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PubMed1999

How advance directives affect hospital resource use. Systematic review of the literature.

OBJECTIVE: To assess whether advance directives influence resource use by hospitalized patients. DATA SOURCES: A systematic search of computerized medical databases, reference lists from relevant articles, and personal files was conducted to identify studies examining the association between advance directives and resource use. STUDY SELECTION: Primary studies assessing the effect of advance directives on hospital resource use were selected if they had a clear quantitative measure of hospital resource use, hospitalized patients as a study population, a control group for comparison, and a description of the advance directive being studied. Data on the following topics were abstracted from studies meeting inclusion criteria: study methods and design, resource use, source of financial data, description of advance directive, population size and composition, length of assessment. SYNTHESIS: Six studies met inclusion criteria. Three retrospective studies showed significant reductions in resource use associated with documentation of advance directives while three prospective studies (two randomized, one not randomized) showed no association between advance directives and reduced resource use. Studies were limited to narrowly defined patient populations in US tertiary care hospitals. CONCLUSIONS: Little evidence supports the hypothesis that advance directives reduce resource use by hospitalized patients. Some retrospective studies have shown savings, but their conclusions are weakened by shortcomings in study design. Prospective trials, which have better experimental methods, have demonstrated no evidence of cost savings with the use of advance directives.

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PubMed1999

[Advance directives in clinical practice].

DEFINITIONS: In the United States advance directives were developed since the late 60s in order to improve patients' medical decision making in case of incompetence in the future. In Germany 3 types of advance directives exist: 1. "Patientenverfügungen". 2. "Berreuungsverfügugen" and 3. "Vorsorgevollmachten". EMPIRICAL STUDIES: In empirical studies, mostly from the US, the implementation of advance directives into clinical practice and the attitude of physicians, patients, relatives and the general population have been examined. This review article provides results of theses studies in text and tables. CONCLUSION: Against the will of patients and of the general population advance directives are not often used in clinical practice. Physicians talk with patients about treatment procedures more often than they talk about end of life decisions. Informing patients about advance directives opens the chance to improve palliative care and respects their choices and values at the end of their lives.

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PubMed1992

Empowerment of the older patient? A randomized, controlled trial to increase discussion and use of advance directives.

OBJECTIVE: To see if an educational intervention directed at older outpatients would lead to increased use or discussion of advance directives and to characterize patients' reasons for not obtaining advance directives. DESIGN: Randomized, controlled trial of an educational intervention versus usual care. SETTING: Outpatient geriatrics clinic of a university hospital. PATIENTS: One hundred and thirty-one non-demented patients over the age of 65 who did not have an advance directive documented in their record at the start of the study. Forty-eight patients were in the trial arm and 83 in the control. MAIN OUTCOME MEASURES: All patients had their charts reexamined 6 months after enrollment to look for the presence of a living will, a durable power of attorney for health care, or a physician's note describing a discussion of advance directives. Trial patients were also re-interviewed to examine their reasons for not executing an advance directive. MAIN RESULTS: Six months after the intervention, only seven of the 48 trial subjects (15%) had an advance directive or note describing discussion of advance directives in their charts compared to eight of the 83 controls (10%) (P greater than 0.05). When asked to give reasons for not obtaining an advance directive, many patients' responses pointed to procrastination as a significant barrier. CONCLUSIONS: Promoting advance directive use is a complicated task. Barriers other than information and access to documents appear to be involved and need to be addressed in future efforts.

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PubMed1993

Religious advance directives: the convergence of law, religion, medicine, and public health.

Because of the deep interpersonal significance of decisions made at the end of life, it is not surprising that religion has played an important role in patient and family decision making. Specific religious concerns about death and dying have led to religious advance directives. Advance directives offer a case study of models of interaction between religious communities and secular institutions. This paper examines why such directives have been created and how they may affect health care decisions. An analysis of their strengths and weaknesses concludes that specific religious instructions are unnecessary in written directives and may undermine both the religious and health care goals of patients.

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PubMed2006

Recent trends in advance directives at nursing home admission and one year after admission.

PURPOSE: Advance directives are important planning and decision-making tools for individuals in nursing homes. DESIGN AND METHODS: By using the nursing facility Minimum Data Set, we examined the prevalence of advance directives at admission and 12 months post-admission. RESULTS: The prevalence of having any advance directive at admission declined slightly from 2000 to 2004, whereas the prevalence of having any advanced directive at 12 months after admission increased slightly during the same period. Compared with admissions, residents at 12 months post-admission were more likely to have their decisions made by family members and to have advance directives of any type. IMPLICATIONS: The results suggest that greater use of advance directives in nursing homes may depend on additional information and support from nursing facility personnel and the health and social services professionals who are in contact with individuals moving toward nursing home admission, as well as those who remain in facilities over time.

Advance Directives↗
PubMedDate not supplied

Elderly outpatients respond favorably to a physician-initiated advance directive discussion.

BACKGROUND: Little is known about the emotional impact of physician-initiated advance directive discussions. METHODS: One hundred ambulatory patients aged 65 years and older were randomly assigned to receive either a physician-initiated discussion of advance directive choices of a discussion of health promotion issues. Prediscussion, immediate postdiscussion, and 1-week postdiscussion measures of positive and negative affect were measured for both groups. RESULTS: Neither discussion topic resulted in adverse emotional or attitudinal responses. Only the advance directive participants showed positive affective and attitudinal responses to the discussion, including an increase in positive affect, an increased sense of physician-patient understanding, and increased thought and discussion about life-support issues in the week following the discussion. For those participants receiving the advance directive discussion, longer physician-patient relationships and higher educational levels significantly predicted a more positive affective response. Lower scores on indices of mental and physical health and a stronger belief that physicians should discuss advance directive issues significantly predicted a more negative affective response to the advance directive discussion. CONCLUSIONS: Physicians should anticipate positive emotional responses when they initiate advance directive discussions with their elderly outpatients. Advance directive discussions will be received most positively by patients who enjoy good psychological and physical health and when initiated in the context of an established physician-patient relationship.

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PubMed1994

Patients' and healthcare providers' opinions regarding advance directives.

PURPOSE/OBJECTIVES: To gain a better understanding of patients' and healthcare providers' preferences regarding when, how, and by whom advance directive information should be given and to explore the nursing role in advance directives. DESIGN: A qualitative study using focus group methodology. SETTING: A National Cancer Institute-designated comprehensive cancer center located within a large, university-affiliated, tertiary care hospital in the northeastern United States. SAMPLE: Two samples participated in the study: eight adult ambulatory patients with cancer and 15 healthcare providers (4 physicians, 10 nurses, and 1 social worker). METHODS: Separate patient and provider focus groups were conducted in private rooms by experienced facilitators using an interview guide with questions based on the literature, the hospital's advance directive materials, and the investigators' experience; sessions were audio-taped, transcribed, and analyzed using qualitative data analysis techniques. FINDINGS: Patients and healthcare providers discussed focus group questions and commented that advance directive discussions should be provided early in the treatment or illness, presented in a short and simple format with reading materials at a level appropriate for the patient, and continued throughout the illness with those who desire follow-up. Nurses, doctors, social workers, or a designated/trained advance directive person were individuals that the patients identified as people with whom they could have advance directive discussions. CONCLUSIONS: Results suggested that advance directive information should be given prior to hospital admission, be provided in a variety of formats, and that nurses, social workers, doctors, or designated staff representatives could all be part of the advance directive process. NURSING IMPLICATIONS: Nursing roles should include early assessment of patients to determine needs for discussion, advocacy on behalf of patients, and provision of information. Future research should examine use of specific personnel for facilitating advance directives and compare different formats for presenting advance directive information to patients.

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PubMedDate not supplied

Thinking outside the box: prenatal care and the call for a prenatal advance directive.

The concept of advance directives is well-known in the care of adults as a mechanism for choosing in advance the extent of medical interventions desired in clinical situations, particularly life-extending interventions such as ventilation support and drugs to maintain cardiopulmonary status. Infants born extremely prematurely often require life-supporting measures for which their parents or guardians report feeling unprepared to make decisions about. Current prenatal care does not include an educational component that teaches women about the length of gestation needed for a healthy viability, survivorship, and outcome without major impairment. Women who go into preterm labor are asked to make immediate decisions during times of crisis without any formal education base for this decision making. Feminist ethics (the philosophical stance that articulates that women's moral experience is worthy of respect and disallows women's subordination) (Becker LB, Becker CB, eds. Feminist ethics. In: Encyclopedia of Ethics. New York: Routledge Press; 2001) requires that healthcare decisions be based on education, context, and particular situations. The purpose of this article is to examine the current content of typical prenatal care and education and to suggest an additional educational component to prenatal care-education of women about infant viability and the planning of future decisions if a nonviable or critically ill newborn is delivered. A prenatal discussion and parental/family directive is suggested.

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PubMed1998

Foreword: planning for the future through advance directive instruments.

The Foreword traces the development of advance directive instruments and discusses their legal enforceability and many benefits. Despite their advantages, advance directives remain underused and are frequently ignored by service providers. The contributors to this special issue discuss why this is so and offer and debate a variety of remedial proposals. They analyze the various legal, clinical, ethical, and practical issues presented by the use of advance directives for health and mental health care and examine new directions in their application. The Foreword describes the organization of this special issue, summarizes the articles it contains, and comments on their significance.

Advance Care Planning↗
PubMed2004

Urban/rural differences in decision making and the use of advance directives among nursing home residents at admission.

CONTEXT: Advance directives promote patient autonomy and encourage greater awareness of final care options while reducing physician and family uncertainty regarding patient preferences. PURPOSE: To investigate differences in decision making authority and the use of advance directives among nursing home residents admitted from urban and rural areas. METHODS: A total of 551,208 admission assessments in the Minimum Data Set were analyzed for all residents admitted to a nursing facility in 2001. Using the Rural Urban Commuting Areas (RUCA) methodology and ZIP code of primary residence before admission, these residents were classified into 4 urban/rural areas. FINDINGS: Residents from rural areas were significantly more likely to have executed a durable power of attorney for health care or for financial decisions than residents admitted from the other areas, with the largest differences observed between residents admitted from urban and rural areas. Almost 6 residents in 10 from urban areas had no advance directives in place at admission compared with only 4 residents in 10 admitted from rural areas. CONCLUSIONS: Health providers and social workers in both rural and urban areas should advise patients about the value of advance directives.

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PubMed1998

Effect of advance directives on the management of elderly critically ill patients.

OBJECTIVE: To evaluate the effects of advance directives on the management of elderly, critically ill patients. DESIGN: Retrospective chart review. SETTING: Teaching hospital medical/surgical, noncardiac intensive care unit (ICU). PATIENTS: The medical records of 401 patients, > or =65 yrs of age, admitted to the ICU between 1992 and 1995 were reviewed. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Advance directive statements included refusal of cardiopulmonary resuscitation (CPR), nutrition, intravenous medications, antibiotics, mechanical ventilation, and blood products. Nineteen (5%) patients had advance directives (study group). These patients were compared with 28 case-matched (age, Acute Physiology and Chronic Health Evaluation II score, and diagnosis) critically ill patients without advance directives (control group). We compared the following data: cost per day; number of surgical procedures; number of radiographic studies; number of central venous and pulmonary artery catheter insertions; number of complete blood counts, electrolytes, and cultures sent for laboratory testing; number of days in the ICU/hospital; and mortality rates. Statistical analysis was performed using the Student's t-test for independent means and the chi-square equation. For all observed parameters, quantitative and dichotomous differences between study and control groups were not statistically significant. Two patients received CPR, despite advance directive statements refusing this treatment. CONCLUSIONS: Few critically ill seniors have advance directives. As assessed by objectively documented information, the level of care delivered to elderly ICU patients is not affected by the presence or absence of advance directive statements. Medical personnel need to be aware of whether or not patients have advance directive statements, as unauthorized CPR was administered to 11% of the patients who died with advance directives.

APACHE↗
PubMed1997

[Theological moral considerations of advance directives].

The forms for advanced directives vary considerably in respect to content and wording. This article intends to develop ethical criteria for such texts, from the moraltheological point of view, also considering the social context.

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PubMed1993

Advance directives: the views of health care professionals.

OBJECTIVES: This study examined the views and experiences of 20 physicians and 20 nurses at a major Canadian teaching hospital regarding the use of advance directives in clinical care. DESIGN: The participants were purposively drawn from four clinical specialties: family and community medicine, oncology, intensive care and geriatrics. Detailed interviews were conducted in person. Content analysis was used to code the data, which were further analysed with both quantitative and qualitative techniques. MAIN RESULTS: Thirty-nine of the 40 participants favoured the use of advance directives in clinical care; physicians had somewhat less positive attitudes than nurses toward such directives. Advance directives were thought by participants to be helpful in resolving disagreements between patients and their families about treatment options; in making patients more comfortable, both physically and psychologically, during the process of dying; and in opening up communication and trust among patients, their families and health care professionals. Concerns about the use of advance directives focused on the lack of clarity in some patients' instructions, the absence of legal status for directives, the possible interference with a practitioner's clinical judgement, the adequacy and appropriateness of patients' information about their circumstances, and the type of intervention (passive or active) requested by patients. CONCLUSIONS: New regulations and legislation are making the use of advance directives more widespread. Health care professionals should participate in the development and implementation of these directives. Continuing professional education is essential in this regard.

Adult↗
PubMed2003

The ethics of advance directives: a rehabilitation perspective.

Advance directives, including living wills and durable healthcare powers of attorney, have achieved broad acceptance by the healthcare system in the United States. Living wills may include provisions for limitation of care in the event of severe disability. These provisions pose ethical concerns in view of societal misconceptions of the quality of life of individuals with disabilities and the inability of people to predict their own capacity to adapt successfully to a disability. Greater reliance on durable healthcare powers of attorney for situations involving disability is proposed, with an emphasis on improving the education of healthcare proxies designated through this mechanism in the quality of life experienced by people with disabilities.

Activities of Daily Living↗
PubMedDate not supplied

Must guardians honor advance directives?

A question asked at a recent advance directives seminar brought divided opinions from the attorneys present, resulting in a lively discussion of whether a court-appointed guardian must honor a patient's advance directive. The question is presented in this article with the first of several legal opinions to be published. As background, the Update presents the following discussion of advance directives by Suzanne Mitchell, assistant professor, Loyola University Law School Institute for Health Law.

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PubMed1996

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.

Adolescent↗
PubMed2004

Knowledge, attitudes, and predictors of advance directive discussions of registered nurses.

The purpose of this study was to describe nurses' knowledge, attitudes, and experiences regarding advance directives. A secondary purpose was to examine predictors of advance directive discussions between nurses and patients. Seven-hundred and nineteen respondents, randomly selected from a list of registered nurses in the state of Ohio, completed mailed questionnaires. Descriptive t test, chi-square, and logistic regression statistics were used in the data analyses. The respondents were knowledgeable and possessed positive attitudes about advance directives. Higher self-perceived confidence in advance directive discussion skills and the experience of caring for at least one patient with a current advance directive were found to be significant predictors of advance directive discussions. These findings suggest that experience with advance directives documents is critical for nurses' comfort and that developing interventions to further nurses' confidence in their discussion skills may increase advance directive discussions.

Adult↗
PubMed1992

Effects of offering advance directives on medical treatments and costs.

OBJECTIVE: To examine the effects of advance directives on medical treatments and on patient satisfaction and well-being and to determine whether the enhancement of patient autonomy through advance directives provides a more ethically feasible approach to cost control than does the imposition of limits through rationing. DESIGN: Randomized, controlled trial. SETTING: University and Veterans Affairs medical center. PATIENTS: Two hundred and four patients with life-threatening illnesses, 100 of whom died after enrollment in the study. INTERVENTION: Patients randomly assigned to the experimental group were offered the California Durable Power of Attorney (a typical proxy-instruction directive), and patients assigned to the control group were not offered the advance directive. Hospital admissions were monitored to assure that a summary of the document was present in the active medical record at each hospitalization. MEASUREMENTS: Cognitive function, patient satisfaction, psychological well-being, health locus of control, sense of coherence, health-related quality of life, receipt of medical treatments, and medical treatment charges. RESULTS: No significant differences were found between advance-directive and control groups regarding psychosocial variables, health outcome variables, and medical treatments or charges. Patients offered an advance directive had an average hospital stay of 40.8 days (95% CI, 32.2 to 49.4 days), compared with an average of 33.1 days (95% CI, 26.0 to 40.2 days) for controls. Patients offered an advance directive were charged an average of $19,502 (95% CI, $13,030 to $25,974) for medical treatments in the last month of life compared with $19,700 (95% CI, $13,704 to $25,696) for controls. CONCLUSIONS: Despite claims that public demand for longer life accounts for rising medical costs, most surveys suggest that patients are calling for less, not more, of the expensive, high-technology treatment often used in terminal phases of illness. Executing the California Durable Power of Attorney for Health Care and having a summary copy placed in the patient's medical record had no significant positive or negative effect on a patient's well-being, health status, medical treatments, or medical treatment charges.

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