Enhancement of proxy appointment for older persons: physician counselling in the ambulatory setting

Increasing the completion rate of the advance directives in primary care setting - a randomized controlled trial

BACKGROUND

The completion rate of Advance Directives (ADs) has been low. This study aims to examine the effectiveness of two interventions 1) active counseling sessions coupled with passive patient education pamphlets, and 2) patient education pamphlets alone, compared with 3) control group (usual care), in increasing the completion rates of ADs in the primary care setting.

METHODS

Multicenter randomised controlled trial in four public primary care clinics in Singapore under Singapore Health Services. Randomization was performed via block randomization with Sequential Numbered Opaque Sealed Envelopes. Participants were randomized into 1) active intervention group (both counseling by primary care physicians and patient education pamphlets) or 2) passive intervention group (only patient education pamphlets), and 3) control group (usual care) with follow-up at 6 weeks. The main outcome measure is the proportion of participants who completed / planned to complete) ADs six weeks post-intervention.

RESULTS

Four hundred five participants were eligible to participate in the study. One hundred eighty-eight participants were recruited into the study (response rate = 46.4%), of which 158 completed the study. There was no significant difference between the control group, passive intervention group, and active intervention group, in terms of completion rates of ADs (29.4, 36.4, and 30.8% respectively).

CONCLUSIONS

This randomized controlled trial did not support the use of patient education pamphlets with or without active counseling sessions in increasing the completion of ADs in a primary care setting in Singapore. The optimal intervention strategy depends on each health system's context and resources, taking into consideration patients' profiles, which deserves further studies.

TRIAL REGISTRATION

Registered on April 17, 2018 clinicaltrials.gov ( NCT03499847 ).

Failure of the Current Advance Care Planning Paradigm: Advocating for a Communications-Based Approach

The purpose of advance care planning (ACP) is to allow an individual to maintain autonomy in end-of-life (EOL) medical decision-making even when incapacitated by disease or terminal illness. The intersection of EOL medical technology, ethics of EOL care, and state and federal law has driven the development of the legal framework for advance directives (ADs). However, from an ethical perspective the current legal framework is inadequate to make ADs an effective EOL planning tool. One response to this flawed AD process has been the development of Physician Orders for Life Sustaining Treatment (POLST). POLST has been described as a paradigm shift to address the inadequacies of ADs. However, POLST has failed to bridge the gap between patients and their autonomous, preferred EOL care decisions. Analysis of ADs and POLST reveals that future policy should focus on a communications-based approach to ACP that emphasizes ongoing interactions between healthcare providers and patients to optimize EOL medical care to the individual patient.

Racial and ethnic differences in beliefs about lung cancer care

BACKGROUND

Disparities in lung cancer treatment and palliative care are well documented. However,the mechanisms underlying these disparities are not fully understood. In this study, we evaluated racial and ethnic differences in beliefs and attitudes about lung cancer treatment and palliative care among patients receiving a new diagnosis of lung cancer.

METHODS

Patients were recruited from four medical centers in New York City and surveyed about their beliefs regarding lung cancer care, including disease-directed treatments, palliative and end-of-life care, and fatalistic and spiritual beliefs. We used univariate and multiple regression analyses to compare the distribution of beliefs among minority (black and Hispanic) and nonminority patients.

RESULTS

Of the 335 patients, 21% were black, 20% were Hispanic, and 59% were nonminority. Beliefs about chemotherapy and radiotherapy were similar across the three groups ( P > .05),whereas black patients were more likely to believe that surgery might cause lung cancer to spread( P =.008). Fatalistic beliefs potentially affecting cancer treatment were more common among both minority groups ( P ≤ .02). No signifi cant differences were found in attitudes toward clinician communication about cancer prognosis ( P > .05). However, both blacks and Hispanics were more likely to have misconceptions about advance directives and hospice care ( P ≤ .02).

CONCLUSIONS

Similarities and differences in beliefs about disease-directed treatment were observed between minority and nonminority patients with lung cancer. Minority patients hold more fatalistic views about the disease and misperceptions about advance care planning and hospice care. Further research is needed to assess the impact of these beliefs on decisions about lung cancer care and patient outcomes.

Exploring attitudes toward advance care directives in two diverse settings

BACKGROUND

Advance care directives (ACD) are not used equally by different ethnic groups in the United States. Theories regarding this difference include lack of access to health care, mistrust of the health care system, absence of surrogate decision makers, and universal lack of knowledge on this topic. Few studies have investigated attitudes toward advance care planning for future end-of-life decision-making in the Latino and Cambodian communities.

METHODS

Six focus groups were conducted, including a total of 20 Latino and 19 Cambodian patients of two community health centers. Focus groups were audiotaped, transcribed, and qualitatively analyzed to identify major themes regarding attitudes toward advance directives and engaging in discussion about advance care planning.

RESULTS

Most patients did not have a health care proxy nor had discussed this topic with their doctor. Two broad themes were identified: integration of belief systems (including religion, suffering/destiny, and importance of quality of life) as well as process/preferences regarding decision-making (including family roles, provider roles, confusion/uncertainty regarding ACD, and openness to learning about ACD).

CONCLUSIONS

In focus groups discussing end-of-life decision making among Latino and Cambodian patients, two main themes emerged: integration of belief systems and process/preferences regarding end-of-life care. In particular, efforts to improve completion of advance care directives in diverse populations should consider patients' emphasis on quality of life and destiny in end-of-life planning as well as the role of family consensus in decision-making.

Clinical Decision Support Technology to Increase Advance Care Planning in the Primary Care Setting

Physicians are often unable to guide patients through the advance care planning (ACP) process due to cost and time constraints. We conducted a retrospective analysis in the primary care setting targeting older adults without an advance medical directive (AMD). An ACP educational packet was sent to intervention patients before their health maintenance examination (HME). Additionally, their physicians had access to a computerized clinical decision support system on AMD completion at the time of the HME. Control participants’ physicians had access to the computerized decision support system and traditional resources only. All participants who received the packet were sent a follow-up survey. In all, 21.6% of intervention participants completed an AMD, compared with 4.1% of control participants. Combining clinical decision support systems and standardized processes enhances the ACP process.

A clinical framework for improving the advance care planning process: start with patients' self-identified barriers

OBJECTIVES

To explore barriers to multiple advance care planning (ACP) steps and identify common barrier themes that impede older adults from engaging in the process as a whole.

DESIGN

Descriptive study.

SETTING

General medicine clinic. San Francisco County.

PARTICIPANTS

One hundred forty-three English and Spanish speakers aged 50 and older (mean 61) enrolled in an advance directive preference study.

MEASUREMENT

Six months after reviewing two advance directives, self-reported ACP engagement and barriers to each ACP step were measured with open- and closedended questions using quantitative and qualitative (thematic content) analyses.

RESULTS

Forty percent of participants did not contemplate ACP, 46% did not discuss with family or friends, 80% did not discuss with their doctor, and 90% did not document ACP wishes. Six barrier themes emerged: perceiving ACP as irrelevant (84%), personal barriers (53%), relationship concerns (46%), information needs (36%), health encounter time constraints (29%), and problems with advance directives (29%). Some barriers were endorsed at all steps (e.g., perceiving ACP as irrelevant). Others were endorsed at individual steps (e.g., relationship concerns for family or friend discussions, time constraints for doctor discussion, and problems with advance directives for documentation).

DISCUSSION

Perceiving ACP to be irrelevant was the barrier theme most often endorsed at every ACP step. Other barriers were endorsed at specific steps. Understanding ACP barriers may help clinicians prioritize and address them and may also provide a framework for tailoring interventions to improve ACP engagement.

Advance Directive Decision Making Among Independent Community-Dwelling Older Adults

The purpose of this systematic review of health science literature was to examine the current state of science regarding advance directive decision making (ADDM) among independent community-dwelling older adults. Seventeen studies fitting study inclusion criteria established for the purpose of this systematic review were examined. Findings revealed that ADDM has predominantly been explored among widowed, divorced, or never married female Caucasian independent community-dwelling older adults aged 65 years and older possessing a high school level of education. Numerous older adult/health care provider barriers to advance directive discussion and completion were found to exist. There is a lack of research regarding ADDM among independent community-dwelling male older adults, older adults from various ethnic and cultural backgrounds, and older adults receiving lower levels of education. Study replication and the implementation of new studies are needed to strengthen the existing body of older adult, advance directive, evidence-based research.

The effectiveness of interventions to increase advance directive completion rates

OBJECTIVE

Despite federal and state laws governing advance directives (ADs), interventions to increase rates of legally completed ADs have not produced significant results. This study synthesizes the state of the science regarding effectiveness of interventions to increase AD completion rates.

METHODS

Garrard's method for conducting a systematic literature review was followed. In all, 25 studies meeting inclusion criteria were reviewed. Interventions fell into two types: (a) didactic-information distributed through an educational program or clinical encounter or by a mailing and (b) interactive-person-to-person interaction where participants had the opportunity to ask questions and/or receive assistance completing the forms.

RESULTS

Postintervention rates of AD completion were: didactic = no change to 34% increase; interactive = 23% to 71% increase.

DISCUSSION

Education without the ability to ask questions does not significantly increase the AD completion rate. Didactic interventions did not usually increase completion rates higher than the predicted average rate for the general population.

The effect of a web-based, patient-directed intervention on knowledge, discussion, and completion of a health care proxy

OBJECTIVES

To examine the effect of patient-directed electronic messages on health care proxy (HCP) use.

DESIGN

Randomized control trial using an electronic message intervention to encourage patients to complete an HCP document.

SETTING

General medical practice at a large tertiary care teaching institution.

PARTICIPANTS

Nine hundred twelve patients aged older than 50.

MEASUREMENTS

We reviewed online medical records (OMRs) to assess for discussion and documentation of HCPs and to collect information on patient characteristics. We surveyed participants to determine knowledge, discussion, and completion of HCPs.

RESULTS

Four hundred thirty participants were randomized to the intervention group and 482 to the control group. Only 1 HCP discussion (intervention group) and only 10 new HCPs (4 in intervention group versus 6 in control group, p = 0.649) were documented in the OMR. Among the 444 survey responders, 205 (46%) reported having an HCP, but only 74 (36%) of these had discussed the HCP with their doctors and only 9 (4%) had a documented HCP in the OMR. Patients in the intervention group were more likely to report knowledge of HCPs (adjusted risk ratio [RR] 1.07; 95% confidence interval [CI], 1.01-1.14) and having a plan to complete one in the future (adjusted RR 1.19; 95% CI, 1.05-1.36).

CONCLUSION

This patient-directed intervention did not increase patient completion of an HCP but was associated with greater knowledge of an HCP and planning to complete one.

Discussing resuscitation preferences with patients: challenges and rewards

Discussing preferences regarding resuscitation is a challenging and important task for any physician. Understanding patients' wishes at the end of life allows physicians to provide the type of care patients want, to avoid unwanted interventions, and to promote patient autonomy and dignity. Hospitalists face an even greater challenge because they are often meeting a patient for the first time in a crisis situation. Despite the frequency with which clinicians have these conversations, they typically fall short when discussing code status with patients. In this evidence-based review, we discuss physician barriers to conducting effective discussions, offer a variety of approaches to enhancing these conversations, and review important communication techniques.

Feasibility of a healthcare proxy counseling program for patients with Alzheimer's disease

BACKGROUND

Although significant progress has been made in the implementation of advance directive counseling programs for cognitively intact patients, there is a paucity of information on the outcome of these programs with patients with Alzheimer's disease. This study investigated the prevalence of completed healthcare proxies in a sample of Alzheimer's disease outpatients, and the feasibility of a systematic proxy counseling program for this population.

METHODS

The setting was a geriatric psychiatry clinic. Ninety-four patients with Alzheimer's disease were surveyed for their previous completion of a healthcare proxy. All patients with capacity and without a proxy were approached to complete the advance directive with a lay counselor.

RESULTS

Thirty-two percent (n = 30) of patients had completed a proxy prior to the initiation of a counseling program. Of patients without proxies (n = 64), 89% had capacity to complete one. Seventy-nine percent subsequently completed a proxy through the counseling program. Hispanics were least likely to have had a proxy prior to initiation of the program, yet were very willing to complete the document.

CONCLUSIONS

The majority of patients with Alzheimer's disease in an outpatient setting did not have healthcare proxies, yet had the capacity and motivation to complete this advance directive. With physician input regarding the presence of decisional capacity, a lay counselor successfully implemented the counseling process. These results support the initiation of similar counseling programs for Alzheimer's outpatients.

Improving completion of advance directives in the primary care setting: a randomized controlled trial

BACKGROUND

Since 1991, hospitals have asked patients whether they have advance directives, but few patients complete these documents. We assessed two simple interventions to improve completion of advance directives among elderly or chronically ill outpatients.

METHODS

We conducted a cluster randomized controlled trial involving 1079 patients from five general medicine clinics that were affiliated with an academic medical center. Patients were either > or =70 years of age or > or =50 years old with a chronic illness. The study comprised three arms: physician reminders recommending documentation of advance directives, physician reminders plus mailing advance directives to patients together with educational literature, or neither intervention (control). The main outcome measure was completion of an advance directive.

RESULTS

After 28 weeks, 1.5% (5/332) of patients in the physician reminder group, 14% (38/277) in the physician reminder plus patient mailing group, and 1.8% (5/286) in the control group had completed advance directives. In multivariate analyses, patients in the physician reminder plus patient mailing group were much more likely than controls to have completed advance directives (odds ratio [OR] = 5.9; 95% confidence interval [CI]: 1.5 to 22), whereas patients in the physician reminder-only group were no more likely than controls to have completed advance directives (OR = 0.88; 95% CI: 0.21 to 3.7).

CONCLUSION

Mailing health care proxy and living will forms and literature to patients before an appointment at which their physicians received a reminder about advance directives yielded a small but significant improvement in completion of these documents. A physician reminder alone did not have an effect.

Advance directive group education in a VA outpatient clinic

Advance directive education is an important social work role in many medical settings. Despite its obvious benefit in terms of time-effectiveness, group education around advance directives has received little previous attention in the social work research literature. In a retrospective cohort (n = 13,913), we compared three education strategies in an attempt to evaluate their effectiveness on advance directive completion: (1) participation in a group session, (2) one or more individual sessions with a social worker, and (3) no advance directive education. Social work education of any kind resulted in an overall completion rate of 20% versus 2.1% in the non-intervention group. Group education was twice as effective as an individual social work session, and as effective as multiple sessions, but less time consuming. Our study confirmed previous findings that older patients are more likely to complete advance directives independent of education strategy. Participants in the group sessions were also older than the rest of the cohort, leading us to hypothesize about the particular appeal of group education to older patients. We conclude that group education is an effective as well as time- and cost-efficient social work tool for facilitating completion of advance medical directives, particularly among older patients.

Objectives for advance care planning

Identifying objectives for advance care planning (ACP) is an important step toward improving care at the end of life. Previous studies of ACP have used many different measures of success. However, there has been no consensus on what should be the objectives for ACP. Lack of attention to specific objectives for ACP may lead to ineffective communication and research. The first step to improving outcomes in ACP is to acknowledge the diversity of objectives that ACP may achieve. Health care providers, patients, and surrogates should identify and agree on common objectives for particular conversations. Various methods, conversations, and forms may be used to achieve these objectives over time. Clarifying objectives from various perspectives is an important step toward achieving the level of understanding necessary to make these difficult decisions. It is time for physicians to reconsider the way in which they think about and discuss ACP with patients. If we are to improve care at the end of life, future patient care, research, and education about ACP should proceed with specific objectives in mind.

Advance directives and community-dwelling older adults

Advance directives (ADs) are documents that allow competent individuals to set forth their medical treatment wishes and/or to name a proxy in the event that they lose the capacity to communicate these decisions in the future. Despite the benefits of and support for such documents, very few people have completed an AD. This posttest-only experimental study examined whether an individualized intervention given to half of the older adults who attended an educational session increased the discussion and/or completion of ADs. Of the 74 participants, 25.7% (n = 19) completed an AD. There were no significant differences between control and intervention groups on the discussion and/or completion of ADs. Multivariate analysis indicated that perceived barriers were significantly associated with the discussion and completion of ADs. Content analysis revealed that major barriers to discussion and completion include procrastination and a reluctance to think about deteriorating health status and/or death.

Advance directives in cardiac and pulmonary rehabilitation patients

PURPOSE

Advance directives have been available in parts of the United States for more than 20 years, but research shows that only a small percentage of adults (5-25%) have some form of written advance directive. The purose of this study was to examine the presence of advance directives among persons entering cardiac and pulmonary rehabilitation, and identify characteristics of persons most likely to have advance directives.

METHODS

The sample consisted of 336 cardiac patients and 181 pulmonary patients who enrolled in the University of Alabama at Birmingham's Cardiopulmonary Rehabilitation Program between January 1996 and December 1999. As part of the initial program assessment, patients were asked two questions: (1) Do you have a living will? (2) Do you have any advance directives? For the purposes of this study, the two questions were combined to examine the presence of either a living will or other type of advance directive.

RESULTS

Results indicate that 25% of both subgroups (cardiac and pulmonary patients) report having written advance directives. Logistic regression analysis indicates that among cardiac patients whites and older persons were more likely to have advance directives. Among pulmonary patients, females and whites were more likely to have advance directives.

CONCLUSIONS

These results indicate that only a minority of cardiopulmonary rehabilitation patients have advance directives upon entry into the program, and that the prevalence differs among gender, racial, and age groups. Cardiac and pulmonary rehabilitation programs may be valuable sites for educating patients about advance directives and efforts by rehabilitation personnel may increase the prevalence of advance directives among patients.

Differences in the execution/nonexecution of advance directives by community dwelling adults

Factors associated with the process of execution or nonexecution of advance directives, that is, living wills and/or durable powers of attorney for health care, by community dwelling adults are described. Data were collected by mail (n = 210, 51% response rate); 18.1% (n = 38) had executed an advance directive (AD). Significant differences were noted between AD executors and nonexecutors. Executors were older than nonexecutors. Executors had greater concern about an executed AD diminishing the quality of care they received. They participated in more MD-initiated discussions about ADs, and had more numerous AD educational experiences, more personal experience with the terminal illnesses or critical injuries of relatives or friends, a greater degree of familiarity with AD documents, and a greater degree of religiosity. The integration of these factors at various points along a continuum of intentional self-change moves an individual through several stages of a behavioral change process, culminating with the execution or nonexecution of an AD.

Use of chart reminders for physicians to promote discussion of advance directives in patients with AIDS

To determine if use of a physician chart reminder improves the rate of physician-initiated discussion and subsequent completion of advance directives (ADs) in patients with AIDS, a controlled study was conducted with 74 patients with AIDS and ten physicians providing primary care at a university-based hospital clinic. Chart reminders were placed on medical records of intervention patients at each primary care clinic visit for six months. Twelve out of 39 (31%) reminder group patients, but only three out of 35 (9%, p = 0.02) control patients underwent AD discussion with physicians. Further, more subjects in the reminder group completed ADs (28% versus 9%, p = 0.03). Controlling for demographic and clinical factors, only assignment to reminder group was associated with discussion and completion of ADs. Physician-level analysis showed that the effect was physician-dependent. Physician chart reminders are an effective tool for promoting discussion and completion of ADs in patients with AIDS although the effect is physician-dependent.

Ethnicity and decision-makers in a group of frail older people

OBJECTIVE

To assess the relationship between ethnicity and decision-makers expressing healthcare wishes in a group of frail older persons enrolled in the Program of All-inclusive Care for the Elderly (PACE).

DESIGN

A retrospective chart review of 1193 participants in the PACE program.

SETTING

Program of All-inclusive Care for the Elderly, a comprehensive managed care demonstration program serving frail older participants at 10 sites across the nation.

PARTICIPANTS

A total of 1193 older adults, all of whom met state criteria for nursing home level of care. Three hundred were non-Hispanic whites, 364 were black, 156 were Hispanic, and 288 were Asian.

MEASUREMENTS

Demographic characteristics of the patients and the presence or absence of an alternative decision-maker; the characteristics of alternative decision-makers included the relationship to the participant as recorded in the patient's medical record.

RESULTS

Ninety-one percent of white patients expressed their own healthcare wishes in contrast to only 85% of Hispanic, 83% of Asian, and 67% of black patients. An alternative decision-maker was identified for about 15% of Asians and Hispanics and for one-third of blacks, but only about 8% of whites had an alternative decision-maker. Black and Hispanic patients were most likely to have a daughter as an alternative decision-maker, Asians were most likely to have a son, and whites patients were most likely to have a spouse as an alternative decision-maker. Blacks, particularly black men, were the most likely to have a relative other than a spouse or child as an alternative decision-maker.

CONCLUSIONS

In this population, we found significant ethnic variation in the person identified to be the decision-maker in a group of frail older people. Ethnic variation reflected sociodemographic as well as cultural differences. However, there are important limitations to this study, and caution should be used in extrapolating the results to other populations or in attributing the results to ethnicity alone. An awareness of cross-cultural patterns in identified or de facto decision-makers can be significant for healthcare workers when they approach patients and their families about issues surrounding end of life decisions.

Patients' attitudes toward advance directives and end-of-life treatment decisions

Much of the patient education about advance directives described in the literature involves explaining the purpose of advance directives to patients and guiding them through the process of issuing a directive. However, well over half of the subjects in this study claimed to know enough about the directives to issue one, and almost all subjects expressed a preference for issuing directives when healthy. Although health care agencies that wish to adhere to the PSDA must continue to ask all patients if they have issued an advance directive, aggressive patient education programs that press hospitalized patients to consider issuing an advance directive may be perceived by patients as coercive and uncaring. Patient education may be more likely to achieve the goals of the PSDA if it is provided before hospitalization and if patients are encouraged to discuss their care preferences with family members who would be in a position to speak for them at the end of life. Further study of the few patients who choose to issue an advance directive would be informative. When and why they chose to issue the directive should be explored. Patients who report issuing an advance directive but do not provide their physician or hospital with a copy of the directive upon admission should also be studied to determine if this represents a desire not to activate the directive during the current admission or simply confusion about the disposition of this document. Finally, most studies of advance directives have been cross-sectional. Longitudinal study of patients who issue advance directives are needed to determine the effectiveness of these documents in influencing the end-of-life treatment that patients receive.

Strategies to promote the use of advance directives in a residency outpatient practice

OBJECTIVE

To evaluate patient education and resident education strategies to promote advance directives in the outpatient setting, and to assess barriers to implementation.

DESIGN

Controlled clinical trial.

SETTING

The internal medicine residents' practice of an urban, university medical center.

PATIENTS/PARTICIPANTS

Medical residents and 250 patients seen at least twice in the 3 months prior to the study.

INTERVENTIONS

We randomized practice days: one to patient education, one to resident education, and three controls. Resident education consisted of a lecture, a videotape of a model advance directives discussion, and videotaping of an actual discussion by each resident, followed by individual review. Patient education consisted of distributing pamphlets in the waiting room and offering all patients an opportunity to discuss advance directives.

MEASUREMENTS AND MAIN RESULTS

We interviewed 187 of these patients (response rate 75%) and surveyed 62 residents (response rate 70%). After 18 months, there were no significant differences in the number of advance directives in charts among the three groups. Documented advance directives discussions with patients in the resident education group increased from 3% to 17% (p < .001), more than those in the patient education (5%) or control group (10%, p = .04). Residents in the resident education group were more likely to report discussing advance directives than those in the patient education or control groups (p = .05). Lack of time (95%) and lack of continuity (76%) were the most frequently cited barriers. In multivariate logistic regression, nonwhite race and non-U.S. birth were negatively associated with patient interest in advance directives. Patient race and birthplace were not associated with actual discussions of advance directives.

CONCLUSIONS

Even with intensive efforts to educate outpatients and residents about advance directives, important barriers remain, raising questions about how best to promote advance directives among outpatients.