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Umberfield EE, Fields MC, Lenko R, Morgan TP, Adair ES, Fromme EK, Lum HD, Moss AH, Wenger NS, Sudore RL, Hickman SE. An Integrative Review of the State of POLST Science: What Do We Know and Where Do We Go? J Am Med Dir Assoc 2024; 25:557-564.e8. [PMID: 38395413 PMCID: PMC10996838 DOI: 10.1016/j.jamda.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 02/25/2024]
Abstract
OBJECTIVES POLST is widely used in the care of seriously ill patients to document decisions made during advance care planning (ACP) conversations as actionable medical orders. We conducted an integrative review of existing research to better understand associations between POLST use and key ACP outcomes as well as to identify directions for future research. DESIGN Integrative review. SETTING AND PARTICIPANTS Not applicable. METHODS We queried PubMed and CINAHL databases using names of POLST programs to identify research on POLST. We abstracted study information and assessed study design quality. Study outcomes were categorized using the international ACP Outcomes Framework: Process, Action, Quality of Care, Health Status, and Healthcare Utilization. RESULTS Of 94 POLST studies identified, 38 (40%) had at least a moderate level of study design quality and 15 (16%) included comparisons between POLST vs non-POLST patient groups. There was a significant difference between groups for 40 of 70 (57%) ACP outcomes. The highest proportion of significant outcomes was in Quality of Care (15 of 19 or 79%). In subdomain analyses of Quality of Care, POLST use was significantly associated with concordance between treatment and documentation (14 of 18 or 78%) and preferences concordant with documentation (1 of 1 or 100%). The Action outcome domain had the second highest positive rate among outcome domains; 9 of 12 (75%) Action outcomes were significant. Healthcare Utilization outcomes were the most frequently assessed and approximately half (16 of 35 or 46%) were significant. Health Status outcomes were not significant (0 of 4 or 0%), and no Process outcomes were identified. CONCLUSIONS AND IMPLICATIONS Findings of this review indicate that POLST use is significantly associated with a Quality of Care and Action outcomes, albeit in nonrandomized studies. Future research on POLST should focus on prospective mixed methods studies and high-quality pragmatic trials that assess a broad range of person and health system-level outcomes.
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Affiliation(s)
- Elizabeth E Umberfield
- Division of Nursing Research, Department of Nursing, Mayo Clinic, Rochester, MN, USA; Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, MN, USA.
| | - Matthew C Fields
- School of Nursing, Indiana University, Indianapolis, IN, USA; Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA
| | - Rachel Lenko
- Department of Nursing, School of Health, Calvin University, Grand Rapids, MI, USA
| | - Teryn P Morgan
- Center for Biomedical Informatics, Regenstrief Institute, Inc, Indianapolis, IN, USA; Department of BioHealth Informatics, School of Informatics and Computing, Indiana University, Indianapolis, IN, USA
| | | | - Erik K Fromme
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Ariadne Labs at Brigham and Women's Hospital and the Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Hillary D Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alvin H Moss
- Center for Health Ethics and Law, West Virginia University Health Sciences Center, Morgantown, WV, USA; Divisions of Nephrology and Palliative Medicine, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA; San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Susan E Hickman
- School of Nursing, Indiana University, Indianapolis, IN, USA; Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA; Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, USA
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Rocha Tardelli N, Neves Forte D, de Oliveira Vidal EI. Advance Care Planning in Brazil. Z Evid Fortbild Qual Gesundhwes 2023; 180:43-49. [PMID: 37380546 DOI: 10.1016/j.zefq.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/10/2023] [Accepted: 04/18/2023] [Indexed: 06/30/2023]
Abstract
Brazil is a country of continental size marked by extreme social inequalities. Its regulation of Advance Directives (AD) was not enacted by law but within the scope of the norms that govern the relationships between patients and physicians, as a resolution of the Federal Medical Council without any specific requirement for notarization. Despite this innovative starting point, most of the debate regarding Advance Care Planning (ACP) in Brazil has been dominated by a legal transactional approach focused on making decisions in advance and the creation of AD. Yet, other novel ACP models have recently emerged in the country with a focus on the creation of a specific quality of relationship between patients, families, and physicians aiming at the facilitating future decision-making. Most of the education on ACP in Brazil happens in the context of palliative care courses. As such, most ACP conversations are performed within palliative care services or by healthcare professionals with training in that area. Hence, the scarce access to palliative care services in the country means that ACP is still rare and that those conversations usually happen late in the course of disease. The authors posit that the existing paternalistic healthcare culture is one of the most important barriers to ACP in Brazil and envision with great concern the risk that its combination with extreme health inequalities and the lack of healthcare professionals' education on shared decision-making could lead to the misuse of ACP as a form of coercive practice to reduce healthcare use by vulnerable populations.
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Affiliation(s)
- Natália Rocha Tardelli
- Geriatrics division, Internal Medicine Department, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil.
| | - Daniel Neves Forte
- Emergency Department, University of São Paulo (USP) Medical School, São Paulo, Brazil; Research and Teaching Institute, Sírio-Libanês Hospital, São Paulo, Brazil
| | - Edison Iglesias de Oliveira Vidal
- Geriatrics division, Internal Medicine Department, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil
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3
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Vranas KC, Plinke W, Bourne D, Kansagara D, Lee RY, Kross EK, Slatore CG, Sullivan DR. The influence of POLST on treatment intensity at the end of life: A systematic review. J Am Geriatr Soc 2021; 69:3661-3674. [PMID: 34549418 DOI: 10.1111/jgs.17447] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/04/2021] [Accepted: 08/06/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Despite its widespread implementation, it is unclear whether Physician Orders for Life-Sustaining Treatment (POLST) are safe and improve the delivery of care that patients desire. We sought to systematically review the influence of POLST on treatment intensity among patients with serious illness and/or frailty. METHODS We performed a systematic review of POLST and similar programs using MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database for Systematic Reviews, and PsycINFO, from inception through February 28, 2020. We included adults with serious illness and/or frailty with life expectancy <1 year. Primary outcomes included place of death and receipt of high-intensity treatment (i.e., hospitalization in the last 30- and 90-days of life, ICU admission in the last 30-days of life, and number of care setting transitions in last week of life). RESULTS Among 104,554 patients across 20 observational studies, 27,090 had POLST. No randomized controlled trials were identified. The mean age of POLST users was 78.7 years, 55.3% were female, and 93.0% were white. The majority of POLST users (55.3%) had orders for comfort measures only. Most studies showed that, compared to full treatment orders on POLST, treatment limitations were associated with decreased in-hospital death and receipt of high-intensity treatment, particularly in pre-hospital settings. However, in the acute care setting, a sizable number of patients likely received POLST-discordant care. The overall strength of evidence was moderate based on eight retrospective cohort studies of good quality that showed a consistent, similar direction of outcomes with moderate-to-large effect sizes. CONCLUSION We found moderate strength of evidence that treatment limitations on POLST may reduce treatment intensity among patients with serious illness. However, the evidence base is limited and demonstrates potential unintended consequences of POLST. We identify several important knowledge gaps that should be addressed to help maximize benefits and minimize risks of POLST.
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Affiliation(s)
- Kelly C Vranas
- Health Services Research & Development, VA Portland Health Care System, Portland, Oregon, USA.,Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, Oregon, USA.,Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Section of Pulmonary and Critical Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Wesley Plinke
- Oregon Health & Science University School of Medicine, Portland, Oregon, USA
| | - Donald Bourne
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Devan Kansagara
- Health Services Research & Development, VA Portland Health Care System, Portland, Oregon, USA.,Division of General Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Robert Y Lee
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Erin K Kross
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Christopher G Slatore
- Health Services Research & Development, VA Portland Health Care System, Portland, Oregon, USA.,Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, Oregon, USA.,Section of Pulmonary and Critical Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Donald R Sullivan
- Health Services Research & Development, VA Portland Health Care System, Portland, Oregon, USA.,Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, Oregon, USA.,Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon, USA
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Smirdec M, Jourdain M, Guastella V, Lambert C, Richard JC, Argaud L, Jaber S, Klouche K, Medard A, Reignier J, Rigaud JP, Doise JM, Chabanne R, Souweine B, Bourenne J, Delmas J, Bertrand PM, Verdier P, Quenot JP, Aubron C, Eisenmann N, Asfar P, Fratani A, Dellamonica J, Terzi N, Constantin JM, Van Lander A, Guerin R, Pereira B, Lautrette A. Impact of advance directives on the variability between intensivists in the decisions to forgo life-sustaining treatment. Crit Care 2020; 24:672. [PMID: 33267904 PMCID: PMC7709386 DOI: 10.1186/s13054-020-03402-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/20/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND There is wide variability between intensivists in the decisions to forgo life-sustaining treatment (DFLST). Advance directives (ADs) allow patients to communicate their end-of-life wishes to physicians. We assessed whether ADs reduced variability in DFLSTs between intensivists. METHODS We conducted a multicenter, prospective, simulation study. Eight patients expressed their wishes in ADs after being informed about DFLSTs by an intensivist-investigator. The participating intensivists answered ten questions about the DFLSTs of each patient in two scenarios, referring to patients' characteristics without ADs (round 1) and then with (round 2). DFLST score ranged from 0 (no-DFLST) to 10 (DFLST for all questions). The main outcome was variability in DFLSTs between intensivists, expressed as relative standard deviation (RSD). RESULTS A total of 19,680 decisions made by 123 intensivists from 27 ICUs were analyzed. The DFLST score was higher with ADs than without (6.02 95% CI [5.85; 6.19] vs 4.92 95% CI [4.75; 5.10], p < 0.001). High inter-intensivist variability did not change with ADs (RSD: 0.56 (round 1) vs 0.46 (round 2), p = 0.84). Inter-intensivist agreement on DFLSTs was weak with ADs (intra-class correlation coefficient: 0.28). No factor associated with DFLSTs was identified. A qualitative analysis of ADs showed focus on end-of-life wills, unwanted things and fear of pain. CONCLUSIONS ADs increased the DFLST rate but did not reduce variability between the intensivists. In the decision-making process using ADs, the intensivist's decision took priority. Further research is needed to improve the matching of the physicians' decision with the patient's wishes. Trial registration ClinicalTrials.gov Identifier: NCT03013530. Registered 6 January 2017; https://clinicaltrials.gov/ct2/show/NCT03013530 .
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Affiliation(s)
- Margot Smirdec
- Department of Anaesthesiology and Critical Care Medicine, Estaing Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Mercé Jourdain
- INSERM U1190, CHU Lille, Department of Critical Care Medicine, Roger Salengro Hospital, Univ. Lille, 59000, Lille, France
| | - Virginie Guastella
- Palliative Care Unit, Louise Michel Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Céline Lambert
- Biostatistics Unit (DRCI), University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Jean-Christophe Richard
- Medical Intensive Care Unit, La Croix Rousse Hospital, University Hospital of Lyon, Lyon, France
| | - Laurent Argaud
- Medical Intensive Care Unit, Edouard Herriot Hospital, University Hospital of Lyon, Lyon, France
| | - Samir Jaber
- Department of Anaesthesiology and Critical Care Medicine, Saint Eloi Hospital, University Hospital of Montpellier, Montpellier, France
| | - Kada Klouche
- Medical Intensive Care Unit, Lapeyronnie Hospital, University Hospital of Montpellier, Montpellier, France
| | - Anne Medard
- Cardiac Surgery Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, Montpied Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Jean Reignier
- Medical Intensive Care Unit, Hotel-Dieu Hospital, University Hospital of Nantes, Nantes, France
| | | | - Jean-Marc Doise
- Intensive Care Unit, Morey Hospital, Hospital of Chalon-Sur-Saône, Chalon-sur-Saône, France
| | - Russell Chabanne
- Neurocritical Care Unit, Department of Anaesthesiology and Critical Care Medicine, Montpied Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Bertrand Souweine
- Medical Intensive Care Unit, Montpied Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Jeremy Bourenne
- Emergency Intensive Care Unit, La Timone Hospital, University Hospital of Marseille, Marseille, France
| | - Julie Delmas
- Intensive Care Unit, Puel Hospital, Hospital of Rodez, Rodez, France
| | | | | | - Jean-Pierre Quenot
- Medical Intensive Care Unit, Mitterrand Hospital, University Hospital of Dijon, Dijon, France
| | - Cecile Aubron
- Medical Intensive Care Unit, Centre Hospitalier Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Nathanael Eisenmann
- Intensive Care Unit, Centre Jean Perrin, 54 Rue Montalembert, BP69, 63003, Clermont-Ferrand, Cedex 1, France
| | - Pierre Asfar
- Medical Intensive Care Unit, Larrey Hospital, University Hospital of Angers, Angers, France
| | - Alexandre Fratani
- Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, Saint-Louis Hospital, Assistance Publique Hopitaux de Paris, Paris, France
| | - Jean Dellamonica
- Medical Intensive Care Unit, l'Archet Hospital, University Hospital of Nice, Nice, France
| | - Nicolas Terzi
- Medical Intensive Care Unit, Michallon Hospital, University Hospital of Grenoble, Grenoble, France
| | - Jean-Michel Constantin
- GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Axelle Van Lander
- UPU ACCePPt, Université Clermont Auvergne, Clermont-Ferrand, France.,EA-481, Laboratoire de Neurosciences, UBFC, Besançon, France
| | - Renaud Guerin
- Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, Estaing Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics Unit (DRCI), University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Alexandre Lautrette
- Intensive Care Unit, Centre Jean Perrin, 54 Rue Montalembert, BP69, 63003, Clermont-Ferrand, Cedex 1, France. .,LMGE «Laboratoire Micro-Organismes: Génome Et Environnement», UMR CNRS 6023, Clermont-Auvergne University, Clermont-Ferrand, France. .,Intensive Care Medicine, Montpied Teaching Hospital, 54 Rue Montalembert, BP69, 63003, Clermont-Ferrand, Cedex 1, France.
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Lovadini GB, Fukushima FB, Schoueri JFL, Reis RD, Fonseca CGF, Rodriguez JJC, Coelho CS, Neves AF, Rodrigues AM, Marques MA, Bassett R, Steinberg KE, Moss AH, Vidal EIO. To What Extent Do Physician Orders for Life-Sustaining Treatment (POLST) Reflect Patients' Preferences for Care at the End of Life? J Am Med Dir Assoc 2020; 22:334-339.e2. [PMID: 33246840 DOI: 10.1016/j.jamda.2020.10.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/09/2020] [Accepted: 10/10/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess whether medical orders within Physician Orders for Life-Sustaining Treatment (POLST) forms reflect patients' preferences for care at the end of life. DESIGN This cross-sectional study assessed the agreement between medical orders in POLST forms and the free-form text documentation of an advance care planning conversation performed by an independent researcher during a single episode of hospitalization. SETTING AND PARTICIPANTS Inpatients at a single public university hospital, aged 21 years or older, and for whom one of their attending physicians provided a negative answer to the following question: "Would I be surprised if this patient died in the next year?" Data collection occurred between October 2016 and September 2017. MEASURES Agreement between medical orders in POLST forms and the free-form text documentation of an advance care planning conversation was measured by kappa statistics. RESULTS Sixty-two patients were interviewed. Patients' median (interquartile range) age was 62 (56-70) years, and 21 patients (34%) were women. Overall, in 7 (11%) cases, disagreement in at least 1 medical order for life-sustaining treatment was found between POLST forms and the content of the independent advance care planning conversation. The kappa statistic for cardiopulmonary resuscitation was 0.92 [95% confidence interval (CI): 0.82-1.00]; for level of medical intervention, 0.90 (95% CI: 0.81-0.99); and for artificially administered nutrition, 0.87 (95% CI: 0.75-0.98). CONCLUSIONS AND IMPLICATIONS The high level of agreement between medical orders in POLST forms and the documentation in an independent advance care planning conversation offers further support for the POLST paradigm. In addition, the finding that the agreement was not 100% underscores the need to confirm frequently that POLST medical orders accurately reflect patients' current values and preferences of care.
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Affiliation(s)
- Gustavo B Lovadini
- Botucatu Medical School, Sao Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil
| | - Fernanda B Fukushima
- Botucatu Medical School, Sao Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil
| | - Joao F L Schoueri
- Botucatu Medical School, Sao Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil
| | - Roberto Dos Reis
- Botucatu Medical School, Sao Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil
| | - Cecilia G F Fonseca
- Botucatu Medical School, Sao Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil
| | - Jahaira J C Rodriguez
- Botucatu Medical School, Sao Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil
| | - Cauana S Coelho
- Botucatu Medical School, Sao Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil
| | - Adriele F Neves
- Botucatu Medical School, Sao Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil
| | - Aniela M Rodrigues
- Botucatu Medical School, Sao Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil
| | - Marina A Marques
- Botucatu Medical School, Sao Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil
| | - Rick Bassett
- Center for Nursing Excellence, St Luke's Health System, Boise, ID, USA
| | - Karl E Steinberg
- California State University, Institute for Palliative Care, Oceanside, CA, USA
| | - Alvin H Moss
- Center for Health Ethics and Law, West Virginia University, Morgantown, WV, USA
| | - Edison I O Vidal
- Botucatu Medical School, Sao Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil.
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7
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Heyland DK. Advance Care Planning (ACP) vs. Advance Serious Illness Preparations and Planning (ASIPP). Healthcare (Basel) 2020; 8:E218. [PMID: 32708449 DOI: 10.3390/healthcare8030218] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 07/07/2020] [Accepted: 07/10/2020] [Indexed: 11/16/2022] Open
Abstract
COVID-19 has highlighted the reality of an impending serious illness for many, particularly for older persons. Those faced with severe COVID-19 infection or other serious illness will be faced with decisions regarding admission to intensive care and use of mechanical ventilation. Past research has documented substantial medical errors regarding the use or non-use of life-sustaining treatments in older persons. While some experts advocate that advance care planning may be a solution to the problem, I argue that the prevailing understanding and current practice of advance care planning perpetuates the problem and results in patients not receiving optimal patient-centered care. Much of the problem centers on the framing of advance care planning around end of life care, the lack of use of decision support tools, and inadequate language that does not support shared decision-making. I posit that a new approach and new terminology is needed. Advance Serious Illness Preparations and Planning (ASIPP) consists of discrete steps using evidence-based tools to prepare people for future clinical decision-making in the context of shared decision-making and informed consent. Existing tools to support this approach have been developed and validated. Further dissemination of these tools is warranted.
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