Advance care planning

Engaging homeless persons in end of life preparations

BACKGROUND

There are no prospective studies that have investigated the effects of an intervention to improve end of life (EOL) care in an underserved population.

OBJECTIVE

To determine whether homeless persons will complete an advance directive (AD).

DESIGN

Randomized trial comparing two modes of providing an opportunity for homeless persons to complete an AD. Half of the subjects were randomized to a self-guided group (SG) who were given an AD and written instructions; the other half were given the same material but, in addition, were offered the opportunity to receive guidance to complete the AD (CG).

PARTICIPANTS

Fifty-nine homeless persons recruited from a drop-in center.

MEASURES

Rate of AD completion and baseline and 3-month follow-up EOL-related knowledge, attitudes, and behaviors.

RESULTS

The overall AD completion rate was 44%, with a statistically significant higher completion rate of 59% in the CG group compared to 30% in the self-guided only group. Frequency of worry about death decreased among those who filled out an AD from 50% to 12.5%, and also among those who did not (25% to 12.5%) (p < .05). Among those who filled out an AD, there were increases in plans to write down EOL wishes (56% to 100%; p < .05) and plans to talk about these wishes with someone (63% to 94%; p < .05).

CONCLUSION

This study demonstrates that people living in dire economic and social situations will complete an AD when offered the opportunity. While offering guidance resulted in higher rates of completion; even a simple self-guided AD process can achieve completion of ADs in this population.

Residency Training in Advance Care Planning: Can It Be Done in the Outpatient Clinic?

Resident physicians are expected to assist their outpatients to understand and complete advance directives, but their efficacy in doing so remains uncertain. After receiving educational training, internal medicine residents identified at-risk patients and solicited them about advance directives. Residents completed pretest and posttest questionnaires that assessed their knowledge, skills, attitude, and comfort with advance directives. Patients were also surveyed about their attitudes regarding advance directives. Ten internal medicine residents and 88 patients participated. Residents' self-assessed knowledge rose from 6.0 to 9.2 on a 10-point Likert scale. Skills using advance directives increased from 4.0 to 7.9, attitudes improved from 6.0 to 8.4, and comfort rose from 5.4 to 8.9. Eighty-four percent of patients expressed interest in completing advance directives, and 16% actually completed documents. An educational intervention improved knowledge, skills, attitudes, and comfort with advance directives among internal medicine residents practicing in the outpatient setting. Meanwhile, patients demonstrated a strong interest in completing advance directives.

Brief report: identifying a proxy for health care as part of routine medical inquiry

BACKGROUND

Physician-initiated advance care planning is desirable, effective, and routinely indicated for competent adult patients, but doctors are often reluctant to begin the necessary conversations.

OBJECTIVE

To determine whether patients are willing and able to designate a surrogate for medical decision making, when asked to do so as part of routine medical inquiry.

DESIGN, PATIENTS, MEASUREMENTS

A survey asking patients to name a health care agent was designed and administered in the context of routine clinical care. Participants were drawn from a consecutive sample of 309 competent adult outpatients. Data were analyzed using ordinary descriptive statistics.

RESULTS

Two hundred ninety-eight of 309 patients (response rate, 96%) completed the survey and were willing and able to specify a proxy for health care. One third of married participants did not choose their spouse as proxy.

CONCLUSIONS

Asking patients to identify a surrogate for medical decision making opens the door for ongoing individualized medical care planning in the context of ordinary patient-physician interaction. This approach is applicable to all competent adults. Documenting proxy choice protects a patient's wishes and preferences until more definitive planning is accomplished.