: Development of integrated patient management required intentional inter-department team communication and did not disrupt the clinic environment of any department. Lower hospitalization rates may be related to increased monitoring of symptoms. Based on this experience, the program was expanded to other clinical sites within KPCO.

Design and Implementation of Patient Portal–Based Advance Care Planning Tools

BackgroundElectronic health record–based portal tools may help patients engage in advance care planning (ACP). We designed and implemented portal-based ACP tools to enable patients to create a medical durable power of attorney (MDPOA). MeasuresMDPOA documentation and System Usability Scale were assessed. InterventionStakeholder-informed portal-based ACP tools include an electronic MDPOA form, patient educational webpage, online messaging, and patient access to completed advance directives. OutcomesA total of 2814 patients used the tools over 15 months. Patients had a mean age 45 years (17–98 years) and 69% were women. Eighty-nine percent completed an MDPOA form, 2% called or sent online messages, and 8% viewed the MDPOA form but did not complete it. The tools were rated highly usable. Conclusions/Lessons LearnedPatients demonstrated willingness to use the portal to complete an MDPOA and rated the new ACP tools as highly usable. Future work will optimize population-based outreach strategies to engage patients in ACP through the portal.

Selected Ethical Issues in Aging: A Practical Perspective

Every day, health care providers in surgical and hospital settings face ethical issues with patients who require medical intervention. Since no one ever knows when he or she might become a patient who has lost the ability to communicate intent caused by an injury or disease, it is important to plan ahead and appoint an agent through a medical durable power of attorney to communicate wishes regarding care. An agent or other surrogate decision-maker often faces very difficult issues when the patient's medical status may mean that he/she is reaching the end of his or her life. Care decisions require a working knowledge of the medical issues and the application of ethical values, along with a process for coping with the emotional issues. Developing options and making medical decisions involves a blend of precise clinical information and the personal style and philosophy of the patient and the principles of clinical ethics.