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Laury ER, MacKenzie-Greenle M, Meghani S. Advance Care Planning Outcomes in African Americans: An Empirical Look at the Trust Variable. J Palliat Med 2018; 22:442-451. [PMID: 30585746 DOI: 10.1089/jpm.2018.0312] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
CONTEXT Racial disparities in rates of hospice use, a marker of quality of end-of-life (EOL) care, have been a long-standing problem. Although distrust has been cited as a main reason for the preference of intensive EOL care among African Americans, the role of trust has not been closely analyzed in predicting EOL care in the context of advance care planning (ACP) outcomes. OBJECTIVES The goal of this review was to empirically examine the role of trust in ACP outcomes. METHODS For this systematic review, we utilized methods adapted from the GRADE process developed by the Cochrane Collaboration. The research question guiding this review was "What is the quantitative influence of trust in the health care system or health care providers on the ACP process for African Americans?" We searched Medline, Embase, and Web of Science for articles published between 1975 and 2016. RESULTS We identified nine quantitative studies that measured and evaluated trust as a predictor or correlate of ACP preferences. Of the studies, eight were observational and one was a pre-post-test study. Three studies were designated as low quality, and six studies were of moderate quality. CONCLUSION Distrust has been cited as a central reason for African Americans' tendency to choose life-sustaining treatments over comfort-focused care; however, our findings do not support this hypothesis. The majority of studies found no significant differences in trust between African Americans and their White counterparts. Further, we found that trust was not associated with ACP outcomes in the majority of studies.
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Affiliation(s)
- Esther R Laury
- 2 M. Louise Fitzpatrick College of Nursing, Villanova University , Villanova, Pennsylvania
| | | | - Salimah Meghani
- 1 University of Pennsylvania School of Nursing , Philadelphia, Pennsylvania
- 3 Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing , Philadelphia, Pennsylvania
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Wilson DM, Houttekier D, Kunju SA, Birch S, Cohen J, MacLeod R, Hewitt JA. A Population-Based Study on Advance Directive Completion and Completion Intention among citizens of the Western Canadian province of Alberta. J Palliat Care 2018. [DOI: 10.1177/082585971302900102] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Determining what proportion of the public has completed an advance directive and which population subgroups complete or do not complete such a directive is crucially important for planning purposes. Our research objective was to examine and compare advance directive completion, intention to complete, and noncompletion rates among citizens of one Canadian province. A telephone survey was conducted with 1,203 Albertans who met gender, age, and other requirements for a representative sample. When asked, “Do you have a living will or personal directive?” 43.6 percent reported having completed a directive and 42.1 percent indicated that they planned or intended to complete one. Completion rates increased with age. Widowed, self-employed, and retired people, and those who had lost a family member or friend and had other select end-of-life experiences and viewpoints were significantly more likely to have completed one. Although older people more often had an advance directive, personal life-and-death experiences should be recognized as major influences on directive completion.
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Affiliation(s)
- Donna M. Wilson
- DM Wilson (corresponding author): Faculty of Nursing, University of Alberta, Level 3, Edmonton Clinic Health Academy, 11405 87 Avenue, Edmonton, Alberta, Canada T6G 1C9
| | - Dirk Houttekier
- End-of-Life Care Research Group, Ghent University and Vrije Universiteit Brussel, Brussels, Belgium
| | - Sabu Aliyar Kunju
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Stephen Birch
- Centre for Health Economics and Policy Analysis, Department of Clinical Epidemiology and Biostatistics, and School of Geography and Earth Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Joachim Cohen
- End-of-Life Care Research Group, Ghent University and Vrije Universiteit Brussel, Brussels, Belgium
| | - Rod MacLeod
- Centre for Health Economics and Policy Analysis, Department of Clinical Epidemiology and Biostatistics, and School of Geography and Earth Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jessica A. Hewitt
- Department of General Practice and Primary Health Care, School of Population Health, University of Auckland, Auckland, New Zealand
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3
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Chu D, Yen YF, Hu HY, Lai YJ, Sun WJ, Ko MC, Huang LY, Chen CC, Curtis JR, Lee YL, Huang SJ. Factors associated with advance directives completion among patients with advance care planning communication in Taipei, Taiwan. PLoS One 2018; 13:e0197552. [PMID: 29979678 PMCID: PMC6034783 DOI: 10.1371/journal.pone.0197552] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 05/06/2018] [Indexed: 12/19/2022] Open
Abstract
Background Although advance directives (AD) have been implemented for years in western countries, the concept of AD is not promoted extensively in eastern countries. In this study we evaluate a program to systematically conduct advance care planning (ACP) communication for hospitalized patients in Taiwan and identify the factors associated with AD completion. Methods In this retrospective evaluation of a clinical ACP program, we identified adult patients with chronic life-limiting illness admitted to Taipei City Hospital between April 2015 and January 2016. Trained healthcare providers held an ACP meeting to discuss patients’ preference regarding end-of-life care and AD completion. A multiple logistic regression was performed to determine the factors associated with the AD completion. Results A total of 2878 patients were determined to be eligible for ACP during the study, among which 1798 (62.5%) completed ACP and data was available for 1411 patients (49.1%). Of the 1411 patients who received ACP communication with complete data, the rate of AD completion was 82.6%. The overall mean (SD) age was 78.2 (14.4) years. Adjusting for other variables, AD completion was associated with patients aged ≥ 85 years [adjusted odds ratio (AOR) = 1.80, 95% CI 1.21–2.67], critical illness (AOR = 1.17, 95% CI 1.06–1.30), and social workers participating in ACP meetings (AOR = 1.74, 95% CI 1.24–2.45). Conclusion The majority of inpatients with chronic life-limiting illness had ACP communication as part of this ACP program and over 80% completed an AD. Our study demonstrates the feasibility of implementing ACP discussion in East Asia and suggests that social workers may be an important component of ACP communication with patients.
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Affiliation(s)
- Dachen Chu
- Department of Neurosurgery, Taipei City Hospital, Taipei, Taiwan
- Institute of Public Health and Community Medicine Research Center, National Yang-Ming University, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
- * E-mail:
| | - Yung-Feng Yen
- Institute of Public Health and Community Medicine Research Center, National Yang-Ming University, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
- Section of Infectious Diseases, Taipei City Hospital, Taipei, Taiwan
| | - Hsiao-Yun Hu
- Institute of Public Health and Community Medicine Research Center, National Yang-Ming University, Taipei, Taiwan
- Department of Education and Research, Taipei City Hospital, Taipei, Taiwan
| | - Yun-Ju Lai
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Puli Branch of Taichung Veterans General Hospital, Nantou, Taiwan
- Department of Exercise Health Science, National Taiwan University of Sport, Taichung, Taiwan
| | - Wen-Jung Sun
- Community Medicine Department & Family Medicine Division, Taipei City Hospital Zhongxing Branch, Taipei, Taiwan
| | - Ming-Chung Ko
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
- Department of Urology, Taipei City Hospital, Taipei, Taiwan
| | - Li-Ying Huang
- School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei, Taiwan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Fu Jen Catholic University Hospital, New Taipei City, Taiwan
| | - Chu-Chieh Chen
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - J. Randall Curtis
- Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
| | - Ya-Ling Lee
- Department of Dentistry, Taipei City Hospital, Taipei, Taiwan
- Department of Dentistry, School of Dentistry, National Yang-Ming University, Taipei, Taiwan
| | - Sheng-Jean Huang
- Department of Neurosurgery, Taipei City Hospital, Taipei, Taiwan
- Department of Surgery, Medical College, National Taiwan University Hospital, Taipei, Taiwan
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4
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Koss C. Encounters With Health-Care Providers and Advance Directive Completion by Older Adults. J Palliat Care 2018; 33:178-181. [PMID: 29651900 DOI: 10.1177/0825859718769099] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The Patient Self-Determination Act (PSDA) requires hospitals, home health agencies, nursing homes, and hospice providers to offer new patients information about advance directives. There is little evidence regarding whether encounters with these health-care providers prompt advance directive completion by patients. OBJECTIVE To examine whether encounters with various types of health-care providers were associated with higher odds of completing advance directives by older patients. METHOD Logistic regression using longitudinal data from the 2012 and 2014 waves of the Health and Retirement Study. Participants were 3752 US adults aged 65 and older who reported not possessing advance directives in 2012. Advance directive was defined as a living will and/or durable power of attorney for health care. Four binary variables measured whether participants had spent at least 1 night in a hospital, underwent outpatient surgery, received home health or hospice care, or spent at least one night in a nursing home between 2012 and 2014. RESULTS Older adults who received hospital, nursing home, or home health/hospice care were more likely to complete advance directives. Outpatient surgery was not associated with advance directive completion. CONCLUSIONS Older adults with no advance directive in 2012 who encountered health-care providers covered by the PSDA were more likely to have advance directives by 2014. The exception was outpatient surgery which is frequently provided in freestanding surgery centers not subject to PSDA mandates. It may be time to consider amending the PSDA to cover freestanding surgery centers.
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Affiliation(s)
- Catheryn Koss
- 1 Department of Gerontology, California State University, Sacramento, CA, USA
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5
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Josephs M, Bayard D, Gabler NB, Cooney E, Halpern SD. Active Choice Intervention Increases Advance Directive Completion: A Randomized Trial. MDM Policy Pract 2018; 3:2381468317753127. [PMID: 30288436 PMCID: PMC6132204 DOI: 10.1177/2381468317753127] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 12/08/2017] [Indexed: 12/03/2022] Open
Abstract
Background. Many people recognize the potential benefits of advance
directives (ADs), yet few actually complete them. It is unknown whether an
active choice intervention influences AD completion. Methods. New
employees were randomized to an active choice intervention (n = 642) or usual
care (n = 637). The active choice intervention asked employees to complete an
AD, confirm prior AD completion, or fill out a declination form. In usual care,
participants could complete an AD, confirm prior completion, or skip the task.
We used multivariable logistic regression to assess the relationship between the
intervention arm and both AD completion online and the return of a signed AD by
mail, as well as assess interactions between intervention group and age, gender,
race, and clinical degree status. Results. Participants assigned to
the active choice intervention more commonly completed ADs online (35.1% v.
20.4%, P < 0.001) (odds ratio [OR] = 2.10; 95% confidence interval [CI] =
1.63–2.71; number needed to treat = 6.8) and returned signed ADs by mail (7.8%
v. 3.9%, P = 0.003; number needed to treat = 25.6). The effect of the
intervention was significantly greater among men (OR = 4.13; 95% CI = 2.32–7.35)
than among women (OR = 1.74; 95% CI = 1.30–2.32) (interaction P value <
0.001). Responses to all eight choices made in the ADs were similar between
groups (all P > 0.10). Limitations. A young and healthy
participant may not benefit from AD completion as an older or seriously ill
patient would. Conclusions. The active choice intervention
significantly increased the proportion of participants completing an AD without
changing the choices in ADs. This relationship was especially strong among men
and may be a useful method to increase AD completion rates without altering
choices.
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Affiliation(s)
- Michael Josephs
- Fostering Improvement in End-of-Life Decision Science Program (MJ, NBG, EC, SDH), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Division of Pulmonary, Allergy and Critical Care Medicine (SDH), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics and Epidemiology (NBG, SDH), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Medical Ethics and Health Policy (SDH), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Palliative and Advanced Illness Research Center (NBG, EC, SDH), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Pulmonary and Critical Care of Atlanta, Atlanta, Georgia (DB)
| | - Dominique Bayard
- Fostering Improvement in End-of-Life Decision Science Program (MJ, NBG, EC, SDH), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Division of Pulmonary, Allergy and Critical Care Medicine (SDH), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics and Epidemiology (NBG, SDH), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Medical Ethics and Health Policy (SDH), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Palliative and Advanced Illness Research Center (NBG, EC, SDH), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Pulmonary and Critical Care of Atlanta, Atlanta, Georgia (DB)
| | - Nicole B Gabler
- Fostering Improvement in End-of-Life Decision Science Program (MJ, NBG, EC, SDH), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Division of Pulmonary, Allergy and Critical Care Medicine (SDH), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics and Epidemiology (NBG, SDH), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Medical Ethics and Health Policy (SDH), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Palliative and Advanced Illness Research Center (NBG, EC, SDH), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Pulmonary and Critical Care of Atlanta, Atlanta, Georgia (DB)
| | - Elizabeth Cooney
- Fostering Improvement in End-of-Life Decision Science Program (MJ, NBG, EC, SDH), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Division of Pulmonary, Allergy and Critical Care Medicine (SDH), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics and Epidemiology (NBG, SDH), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Medical Ethics and Health Policy (SDH), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Palliative and Advanced Illness Research Center (NBG, EC, SDH), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Pulmonary and Critical Care of Atlanta, Atlanta, Georgia (DB)
| | - Scott D Halpern
- Fostering Improvement in End-of-Life Decision Science Program (MJ, NBG, EC, SDH), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Division of Pulmonary, Allergy and Critical Care Medicine (SDH), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics and Epidemiology (NBG, SDH), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Medical Ethics and Health Policy (SDH), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Palliative and Advanced Illness Research Center (NBG, EC, SDH), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Pulmonary and Critical Care of Atlanta, Atlanta, Georgia (DB)
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Inoue M, Ihara E, Terrillion A. Making Your Wishes Known: Who Completes an Advance Directive and Shares It With Their Health Care Team or Loved Ones? J Appl Gerontol 2017; 38:1746-1762. [DOI: 10.1177/0733464817748778] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Using Andersen’s health behavioral model as a framework, this study examined factors associated with the completion of advance directives and the behavior of sharing them with one’s family and health care providers. Data were from the 2014 United States of Aging Survey ( N = 1,153; aged 60 or older), and multinomial logistic regression was used for analysis. We found that 73% of respondents had advance directives. However, 28% have not shared their advance directives with anyone. The sense of having completed a great deal of preparation for the future and the number of illnesses were found to be relevant to the behavior of sharing advance directives. Existing educational training and interventions can be expanded to increase public awareness and encourage people to share their completed advance directives with others. Policies mandating physicians to engage in advance directive conversations with patients during annual checkups might improve completion and sharing of advance directives.
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7
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Mitchell SE, Weigel GM, Stewart SK, Mako M, Loughnane JF. Experiences and Perspectives on Advance Care Planning among Individuals Living with Serious Physical Disabilities. J Palliat Med 2017; 20:127-133. [DOI: 10.1089/jpm.2016.0168] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Suzanne E. Mitchell
- Boston Medical Center, Boston University Medical Center, Boston, Massachusetts
| | - Gabriela M. Weigel
- Department of Family Medicine, Boston Medical Center, The University of California, San Francisco School of Medicine, Boston, Massachusetts
| | - Sabrina K.A. Stewart
- Department of Family Medicine, Boston Medical Center, The University of Nottingham Medical School, Nottingham, United Kingdom
| | - Morgan Mako
- Department of Family Medicine, Yale University School of Nursing, Boston Scientific, Orange, Connecticut
| | - John F. Loughnane
- Commonwealth Community Care, Commonwealth Care Alliance Medical Group, Lawrence, Kansas
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8
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Rodríguez-Arias D, Moutel G, Aulisio MP, Salfati A, Coffin JC, Rodríguez-Arias JL, Calvo L, Hervé C. Advance directives and the family: French and American perspectives. ACTA ACUST UNITED AC 2016; 2:139-145. [PMID: 21957397 DOI: 10.1258/147775007781870038] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Several studies have explored differences between North American and European doctor-patient relationships. They have focused primarily on differences in philosophical traditions and historic and socio-economic factors between these two regions that might lead to differences in behaviour, as well as divergent concepts in and justifications of medical practice. However, few empirical intercultural studies have been carried out to identify in practice these cultural differences. This lack of standard comparative empirical studies led us to compare differences between France and the USA regarding end-of-life decision making. We tested certain assertions put forward by bioethicists concerning the impact of culture on the acceptance of advance directives in such decisions. In particular, we compared North American and French intensive care professional's attitudes toward: 1) advance directives and 2) the role of the family in decisions to withhold or withdraw life-support.
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Affiliation(s)
- David Rodríguez-Arias
- Laboratoire d'éthique médicale et médecine légale Université Paris Descartes Faculté de médecine, 45 rue des Saints-Pères, Paris 75006,FR
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9
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Anunobi E, Detweiler MB, Sethi R, Thomas R, Lutgens B, Detweiler JG. Comparison of Advance Medical Directive Inquiry and Documentation for Hospital Inpatients in Three Medical Services: Implications for Policy Changes. J Aging Soc Policy 2015; 27:156-72. [DOI: 10.1080/08959420.2014.983356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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10
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Vandervoort A, Houttekier D, Van den Block L, van der Steen JT, Vander Stichele R, Deliens L. Advance care planning and physician orders in nursing home residents with dementia: a nationwide retrospective study among professional caregivers and relatives. J Pain Symptom Manage 2014; 47:245-56. [PMID: 23796587 DOI: 10.1016/j.jpainsymman.2013.03.009] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Revised: 03/05/2013] [Accepted: 03/19/2013] [Indexed: 11/27/2022]
Abstract
CONTEXT Advance care planning (ACP) is key to good palliative care for nursing home (NH) residents with dementia. OBJECTIVES We examined the extent to which the family physicians (FPs), nurses, and the relative most involved in the resident's care are informed about ACP, written advance directives, and FP treatment orders (FP-orders) for NH residents dying with dementia. We also examined the congruence among FP, nurse, and relative regarding the content of ACP. METHODS This was a representative nationwide post-mortem study (2010) in Flanders, Belgium, using random cluster sampling. In selected NHs, all deaths of residents with dementia in a three month period were reported. A structured questionnaire was completed by the FP, the nurse, and the patient's relative. RESULTS We identified 205 deceased residents with dementia in 69 NHs. Residents expressed their wishes regarding end-of-life care in 11.8% of cases according to the FP. The FP and nurse spoke with the resident in 22.0% and 9.7% of cases, respectively, and with the relative in 70.6% and 59.5%, respectively. An advance directive was present in 9.0%, 13.6%, and 18.4% of the cases according to the FP, nurse, and the relative, respectively. The FP-orders were present in 77.3% according to the FP, and discussed with the resident in 13.0% and with the relative in 79.3%. Congruence was fair (FP-nurse) on the documentation of FP-orders (k=0.26), and poor to slight on the presence of an advance directive (FP-relative, k=0.03; nurse-relative, k=-0.05; FP-nurse k=0.12). CONCLUSION Communication regarding care is rarely patient driven and more often professional caregiver or family driven. The level of congruence between professional caregivers and relatives is low.
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Affiliation(s)
- An Vandervoort
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Brussels, Belgium.
| | - Dirk Houttekier
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Brussels, Belgium
| | - Lieve Van den Block
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Brussels, Belgium; Department of Family Medicine, Vrije Universiteit Brussel, Brussels, Belgium
| | - Jenny T van der Steen
- Department of General Practice & Elder Care Medicine, EMGO Institute for Health and Care Research and Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, The Netherlands
| | - Robert Vander Stichele
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Brussels, Belgium; Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Brussels, Belgium; Department of Public and Occupational Health, EMGO Institute for Health and Care Research and Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, The Netherlands
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11
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De Gendt C, Bilsen J, Stichele RV, Deliens L. Advance care planning and dying in nursing homes in Flanders, Belgium: a nationwide survey. J Pain Symptom Manage 2013; 45:223-34. [PMID: 22917717 DOI: 10.1016/j.jpainsymman.2012.02.011] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Revised: 02/06/2012] [Accepted: 02/14/2012] [Indexed: 11/28/2022]
Abstract
CONTEXT In Belgium, data on actual advance care planning (ACP) in nursing homes (NHs) are scarce. OBJECTIVES To investigate the prevalence and characteristics of documented advance directives and physicians' orders for end-of-life care in NHs, and the authorization of a legal representative in relation to the residents' demographic and clinical characteristics and care received. METHODS This was a retrospective cross-sectional study, including all NH residents deceased during September and October 2006 in all 594 NHs in Flanders, Belgium. Structured mail questionnaires about the resident's characteristics, hospital transfers, palliative care delivery, ACPs, and authorization of legal representatives were completed via the NH administrators and nurses involved in the care of the resident. RESULTS Administrators of 318 NHs (53.5%) reported 1303 deaths. Nurses provided information about 1240 (95.2%) of these deaths. At the end of life, NH residents often had dementia (65.2%) and were severely dependent (76.1%). Almost half (43.1%) had at least one hospital transfer during the last three months of life and two-thirds received palliative care. Half had an ACP, predominantly a physician's order and less often an advance directive. Having advance directives or physician's orders was associated with receiving palliative care. Residents with a physician's order more often died in the NH. Nine percent had an authorized legal representative. CONCLUSION Prevalence of ACPs and formal authorization of a legal representative was low among the deceased NH residents in Flanders, Belgium. There was a higher prevalence of physicians' orders, often established after the resident had lost capacity. Initiatives should be developed to stimulate more advance discussion on care options and making end-of-life decision with the residents while they retain capacity.
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Affiliation(s)
- Cindy De Gendt
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Brussels, Belgium
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Silvester W, Fullam RS, Parslow RA, Lewis VJ, Sjanta R, Jackson L, White V, Gilchrist J. Quality of advance care planning policy and practice in residential aged care facilities in Australia. BMJ Support Palliat Care 2012; 3:349-57. [PMID: 24644755 PMCID: PMC3756507 DOI: 10.1136/bmjspcare-2012-000262] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To assess existing advance care planning (ACP) practices in residential aged care facilities (RACFs) in Victoria, Australia before a systematic intervention; to assess RACF staff experience, understanding of and attitudes towards ACP. DESIGN Surveys of participating organisations concerning ACP-related policies and procedures, review of existing ACP-related documentation, and pre-intervention survey of RACF staff covering their role, experiences and attitudes towards ACP-related procedures. SETTING 19 selected RACFs in Victoria. PARTICIPANTS 12 aged care organisations (representing 19 RACFs) who provided existing ACP-related documentation for review, 12 RACFs who completed an organisational survey and 45 staff (from 19 RACFs) who completed a pre-intervention survey of knowledge, attitudes and behaviour. RESULTS Findings suggested that some ACP-related practices were already occurring in RACFs; however, these activities were inconsistent and variable in quality. Six of the 12 responding RACFs had written policies and procedures for ACP; however, none of the ACP-related documents submitted covered all information required to meet ACP best practice. Surveyed staff had limited experience of ACP, and discrepancies between self reported comfort, and levels of knowledge and confidence to undertake ACP-related activities, indicated a need for training and ongoing organisational support. CONCLUSIONS Surveyed organisations â policies and procedures related to ACP were limited and the quality of existing documentation was poor. RACF staff had relatively limited experience in developing advance care plans with facility residents, although attitudes were positive. A systematic approach to the implementation of ACP in residential aged care settings is required to ensure best practice is implemented and sustained.
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Affiliation(s)
- William Silvester
- Respecting Patient Choices, Austin Health, Heidelberg, Victoria, Australia
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Advance directives and physicians' orders in nursing home residents with dementia in Flanders, Belgium: prevalence and associated outcomes. Int Psychogeriatr 2012; 24:1133-43. [PMID: 22364648 DOI: 10.1017/s1041610212000142] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Advance care planning (ACP) is an important element of high-quality care in nursing homes, especially for residents having dementia who are often incompetent in decision-making toward the end of life. The aim of this study was describe the prevalence of documented ACP among nursing home residents with dementia in Flanders, Belgium, and associated clinical characteristics and outcomes. METHODS All 594 nursing homes in Flanders were asked to participate in a retrospective cross-sectional postmortem survey in 2006. Participating homes identified all residents who had died over the last two months. A structured questionnaire was mailed to the nurses closely involved in the deceased resident's care regarding the diagnosis of dementia and documented care planning, i.e. advance patient directives, authorization of a legal representative, and general practitioners' treatment orders (GP orders). RESULTS In 345 nursing homes (58% response rate), nurses identified 764 deceased residents with dementia of whom 62% had some type of documented care plan, i.e. advance patient directives in 3%, a legal representative in 8%, and GP orders in 59%. Multivariate logistic regression showed that the presence of GP orders was positively associated with receiving specialist palliative care in the nursing home (OR 3.10; CI, 2.07-4.65). Chances of dying in a hospital were lower if there was a GP order (OR 0.38; CI, 0.21-0.70). CONCLUSIONS Whereas GP orders are relatively common among residents with dementia, advance patient directives and a legal representative are relatively uncommon. Nursing home residents receiving palliative care are more likely to have a GP order. GP orders may affect place of death.
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Zafirau WJ, Snyder SS, Hazelett SE, Bansal A, McMahon S. Improving transitions: efficacy of a transfer form to communicate patients' wishes. Am J Med Qual 2012; 27:291-6. [PMID: 22327023 DOI: 10.1177/1062860611427413] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The objective of this study was to test the efficacy of a standardized form used during transfers between long-term care facilities (LTCFs) and the acute care setting. The intervention consisted of development and implementation of the transfer form and education about its use. Charts from 26 LTCFs and 1 acute care hospital were reviewed at 1 and 6 months prior to initiation of the transfer form (2007) and at 1 and 6 months after initiation of the transfer form (2008); 210 patient charts were reviewed in 2007 and 172 in 2008. There was 79% concordance between documented LTCF advance directives (ADs) and hospital ADs in 2008-an increase from 66.6% in 2007 (P = .038). Inpatient hospice/palliative care admissions rose from 1.5% in 2007 to 7.7% in 2009 (P = .015). The standardized transfer form improved communication of ADs between LTCFs and the hospital. Secondarily, it may have increased admissions to the acute palliative care unit.
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15
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Meeussen K, Van den Block L, Echteld M, Bossuyt N, Bilsen J, Van Casteren V, Abarshi E, Donker G, Onwuteaka-Philipsen B, Deliens L. Advance care planning in Belgium and The Netherlands: a nationwide retrospective study via sentinel networks of general practitioners. J Pain Symptom Manage 2011; 42:565-77. [PMID: 21530152 DOI: 10.1016/j.jpainsymman.2011.01.011] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Revised: 01/20/2011] [Accepted: 01/25/2011] [Indexed: 11/25/2022]
Abstract
CONTEXT Advance care planning (ACP) is an important part of patient-centered palliative care. There have been few nationwide studies of ACP, especially in Europe. OBJECTIVES To investigate the prevalence and characteristics of ACP in two European countries and identify the associated factors. METHODS A mortality follow-back study was undertaken in 2007 via representative nationwide Sentinel Networks of general practitioners (GPs) in Belgium and The Netherlands using similar standardized procedures. All GPs reported on each non-suddenly deceased patient in their practice. Our main outcome measure was whether or not ACP, that is, an agreement for medical treatment and/or medical decisions in the last phase of life in the case of the patient losing competence, was present. RESULTS Among 1072 non-sudden deaths, ACP was done with 34% of patients and most often related to the forgoing of potential life-prolonging treatments in general (24%). In 8% of cases, ACP was made in consultation with the patient and in writing. In 23% of cases, care was planned with the patient's family only. Multivariate analysis revealed that ACP was more often made with patients if they were capable of decision making during the last three days of life (odds ratio [OR] 3.86; 95% confidence interval [CI] 2.4-6.1), received treatment aimed at palliation in the last week (OR 2.57; 95% CI 1.6-4.2), had contact with a GP in the last week (OR 2.71; 95% CI 1.7-4.1), died of cancer (OR 1.46; 95% CI 1.1-2.0), or died at home (OR 2.16; 95% CI 1.5-3.0). CONCLUSION In these countries, ACP is done with approximately one-third of the studied terminally ill patient population. Most agreements are made only verbally, and care also is often planned with family only. ACP relates strongly both to patient factors and to health care measures performed at the very end of life.
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Affiliation(s)
- Koen Meeussen
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Brussels, Belgium.
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Cai X, Cram P, Li Y. Origination of medical advance directives among nursing home residents with and without serious mental illness. Psychiatr Serv 2011; 62:61-6. [PMID: 21209301 PMCID: PMC3785002 DOI: 10.1176/ps.62.1.pss6201_0061] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Nursing home residents with serious mental illness need a high level of general medical and end-of-life services. This study tested whether persons with serious mental illness are as likely as other nursing home residents to make informed choices about treatments through medical advance care plans. METHODS Secondary analyses were conducted with data from a 2004 national survey of nursing home residents with (N=1,769) and without (N=11,738) serious mental illness. Bivariate and multivariate analyses determined differences in documented advance care plans, including living wills; do-not-resuscitate and do-not-hospitalize orders; and orders concerning restriction of feeding tube, medication, or other treatments. RESULTS The overall rates of having any of the four advance care plans were 57% and 68% for residents with and without serious mental illness, respectively (p<.001). Residents with serious mental illness also showed lower rates for individual advance care plans. In a multivariate analysis that adjusted for resident and facility characteristics (N=1,174 nursing homes) as well as survey procedures, serious mental illness was associated with a 24% reduced odds of having any advance directives (adjusted odds ratio=.76, 95% confidence interval=.66-.87, p<.001). Similar results were found for individual documented plans. CONCLUSIONS Among U.S. nursing home residents, those with serious mental illness were less likely than others to have written medical advance directives. Future research is needed to help understand both resident factors (such as inappropriate behaviors, impaired communication skills, and disrupted family support) and provider factors (including training, experience, and attitude) that underlie this finding.
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Affiliation(s)
- Xueya Cai
- Division of General Internal Medicine, Carver College of Medicine, University of Iowa, 200 Hawkins Dr., C44-N GH, Iowa City, IA 52242, USA.
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Carlson MDA, Lim B, Meier DE. Strategies and innovative models for delivering palliative care in nursing homes. J Am Med Dir Assoc 2010; 12:91-8. [PMID: 21266284 DOI: 10.1016/j.jamda.2010.07.016] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Revised: 07/29/2010] [Accepted: 07/29/2010] [Indexed: 11/17/2022]
Abstract
The goals of palliative care address critical issues for individuals with complex and serious illness residing in nursing homes, including pain and symptom management, communication, preparation for death, decisions about treatment preferences, and caregiver support. Because of the uncertain prognosis associated with chronic nonmalignant diseases such as dementia, many nursing home residents are either not referred to hospice or have very short or very long hospice stays. The integration of palliative care into nursing homes offers a potential solution to the challenges relating to hospice eligibility, staffing, training, and obtaining adequate reimbursement for care that aligns with resident and surrogate's preferences and needs. However, the delivery of palliative care in nursing homes is hindered by both regulatory and staffing barriers and, as a result, is rare. In this article, we draw on interviews with nursing home executives, practitioners, and researchers to describe the barriers to nursing home palliative care. We then describe 3 existing and successful models for providing nonhospice palliative care to nursing home residents and discuss their ongoing strengths and challenges. We conclude with specific policy proposals to expedite the integration of palliative care into the nursing home setting.
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Affiliation(s)
- Melissa D A Carlson
- Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York, NY 10029, USA.
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van Wijmen MPS, Rurup ML, Pasman HRW, Kaspers PJ, Onwuteaka-Philipsen BD. Design of the Advance Directives Cohort: a study of end-of-life decision-making focusing on Advance Directives. BMC Public Health 2010; 10:166. [PMID: 20346111 PMCID: PMC3091542 DOI: 10.1186/1471-2458-10-166] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Accepted: 03/26/2010] [Indexed: 11/10/2022] Open
Abstract
Background ADs are documents in which one can state one's preferences concerning end-of-life care, aimed at making someone's wishes known in situations where he/she is not able to do so in another manner. There is still a lot unclear about ADs. We designed a study aimed at investigating the whole process from the formulating of an AD to its actual use at the end of life. Methods/Design The study has mixed methods: it's longitudinal, consisting of a quantitative cohort-study which provides a framework for predominantly qualitative sub-studies. The members of the cohort are persons owning an AD, recruited through two Dutch associations who provide the most common standard ADs in the Netherlands, the NVVE (Right to Die-NL), of which 5561 members participate, and the NPV (Dutch Patient Organisation), of which 1263 members participate. Both groups were compared to a sample of the Dutch general public. NVVE-respondents are more often single, higher educated and non-religious, while amongst NPV-respondents there are more Protestants compared to the Dutch public. They are sent a questionnaire every 1,5 year with a follow-up of at least 7,5 years. The response rate after the second round was 88% respectively 90% for the NVVE and NPV. Participants were asked if we were allowed to approach close-ones after their possible death in the future. In this way we can get insight in the actual use of ADs at the end of life, also by comparing our data to that from the Longitudinal Aging Study Amsterdam, whose respondents generally do not have an AD. Discussion The cohort is representative for people with an AD as is required to study the main research questions. The longitudinal nature of the study as well as the use of qualitative methods makes it has a broad scope, focusing on the whole course of decision-making involving ADs. It is possible to compare the end of life between patients with and without an AD with the use of data from another cohort.
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Affiliation(s)
- Matthijs P S van Wijmen
- Department Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, van der Boechorststraat 7, Amsterdam, 1081 BT, the Netherlands.
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De Gendt C, Bilsen J, Stichele RV, Deliens L. Nursing home policies regarding advance care planning in Flanders, Belgium. Eur J Public Health 2009; 20:189-94. [DOI: 10.1093/eurpub/ckp121] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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20
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Wick JY. Rethinking code blue in long-term care. ACTA ACUST UNITED AC 2009; 24:180-4, 186-8. [PMID: 19555133 DOI: 10.4140/tcp.n.2009.180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Losing a loved one is often emotional and painful for families, and most aspects of death and dying are usually difficult for them to discuss. Our traditional view of death (as a failure) is being reassessed. Many residents' conditions place them at high risk for death, or they may have conditions considered terminal. Numerous facilities are rethinking their approach to Code Blue, and this is an ideal time to analyze the entire process, especially since death is a frequent occurrence in long-term care facilities. Approximately 10% of residents admitted under the Medicare benefit die, or are hospitalized and subsequently die, within 30 days of admission. In addition to simplifying rescue techniques, a movement is afoot to allow family members into scenes previously considered sacrosanct by medical care providers.
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Affiliation(s)
- Jeannette Y Wick
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
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Daaleman TP, Williams CS, Preisser JS, Sloane PD, Biola H, Zimmerman S. Advance care planning in nursing homes and assisted living communities. J Am Med Dir Assoc 2009; 10:243-51. [PMID: 19426940 DOI: 10.1016/j.jamda.2008.10.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2008] [Revised: 10/27/2008] [Accepted: 10/29/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To determine the prevalence and characteristics of advance care planning (ACP) among persons dying in long-term care (LTC) facilities, and to examine the relationship between respondent, facility, decedent, and family characteristics and ACP. DESIGN After-death interviews of family members of decedents and facility liaisons where decedents received care. SETTING Stratified sample of 164 residential care/assisted living facilities and nursing homes in Florida, Maryland, New Jersey, and North Carolina. SUBJECTS Family members and facility liaisons who gave 446 and 1014 reports, respectively, on 1015 decedent residents. MEASUREMENTS Reports of death/dying discussions, known treatment preferences, and reports and records of signed living wills (LW), health care powers of attorney (HCPOA), do-not-resuscitate orders, and do-not-hospitalize orders. RESULTS Family respondents reported a higher prevalence, compared with facility reports, of HCPOAs (92% versus 49%) and LWs (84% versus 43%). In family reports, non-white race and no private insurance were significantly associated with lower prevalence of LWs and HCPOAs; additionally, residing in nursing homes (versus assisted living facilities) and in North Carolina were associated with lower prevalence of reported LWs. In facility reports, non-white race, unexpected death, and residing in North Carolina or Maryland were significantly associated with lower prevalence of LWs, whereas high Medicaid case mix, intact cognitive status, and high family involvement were associated with lower prevalence of HCPOAs. Concordance of family and facility reporting of HCPOAs was significantly greater in facilities with fewer than 120 beds. CONCLUSIONS The prevalence of ACP in LTC is much higher than previously described, and there is marked variation in characteristics associated with ACP, despite moderately high concordance, when reported by the facility or family caregivers.
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Affiliation(s)
- Timothy P Daaleman
- Department of Family Medicine, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7595, USA.
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Triplett P, Black BS, Phillips H, Richardson Fahrendorf S, Schwartz J, Angelino AF, Anderson D, Rabins PV. Content of advance directives for individuals with advanced dementia. J Aging Health 2008; 20:583-96. [PMID: 18625761 DOI: 10.1177/0898264308317822] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine how people with end-stage dementia have conveyed their wishes for end-of-life care in advance directives. METHOD The documents of 123 residents of three Maryland nursing homes, all with end-stage dementia, were reviewed. RESULTS More years of education and White race were significantly associated with having an advance directive. With the exceptions of comfort care and pain treatment, advance directives were used primarily to restrict, not request, many forms of care at the end of life. Decisions about care for end-stage conditions such as Alzheimer's dementia are less often addressed in these documents than for terminal conditions and persistent vegetative state. DISCUSSION For advance directives to better reflect a person's wishes, discussions with individuals and families about advance directives should include a range of care issues in the settings of terminal illness, persistent vegetative state or end-stage illness. These documents should be reviewed periodically to make certain that they convey accurately the person's treatment preferences.
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Affiliation(s)
- Patrick Triplett
- Department of Psychiatry, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Meyer 279, 600 North Wolfe Street, Baltimore, MD 21287, USA.
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Resnick HE, Schuur JD, Heineman J, Stone R, Weissman JS. Advance Directives in Nursing Home Residents Aged ≥65 Years: United States 2004. Am J Hosp Palliat Care 2008; 25:476-82. [DOI: 10.1177/1049909108322295] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
In 1996, 53% of US nursing home residents had advance directives. This report defines documentation of advance directives in a nationally representative survey of US nursing home residents aged !65 years in 2004, as well as advance directive use in relation to demographic factors and receipt of specialty services including hospice/palliative care. In 2004, advance directives were documented in 69.9% of US nursing home residents aged !65 years and in 93.6% of residents receiving hospice/palliative care. Documentation of advance directives increased substantially between 1996 and 2004 and is nearly universal among residents receiving hospice/palliative care services. However in 2004, 3 of every 10 US nursing home residents did not have documentation of advance care plans. Continued efforts are needed to promote the importance of advance care planning among US nursing home residents.
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Affiliation(s)
- Helaine E. Resnick
- Institute for the Future of Aging Services, American Association of Homes and Services for the Aging, Department of Medicine, Georgetown University Washington, DC,
| | - Jeremiah D. Schuur
- Department of Emergency Medicine, Brigham and Women's Hospital, Department of Medicine, Harvard Medical School Boston
| | - Janice Heineman
- Institute for the Future of Aging Services, American Association of Homes and Services for the Aging
| | - Robyn Stone
- Institute for the Future of Aging Services, American Association of Homes and Services for the Aging
| | - Joel S. Weissman
- Department of Health Care Policy, Harvard Medical School and the Department of Health Policy and Management, Harvard School of Public Health, Institute for Health Policy, Massachusetts General Hospital Boston, Massachusetts
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Weinick RM, Wilcox SR, Park ER, Griffey RT, Weissman JS. Use of Advance Directives for Nursing Home Residents in the Emergency Department. Am J Hosp Palliat Care 2008; 25:179-83. [DOI: 10.1177/1049909108315512] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Documented requests can ensure that patients' end-of-life care preferences are implemented, particularly in emergent circumstances. This study a) compared information on advance directives found in different sources of documentation in the hospital record of nursing home patients admitted through the emergency department and b) assessed emergency department clinicians' perceptions of how end-of-life care requests are communicated to them. Seven potential sources of documentation were reviewed in the medical records of 40 patients, and semistructured interviews were conducted with 10 emergency department clinicians. We found little concordance among sources of advance directive documentation. Our results suggest variability in documentation for nursing home patients on transfer to the emergency department, and that emergency department clinicians experience substantial difficulty in reliably obtaining information about advance directives. As treatment may vary based solely on available documentation, such information gaps may decrease the likelihood of adherence in the emergency department to patients' previously expressed care preferences.
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Affiliation(s)
- Robin M. Weinick
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School,
| | - Susan R. Wilcox
- Department of Emergency Medicine, Harvard Affiliated Emergency Medicine Residency, Brigham and Women's Hospital Boston, Massachusetts
| | - Elyse R. Park
- Department of Psychiatry and the Institute for Health Policy, Massachusetts General Hospital, Harvard Medical School
| | - Richard T. Griffey
- Department of Emergency Medicine, Washington University, St Louis, Missouri
| | - Joel S. Weissman
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School
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Abstract
PURPOSE To examine perspectives of Japanese elderly people on advance directives (ADs) and factors related to positive attitudes toward ADs. METHOD The data were collected by a structured questionnaire from 313 of 565 older adult members of senior citizens' centers in two cities in Japan. Survey items pertained to demographic characteristics, terminal care preferences, and personal values, including autonomy, family function, and religious piety. FINDINGS Of the 313 elderly people who completed questionnaires, 72.9% had positive preferences for executing living wills. With regard to durable power of attorney for health care, 62.2% approved of it. The supporters of ADs were more likely to have had discussions about terminal care with family members or physicians, experience of a family member hospitalized for terminal illness or injury, preferences for life-sustaining treatments that were self-determined, and personal values such as religious piety. The relationship between positive preferences toward durable power of attorney for health care and sex, marital status, and living arrangements were significant. CONCLUSIONS Most Japanese older adults in this study approved of ADs, and family structure was important to the acceptance of designating a proxy. Discussion about end-of-life care and respect for life-sustaining treatment preferences are important decisions, about the end of life.
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Affiliation(s)
- Miho Matsui
- Department of Gerontological Nursing, Nagasaki University Graduate School of Biomedical Sciences, Japan.
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Furman CD, Pirkle R, O'Brien JG, Miles T. Barriers to the implementation of palliative care in the nursing home. J Am Med Dir Assoc 2007; 8:e45-8. [PMID: 17352986 DOI: 10.1016/j.jamda.2006.12.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Christian Davis Furman
- Department of Family and Geriatric Medicine, University of Louisville, Louisville, KY 40202, USA.
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Barriers to the implementation of palliative care in the nursing home. J Am Med Dir Assoc 2006; 7:506-9. [PMID: 17027628 DOI: 10.1016/j.jamda.2006.07.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2006] [Revised: 07/14/2006] [Accepted: 07/29/2006] [Indexed: 10/24/2022]
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Troyer JL, McAuley WJ. Environmental contexts of ultimate decisions: why White nursing home residents are twice as likely as African American residents to have an advance directive. J Gerontol B Psychol Sci Soc Sci 2006; 61:S194-202. [PMID: 16855040 DOI: 10.1093/geronb/61.4.s194] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The purpose of this study was to determine the extent to which observed differences between White and African American nursing home residents in having an advance directive are attributable to differences between the groups in personal characteristics, the organizational environment of the nursing home, and the geographical environment of the counties in which the nursing homes are located. METHODS By using the Medical Expenditure Panel Survey Nursing Home Component matched with county-level measures from the Area Resource File, we modeled the probability of having an advance directive as a function of nursing home resident, facility, and county characteristics for African American and White residents. RESULTS The probability of having an advance directive was 27.0% for African American residents and 63.6% for White residents. Nearly half of this 36.6 percentage point gap could be explained by group differences in personal, facility, and county characteristics. DISCUSSION County characteristics play a more prominent role than do personal or facility measures in explaining the observed ethnic gap in the prevalence of advance directives. Additional studies should focus further on geographic, health status, and attitudinal variations among nursing home residents that may account for the remaining ethnic difference in the prevalence of advance directives among nursing home residents.
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Affiliation(s)
- Jennifer L Troyer
- Department of Economics, University of North Carolina at Charlotte, Charlotte, NC 28223, USA.
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Dobalian A. Advance care planning documents in nursing facilities: Results from a nationally representative survey. Arch Gerontol Geriatr 2006; 43:193-212. [PMID: 16325939 DOI: 10.1016/j.archger.2005.10.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2005] [Revised: 10/17/2005] [Accepted: 10/19/2005] [Indexed: 11/22/2022]
Abstract
This study assessed clinical, demographic, facility, and regional factors associated with documented do-not-resuscitate (DNR) orders, feeding/medication/other treatment (FMT) restrictions, and living wills among nursing facility residents. Using the Nursing Home Component of the 1996 Medical Expenditure Panel Survey, a nationally representative sample of 815 facilities and 5899 residents, three separate multivariate logistic regression models were developed. DNR orders were more prevalent among residents aged 75+ and those with severe cognitive impairment, dementia, emphysema, and cancer, but less common among African Americans and Latinos than whites. Residents with living children were more likely to have DNR orders. Latinos were less likely to have FMT restrictions. Living wills were more common among residents aged 75+ and those with psychiatric/mood disorders and heart disease, but less prevalent among African Americans. Residents with less social engagement and household incomes below 400% of the Federal Poverty Level were less likely to have a living will. Residents with Medicaid as their largest payer were less likely to have an advance care plan than those with Medicare or other payment mechanisms. To increase the use of advance care plans, interventions should focus on groups with less social engagement and lower household income.
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Affiliation(s)
- Aram Dobalian
- VA GLA HSR&D Center of Excellence for the Study of Healthcare Provider Behavior, Sepulveda Ambulatory Care Center and Nursing Home, 16111 Plummer St. (152), Bldg. 25, Rm. B110, Sepulveda, CA 91343, USA.
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Rurup ML, Onwuteaka-Philipsen BD, van der Heide A, van der Wal G, Deeg DJH. Frequency and determinants of advance directives concerning end-of-life care in The Netherlands. Soc Sci Med 2006; 62:1552-63. [PMID: 16162380 DOI: 10.1016/j.socscimed.2005.08.010] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2005] [Indexed: 10/25/2022]
Abstract
In the USA, the use of advance directives (ADs) has been studied extensively, in order to identify opportunities to increase their use. We investigated the prevalence of ADs and the factors associated with formulation of an AD in The Netherlands, using samples of three groups: the general population up to 60 years of age, the general population over 60 years of age, and the relatives of patients who died after euthanasia or assisted suicide. The associated factors were grouped into three components: predisposing factors (e.g. age, gender), enabling factors (e.g. education) and need factors (e.g. health-related factors). We found that living wills had been formulated by 3% of younger people, 10% of older people, and 23% of the relatives of a person who died after euthanasia or assisted suicide. Most living wills concerned a request for euthanasia. In all groups, 26-29% had authorized someone to make decisions if they were no longer able to do so themselves. Talking to a physician about medical end-of-life treatment occurred less frequently, only 2% of the younger people and 7% of the older people had done so. Most people were quite confident that the physician would respect their end-of-life wishes, but older people more so than younger people. In a multivariate analysis, many predisposing factors were associated with the formulation of an AD: women, older people, non-religious people, especially those who lived in an urbanized area, and people with less confidence that the physician would respect their end-of-life wishes were more likely to have formulated an AD. Furthermore, the enabling factor of a higher level of education, the need factor of contact with a medical specialist in the past 6 months, and the death of a marital partner were associated with the formulation of an AD.
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Affiliation(s)
- Mette L Rurup
- VU University Medical Center, Department of Public and Occupational Health, Institute for Research in Extramural Medicine, Amsterdam, The Netherlands.
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Abstract
OBJECTIVES To determine (1) the point prevalence of do not hospitalize (DNH) policies in nursing facilities directed by members of the American Medical Directors Association (AMDA) Foundation Long-term Care Research Network, (2) the frequency with which physicians are writing DNH orders, and (3) respondent perceptions about the appropriateness of the number of DNH orders as too few or too many and reasons for such perceptions. DESIGN Online survey of members of the AMDA Foundation Long-term Care Research Network. SETTING Nursing facilities. PARTICIPANTS All members of the AMDA Foundation Long-term Research Network on July 1, 2003 were eligible for participation (N = 293). INTERVENTION None. MEASUREMENTS Demographic information regarding census, region, setting, governance, presence of teaching and/or hospice affiliation, prevalence of DNH orders, and qualitative information regarding the use of DNH orders in each facility. RESULTS The response rate was 32% (n = 95). DNH policies were in place for 62% of facilities and the prevalence of DNH orders ranged from 12% to 23% when facilities were stratified by size. Percentage of residents with documented DNH orders ranged from 0% to 99% at individual facilities. No significant differences were found although trends were noted as follows: chain facilities had fewer DNH policies (RR = 0.8; 95% CI = 0.6-1.1) whereas rural facilities (RR = 1.1, 95% CI = 0.8-1.5) and those associated with a teaching institution (RR = 1.1, 95% CI = 0.8-1.5) were more likely to have a DNH policy. Of respondents, 80% indicated that physicians in their facilities were writing DNH orders but 77% believed that the number of DNH orders was too few. Respondents cited overly optimistic prognosis and lack of knowledge about DNH orders as barriers to writing more DNH orders. CONCLUSION The prevalence of DNH orders in this investigation is higher than previous estimates from national data samples. Most facilities had a DNH policy and although respondents indicated that physicians do write DNH orders, they believed that DNH orders were not utilized frequently enough. There is a large variation in prevalence of DNH orders across the facilities included in this survey. Barriers to use, as perceived by medical directors, included unrealistic expectations by family, fear of litigation, and staff discomfort with managing residents who experience clinical decline. Nevertheless, DNH orders are used extensively in some facilities associated with members of the AMDA Foundation Long-term Care Research Network.
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Affiliation(s)
- John Culberson
- University of Texas Health Science Center, Michael E. DeBakey VAMC, Houston, TX 77030, USA.
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Levy CR, Fish R, Kramer A. Do-Not-Resuscitate and Do-Not-Hospitalize Directives of Persons Admitted to Skilled Nursing Facilities Under the Medicare Benefit. J Am Geriatr Soc 2005; 53:2060-8. [PMID: 16398888 DOI: 10.1111/j.1532-5415.2005.00523.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine prevalence and factors associated with do-not-resuscitate (DNR) and do-not-hospitalize (DNH) directives of residents admitted under the Medicare benefit to a skilled nursing facility (SNF). To explore geographic variation in use of DNR and DNH orders. DESIGN Retrospective cohort study. SETTING Nursing homes in the United States. PARTICIPANTS Medicare admissions to SNFs in 2001 (n=1,962,742). MEASUREMENTS Logistic regression was used to select factors associated with DNR and DNH directives and state variation in their use. RESULTS Thirty-two percent of residents had DNR directives, whereas less than 2% had DNH directives. Factors associated with having a DNR or DNH directive at the resident level included older age, cognitive impairment, functional dependence, and Caucasian ethnicity. African-American, Hispanic, Asian, and North American Native residents were all significantly less likely than Caucasian residents to have DNR (adjusted odds ratio (OR)=0.35, 0.51, 0.61, and 0.62, respectively) or DNH (adjusted OR=0.26, 0.41, 0.43, and 0.67, respectively) directives. In contrast, residents in rural and government facilities were more likely to have DNR or DNH directives. After controlling for resident and facility characteristics, significant variation between states existed in the use of DNR and DNH directives. CONCLUSION Ethnic minorities are less likely to have DNR and DNH directives even after controlling for disease status, demographic, facility, and geographic characteristics. Wide variation in the likelihood of having DNR and DNH directives between states suggests a need for better-standardized methods for eliciting the care preferences of residents admitted to SNFs under the Medicare benefit.
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Affiliation(s)
- Cari R Levy
- Division of Health Care Policy and Research, University of Colorado Health Sciences Center, Denver, Colorado 80011, USA.
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Abstract
Advance directives allow patients to have some control over decisions even when they are no longer able to make decisions themselves. All states authorize written advance directives, such as the appointment of a health care proxy, but commonly impose procedural requirements. Some states have restricted the use of oral advance directives, although they are frequently used in everyday practice. Advance directives are limited because they are infrequently used, may not be informed, and may conflict with the patient's current best interests. Moreover, surrogates often cannot state patients' preferences accurately. Furthermore, discussions among physicians and patients about advance directives are flawed. Physicians can improve discussions about advance directives by asking the patient who should serve as proxy and by ascertaining the patient's values and general preferences before discussing specific clinical situations.
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Affiliation(s)
- Bernard Lo
- The Program in Medical Ethics, the Division of General Internal Medicine, Department of Medicine at the University of California, San Francisco, USA.
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Affiliation(s)
- Muriel R Gillick
- Harvard Vanguard Medical Associates and the Department of Ambulatory Care and Prevention, Harvard Medical School, Boston, MA 02215, USA.
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Abstract
PURPOSE This study sought to determine whether nursing homes comply with residents' do-not-hospitalize (DNH) orders prohibiting inpatient hospitalization. DESIGN AND METHODS With the use of data from the nationally representative 1996 Nursing Home Component of the Medical Expenditure Panel Survey, a multivariate logistic regression model was developed. RESULTS Three percent of residents had DNH orders. These residents were half as likely to be hospitalized. Residents in not-for-profit or public facilities were less likely to be hospitalized than those in for-profit homes. Hospitalization was more likely among men, racial or ethnic minorities, those with more diagnosed health conditions, and those in facilities in the South compared with those in the Midwest. Hospitalized residents with DNH orders had no limitations of activities of daily living, were not located in hospital-based nursing homes, were less likely to be in a for-profit facility, and were sicker than nonhospitalized residents with DNH orders. IMPLICATIONS Improved education regarding advance directives, particularly DNH orders, is necessary for health care practitioners and patients. More consistent and rigorous policies should be implemented in nursing facilities.
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Affiliation(s)
- Aram Dobalian
- Department of Health Services Administration, University of Florida, PO Box 100195, Gainesville, FL 32610-0195, USA.
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Pekmezaris R, Breuer L, Zaballero A, Wolf-Klein G, Jadoon E, D'Olimpio JT, Guzik H, Foley CJ, Weiner J, Chan S. Predictors of Site of Death of End-of-Life Patients: The Importance of Specificity in Advance Directives. J Palliat Med 2004; 7:9-17. [PMID: 15000779 DOI: 10.1089/109662104322737205] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Despite the compelling reasons for advance directives and their endorsement by the public and medical professions, little is known about their actual use and impact on site of death. This study was conducted to examine the role of advance directives and other "drivers" of hospitalization of the long-term care end-of-life patient. The medical records of 100 deceased consecutive nursing home residents, stratified by site of death (skilled nursing facility or acute care hospital), were reviewed by a team of geriatric researchers to obtain patient information in the following domains: sociodemographic, advance directives, transfer and death information, patient diagnoses at admission, discharge, and other time intervals; medication usage and signs and symptoms precipitating death. Severity of illness was assessed using the Cumulative Illness Rating Scale-G (CIRS-G). In testing for differences between patients by site of death, sociodemographic variables (gender, age, race, payer at discharge, cognitive capacity) did not significantly differ between the two groups of patients. Strong similarities between the groups were also found in terms of severity of illness and medication usage. Significantly higher proportions of patients dying in the nursing home had specific advance directives (do not resuscitate, do not intubate, do not artificially feed, do not hydrate, and do not hospitalize), as opposed to those dying in the hospital. The findings of this study demonstrate the impact of the explicit advance directive on the decision to transfer the patient to the acute care setting at the end of life.
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Affiliation(s)
- Renée Pekmezaris
- Parker Jewish Institute for Health Care and Rehabilitation, New Hyde Park, New York 11040, USA.
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Abstract
This study was conducted to determine whether two types of advance directives exist for individuals residing in long-term care facilities. Findings were based on data from the Medical Expenditure Panel Study-Nursing Home Component (MEPS-NHC), a survey using a two-stage stratified probability sample of nursing homes and residents to produce valid national estimates of the nursing home population in the United States. The two types of advance directives included basic, i.e., living will or do-not-resuscitate (DNR) order, and progressive (do-not-hospitalize order or orders restricting feeding, medication, or other treatment). Approximately 59 percent of long-term care residents had a basic advance directive, 9 percent have a progressive directive, and 60 percent have some type of directive. Logistic regression results indicate that the factors associated with the likelihood of each type of directive differ considerably, and only two variables (African American ethnicity and less time in the facility) were associated with a reduced likelihood of having either type of directive. Our results indicate that the two proposed types of advance directives are distinct with regard to the variables predicting each.
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Affiliation(s)
- William J McAuley
- Health Behavior and Administration, College of Health and Human Services, University of North Carolina, Charlotte, North Carolina, USA
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Baker DW, Einstadter D, Husak S, Cebul RD. Changes in the use of do-not-resuscitate orders after implementation of the Patient Self-Determination Act. J Gen Intern Med 2003; 18:343-9. [PMID: 12795732 PMCID: PMC1494855 DOI: 10.1046/j.1525-1497.2003.20522.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine changes in the use of do-not-resuscitate (DNR) orders and mortality rates following a DNR order after the Patient Self-determination Act (PSDA) was implemented in December 1991. DESIGN Time-series. SETTING Twenty-nine hospitals in Northeast Ohio. PATIENTS/PARTICIPANTS Medicare patients (N = 91,539) hospitalized with myocardial infarction, heart failure, gastrointestinal hemorrhage, chronic obstructive pulmonary disease, pneumonia, or stroke. MEASUREMENTS AND MAIN RESULTS The use of "early" (first 2 hospital days) and "late" DNR orders was determined from chart abstractions. Deaths within 30 days after a DNR order were identified from Medicare Provider Analysis and Review files. Risk-adjusted rates of early DNR orders increased by 34% to 66% between 1991 and 1992 for 4 of the 6 conditions and then remained flat or declined slightly between 1992 and 1997. Use of late DNR orders declined by 29% to 53% for 4 of the 6 conditions between 1991 and 1997. Risk-adjusted mortality during the 30 days after a DNR order was written did not change between 1991 and 1997 for 5 conditions, but risk-adjusted mortality increased by 21% and 25% for stroke patients with early DNR and late DNR orders, respectively. CONCLUSIONS Overall use of DNR orders changed relatively little after passage of the PSDA, because the increase in the use of early DNR orders between 1991 and 1992 was counteracted by decreasing use of late DNR orders. Risk-adjusted mortality rates after a DNR order generally remained stable, suggesting that there were no dramatic changes in quality of care or aggressiveness of care for patients with DNR orders. However, the increasing mortality for stroke patients warrants further examination.
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Affiliation(s)
- David W Baker
- Center for Health Care Research and Policy and Department of Medicine ,Case Western Reserve University at MetroHealth Medical Center, Cleveland, Ohio, USA.
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Affiliation(s)
- Ann M Butterworth
- Senior Campus Physician's Group, Charlestown Erickson Retirement Community, Baltimore, MD, USA
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Ethics Corner: Cases from the Hebrew Rehabilitation Center for Aged—Friends. J Am Med Dir Assoc 2003. [DOI: 10.1016/s1525-8610(04)70285-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
Advance directives, including living wills and durable healthcare powers of attorney, have achieved broad acceptance by the healthcare system in the United States. Living wills may include provisions for limitation of care in the event of severe disability. These provisions pose ethical concerns in view of societal misconceptions of the quality of life of individuals with disabilities and the inability of people to predict their own capacity to adapt successfully to a disability. Greater reliance on durable healthcare powers of attorney for situations involving disability is proposed, with an emphasis on improving the education of healthcare proxies designated through this mechanism in the quality of life experienced by people with disabilities.
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Affiliation(s)
- Joel Stein
- Spaulding Rehabilitation Hospital, Boston, Massachusetts 02114, USA
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Abstract
Public health activities to prevent and control disease have produced an extraordinary decline in mortality rates during the last century. This phenomenon has widespread implications, not the least of which is that death often occurs at a later age and frequently after a protracted illness. With a prolonged death due to technological advances now common in developed countries, quality of life at the end of life has become a societal concern. It is logical that public health should embrace the end of life as an area worthy of study and intervention. After all, the end of life has three characteristics of other public health priorities: high burden, major impact, and a potential for preventing the suffering associated with illness. In this paper, we propose three initial roles for the public health profession and a process for developing a public health agenda for the end of life.
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Affiliation(s)
- Jaya K Rao
- Health Care and Aging Studies Branch, Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia 30341, USA.
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Metzger ED, Gillick MR. Ethics Corner: Cases from the Hebrew Rehabilitation Center for Aged—Problematic Proxies. J Am Med Dir Assoc 2002. [DOI: 10.1016/s1525-8610(04)70488-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Volicer L, Cantor MD, Derse AR, Edwards DM, Prudhomme AM, Gregory DCR, Reagan JE, Tulsky JA, Fox E. Advance care planning by proxy for residents of long-term care facilities who lack decision-making capacity. J Am Geriatr Soc 2002; 50:761-7. [PMID: 11982681 DOI: 10.1046/j.1532-5415.2002.50175.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This report examines whether long-term care facilities should implement policies and procedures to support advance care planning by proxy for residents who lack decision-making capacity. The report focuses on advance care planning in the Department of Veterans Affairs. After reviewing clinical, legal, and ethical perspectives, the authors conclude that advance proxy planning is ethically sound and can improve patient care. However, because experience with advance proxy planning is still fairly limited, the authors do not recommend that a particular standardized approach be mandated at the national level. Instead, local facilities are advised to develop their own policies and then evaluate their effect. The report contains specific recommendations for the advance proxy planning process.
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Affiliation(s)
- Ladislav Volicer
- Geriatric Research, Education and Clinical Center, Dementia Study Unit, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, USA
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Gillick M. When the Nursing Home Resident with Advanced Dementia Stops Eating: What Is the Medical Director to Do? J Am Med Dir Assoc 2002. [DOI: 10.1016/s1525-8610(04)70447-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Gillick M. When the Nursing Home Resident with Advanced Dementia Stops Eating: What is the Medical Director to Do? J Am Med Dir Assoc 2001. [DOI: 10.1016/s1525-8610(04)70214-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
OBJECTIVE To measure the frequency with which nursing home residents and their surrogates discuss with clinicians the resident's wishes concerning future treatment and to assess the influence of the Patient Self Determination Act (PSDA) on the frequency and nature of such discussions. DESIGN Retrospective cohort study of residents admitted to nursing homes before and after the PSDA. SETTING Six large (at least 120 licensed chronic care beds), randomly selected nursing homes in Connecticut. PARTICIPANTS Six hundred randomly selected nursing home residents admitted during 1990 and 1994 to one of the six study nursing homes. MEASUREMENTS Documented discussions concerning future treatment wishes were abstracted from residents' nursing home medical records. Participants in the discussion, as well as the timing (i.e., date) and content of the documented discussions were recorded. Sociodemographic and health status factors were also obtained from the medical record. RESULTS A large majority of residents (71.5%) had no discussion of future treatment wishes documented in their medical record. However, the percentage of residents with documented discussions had increased since the implementation of the PSDA (36.7% post-PSDA vs 20.3% pre-PSDA). Of those in the post-PSDA cohort who had had discussions, 90% had only one discussion within the first year of admission, and more than half (58.1%) of those who had discussions discussed only life-support systems (cardiopulmonary resuscitation, artificial nutrition and hydration, and ventilation) rather than broader preferences for future treatment, including proxy decision-making. CONCLUSIONS Despite the increased prevalence of discussions about future treatment wishes since the enactment of the PSDA, no discussions were documented for most residents. For those with documented discussions, such conversations occurred rarely and were narrow in scope, suggesting that residents' and families' roles in medical decision-making in nursing homes may be limited.
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Affiliation(s)
- E H Bradley
- Department of Epidemiology and Public Health, Yale School of Medicine, New Haven, Connecticut 06520-8034, USA
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