Increasing the use of advance directives in medical outpatients

Landry, Frank J.; Kroenke, Kurt; Lucas, Chris; Reeder, Jean M.

doi:10.1046/j.1525-1497.1997.00072.x

Cited by 57 publications

(47 citation statements)

References 13 publications

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“…7 Research found that a simple 1-hour education session for ambulatory care improves completion of ACD paperwork, but data are lacking regarding educational interventions for ambulatory residency training. 8 We implemented a program to improve resident physician confidence to lead discussions in the outpatient setting regarding ACD, and to increase patient opportunity to discuss end-of-life care with their physician.…”

Section: Resultsmentioning

confidence: 99%

Advanced Care Directives: Overcoming the Obstacles

Allen¹,

Davis²,

Rousseau³

et al. 2015

Journal of Graduate Medical Education

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Background Advanced care directives (ACDs) and end-of-life discussions are important and typically difficult to initiate because of the sensitive nature of the topic and competing clinical priorities. Resident physicians need to have these conversations but often do not in their continuity clinics. Objective We implemented a program to (1) increase physician opportunity to discuss end-of-life wishes with their patients, and (2) improve residents' confidence in leading discussions regarding ACDs. Intervention A total of 95 residents in an academic outpatient internal medicine resident continuity clinic participated in a formalized curriculum (didactic sessions, simulations, and academic detailing). Clinic workflow alterations prompted the staff to question if patients had an ACD or living will, and then cued residents to discuss these issues with the patients if they did not. Results Of the 77% of patients who were asked about ACDs, 74% had no ACD but were interested in discussing this topic. After our intervention, 65% (62 of 95) of our residents reported having at least 1 outpatient discussion with their patients. Residents reported increased confidence directing and discussing advanced care planning with older patients and conducting a family meeting (P < .01). Conclusions By delivering a formalized curriculum and creating a clinical environment that supports such discussions, resident physicians had more ACD discussions with their patients and reported increased confidence. When provided information and opportunity, patients consistently expressed interest in talking with their physician about their advanced care wishes.

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Section: Resultsmentioning

confidence: 99%

Advanced Care Directives: Overcoming the Obstacles

Allen¹,

Davis²,

Rousseau³

et al. 2015

Journal of Graduate Medical Education

View full text Add to dashboard Cite

show abstract

“…advance directives are completed, they often do not result in care consistent with patients' previously stated goals. [6][7][8][9] Interventions to improve advance care planning have been at best modestly successful, 8,10,11 although multicomponent interventions that affect multiple aspects of the health-care system have demonstrated a greater effect of advance care planning on care and patient outcomes. 12,13 Ineffective transfer of patients' advance care planning information to medical records in the various settings where end-of-life care decisions are made could partly explain advance care planning interventions' limited benefit.…”

Section: Introductionmentioning

confidence: 99%

Documentation of Advance Care Planning for Community-Dwelling Elders

Yung

Walling

Min

et al. 2010

Journal of Palliative Medicine

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Background: Advance planning for end-of-life care has gained acceptance, but actual end-of-life care is often incongruent with patients' previously stated goals. We assessed the flow of advance care planning information from patients to medical records in a community sample of older adults to better understand why advance care planning is not more successful. Methods: Our study used structured interview and medical record data from community-dwelling older patients in two previous studies: Assessing Care of Vulnerable Elders (ACOVE)-1 (245 patients age 65 years and screened for high risk of death/functional decline in 1998-1999) and ACOVE-2 (566 patients age 75 who screened positive for falls/mobility disorders, incontinence, and/or dementia in [2002][2003]. We compared interview data on patients' preferences, advance directives, and surrogate decision-makers with findings from the medical record. Results: In ACOVE-1, 38% of surveyed patients had thought about limiting the aggressiveness of medical care; 24% of surveyed patients stated that they had spoken to their doctor about this. The vast majority of patients (88%-93%) preferred to die rather than remain permanently in a coma, on a ventilator, or tube fed. Regardless of patients' specific preferences, 15%-22% of patients had preference information in their medical record. Among patients who reported that they had completed an advance directive and had given it to their health-care provider, 15% (ACOVE-1) and 47% (ACOVE-2) had advance directive information in the medical record. Among patients who had not completed an advance directive but had given surrogate decision-maker information to their provider, 0% (ACOVE-1) and 16% (ACOVE-2) had documentation of a surrogate decision-maker in the medical record. Conclusions: Community-dwelling elders' preferences for end-of-life care are not consistent with documentation in their medical records. Electronic health records and standardized data collection for end-of-life care could begin to ameliorate this problem.

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“…One study reported that less than 20% of patients who had completed an advance directive told their primary care physician and less than half of those patients had the documentation in their medical record [23]. Another found that only 30% of patients who had discussed their wishes had done so with their family physician [1].…”

Section: Discussionmentioning

confidence: 99%