Medline ® Abstracts for References 1,9,11,12
of 'Advance care planning and advance directives'
Defining Advance Care Planning for Adults: A Consensus Definition From a Multidisciplinary Delphi Panel.
Sudore RL, Lum HD, You JJ, Hanson LC, Meier DE, Pantilat SZ, Matlock DD, Rietjens JAC, Korfage IJ, Ritchie CS, Kutner JS, Teno JM, Thomas J, McMahan RD, Heyland DK
J Pain Symptom Manage. 2017;53(5):821. Epub 2017 Jan 3.
CONTEXT: Despite increasing interest in advance care planning (ACP) and previous ACP descriptions, a consensus definition does not yet exist to guide clinical, research, and policy initiatives.
OBJECTIVE: The aim of this study was to develop a consensus definition of ACP for adults.
METHODS: We convened a Delphi panel of multidisciplinary, international ACP experts consisting of 52 clinicians, researchers, and policy leaders from four countries and a patient/surrogate advisory committee. We conducted 10 rounds using a modified Delphi method and qualitatively analyzed panelists' input. Panelists identified several themes lacking consensus and iteratively discussed and developed a final consensus definition.
RESULTS: Panelists identified several tensions concerning ACP concepts such as whether the definition should focus on conversations vs. written advance directives; patients' values vs. treatment preferences; current shared decision making vs. future medical decisions; and who should be included in the process. The panel achieved a final consensus one-sentence definition and accompanying goals statement: "Advance care planning is a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care. The goal of advance care planning is to help ensure that people receive medical care that is consistent with their values, goals and preferences during serious and chronic illness." The panel also described strategies to best support adults in ACP.
CONCLUSIONS: A multidisciplinary Delphi panel developed a consensus definition for ACP for adults that can be used to inform implementation and measurement of ACP clinical, research, and policy initiatives.
Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA; San Francisco Veterans Affairs Medical Center, San Francisco, California, USA. Electronic address: email@example.com.
Advance directives and outcomes of surrogate decision making before death.
Silveira MJ, Kim SY, Langa KM
N Engl J Med. 2010;362(13):1211.
BACKGROUND: Recent discussions about health care reform have raised questions regarding the value of advance directives.
METHODS: We used data from survey proxies in the Health and Retirement Study involving adults 60 years of age or older who had died between 2000 and 2006 to determine the prevalence of the need for decision making and lost decision-making capacity and to test the association between preferences documented in advance directives and outcomes of surrogate decision making.
RESULTS: Of 3746 subjects, 42.5% required decision making, of whom 70.3% lacked decision-making capacity and 67.6% of those subjects, in turn, had advance directives. Subjects who had living wills were more likely to want limited care (92.7%) or comfort care (96.2%) than all care possible (1.9%); 83.2% of subjects who requested limited care and 97.1% of subjects who requested comfort care received care consistent with their preferences. Among the 10 subjects who requested all care possible, only 5 received it; however, subjects who requested all care possible were far more likely to receive aggressive care as compared with those who did not request it (adjusted odds ratio, 22.62; 95% confidence interval [CI], 4.45 to 115.00). Subjects with living wills were less likely to receive all care possible (adjusted odds ratio, 0.33; 95% CI, 0.19 to 0.56) than were subjects without living wills. Subjects who had assigned a durable power of attorney for health care were less likely to die in a hospital (adjusted odds ratio, 0.72; 95% CI, 0.55 to 0.93) or receive all care possible (adjusted odds ratio, 0.54; 95% CI, 0.34 to 0.86) than were subjects who had not assigned a durable power of attorney for health care.
CONCLUSIONS: Between 2000 and 2006, many elderly Americans needed decision making near the end of life at a time when most lacked the capacity to make decisions. Patients who had prepared advance directives received care that was strongly associated with their preferences. These findings support the continued use of advance directives.
Veterans Affairs Center for Clinical Management Research, and Division of General Medicine, University of Michigan, Ann Arbor, USA. firstname.lastname@example.org
Moral distress of staff nurses in a medical intensive care unit.
Elpern EH, Covert B, Kleinpell R
Am J Crit Care. 2005 Nov;14(6):523-30.
BACKGROUND: Moral distress is caused by situations in which the ethically appropriate course of action is known but cannot be taken. Moral distress is thought to be a serious problem among nurses, particularly those who practice in critical care. It has been associated with job dissatisfaction and loss of nurses from the workplace and the profession.
OBJECTIVES: To assess the level of moral distress of nurses in a medical intensive care unit, identify situations that result in high levels of moral distress, explore implications of moral distress, and evaluate associations among moral distress and individual characteristics of nurses.
METHODS: A descriptive, questionnaire study was used. A total of 28 nurses working in a medical intensive care unit anonymously completed a 38-item moral distress scale and described implications of experiences of moral distress.
RESULTS: Nurses reported a moderate level of moral distress overall. Highest levels of distress were associated with the provision of aggressive care to patients not expected to benefit from that care. Moral distresswas significantly correlated with years of nursing experience. Nurses reported that moral distress adversely affected job satisfaction, retention, psychological and physical well-being, self-image, and spirituality. Experience of moral distress also influenced attitudes toward advance directives and participation in blood donation and organ donation.
CONCLUSIONS: Critical care nurses commonly encounter situations that are associated with high levels of moral distress. Experiences of moral distress have implications that extend well beyond job satisfaction and retention. Strategies to mitigate moral distress should be developed and tested.
Rush University Medical Center, Chicago, Ill., USA.
Death and end-of-life planning in one midwestern community.
Hammes BJ, Rooney BL
Arch Intern Med. 1998 Feb;158(4):383-90.
BACKGROUND: The major health care organizations in a geographically defined area implemented an extensive, collaborative advance directive education program approximately 2 years prior to this study.
OBJECTIVES: To determine for a geographically defined population the prevalence and type of end-of-life planning and the relationship between end-of-life plans and decisions in all local health care organizations, including hospitals, medical clinics, long-term care facilities, home health agencies, hospices, and the county health department.
METHODS: For more than 11 months, end-of-life planning and decisions were retrospectively studied for all adult decedents residing in areas within 5 ZIP codes. These decedents were mentally capable in the 10 years prior to death and died while under the care of the participating health care organizations. Data were collected from medical records and death certificates. Treating physicians and decedent proxies were also contacted for interviews.
RESULTS: A total of 540 decedents were included in this study. The prevalence of written advance directives was 85%. Almost all these documents (95%) were in the decedent's medical record. The median time between advance directive documentation and death was 1.2 years. Almost all advance directive documents requested that treatment be forgone as death neared. Treatment was forgone in 98% of the deaths. Treatment preferences expressed in advance directives seemed to be consistently followed while making end-of-life decisions.
CONCLUSIONS: This study provides a more complete picture of death, end-of-life planning, and decision making in a geographic area where an extensive advance directive education program exists. It indicates that advance planning can be prevalent and can effectively guide end-of-life decisions.
Gundersen Lutheran Medical Center, La Crosse, Wisconsin, USA. email@example.com