The state of advance care planning: one decade after SUPPORT

Occupational differences in advance care planning: Are medical professionals more likely to plan?

Advance care planning (ACP) helps ensure that treatment preferences are met at the end of life. Medical professionals typically are responsible for facilitating patients' ACP, and may be especially effective in doing so if they have first-hand insights from their own planning. However, no large-scale U.S. studies examine whether persons working on the front lines of health care are more likely than other workers to have done ACP. We contrast the use of three ACP components (living wills, durable power of attorney for health care, and informal discussions) among persons working in medical, legal, social/health support services, other professional, and other non-professional occupations. Data are from the Health and Retirement Study (n = 7668) and Wisconsin Longitudinal Study (n = 5464). Multivariable logistic regression analyses are adjusted for socioeconomic, demographic, health, and psychosocial factors that may confound associations between occupational group and ACP. Medical professionals in both samples are more likely than other professional workers to discuss their own treatment preferences, net of all controls. Medical professionals in the WLS are more likely to execute living wills and DPAHC designations, whereas legal professionals in the HRS are more likely to name a DPAHC. Non-professional workers are significantly less likely to do all three types of planning, although these differences are accounted for by socioeconomic factors. Social and health services professionals are no more likely than other professionals to do ACP. The on-the-job experiences and expertise of medical professionals may motivate them to discuss their own end-of-life preferences, which may render them more trustworthy sources of information for patients and clients. The Affordable Care Act provides reimbursement for medical professionals' end-of-life consultations with Medicare beneficiary patients, yet practitioners uncomfortable with such conversations may fail to initiate them. Programs to increase medical professionals' own ACP may have the secondary benefit of increasing ACP among their patients.

Development of a Japanese version of the Advance Care Planning Engagement Survey: Examination of its reliability and validity

OBJECTIVES

The importance of supporting advance care planning (ACP) by healthcare professionals is recognized worldwide, and assessing the outcomes, such as people's understanding and readiness for ACP, using an appropriate instrument is essential. We, therefore, developed a Japanese version of the Advance Care Planning Engagement Survey (ACP Engagement Survey; 15 items, 9 items, and 4 items), an international scale for assessing the progress of the ACP, and examined its validity and reliability.

METHODS

The ACP Engagement Survey was translated into Japanese, back-translated, and culturally adapted, and the final version was reviewed by the author of the original version. Data on basic demographic information and ACP-related experiences were simultaneously collected as external criteria in an online survey of older adults with chronic diseases. The Cronbach's alpha was calculated to assess its internal consistency, and a retest was performed three days later to calculate the intra-class correlation coefficients (ICCs).

RESULTS

A total of 200 respondents (mean age 70; 9.5% female) were included in the analysis. None of the items showed a ceiling effect, but several items did exhibit a floor effect. The factor structure was the same 2-factor structure as the original version, and both factors exhibited a high cumulative contribution rate. The Cronbach's alphas were 0.94 (15-item version), 0.91 (9-item version), and 0.95 (4-item version), and ICCs were of 0.88 (15-item version), 0.9 (9-item version), and 0.84 (4-item version).

SIGNIFICANCE OF RESULTS

The Japanese version of the ACP Engagement Survey was confirmed to have very good reliability regarding both internal consistency and test-retest reliability. Together with the result of the item analysis, we can conclude that the Japanese version of the ACP Engagement Survey is sufficiently reliable to be utilized in interventional studies, and it has acceptable content validity, construct validity, and criterion-related validity.

A realist review of advance care planning for people with multiple sclerosis and their families

Background

Advance care planning (ACP) is reported to improve the quality of outcomes of care among those with life-limiting conditions. However, uptake is low among people living with multiple sclerosis (MS) and little is known about why or how people with MS engage in this process of decision-making.

Aims

To develop and refine an initial theory on engagement in ACP for people with MS and to identify ways to improve its uptake for those who desire it.

Methods

Realist review following published protocol and reporting following Realist and Meta-narrative Evidence Synthesis: Evolving Standards (RAMESES) guidelines. A multi-disciplinary team searched MEDLINE, PsychInfo, CINAHL, Scopus, Web of Science, Embase, Google Scholar in addition to other sources from inception to August 2019. Quantitative or qualitative studies, case reports, and opinion or discussion articles related to ACP and/or end of life discussions in the context of MS were included, as well as one article on physical disability and one on motor neuron disease, that contributed important contextual information. Researchers independently screened abstracts and extracted data from full-text articles. Using abductive and retroductive analysis, each article was examined for evidence to support or refute ‘context, mechanism, and outcome’ (CMO) hypotheses, using the Integrated Behaviour Model to guide theory development. Quality was assessed according to methodological rigour and relevance of evidence. Those studies providing rich descriptions were synthesised using a realist matrix to identify commonalities across CMO configurations.

Results

Of the 4,034 articles identified, 33 articles were included in the synthesis that supported six CMO hypotheses that identified contexts and mechanisms underpinning engagement in ACP for people with MS and included: acceptance of their situation, prior experiences, confidence, empowerment, fear (of being a burden, of death and of dying) and the desire for autonomy. Acceptance of self as a person with a life-limiting illness was imperative as it enabled people with MS to see ACP as pertinent to them. We identified the context of MS—its long, uncertain disease trajectory with periods of stability punctuated by crisis—inhibited triggering of mechanisms. Similarly, the absence of skills and confidence in advanced communication skills among health professionals prevented possibilities for ACP discussions taking place.

Conclusion

Although mechanisms are inhibited by the context of MS, health professionals can facilitate greater uptake of ACP among those people with MS who want it by developing their skills in communication, building trusting relationships, sharing accurate prognostic information and sensitively discussing death and dying.

Advance Care Planning in Chronically Ill Persons Diagnosed With Heart Failure or Chronic Obstructive Pulmonary Disease: An Integrative Review

INTRODUCTION

Advance care planning (ACP) discussions help guide future medical care consistent with patient wishes. These discussions should be a part of routine care and should be readdressed frequently as a patient's medical condition changes. Limited literature exists supporting structured processes for identifying persons who may benefit from these conversations. The purpose of this integrative review was to understand whether targeting patients with episodic disease trajectories in the acute care setting will increase their willingness to participate in ACP discussions.

METHODS

Using the Johns Hopkins Nursing Evidence-Based Practice Model as a guideline, this integrative review focused on the research query "In the acute care setting, does targeting patients with heart failure or chronic obstructive pulmonary disease for ACP lead to increased willingness to participate in these discussions." Articles from 2009 to September 2019 were considered for review.

RESULTS

Six articles met inclusion criteria for final analysis. Articles outside of the United States were excluded. Four themes emerged from the literature: (1) improved patient attitudes toward ACP, (2) effective communication surrounding care preferences, (3) strengthened connection between preferred and delivered care, and (4) increased patient involvement in ACP.

CONCLUSION

Chronic diseases such as heart failure and COPD have a high symptom burden punctuated by exacerbations, making it difficult to know when introduction of ACP discussions would be most beneficial. Future research should focus on a deeper evaluation of when to introduce ACP conversations in this population and which ACP interventions are effective to facilitate these discussions.

'We need a physician who is a human being too': exploration of barriers and facilitators for hospitalised palliative patients and their families to discuss advance care planning

BACKGROUND

Advance care planning (ACP) is not well implemented in hospital. Implementation theory stresses the importance of knowing what hospitalised palliative patients and their families experience as barriers or as facilitators in the uptake of ACP with their treating physician.

AIMS

This study aimed to gain an in-depth understanding of what hospitalised palliative patients and their families experienced as barriers or facilitators for having ACP conversations.

METHODS

We used a tape-assisted recall procedure to conduct 29 videotaped interviews with hospitalised patients and their families. We used content analysis based on grounded theory principles.

RESULTS

Four major fields of tension were discovered: not knowing what to expect from the treating physician; not being sure the treating physician can be a trusted partner; daring to speak about ACP; and staying loyal to one's own wishes.

CONCLUSIONS

Patients and families need physicians who are accessible and can be trusted ACP partners throughout the disease process.

Cognition, functionality and symptoms in patients under home palliative care

OBJECTIVE

Evaluating the degree of cognition, functionality, presence of symptoms and medications prescribed for patients under palliative home care.

METHOD

Descriptive, cross-sectional study where 55 patients under palliative home care were interviewed. Cognition was evaluated using the Mini-Mental state examination (MM), with patients being separated into two groups: with preserved cognitive ability (MM>24), or altered (MM <24). The functionality was verified by the Palliative Performance Scale (PPS) and the patients were divided into two groups: PPS≤50 and PPS≥60. The symptoms presence was evaluated by ESAS (Edmonton Symptom Assessment System) being considered as mild (ESAS 1-3), moderate (ESAS 4-6) or severe (ESAS 7-10) symptoms. Medications prescribed to control the symptoms were registered. Statistical analysis used Student's t test (p <0.05).

RESULTS

Most of the 55 patients were women (63.6%), 70.9% of these had MM> 24, 83.6% had PPS <50 and 78.2% presented chronic non-neoplastic degenerative disease. There was a significant relationship between PPS≤50 and MM≤24. Symptoms were present in 98% of patients. Asthenia was more frequently reported and was not treated in 67% of the cases. Severe pain was present in 27.3%: 46% without medication and 13% with medication, if necessary. Most patients with severe dyspnea used oxygen.

CONCLUSIONS

Most of the analysed patients had their cognition preserved, presented low functionality and 98% reported the presence of symptoms. Severe pain was present in almost 1/3 of the patients without effective treatment. Re-evaluate palliative home care is suggested to optimize patient's quality of life.

Goals of Care Ambulatory Resident Education: Training Residents in Advance Care Planning Conversations in the Outpatient Setting

BACKGROUND

Advance care planning (ACP) discussions often occur in the inpatient setting when patients are too ill to participate in decision making. Although the outpatient setting is the preferred time to begin these discussions, few physicians do so in practice. Many internal medicine (IM) residents report inadequate training as a barrier to having outpatient ACP discussions.

OBJECTIVE

To assess whether a novel curriculum entitled Goals of Care Ambulatory Resident Education (GOCARE) improved resident physicians' understanding of and preparedness for conducting ACP discussions in the outpatient setting.

DESIGN

The curriculum was delivered over four weekly three-hour small group sessions to IM residents. Each session included didactics, a demonstration of skills, and a simulated patient communication laboratory that emphasized deliberate practice.

SETTING/SUBJECTS

IM residents from an urban, academic ambulatory care practice.

MEASUREMENTS

Impact of the intervention was evaluated using a retrospective pre-post design. Residents completed surveys immediately after the course and six months later.

RESULTS

Forty-two residents participated in the curriculum and 95% completed the postcourse survey. Residents' self-rated level of preparedness increased for ACP discussions overall (4.0 pre vs. 5.2 post on 7-point Likert scale) and for communication steps involved in ACP (p < 0.001). Fifty-nine percent of participants completed the six-month follow-up survey. Residents' self-rated preparedness to engage in outpatient ACP discussions remained high (4.5 pre vs. 5.5 post at six months p < 0.001). Residents also reported increased use of ACP communication skills (p < 0.001) six months later.

CONCLUSIONS

The GOCARE curriculum provides an alternative model of communication training that can be integrated into residency training and improve residents' skills in outpatient ACP discussions.

The Importance of Intergenerational Communication in Advance Care Planning: Generational Relationships among Perceptions and Beliefs

This study explores triadic intergenerational perceptions of family members' beliefs and behaviors that often impact an individual's willingness to engage in advance care planning. Using data from 189 triads of young adults, their parents, and their grandparents, we examined generational relationships among individuals' openness about death, death anxiety, knowledge of surrogate decision-making, and advance care planning self-efficacy. Results of this study found significant relationships between grandparents and parents, as well as between parents and children for all variables except self-efficacy. Additionally, results of this study found indirect relationships between grandparents and their grandchildren for three variables. These findings underscore the need to treat advance care planning as a family communication issue. Implications for how advance care planning should be approached in conversations with healthcare providers and within the family are discussed.

Factors Influencing Advance Care Planning Among Older Adults in Two Socioeconomically Diverse Living Communities

BACKGROUND/OBJECTIVES

Advance care planning (ACP) is an iterative, complex, and dynamic process of discussion, decision-making, and documentation about end-of-life care. The extent to which this process takes place in older adults in diverse socioeconomic settings is not well documented. The aim of this study was to assess the knowledge, attitudes, and beliefs about ACP among older adults in two socioeconomically diverse settings to identify the individual and contextual factors that influence behaviors regarding end-of-life care.

DESIGN

A cross-sectional survey design was used.

SETTING

An affordable independent continuing care retirement community and a high-income eligible (HIE) independent continuing care retirement community.

PARTICIPANTS

Individuals aged 55 years and older who resided in independent living.

MEASUREMENTS

A 61-item survey was administered. Simple descriptive statistics were used to examine the responses, and inferential statistics were used to evaluate which items were associated with key outcomes between the 2 settings.

RESULTS

Seventy-seven older adults completed the survey. Significant differences in familiarity of terminology and knowledge of ACP, as well as significant differences in completion of advance directives and communication, were found between the 2 communities. No differences were found in attitudes and beliefs about end-of-life issues.

CONCLUSION

Higher levels of knowledge and engagement in ACP were reported at the HIE community as compared to the affordable housing community. These findings provide insight into the influence of the contextual forces that encourage and support ACP.

[Advance directives. Representatives' opinions]

INTRODUCTION

The use and usefulness of Advance Directives has led to a lot of controversy about their validity and effectiveness. Those areas are unexplored in our country from the perspective of representatives.

OBJECTIVE

To determine the opinion of the representatives appointed in a registered Statement of Advance Directives (SAD) on the use of this document.

METHODS

Telephone survey of representatives of 146 already dead people and who, since February 2012, had registered a SAD document.

RESULTS

More the two-thirds (98) of respondents recalled that the SAD was consulted, with 86 (58.9%) saying that their opinion as representative was consulted, and 120 (82.1%) believe that the patient's will was respected. Of those interviewed, 102 (69.9%) believe that patients who had previously planned their care using a SAD had a good death, with 33 (22.4%) saying it could have been better, and 10 (6.9%) believe they suffered greatly.

CONCLUSION

The SAD were mostly respected and consulted, and possibly this is related to the fact that most of the representatives declare that the death of those they represented was perceived as comfortable. It would be desirable to conduct further studies addressed at health personnel in order to know their perceptions regarding the use of Advance Directives in the process of dying.

Team-based Palliative and End-of-life Care for Heart Failure

Clinical practice guidelines endorse the use of palliative care in patients with symptomatic heart failure. Palliative care is conceptualized as supportive care afforded to most patients with chronic, life-limiting illness. However, the optimal content and delivery of palliative care interventions remains unknown and its integration into existing heart failure disease management continues to be a challenge. Therefore, this article comments on the current state of multidisciplinary care for such patients, explores evidence supporting a team-based approach to palliative and end-of-life care for patients with heart failure, and identifies high-priority areas for research.

Advance care planning in 21st century Australia: a systematic review and appraisal of online advance care directive templates against national framework criteria

Objectives A drive to promote advance care planning at a population level has led to a proliferation of online advance care directive (ACD) templates but little information to guide consumer choice. The current study aimed to appraise the quality of online ACD templates promoted for use in Australia. Methods A systematic review of online Australian ACD templates was conducted in February 2014. ACD templates were identified via Google searches, and quality was independently appraised by two reviewers against criteria from the 2011 report A National Framework for Advance Care Directives. Bias either towards or against future medical treatment was assessed using criteria designed to limit subjectivity. Results Fourteen online ACD templates were included, all of which were available only in English. Templates developed by Southern Cross University best met the framework criteria. One ACD template was found to be biased against medical treatment – the Dying with Dignity Victoria Advance Healthcare Directive. Conclusions More research is needed to understand how online resources can optimally elicit and record consumers’ individual preferences for future care. Future iterations of the framework should address online availability and provide a simple rating system to inform choice and drive quality improvement. What is known about the topic? Online availability of ACD templates provides consumers with an opportunity for advance care planning outside of formal healthcare settings. While online availability has advantages, there is a risk that templates may be biased either for or against medical treatment and may not elicit directives that are appropriately informed by reflection on personal values and discussion with family and health professionals. What does this paper add? This is the first attempt at monitoring the quality and bias of online ACD templates designed for use in Australia. What are the implications for practitioners? The results of this review provide a description and quality index to assist consumers and clinicians in deciding which online ACD template to use or recommend.

The impact of a tumor diagnosis on patients' attitudes toward advance directives

BACKGROUND

Although advance care planning and the completion of advance directives (ADs) are important tools to avoid unwanted aggressive care once patients have lost their decision-making capacity, only a minority of cancer patients are admitted with completed ADs, and little is known about patients' wishes regarding AD consultations.

METHODS

For 1 year, every new patient admitted to the hematology/oncology outpatient clinic of the University Hospital Regensburg received a self-administered questionnaire comprising a self-evaluation of AD knowledge and questions about preferences regarding consultation partners and the time of consultation. Disease-related data were collected from medical records. Statistics were calculated with SPSS.

RESULTS

Of the 500 questionnaires handed out, 394 (75%) were evaluable and analyzed. Twenty-eight percent of the participants had completed an AD (living will or health care proxy). Ninety-two percent of the participants without ADs had never received a consultation offer from any professional involved. Only 20% perceived a clear relation between cancer and AD consultations. More than 50% of the participants without ADs were in favor of consultations 'now' or 'in a few weeks', while more than 40% objected to AD consultations.

CONCLUSIONS

Oncology patients have a large unmet demand for AD consultations. However, a relevant percentage of these patients object to AD consultations. Structured and early AD consultation offers should be made, and early discussions about indications for aggressive treatment should take place.

Motivations, aims and communication around advance directives: a mixed-methods study into the perspective of their owners and the influence of a current illness

OBJECTIVE

What are motivations of owners of an advance directive (AD) to draft an AD, what do they aim for with their AD and do they communicate about their AD?

METHODS

Written questionnaires were sent to a cohort of people owning different types of ADs (n=5768). A purposive sample of people suffering from an illness was selected from the cohort for an in-depth interview (n=29).

RESULTS

About half of our population had no direct motivation to draft their AD. Most mentioned motivation for the other half was an illness of a family member or friend. Many different and specific aims for drafting an AD were mentioned. An often mentioned more general aim in people with different ADs was to prevent unnecessary lengthening of life or treatment (14-16%). Most respondents communicated about having an AD with close-ones (63-88%) and with their GP (65-79%). In the interviews people gave vivid examples of experiences of what they hoped to prevent at the end of life. Some mentioned difficulties foreseeing the future and gave examples of response shift.

CONCLUSION

ADs can give directions to caregivers about what people want at the end of life.

PRACTICE IMPLICATIONS

ADs have to be discussed in detail by their owners and caregivers, since owners often have specific aims with their AD.

Planning for serious illness by the general public: a population-based survey

Background. While rates of advance care documentation amongst the general public remain low, there is increasing recognition of the value of informal planning to address patient preferences in serious illness. Objectives. To determine the associations between personal attributes and formal and informal planning for serious illness across age groups. Methods. This population-based, online survey was conducted in Saskatchewan, Canada, in April, 2012, using a nonclinical sample of 827 adults ranging from 18 to 88 years of age and representative of age, sex, and regional distribution of the province. Associations between key predictor variables and planning for serious illness were assessed using binary logistic regression. Results. While 16.6% of respondents had completed a written living will or advance care plan, half reported having conversations about their treatment wishes or states of health in which they would find it unacceptable to live. Lawyers were the most frequently cited source of assistance for those who had prepared advance care plans. Personal experiences with funeral planning significantly increased the likelihood of activities designed to plan for serious illness. Conclusions. Strategies designed to increase the rate of planning for future serious illness amongst the general public must account for personal readiness.

Planning for Serious Illness amongst Community-Dwelling Older Adults

Older adults have long been encouraged to maintain their autonomy by expressing their wishes for health care before they become too ill to meaningfully participate in decision making. This study explored the manner in which community-dwelling adults aged 55 and older plan for serious illness. An online survey was conducted within the province of Saskatchewan, Canada, with 283 adults ranging in age from 55 to 88 years. Planning for future medical care was important for the majority (78.4%) of respondents, although only 25.4% possessed a written advance care plan and 41.5% had designated a substitute decision maker. Sixty percent of respondents reported conversations about their treatment wishes; nearly half had discussed unacceptable states of health. Associations between key predictor variables and planning behaviors (discussions about treatment wishes or unacceptable states of health; designation of a substitute decision maker; preparation of a written advance care plan) were assessed using binary logistic regression. After controlling for all predictor variables, self-reported knowledge about advance care planning was the key variable significantly associated with all four planning behaviors. The efforts of nurses to educate older adults regarding the process of advance care planning can play an important role in enhancing autonomy.

Advance care planning and the quality of end-of-life care in older adults

OBJECTIVES

To determine whether advance care planning influences quality of end-of-life care.

DESIGN

In this observational cohort study, Medicare data and survey data from the Health and Retirement Study (HRS) were combined to determine whether advance care planning was associated with quality metrics.

SETTING

The nationally representative HRS.

PARTICIPANTS

Four thousand three hundred ninety-nine decedent subjects (mean age 82.6 at death, 55% women).

MEASUREMENTS

Advance care planning (ACP) was defined as having an advance directive (AD), durable power of attorney (DPOA) or having discussed preferences for end-of-life care with a next of kin. Outcomes included previously reported quality metrics observed during the last month of life (rates of hospital admission, in-hospital death, >14 days in the hospital, intensive care unit admission, >1 emergency department visit, hospice admission, and length of hospice ≤ 3 days).

RESULTS

Seventy-six percent of subjects engaged in ACP. Ninety-two percent of ADs stated a preference to prioritize comfort. After adjustment, subjects who engaged in ACP were less likely to die in a hospital (adjusted relative risk (aRR) = 0.87, 95% confidence interval (CI) = 0.80-0.94), more likely to be enrolled in hospice (aRR = 1.68, 95% CI = 1.43-1.97), and less likely to receive hospice for 3 days or less before death (aRR = 0.88, 95% CI = 0.85-0.91). Having an AD, a DPOA or an ACP discussion were each independently associated with a significant increase in hospice use (P < .01 for all).

CONCLUSION

ACP was associated with improved quality of care at the end of life, including less in-hospital death and increased use of hospice. Having an AD, assigning a DPOA and conducting ACP discussions are all important elements of ACP.

The social stratification of older adults' preparations for end-of-life health care

I use data from the Wisconsin Longitudinal Study (n = 4,971) to evaluate the extent to which socioeconomic status affects three health-related (living will, durable power of attorney for health care, and discussions) and one financial (will) component of end-of-life planning. Net worth is positively associated with all four types of planning, after demographic, health, and psychological characteristics are controlled. Low rates of health-related planning among persons with low or negative assets are largely accounted for by the fact that they are less likely to execute a will, an action that triggers health-related preparations. Rates of health-related planning alone are higher among recently hospitalized persons, whereas financial planning only is more commonly done by homeowners and those with richer assets. The results suggest that economically advantaged persons engage in end-of-life planning as a two-pronged strategy entailing financial and health-related preparations. Implications for health policy, practice, and theory are discussed.

"I don't want to die like that ...": the impact of significant others' death quality on advance care planning

PURPOSE OF THE STUDY

I examine whether 5 aspects of a significant other's death quality (pain, decision-making capacity, location, problems with end-of life care, and preparation) affect whether one does advance care planning (ACP). I also identify specific aspects of others' deaths that respondents say triggered their own planning.

DESIGN AND METHODS

Data are from the New Jersey End of Life study, a survey of 305 adults age 55+ seeking care at 2 major New Jersey medical centers. I estimate multivariate logistic regression models for a subsample of 253 participants who recently lost a loved one and provide descriptive findings from an open-ended question regarding the motivation for one's ACP.

RESULTS

Multivariate analyses revealed "positive" role model effects; persons who witnessed significant others' deaths that occurred at home, were free of problems associated with end-of-life care, and where advance directives were used are more likely to make end-of-life preparations. Open-ended data showed that 19% cited others' deaths as the main trigger for their own planning, with most citing negative factors (pain, connection to machines, coma) that they hoped to avoid.

IMPLICATIONS

Practitioners should encourage patients to use conversations about others' deaths as springboards for discussions about one's own end-of-life care, and to engage in ACP together with family. Implications for health care reform are highlighted.

Experiences with advance care planning: older people and family members' perspective

AIMS AND OBJECTIVES

The aim of this study is to report the findings of a case study that explored the phenomenon of advance care planning and advanced care directives in residential care settings in Australia. In particular, this study focuses on the experiences of residents' and family members'.

BACKGROUND

Understanding the phenomenon of advance care planning and advanced care directives is vital to end of life decision making. There are few studies that report the experiences of older people and family members in relation to advance care planning and advanced care directives.

METHODS

A case-study research was conducted and data was collected over 7 months involving participant observation, field notes, semi-structured interviews and document analysis.

FINDINGS

The participants' early experiences with advance care planning were expressed in unpleasant, hostile and negative ways. However, those emotions and concerns were transformed to more stable, amenable and positive attitudes and feelings as issues were resolved. The factors that enhanced or inhibited the transition were described.

CONCLUSION

Older people and families view the end of life with broader psychosocial and spiritual meanings shaped by a lifetime of experiences. Advance care planning led to a different level of appreciation of personal entity and transcendence. However, advance care planning demands concerted action and support by everyone involved.

Are Canadians providing advance directives about health care and research participation in the event of decisional incapacity?

OBJECTIVE

Advance planning for health care and research participation has been promoted as a mechanism to retain some control over one's life, and ease substitute decision making, in the event of decisional incapacity. Limited data are available on Canadians' current advance planning activities. We conducted a postal survey to estimate the frequency with which Canadians communicate their preferences about health care and research should they become incapacitated.

METHOD

We surveyed 5 populations (older adults, informal caregivers, physicians, researchers in aging, and research ethics board members) from Nova Scotia, Ontario, Alberta, and British Columbia. We asked respondents whether they had expressed their preferences regarding a substitute decision maker, health care, and research participation in the event of incapacity.

RESULTS

Two out of 3 respondents (62.0%; 95% CI 59.1% to 64.8%) had been advised to communicate their health care preferences in advance. Oral expression of wishes was reported by 69.1% of respondents (95% CI 66.8% to 71.3%), and written expression by 46.7% (95% CI 44.3% to 49.2%). Among respondents who had expressed wishes in advance (orally or in writing), 91.2% had chosen a substitute decision maker, 80.9% had voiced health care preferences, and 19.5% had voiced preferences regarding research participation. Having been advised to communicate wishes was a strong predictor of the likelihood of having done so.

CONCLUSIONS

Advance planning has increased over the last 2 decades in Canada. Nonetheless, further efforts are needed to encourage Canadians to voice their health care and research preferences in the event of incapacity. Physicians are well situated to promote advance planning to Canadians.

The evolution of health care advance planning law and policy

CONTEXT

The legal tools of health care advance planning have substantially changed since their emergence in the mid-1970s. Thirty years of policy development, primarily at the state legislative level addressing surrogate decision making and advance directives, have resulted in a disjointed policy landscape, yet with important points of convergence evolving over time. An understanding of the evolution of advance care planning policy has important implications for policy at both the state and federal levels.

METHODS

This article is a longitudinal statutory and literature review of health care advance planning from its origins to the present.

FINDINGS

While considerable variability across the states still remains, changes in law and policy over time suggest a gradual paradigm shift from what is described as a "legal transactional approach" to a "communications approach," the most recent extension of which is the emergence of Physician Orders for Life-Sustaining Treatment, or POLST. The communications approach helps translate patients' goals into visible and portable medical orders.

CONCLUSIONS

States are likely to continue gradually moving away from a legal transactional mode of advance planning toward a communications model, albeit with challenges to authentic and reliable communication that accurately translates patients' wishes into the care they receive. In the meantime, the states and their health care institutions will continue to serve as the primary laboratory for advance care planning policy and practice.

Progress in ethical decision making in the care of the dying

Practitioners in critical care have made a significant progress in caring for dying patients in critical care by taking advantage of the suggestions from their professional groups. Progress has been made in responding to and controlling patients' pain. Major initiatives from the Joint Commission and the American Pain Society have helped direct this improvement. Palliative care consultations as well as ethics consultations have improved symptom control in the critically ill. Issues of consent have been problematic for dying patients in critical care especially in the area of discontinuing therapies. But, better policies related to advance directives have been developed to ensure good care. Spiritual care has received more attention, and now chaplains are recognized by the Society for Critical Care Medicine as integral to the critical care team. The American Association of Critical-Care Nurses has been a leader in improving end-of-life issues and continues to spearhead many projects to improve end-of-life care.

Design of the Advance Directives Cohort: a study of end-of-life decision-making focusing on Advance Directives

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.

End-of-Life Treatment Preferences Among Older Adults: An Assessment of Psychosocial Influences

We explore the content and correlates of older adults' end-of-life treatment preferences in two hypothetical terminal illness scenarios: severe physical pain with no cognitive impairment, and severe cognitive impairment with no physical pain. For each scenario, we assess whether participants would reject life-prolonging treatment, accept treatment, or do not know their preferences. Using data from the 2004 wave of the Wisconsin Longitudinal Study (N = 5,106), we estimate multinomial logistic regression models to evaluate whether treatment preferences are associated with direct experience with end-of-life issues, personal beliefs, health, and sociodemographic characteristics. Persons who have made formal end-of-life preparations, persons with no religious affiliation, mainline Protestants, and persons who are pessimistic about their own life expectancy are more likely to reject treatment in both scenarios. Women and persons who witnessed the painful death of a loved one are more likely to reject treatment in the cognitive impairment scenario only. Consistent with rational choice perspectives, our results suggest that individuals prefer treatments that they perceive to have highly probable desirable consequences for both self and family.

The Impact of Late-Life Parental Death on Adult Sibling Relationships: Do Parents' Advance Directives Help or Hurt?

The authors examined whether the effect of parental death on adults siblings' relationship quality varies on the basis of the presence and perceived effectiveness of a deceased parent's formal preparations for end-of-life care. The authors used data from the Wisconsin Longitudinal Study and focused on the relationship quality of a bereaved adult child and his or her randomly selected sibling. Parental death was associated with a decrease in sibling closeness. The parent's use of advance directives (living will and durable power of attorney for health care) did not have uniformly positive effects on adult siblings' relationship quality. Sibling relationships suffered when the living will was believed to "cause problems," but relationships improved when the deceased parent named someone other than his or her spouse or a child as durable power of attorney for health care. The authors discuss the implications for developing effective end-of-life preparations that benefit both the decedent and surviving kin.

End-of-life issues in the acute and critically ill patient

The challenges of end-of-life care require emergency physicians to utilize a multifaceted and dynamic skill set. Such skills include medical therapies to relieve pain and other symptoms near the end-of-life. Physicians must also demonstrate aptitude in comfort care, communication, cultural competency, and ethical principles. It is imperative that emergency physicians demonstrate a fundamental understanding of end-of-life issues in order to employ the versatile, multidisciplinary approach required to provide the highest quality end-of-life care for patients and their families.

Staff opinions about the components of a good death in long-term care

AIM

The aim of this study was to identify differences of opinion about the relative importance of different components of a good death among care providers in a long-term care home serving Canadian war veterans.

METHODS

The Concept of a Good Death scale (Swartz et al, 2003), with slight adaptations to fit the long-term care context, was made available to all staff. Responses were accepted for a one-month period.

FINDINGS

Survey return rate was 30.4%. There was a majority (greater than 50%) opinion that 12 of the 20 items were essential or important to a good death, and that three items were not necessary: 'that death is sudden and unexpected' (64.5%), 'that there be control of bodily functions to the end' (61.8%) and 'that there be mental alertness to the end' (55.3%). There was not a majority opinion on the five remaining items: 'that the dying period be short', 'that death occurs naturally without technical equipment', 'that the person lived until a key event', 'that the ability to communicate be present until death', and 'that death occurs during sleep'.

CONCLUSIONS

Detailed analysis of survey results identified differences of opinion that could have implications for consistency and quality of care. The findings suggest ways in which the unique characteristics of the long-term care environment and population influence opinions about the components of a good death.

Difficult conversations and chronic heart failure: do you talk the talk or walk the walk?

PURPOSE OF REVIEW

Effective communication is critical for palliative and supportive care in heart failure. This article contains a review of available information to assist clinicians in undertaking discussions regarding prognosis, treatment decisions and advance care planning.

RECENT FINDINGS

Emerging from a range of studies at the end of life is that patients and their families appreciate honesty and do not want to be abandoned by healthcare providers. Further, the receptivity of patients and their carers to information is highly variable, underscoring the importance of an individualized approach.

SUMMARY

When having these difficult conversations, clinicians need to assess the individual's need and wishes for information as well as their social and cultural background. They also need to consider the setting, timing and content of the discussion, as well as strategies to promote coping and adjustment. Most importantly, patients need a treatment plan to address palliative and supportive care needs to be implemented at the time of breaking this bad news, so that they and their families do not feel abandoned. Learning effective communication skills, implementing strategies for debriefing and the fostering of a team approach, may minimize burden on health providers and improve palliative and supportive care for people with heart failure.

What explains racial differences in the use of advance directives and attitudes toward hospice care?

Cultural beliefs and values are thought to account for differences between African Americans and whites in the use of advance directives and beliefs about hospice care, but few data clarify which beliefs and values explain these differences. Two hundred five adults aged 65 and older who received primary care in the Duke University Health System were surveyed. The survey included five scales: Hospice Beliefs and Attitudes, Preferences for Care, Spirituality, Healthcare System Distrust, and Beliefs About Dying and Advance Care Planning. African Americans were less likely than white subjects to have completed an advance directive (35.5% vs 67.4%, P<.001) and had less favorable beliefs about hospice care (Hospice Beliefs and Attitudes Scale score, P<.001). African Americans were more likely to express discomfort discussing death, want aggressive care at the end of life, have spiritual beliefs that conflict with the goals of palliative care, and distrust the healthcare system. In multivariate analyses, none of these factors alone completely explained racial differences in possession of an advance directive or beliefs about hospice care, but when all of these factors were combined, race was no longer a significant predictor of either of the two outcomes. These findings suggest that ethnicity is a marker of common cultural beliefs and values that, in combination, influence decision-making at the end of life. This study has implications for the design of healthcare delivery models and programs that provide culturally sensitive end-of-life care to a growing population of ethnically diverse older adults.

Substitute decision making in medicine: comparative analysis of the ethico-legal discourse in England and Germany

Health care decision making for patients without decisional capacity is ethically and legally challenging. Advance directives (living wills) have proved to be of limited usefulness in clinical practice. Therefore, academic attention should focus more on substitute decision making by the next of kin. In this article, we comparatively analyse the legal approaches to substitute medical decision making in England and Germany. Based on the current ethico-legal discourse in both countries, three aspects of substitute decision making will be highlighted: (1) Should there be a legally predefined order of relatives who serve as health care proxies? (2) What should be the respective roles and decisional powers of patient-appointed versus court-appointed substitute decision-makers? (3) Which criteria should be determined by law to guide substitute decision-makers?

Perspectives of Elderly People on Advance Directives in Japan

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.