Participation In Advance Care Planning Research Articles

Dances With Denial: Have Medical Oncology Outpatients Conveyed Their End-of-Life Wishes and Do They Want To?

Objectives: This study surveyed a sample of medical oncology outpatients to determine (1) the proportion who have already discussed and documented their end-of-life (EOL) wishes; (2) when and with whom they would prefer to convey their EOL wishes; (3) the EOL issues they would want to discuss; and (4) the association between perceived cancer status and advance care planning (ACP) participation. Methods: Adult medical oncology outpatients were approached in the waiting room of an Australian tertiary treatment center. Consenting participants completed a pen-and-paper survey assessing participation in ACP, preferences for conveying EOL wishes, timing of EOL discussions, and EOL issues they want to be asked about. Results: A total of 203 patients returned the survey (47% of eligible). EOL discussions occurred more frequently with support persons (47%) than with doctors (7%). Only 14% had recorded their wishes, and 45% had appointed an enduring guardian. Those who perceived their cancer as incurable were more likely to have participated in ACP. If facing EOL, patients indicated that they would want family involved in discussions (85%), to be able to write down EOL wishes (82%), and to appoint enduring guardians (91%). Many (45%) preferred the first discussion to happen when their disease became incurable. Slightly less than one-third thought discussions regarding EOL should be patient-initiated. Most agreed doctors should ask about preferred decision-making involvement (92%), how important it is that pain is managed well (95%), and how important it is to remain conscious (82%). Fewer (55%) wanted to be asked about the importance of care extending life. Conclusions: Many patients would like to have discussions regarding EOL care with their doctor and involve their support persons in this process. Only a small percentage of respondents had discussed EOL care with their doctors, recorded their wishes, or appointed an enduring guardian. The first step requires clinicians to ask whether an individual patient wishes to discuss EOL issues, in what format, and at what level of detail.

Expanding The INSPIRED COPD Outreach Program™ to the emergency department: a feasibility assessment.

BackgroundThe Halifax-based INSPIRED COPD Outreach Program™ is a facility-to-community home-based novel clinical initiative that through improved care transitions, self-management, and engagement in advance care planning has demonstrated a significant (60%–80%) reduction in health care utilization with substantial cost aversion. By assessing the feasibility of expanding INSPIRED into the emergency department (ED) we anticipated extending reach and potential for positive impact of INSPIRED to those with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) who avoid hospital admission.MethodsPatients were eligible for the INSPIRED-ED study if >40 years of age, diagnosed with AECOPD and discharged from the ED, willing to be referred, community dwelling with at least one of: previous use of the ED services, admission to Intermediate Care Unit/Intensive Care Unit, or admission to hospital with AECOPD in the past year. We set feasibility objectives for referral rates, completion of action plans, advance care planning participation, and reduction in ED visit frequency.ResultsReferral rates were 0.5/week. Among eligible patients (n=174) 33 (19%) were referred of whom 15 (M=4, F=11) enrolled in INSPIRED-ED. Mean (SD) age was 68 (7) years, post-bronchdilator FEV1 44.2 (15.5) % predicted, and Medical Research Council (MRC) dyspnea score 3.8 (0.41). We met feasibility objectives for action plan and advance care planning completion. Frequency of subsequent ED visits fell by 54%. Mean (SD) Care Transition Measure (CTM-3) improved from 8.6 (2.0) to 11.3 (1.3), P=0.0004, and of 14 patients responding 12 (86%) found the program very helpful. An additional 34 patients were enrolled to our regular program from those referred but ineligible for INSPIRED-ED (n=27) or unwilling to participate (n=7).ConclusionsINSPIRED-ED outcomes were generally positive, however referral and enrollment rates were lower than anticipated. Despite the potential of early self-management education, the ED may not be the ideal recruitment setting for home-based programs. Our findings underline the importance of conducting preliminary work to ascertain best settings for implementing new self-management education initiatives.

Engagement in Advance Care Planning and Surrogates’ Knowledge of Patients’ Treatment Goals

A key objective of advance care planning (ACP) is improving surrogates' knowledge of patients' treatment goals. Little is known about whether ACP outside of a trial accomplishes this. The objective was to examine patient and surrogate reports of ACP engagement and associations with surrogate knowledge of goals. Cohort study SETTING: Primary care in a Veterans Affairs Medical Center. 350 community-dwelling veterans age ≥55 years and the individual they would choose to make medical decisions on their behalf, interviewed separately. Treatment goals were assessed by veterans' ratings of 3 health states: severe physical disability, cognitive disability, and pain, as an acceptable or unacceptable result of treatment for severe illness. Surrogates had knowledge if they correctly predicted all 3 responses. Veterans and surrogates were asked about living will and health care proxy completion and communication about life-sustaining treatment and quality versus quantity of life (QOL). Over 40% of dyads agreed that the veteran had not completed a living will or health care proxy and that there was no QOL communication. For each activity, sizeable proportions (18-34%) disagreed about participation. In dyads who agreed QOL communication had occurred, 30% of surrogates had knowledge, compared to 21% in dyads who agreed communication had not occurred and 15% in dyads who disagreed (P = .01). This relationship persisted in multivariable analysis. Agreement about other ACP activities was not associated with knowledge. Disagreement about ACP participation was common. Agreement about communication regarding QOL was modestly associated with surrogate knowledge of treatment goals. Eliciting surrogates' perspectives is critical to ACP. Even dyads who agree about participation may need additional support for successful engagement.

Implementation and Impact of Lay Navigator-Led Advance Care Planning for Cancer Patients (FR440C)

•Understand implementation of lay navigator-led ACP.•Describe navigator self-efficacy in conducting ACP before and after training.•Compare resource utilization (hospitalization, ICU admissions) between cancer patients who did and did not participate in navigator-led ACP. The Institute of Medicine, American Society of Clinical Oncology, and American Academy of Hospice and Palliative Medicine recommend that persons with serious, life-limiting illness engage in advance care planning (ACP), but implementation is time-consuming for medical personal. One potential solution for cancer patients is to delegate ACP tasks to lay navigators. Understand implementation of lay navigator-led ACP Describe navigator self-efficacy in conducting ACP before and after training Compare resource utilization (hospitalization, ICU admissions) between cancer patients who did and did not participate in navigator-led ACP A convergent, parallel mixed-methods study was used to evaluate implementation of a lay navigator-led ACP program across 12 Southeastern US cancer centers. Data collection included: (1) electronic records of ACP conversations initiated, declined, on-going, and completed (2) pre- and post-training surveys completed by navigators measuring navigator self-efficacy and knowledge (n=45), and (3) Medicare claims-based patient outcomes (n=820) including hospitalizations, ICU admissions, chemotherapy within last 14 days of life, and hospice use. Between 6/1/14-12/31/15, 50 navigators were certified as Respecting Choices® First Steps ACP Facilitators. Navigators initiated 1571 ACP conversations; 672 completed; 412 were on-going; 487 were declined. The mean score for feeling prepared to conduct ACP conversations increased from 5.6/10 pre-training to 7.5/10 after training (p=0.001). In comparison to navigated patients declining participation in ACP (n=167), there was a trend toward fewer hospitalizations (47% and 55%, p=0.06) and ICU admissions (17% vs 24%, p = 0.05) 30 days prior to death for decedents engaging in ACP with navigators (n=409). A navigator-led ACP program was able to be widely disseminated and may be associated with lower rates of hospitalizations and ICU admissions near EOL.

"I just think that we should be informed" a qualitative study of family involvement in advance care planning in nursing homes.

BackgroundAs part of the research project “End-of-life Communication in Nursing Homes. Patient Preferences and Participation”, we have studied how Advance Care Planning (ACP) is carried out in eight Norwegian nursing homes. The concept of ACP is a process for improving patient autonomy and communication in the context of progressive illness, anticipated deterioration and end-of-life care. While an individualistic autonomy based attitude is at the fore in most studies on ACP, there is a lack of empirical studies on how family members’ participation and involvement in ACP- conversations may promote nursing home patients’ participation in decisions on future treatment and end-of-life care. Based on empirical data and family ethics perspectives, the purpose of this study is to add insights to the complexity of ACP-conversations and illuminate how a family ethics perspective may improve the quality of the ACP and promote nursing home patients’ participation in advance care planning.MethodsParticipant observations of ACP-conversations in eight nursing homes. The observations were followed by interviews with patients and relatives together on how they experienced being part of the conversation, and expressing their views on future medical treatment, hospitalization and end-of-life issues.ResultsWe found that the way nursing home patients and relatives are connected and related to each other, constitutes an intertwined unit. Further, we found that relatives’ involvement and participation in ACP- conversations is significant to uncover, and give the nursing home staff insight into, what is important in the nursing home patient’s life at the time. The third analytical theme is patients’ and relatives’ shared experiences of the dying and death of others. Drawing on past experiences can be a way of introducing or talking about death.ConclusionsAn individual autonomy approach in advance care planning should be complemented with a family ethics approach. To be open to family ethics when planning for the patient’s future in the nursing home is to be open to diversity and nuances and to the significance of the patient’s former life and experiences.

Patient, family member, and clinician perspectives on advance care planning (ACP) in hematology and hematopoietic stem cell transplantation (HSCT).

7 Background: Studies have found that ACP engagement remains low in patients undergoing HSCT in spite of the high risks of treatment-related morbidity and mortality. Methods: This qualitative study used Thorne’s Interpretive Description methodology. Participants were accrued from hematological malignancy outpatient clinics at a tertiary oncology center and underwent audio-recorded semi-structured interviews. Analysis involved meticulous review of interview transcripts. The constant comparative method was utilized; data collection occurred concurrently with analysis until saturation of themes was achieved. Results: The study involved 6 patients, 5 family members and 8 clinicians (physicians, nurses, social worker). Participants thought that ACP was both acceptable and important yet many had not engaged in ACP. Perceived barriers to ACP included: system-related barriers such as lack of process for ACP, lack of time and/or resources; patient-related factors such as lack of understanding of disease, prognosis and/or expectations of HSCT, lack of patient/family understanding of ACP, a desire to ‘focus on positives’; and disease/treatment-related factors such as unpredictability of the disease and treatment trajectories in hematology and HSCT. Potential facilitators identified by participants included: integrating ACP as part of routine HSCT care, involving the multidisciplinary team in ACP, and introducing ACP early and revisiting frequently. Conclusions: This study revealed various barriers and facilitators related to participation in ACP. We are using the results of this study to inform and tailor interventions on ACP at our center. Introducing ACP as part of standard care in HSCT and providing ongoing facilitation of ACP, including discussion of disease and treatment expectations at the outset, and when complications arise, may assist patients and families in recognizing how ACP fits into their care. Given the inherent unpredictability in this population, we suggest revisiting ACP frequently to optimize patient experience and ensure patients and family members are aware of other treatment options including supportive and palliative care.

Trends in Advance Care Planning in Patients With Cancer: Results From a National Longitudinal Survey.

Advance care planning (ACP) may prevent end-of-life (EOL) care that is nonbeneficial and discordant with patient wishes. Despite long-standing recognition of the merits of ACP in oncology, it is unclear whether participation in ACP by patients with cancer has increased over time. To characterize trends in durable power of attorney (DPOA) assignment, living will creation, and participation in discussions of EOL care preferences and to explore associations between ACP subtypes and EOL treatment intensity as reflected in EOL care decisions and terminal hospitalizations. We analyzed prospectively collected survey data from 1985 next-of-kin surrogates of Health and Retirement Study (HRS) participants with cancer who died between 2000 and 2012, including data from in-depth "exit" interviews conducted with the surrogates after the participant's death. The HRS is a nationally representative, biennial, longitudinal panel study of US residents older than 50 years. Trends in ACP subtypes were tested, and multivariable logistic regression models examined for associations between ACP subtypes and measures of treatment intensity. Trends in the surrogate-reported frequency of DPOA assignment, living will creation, and participation in discussions of EOL care preferences; associations between ACP subtypes and both surrogate-reported EOL care decisions and terminal hospitalizations. From 2000 to 2012, there was an increase in DPOA assignment (52% to 74%, P = .03), without significant change in use of living wills (49% to 40%, P = .63) or EOL discussions (68% to 60%, P = .62). Surrogate reports that patients received "all care possible" at EOL increased during the period (7% to 58%, P = .004), and rates of terminal hospitalizations were unchanged (29% to 27%, P = .70). Limiting or withholding treatment was associated with living wills (adjusted odds ratio [AOR], 2.51; 95% CI, 1.53-4.11; P < .001) and EOL discussions (AOR, 1.93; 95% CI, 1.53-3.14; P = .002) but not with DPOA assignment. Use of DPOA increased significantly between 2000 and 2012 but was not associated with EOL care decisions. Importantly, there was no growth in key ACP domains such as discussions of care preferences. Efforts that bolster communication of EOL care preferences and also incorporate surrogate decision makers are critically needed to ensure receipt of goal-concordant care.

Five-year retrospective review of end-of-life care quality metrics in a large, multidisciplinary community oncology practice.

108 Background: It is increasingly recognized that earlier integration of palliative care for patients with advanced cancers positively impacts both cost and quality of oncology care. Compass Oncology (CO) is a multidisciplinary community oncology practice and a member of The US Oncology Network; 39 medical, gynecologic, and radiation oncologists and 18 advance practice providers serve patients at 6 sites in Oregon and Washington. In 2008, CO prioritized practice improvement in end of life care, identifying metrics for ongoing assessment. Between 2009 and 2014, quality improvement (QI) projects focused on communication skills; whole-staff palliative care education; integration of social workers; initiation of embedded palliative care at 2 sites; and development of a more standardized approach to Advance Care Planning (ACP). Methods: Systematic retrospective record review of patient deaths from January 2009 to December 2013, targeting analysis of hospice utilization, chemotherapy use at end of life, and ACP. Results: Among patients with a CO visit within 6 months of a documented date of death (n= 783 in 2009; n= 909 in 2013), both hospice utilization and ACP participation improved significantly. Percent of patients with evidence for Advance Directive (AD), POLST or code status documented in the electronic medical record (EMR) improved from 36% in 2009 to 50 % in 2013 (p&lt;0.001). Percent of patients enrolled in hospice at the time of death improved from 56% in 2009 to 63% in 2013 (p= 0.003). No statistically significant change was noted in % patients receiving chemotherapy in the last 14 days of life. Conclusions: Focused implementation of end of life care QI strategies in a large multidisciplinary community oncology practice appears to result in both improved hospice utilization and ACP. Chemotherapy usage in the last 14 days of life remains a meaningful target for intervention. Future QI efforts will focus on ongoing, scalable improvement in these metrics. [Table: see text]

Advance care planning discussions among residents of long term care and designated assisted living: experience from Calgary, Alberta

ObjectivesPatients, physicians and the healthcare system are faced with the challenge of determining, and respecting, the medical wishes of an aging population. Our study sought to describe who participates in...

‘Not yet’ and ‘Just ask’: barriers and facilitators to advance care planning—a qualitative descriptive study of the perspectives of seriously ill, older patients and their families

ObjectivesTo explore seriously ill, older hospitalised patients’ and their family members’ perspectives on the barriers and facilitators of advance care planning (ACP).MethodsWe used qualitative descriptive study methodology to analyse data...

Family-Centered Advance Care Planning for Teens With Cancer

Advance care planning (ACP) prepares patients and their families for future health care decisions; however, the needs of adolescent oncology patients for participation in ACP have not been well studied. To examine the efficacy of family-centered ACP. Two-group randomized controlled trial in a pediatric oncology program. Sixty adolescents aged 14 to 21 years with cancer and their surrogates or families were enrolled in the study between January 17, 2011, and March 29, 2012. Thirty dyads received 3- to 60-minute sessions 1 week apart. Intervention dyads completed (1) the Lyon Family-Centered ACP Survey, (2) the Respecting Choices interview, and (3) Five Wishes. Control subjects received standard care plus information. Statement of treatment preferences and Decisional Conflict Scale score. The mean age of the adolescents was 16 years; 36 (60%) were male, 30 (50%) white, 26 (43%) black, and 4 (7%) Asian. Diagnoses were as follows: leukemia (14 patients [47%]), brain tumor (8 [27%]), solid tumor (6 [20%]), and lymphoma (2 [7%]). Significantly increased congruence was observed for intervention dyads compared with controls for 4 of the 6 disease-specific scenarios; for example, for situation 2 ("treatment would extend my life by not more than 2 to 3 months"), intervention dyads demonstrated higher congruence (κ = 0.660; P < .001) vs control dyads (κ = -0.0636; P = .70). Intervention adolescents (100%) wanted their families to do what is best at the time, whereas fewer control adolescents (62%) gave families this leeway. Intervention adolescents were significantly better informed about end-of-life decisions (t = 2.93; effect size, 0.961; 95% CI, 0.742-1.180; P = .007). Intervention families were more likely to concur on limiting treatments than controls. An ethnic difference was found in only one situation. Advance care planning enabled families to understand and honor their adolescents' wishes. Intervention dyads were more likely than controls to limit treatments. Underserved African American families were willing to participate.

Promoting advance care planning as health behavior change: Development of scales to assess Decisional Balance, Medical and Religious Beliefs, and Processes of Change

ObjectiveTo develop measures representing key constructs of the Transtheoretical Model (TTM) of behavior change as applied to advance care planning (ACP) and to examine whether associations between these measures replicate the relationships posited by the TTM. MethodsSequential scale development techniques were used to develop measures for Decisional Balance (Pros and Cons of behavior change), ACP Values/Beliefs (religious beliefs and medical misconceptions serving as barriers to participation), Processes of Change (behavioral and cognitive processes used to foster participation) based on responses of 304 persons age≥65 years. ResultsItems for each scale/subscale demonstrated high factor loading (>.5) and good to excellent internal consistency (Cronbach α .76–.93). Results of MANOVA examining scores on the Pros, Cons, ACP Values/Beliefs, and POC subscales by stage of change for each of the six behaviors were significant, Wilks’λ=.555–.809, η2=.068–.178, p≤.001 for all models. ConclusionCore constructs of the TTM as applied to ACP can be measured with high reliability and validity. Practice implicationsCross-sectional relationships between these constructs and stage of behavior change support the use of TTM-tailored interventions to change perceptions of the Pros and Cons of participation in ACP and promote the use of certain Processes of Change in order to promote older persons’ engagement in ACP.

Agreement Between Older Persons and Their Surrogate Decision-Makers Regarding Participation in Advance Care Planning

To examine agreement between older persons and their surrogates regarding participation in advance care planning (ACP). Observational cohort study. Community. Persons aged 65 and older and the individual they identified as most likely to make treatment decisions on their behalf. Older persons were asked about participation in four activities: completion of living will, completion of healthcare proxy, communication regarding views about life-sustaining treatment, and communication regarding views about quality versus quantity of life. Surrogates were asked whether they believed the older person had completed these activities. Of 216 pairs, 81% agreed about whether a living will had been completed (κ=0.61, 95% confidence interval (CI) 0.51-0.72). Only 68% of pairs agreed about whether a healthcare proxy had been completed (κ=0.39, 95% CI 0.29-0.50), 64% agreed about whether they had communicated regarding life-sustaining treatment (κ=0.22, 95% CI 0.09-0.35), and 62% agreed about whether they had communicated regarding quality versus quantity of life (κ=0.23, 95% CI 0.11-0.35). Although agreement between older persons and their surrogates regarding living will completion was good, agreement about participation in other aspects of ACP was fair to poor. Additional study is necessary to determine who is providing the most accurate report of objective ACP components and whether agreement regarding participation in ACP is associated with greater shared understanding of patient preferences.

Advance care planning in general practice

Barwon Health's (BH) Respecting Patient Choices (RPC) program together with the local General Practitioner's (GP) Association and two GP developed a project plan to implement a model of advance care...

Stages of Change for the Component Behaviors of Advance Care Planning

To develop stages-of-change measures for advance care planning (ACP), conceptualized as a group of interrelated but separate behaviors, and to use these measures to characterize older persons' engagement in and factors associated with readiness to participate in ACP. Observational cohort study. Community. Persons aged 65 and older recruited from physician offices and a senior center. Stages of change for six ACP behaviors: completion of a living will and healthcare proxy, communication with loved ones regarding use of life-sustaining treatments and quantity versus quality of life, and communication with physicians about these same issues. Readiness to participate in ACP varied widely across behaviors. Whereas between approximately 50% and 60% of participants were in the action or maintenance stage for communicating with loved ones about life-sustaining treatment and completing a living will, 40% were in the precontemplation stage for communicating with loved ones about quantity versus quality of life, and 70% and 75% were in the precontemplation stage for communicating with physicians. Participants were frequently in different stages for different behaviors. Few sociodemographic, health, or psychosocial factors were associated with stages of change for completing a living will, but a broader range of factors was associated with stages of change for communication with loved ones about quantity versus quality of life. Older persons show a range of readiness to engage in different aspects of ACP. Individualized assessment and interventions targeted to stage of behavior change for each component of ACP may be an effective strategy to increase participation in ACP.

Factors that influence the participation of healthcare professionals in advance care planning for patients with terminal cancer: A nationwide survey in Taiwan

A nationwide study was undertaken to investigate participation in advance care planning (ACP) by cancer care professionals following the enactment of the Natural Death Act in Taiwan in 2000. This multi-center study surveyed 600 physicians and nurses working in oncology care wards or palliative care units using a structured mailed questionnaire. Logistic regression analysis revealed that working in a hospice, attitudes about the Natural Death Act and knowledge about the Natural Death Act were three independent factors that positively influenced the participation in ACP. The results demonstrate that the enactment of the Natural Death Act in Taiwan contributes to promoting the participation in ACP. Educating cancer care professionals about practicing palliative care and building positive attitudes toward the Act should be strongly encouraged.

Psychological Correlates of Having Advance Care Planning in Patients with Hematological Malignancies.

Abstract 72 Background:Previous studies in patients with hematologic malignancies who underwent hematopoietic cell transplantation show only 50% have participated in advance care planning (ACP) at the time of transplant. Moreover, the group that lacked ACP had a higher mortality rate, suggesting that the group least likely to have ACP is the group most likely to need it. Having ACP is thought to be an indicator of quality of care, thus efforts to increase in engagement of ACP are becoming part of clinical practice. However, many argue that discussions about possible death can potentially add to the stress cancer patients already face. We therefore studied the psychological correlates of having ACP to help understand how best to design intervention(s) that may increase engagement in ACP. Methods:Data are derived from the HEMA-COMM study cohort – an observational study of patients with hematologic malignancies evaluating doctor-patient communication; 293 patients had self-reported information about ACP and were categorized as to presence or absence of ACP. ACP+ was defined as both having a designated health care proxy and completion of a living will. ACP- lacked one or both. Variables compared include: socio-demographic characteristics, diagnosis, previous treatments, patient and physicians estimate of cure and life expectancy, discussions of wishes for life support, and various measures for coping (BRIEF-COPE), depression/anxiety (HADS), denial, social support (MOS) and quality of life (SF-36). Multivariate logistic regression was used to evaluate the association between the different psychosocial measures and having ACP while adjusting for patient characteristics. Results:Of the 293 patients included, 149 (51%) had ACP. Patients with ACP were more likely to be older (56y v 52y), have higher income, have leukemia or MDS, and have received prior cancer treatment. Of the patients with ACP, only 30% had discussed them with physicians with or without family, 62% had discussed with family only, while 8% had not discussed wishes for life support at all. Patients with ACP had worse estimated prognosis as measured by lower cure rate and life expectancy estimates provided by their physicians. In the multivariate analysis after adjustment for age, diagnosis, income, prior treatment, and patients' perceived life expectancy, patients who use the following coping styles were more likely to have ACP: 1) use of instrumental support (advice, assistance or information), p<0.001; 2) active coping (doing something), p=0.006; 3) use of emotional support (seek moral support, discuss feelings), p=0.009; 4) planning (strategize a plan of action), p=0.04; and 5) positive reframing (positive outlook), p=0.04. These coping styles are all consistent with problem-focused coping as opposed to emotion-focused coping. Discussing ACP wishes with physicians was associated with general health (p=0.007) and overall physical composite SF-36 score (p=0.03). Measures of depression, anxiety, social support, and level of denial were not associated with having or discussing ACP. Conclusion:Our results suggest that patients who engage in ACP have problem-focused coping patterns and may perceive a need based on worse prognosis. Our findings could also suggest that engagement in ACP may be reflective of a patient's realistic or pragmatic view of clinical outcomes. Therefore, efforts to increase engagement in ACP should emphasize the practical benefits of ACP regardless of prognosis and de-emphasize the emotional content of ACP. These approaches may be more appealing to patients regardless of coping style and help increase ACP participation. Disclosures:No relevant conflicts of interest to declare.

Advance Care Planning by or on Behalf of Peritoneal Dialysis Patients in Long-Term Care

Advance care planning (ACP) is recommended for dialysis patients, especially those living in long-term-care facilities. Factors influencing ACP and the effect of plans on outcome are incompletely studied. We performed a retrospective chart review and follow-up of all peritoneal dialysis patients admitted to an academic nursing home between 1986 and 2000 and abstracted demographics, comorbidities, functional status as activities of daily living (ADL) score, documentation of ACP, and actual interventions. Of 109 patients, 108 had ACP; of these, patients participated in 71%. Plans to do not attempt resuscitation (DNAR) were associated with the presence of coronary disease (odds ratio, 4.24; confidence interval [CI], 1.49 to 12.02), lower ADL score (odds ratio, 1.22; CI, 1.08 to 1.38), and older age (odds ratio, 1.04; CI, 1.0007 to 1.09). Plans to do not hospitalize (DNH) were associated with ADL score only (odds ratio, 1.26; CI, 1.07 to 1.48). Patients with DNAR plans had poorer 3-, 6-, and 12-month survival (P < 0.02), but not after adjustment for age of 75 years or older, poor functional status, coronary disease, and decubiti. Plan compliance was limited. DNH plans were not associated with the likelihood of hospitalization (5 of 14 versus 42 of 93 patients) or length of stay (11.0 +/- 16.4 versus 8.0 +/- 15.1 days). Compliance with DNAR plans was determined for 81 of 108 patients. No patient with a DNAR plan had resuscitation attempted. Only 7 of 46 patients with plans to undergo resuscitation had it attempted. For these chronically ill patients, age and functional status strongly influence DNAR and DNH plans. ACP was not decisive in determining events during acute illness.