Facing Death: A Critical Analysis of Advance Care Planning in the United States

Nurse-Led Advance Care Planning in Adults in the U.S.- A Scoping Review

BACKGROUND

Advance care planning involves discussing individuals' future medical treatment and care preferences. Nurses, due to their close relationships with patients and families, may be well-positioned to lead these discussions. Exploring the components and characteristics of nurse-led ACP interventions is essential for enhancing their implementation, effectiveness, and sustainability.

OBJECTIVE

This scoping review aimed to explore the characteristics of nurse-led ACP interventions in adult patients, identify the populations and settings where these interventions have been utilized, and the outcomes of these interventions in the U.S.

METHODS

A scoping review was conducted following Arksey and O'Malley's five-stage framework. Using keywords related to nurse-led ACP interventions, a comprehensive search was performed across PubMed, Web of Science, CINAHL, EMBASE, and PsycINFO databases.

RESULTS

Twelve studies met the inclusion criteria. These studies were conducted in varied settings. Registered nurses, oncology nurse navigators, and other specialized nurses primarily delivered nurse-led ACP interventions. The interventions ranged from one to two sessions and utilized various models and resources such as the Five Wishes and Respecting Choices.

CONCLUSIONS

Nurse-led ACP interventions have shown significant positive outcomes, including increased engagement in ACP, improved attitudes towards ADs, higher completion rates of ADs, and enhanced patient-surrogate congruence. These interventions are well-received by patients and can be implemented in diverse settings. However, a general guideline regarding nurse-led ACP interventions is needed to address the specific duration, sessions, and mode of delivery required for their optimal effectiveness.

Exploring Online Twitter Conversations surrounding National Healthcare Decisions Day and Advance Care Planning from a Socio-Cultural Perspective: A Computational Mixed-Methods Analysis (Preprint)

Background

Within the cultures and societies of the United States, topics related to death and dying continue to be taboo, and as a result, opportunities for presence and engagement during the end of life, which could lead to a good death, are avoided. Several efforts have been made to help people engage in advance care planning (ACP) conversations, including completing advance care directives so that they may express their goals of care if they become too sick to communicate their wishes. A major effort in the United States toward encouraging such challenging discussions is the annual celebration of the National Healthcare Decisions Day.

Objective

This study aimed to explore ACP from a sociocultural perspective by using Twitter as a communication tool.

Methods

All publicly available tweets published between August 1, 2020, and July 30, 2021 (N=9713) were collected and analyzed using the computational mixed methods Analysis of Topic Model Network approach.

Results

The results revealed that conversations driven primarily by laypersons (7107/7410, 95.91% of tweets originated from unverified accounts) surrounded the following three major themes: importance and promotion, surrounding language, and systemic issues.

Conclusions

On the basis of the results, we argue that there is a need for awareness of the barriers that people may face when engaging in ACP conversations, including systemic barriers, literacy levels, misinformation, policies (including Medicare reimbursements), and trust among health care professionals, in the United States. This is incredibly important for clinicians and scholars worldwide to be aware of as we strive to re-envision ACP, so that people are more comfortable engaging in ACP conversations. In terms of the content of tweets, we argue that there is a chasm between the biomedical and biopsychosocial elements of ACP, including patient narratives. If used properly, Twitter conversations and National Health Care Decision Day hashtags could be harnessed to serve as a connecting point among organizations, physicians, patients, and family members to lay the groundwork for the trajectory toward a good death.

Advance care directive prevalence among older Australians and associations with person-level predictors and quality indicators

BACKGROUND

Advance care planning (ACP) conversations may result in preferences for medical care being documented.

OBJECTIVE

To explore the uptake and quality of advance care directives (ACDs) among older Australians accessing health and aged care services, by overall ACP documentation prevalence, person-level predictors and ACD quality indicators.

DESIGN AND SETTING

National multi-centre health record audit in general practices (GP), hospitals and residential aged care facilities (RACF).

PARTICIPANTS

A total of 4187 people aged ≥65 years attending their GP (n = 676), admitted to hospital (n = 1122) or residing in a RACF (n = 2389).

MAIN OUTCOME MEASURES

ACP documentation prevalence by setting and type including person-completed ACDs and non-ACD documents (completed by a health professional or someone else); person-level predictors and quality indicators of ACDs.

RESULTS

Overall ACP documentation prevalence was 46.5% (29.2% weighted). ACD prevalence was 25.3% (14.2% weighted). Unweighted ACD prevalence was higher in RACFs (37.7%) than in hospitals (11.1%) and GPs (5.5%). 35.8% of ACP documentation was completed by a health professional (9.7% weighted), and 18.1% was completed by someone else (10.6% weighted). Having an ACD was positively associated with being female, older, having two or more medical conditions, receiving palliative care, being divorced/separated and being in a RACF. Only 73% of ACDs included full name, signature, document date and witnessing.

CONCLUSIONS AND CONTRIBUTION

Low ACP documentation prevalence and a lack of accessible, person-completed and quality ACDs represent an important ACP implementation issue. Low prevalence is complicated by poor document quality and a higher prevalence of documents being completed by someone other than the person.

Improving Patient Preparedness and Confidence in Discussing Advance Directives for End-of-Life Care with Health Care Providers in the United States and Japan

BACKGROUND

The low completion rate of advance directives (ADs) has received attention in Japan and the United States, as policy makers and health care professionals face aging populations with multiple comorbidities. Among the barriers to AD planning, cultural values and attitudes appear to be particularly influential. A comparison of culturally distinct societies provides a deeper understanding of these barriers. Through such an approach, this study identifies strategies for increasing AD planning among late-middle-age Japanese and US individuals.

METHODS

After giving informed consent for the Institutional Review Board-approved study, Japanese and US respondents (45-65 y; 50% female) without ADs completed a language-appropriate online survey. Participants were asked to review a decision aid as part of a scenario-based physician consultation regarding artificial nutrition and hydration (ANH). Hypotheses were analyzed using multigroup structural equation modeling.

RESULTS

Important similarities were identified across the 2 groups. After reviewing the decision aid, both samples strongly preferred "no ANH." Respondents who strongly valued either self-reliance or interpersonal relationships experienced greater preparedness for AD planning. In both countries, greater decision preparedness and positive death attitude predicted greater confidence to discuss care options with a provider. Finally, cultural values predicted preference for family participation: respondents with a strong interdependent self-concept desired more family involvement, whereas high independents preferred less.

CONCLUSIONS

Findings indicate the importance of documenting care preferences and accounting for individual differences. To increase AD adoption, providers should identify patient segments likely to benefit most from the interventions. Targeting individuals in both countries who value self-reliance and interpersonal relationships appears to be a good place to begin. Such individuals can be identified clinically through administration of validated measures used in this study.

Advance Care Planning in a Geriatric Primary Care Clinic: A Retrospective Chart Review

PURPOSE:

Advance care planning (ACP) is theorized to benefit both the patient and their family when end of life is near as well as earlier in the course of serious illness. However, ACP remains underutilized, and little is known about the nature of ACP documentation in geriatrics practices. The study investigated the prevalence and nature of ACP documentation within a geriatric primary care clinic.

METHODS:

A retrospective chart review was conducted on a randomly selected sample of electronic medical record (EMR) charts. The sample consisted of patients aged 65 and older who were seen in the clinic from January 1, 2015, to December 31, 2016. Charts were reviewed for ACP documentation and data regarding age, gender, race, religion, comorbidities (end-stage renal disease, congestive heart failure, cancer, and dementia), recent hospitalizations, and visit type.

RESULTS:

Ninety-eight charts were reviewed (n = 98). Nine patients (9.18%) had an advance directive (AD) or power of attorney (POA) available within their EMR. Twenty-five patients (25.5%) had provider notes documenting that they have an AD, POA, or preferred health-care decision maker; however, no documents were available. The remaining 64 (65.3%) patients had no evidence of ACP documentation within their EMR. Age was the only demographic variable associated with completion of an AD ( P = .038).

DISCUSSION:

The rate of ACP documentation (34.6%) was lower than the average among US adults aged 65 and over (45.6%); further, most patients with ACP documentation did not have an AD or POA on file. The authors plan to reevaluate ACP statistics in the same office following a future intervention.