Assessment of advance care planning documentation for residents of residential aged care facilities presenting to the emergency department

Abstract

ObjectiveThis study assessed the availability and quality of advance care planning (ACP) documentation among older residential aged care facility (RACF) residents who presented to the emergency department (ED). MethodsA prospective review of the medical records of RACF residents aged ≥75 years who presented to the ED from May to June 2018 was conducted. Availability of ACP was determined based on the presence of an ACP document inclusive of an advance care directive (ACD) in the medical record. The quality of ACP documentation was determined based on the presence of nine key components. ResultsIn all, 48.8% of patients presented to the ED with either ACP or an ACD. However, only a mean total of 3.8 (out of 9) ACP components were documented in these documents. ConclusionsJust under half (48.8%) of RACF residents presented to the ED with ACP documentation. There was limited coverage of core ACP components needed to guide clinical decision making. What is known about the topic?RACF residents are in the last years of their life and commonly lack capacity to make decisions regarding health care. Residents are at high risk of dying when acutely unwell in hospital. ACP documentation, when readily available, helps provide appropriate end-of-life care and improves both patient and family satisfaction. What does this paper add?Less than half the residents reporting to the ED from an RACF had ACP documentation available for clinicians. For those who presented to the ED with ACP documentation, most lacked sufficient information needed to provide care in full accordance with the patient’s preferences. What are the implications for practitioners?There is a need to encourage, initiate, actively engage and develop systems for ACP conversations, documentation and availability when acutely unwell for people living in RACFs to provide sufficient information to guide clinical decision making. Without quality ACP, the provision of patient-centred health care may be compromised.

Advance directives in the emergency department–a systematic review of the status quo

“…Of the 22 included studies, most ( n = 12) were from the United States [ 4 , 20 – 23 , 27 , 30 – 33 , 37 , 39 ], followed by Australia ( n = 4) [ 11 , 24 , 29 , 35 ], Canada ( n = 2) [ 26 , 38 ], South Korea [ 34 ], Germany [ 28 ], the United Kingdom [ 25 ] and Switzerland [ 36 ] ( n = 1 each). The earliest study was published in 1996, the most recent in 2019, with over half ( n = 13) of the research published after 2010.…”

“…3 ). Availability in the geriatric population varied broadly between 1.1% [ 26 , 34 ] and 48.8% [ 35 ] (Fig. 3 ).…”

“…In the studies where both existence and availability were examined, the proportion of existing DPW that were available was calculated. Five studies reported values of 11.6% or below [ 26 – 28 , 31 , 32 , 36 ]. Russell et al found that in patients with terminal disease, 41.7% of possessed DPW were available upon ED presentation [ 38 ]; McQuown and Harrison reported 41.2% and 50% of DPW being available in NH patients transferred to the ED, respectively [ 33 , 39 ].…”

“…All studies that examined potential predicting factors [ 5 , 21 , 22 , 24 , 28 , 30 – 32 , 36 ], except one [ 39 ] identified older age as a positive predictor of documented patient wishes Likewise, several studies found a correlation between comorbidities or self-rating of generally poorer health and increased likelihood of holding a DPW [ 22 , 29 , 36 ]. The use of health care services, especially NH or similar institutions, seems to correlate with a higher rate of DPW [ 29 , 30 , 36 ].…”

Supporting residential aged care through aCommunityofPractice

“…SDM about goals of care can be particularly challenging in the ACE Program if a resident cannot participate (Chua et al, 2020). The "person responsible" is often a family member.…”