A Randomized Controlled Trial of a Goals-of-Care Video for Elderly Patients Admitted to Skilled Nursing Facilities

Abstract

Objective: To determine the impact of a video on preferences for the primary goal of care. Design, subjects, and intervention: Consecutive subjects 65 years of age or older (n = 101) admitted to two skilled nursing facilities (SNFs) were randomized to a verbal narrative (control) or a video (intervention) describing goals-of-care options. Options included: life-prolonging (i.e., cardiopulmonary resuscitation), limited (i.e., hospitalization but no cardiopulmonary resuscitation), or comfort care (i.e., symptom relief). Main measures: Primary outcome was patients' preferences for comfort versus other options. Concordance of preferences with documentation in the medical record was also examined. Results: Fifty-one subjects were randomized to the verbal arm and 50 to the video arm. In the verbal arm, preferences were: comfort, n = 29 (57%); limited, n = 4 (8%); life-prolonging, n = 17 (33%); and uncertain, n = 1 (2%). In the video arm, preferences were: comfort, n = 40 (80%); limited, n = 4 (8%); and life-prolonging, n = 6 (12%). Randomization to the video was associated with greater likelihood of opting for comfort (unadjusted rate ratio, 1.4; 95% confidence interval [CI], 1.1-1.9, p = 0.02). Among subjects in the verbal arm who chose comfort, 29% had a do-not-resuscitate (DNR) order (j statistic 0.18; 95% CI-0.02 to 0.37); 33% of subjects in the video arm choosing comfort had a DNR order (j statistic 0.06; 95% CI-0.09 to 0.22). Conclusion: Subjects admitted to SNFs who viewed a video were more likely than those exposed to a verbal narrative to opt for comfort. Concordance between a preference for comfort and a DNR order was low. These findings suggest a need to improve ascertainment of patients' preferences. Trial Registration: Clinicaltrials.gov Identifier: NCT01233973.

Advance Care Planning in the Elderly

“…General scope of care options: life-prolonging (ie, CPR and life-sustaining treatments), limited interventions (ie, hospitalization with limitations in the extent of medical intervention), or comfort care (ie, symptom relief) 34,35 Role of artificial nutrition and hydration Role of hospitalization and/or outpatient services such as hospice 11 Role of CPR, including recommending for or against this procedure 36 Table 2 provides examples for talking with older adults and translating preferences into current medical care plans, such as CPR directives, do-not-resuscitate orders, and out-of-hospital medical orders. Specifically, clinicians can use POLST forms to translate ACP preferences into medical orders, including CPR, scope of treatment, artificial nutrition by tube, and, in some states, antibiotic use, based on conversations with patients or surrogates.…”

“…ACP Decisions (http://www.acpdecisions.org/) presents ACP videos describing how overall goals of care, CPR, and mechanical ventilation can influence patients' and surrogates' preferences for end-of-life care. 35,44 The Conversation Project (http://theconversationproject.org/) 45 provides a written toolkit with values-based questions to help individuals start ACP conversations. The GO WISH Card Game, 46 a set of cards that describe potential quality-of-life values, may facilitate conversations among older adults with cognitive impairment.…”

YouTube as a Tool for Pain Management With Informal Caregivers of Cancer Patients: A Systematic Review

“…Patients exposed to video decision support tools had a greater likelihood to choose comfort goals (9), greater likelihood to complete advance directive documentation (10), and were less likely to opt for cardiopulmonary resuscitation (11). A randomized controlled trial of cancer patients found that an educational video on cancer pain improved outcomes associated with the Brief Pain Inventory and the Patient Pain Questionnaire (12).…”

Why don't end-of-life conversations go viral? A review of videos on YouTube

“…Fourteen ACP stakeholders (three surgeons, two patient family advocates, two health services researchers, four palliative care clinicians and/or researchers, one medical film-maker, one patient-centered outcomes researcher and one patient safety and quality researcher) met to review a representative sample of seven ACP videos selected from published studies,30 websites31 or YouTube 4. Using design-thinking techniques,32 stakeholders identified important video elements to be: (1) patient-centered videos that feature personal stories delivered by ‘real’ patients and families; (2) a decision framework that emphasises and elicits ‘how people want to live’ rather than the treatments they want or do not want and (3) ‘upbeat’ music (where upbeat music was highly linked to increased engagement).…”