Medline ® Abstracts for References 1,13
of 'Advance care planning and advance directives'
The impact of advance care planning on end of life care in elderly patients: randomised controlled trial.
Detering KM, Hancock AD, Reade MC, Silvester W
BMJ. 2010;340:c1345. Epub 2010 Mar 23.
OBJECTIVE: To investigate the impact of advance care planning on end of life care in elderly patients.
DESIGN: Prospective randomised controlled trial.
SETTING: Single centre study in a university hospital in Melbourne, Australia.
PARTICIPANTS: 309 legally competent medical inpatients aged 80 or more and followed for six months or until death.
INTERVENTIONS: Participants were randomised to receive usual care or usual care plus facilitated advance care planning. Advance care planning aimed to assist patients to reflect on their goals, values, and beliefs; to consider future medical treatment preferences; to appoint a surrogate; and to document their wishes.
MAIN OUTCOME MEASURES: The primary outcome was whether a patient's end of life wishes were known and respected. Other outcomes included patient and family satisfaction with hospital stay and levels of stress, anxiety, and depression in relatives of patients who died.
RESULTS: 154 of the 309 patients were randomised to advance care planning, 125 (81%) received advance care planning, and 108 (84%) expressed wishes or appointed a surrogate, or both. Of the 56 patients who died by six months, end of life wishes were much more likely to be known and followed in the intervention group (25/29, 86%) compared with the control group (8/27, 30%; P<0.001). In the intervention group, family members of patients who died had significantly less stress (intervention 5, control 15; P<0.001), anxiety (intervention 0, control 3; P=0.02), and depression (intervention 0, control 5; P=0.002) than those of the control patients. Patient and family satisfaction was higher in the intervention group.
CONCLUSIONS: Advance care planning improves end of life care and patient and family satisfaction and reduces stress, anxiety, and depression in surviving relatives. Trial registration Australian New Zealand clinical trials registry ACTRN12608000539336.
Respecting Patient Choices Program, Austin Health, PO Box 555, Heidelberg, Victoria, Australia. Karen.firstname.lastname@example.org
Association between advance directives and quality of end-of-life care: a national study.
Teno JM, Gruneir A, Schwartz Z, Nanda A, Wetle T
J Am Geriatr Soc. 2007;55(2):189.
OBJECTIVES: To examine the role of advance directives (ADs) 10 years after the Patient Self-Determination Act.
DESIGN: Mortality follow-back survey.
SETTING: People who died in a nursing home, hospital, or at home.
PARTICIPANTS: Bereaved family member or other knowledgeable informant.
MEASUREMENTS: Telephone interviewers that asked about the use of written ADs, use of life-sustaining treatment, and quality of care by asking whether staff provided desired symptom relief, treated the dying with respect, supported shared decision-making, coordinated care, and provided family with the needed information and emotional support.
RESULTS: Of the 1,587 people who died, 70.8% had an AD. Persons who died athome with hospice or in a nursing home were more likely to have an AD. In addition, those with an AD were less likely to have a feeding tube (17% vs 27%) or use a respirator in the last month of life (11.8% vs 22.0%). Bereaved family members who reported that the decedent did not have an AD were more likely to report concerns with physician communication (adjusted odds ratio (AOR)=1.4, 95% confidence interval (CI)=1.1-1.6) and with being informed about what to expect (AOR=1.2, 95% CI=1.0-1.3). No statistically significant differences were observed in other outcomes. Even in those with an AD, important quality concerns remained; one in four reported an unmet need in pain, one in two reported inadequate emotional support for the patient, and one in three stated inadequate family emotional support.
CONCLUSION: Bereaved family member report of completion of an AD was associated with greater use of hospice and fewer reported concerns with communication, yet important opportunities remain to improve the quality of end-of-life care.
Center for Gerontology and Health Care Research, Brown Medical School, Providence, Rhode Island, USA. Joan_Teno@brown.edu