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Medline ® Abstracts for References 1,15

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.detering@austin.org.au
Systematic implementation of an advance directive program in nursing homes: a randomized controlled trial.
Molloy DW, Guyatt GH, Russo R, Goeree R, O'Brien BJ, Bédard M, Willan A, Watson J, Patterson C, Harrison C, Standish T, Strang D, Darzins PJ, Smith S, Dubois S
JAMA. 2000;283(11):1437.
CONTEXT: Although advance directives are commonly used in the community, little is known about the effects of their systematic implementation.
OBJECTIVES: To examine the effect of systematically implementing an advance directive in nursing homes on patient and family satisfaction with involvement in decision making and on health care costs.
DESIGN: Randomized controlled trial conducted June 1, 1994, to August 31, 1998.
SETTING AND PARTICIPANTS: A total of 1292 residents in 6 Ontario nursing homes with more than 100 residents each.
INTERVENTION: The Let Me Decide advance directive program included educating staff in local hospitals and nursing homes, residents, and families about advance directives and offering competent residents or next-of-kin of mentally incompetent residents an advance directive that provided a range of health care choices for life-threatening illness, cardiac arrest, and nutrition. The 6 nursing homes were pair-matched on key characteristics, and 1 home per pair was randomized to take part in the program. Control nursing homes continued with prior policies concerning advance directives.
MAIN OUTCOME MEASURES: Residents' and families' satisfaction with health care and health care services utilization over 18 months, compared between intervention and control nursing homes.
RESULTS: Of 527 participating residents in intervention nursing homes, 49% of competent residents and 78% of families of incompetent residents completed advance directives. Satisfaction was not significantly different in intervention and control nursing homes. The mean difference (scale, 1-7) between intervention and control homes was -0.16 (95 % confidence interval [CI], -0.41 to 0.10) for competent residents and 0.07 (95% CI, -0.08 to 0.23) for families of incompetent residents. Intervention nursing homes reported fewer hospitalizations per resident (mean, 0.27 vs 0.48; P = .001) and less resource use (average total cost per patient, Can $3490 vs Can $5239; P = .01) than control nursing homes. Proportion of deaths in intervention (24%) and control (28%) nursing homes were similar (P = .20).
CONCLUSION: Our data suggest that systematic implementation of a program to increase use of advance directives reduces health care services utilization without affecting satisfaction or mortality.
Department of Medicine, McMaster University, Ontario, Canada. molloy@mcmaster.ca