Strategies to promote the use of advance directives in a residency outpatient practice

What is the evidence for efficacy of advance care planning in improving patient outcomes? A systematic review of randomised controlled trials

Objectives

To conduct an up-to-date systematic review of all randomised controlled trials assessing efficacy of advance care planning (ACP) in improving patient outcomes, healthcare use/costs and documentation.

Design

Narrative synthesis conducted for randomised controlled trials. We searched electronic databases (MEDLINE/PubMed, Embase and Cochrane databases) for English-language randomised or cluster randomised controlled trials on 11 May 2020 and updated it on 12 May 2021 using the same search strategy. Two reviewers independently extracted data and assessed methodological quality. Disagreements were resolved by consensus or a third reviewer.

Results

We reviewed 132 eligible trials published between 1992 and May 2021; 64% were high-quality. We categorised study outcomes as patient (distal and proximal), healthcare use and process outcomes. There was mixed evidence that ACP interventions improved distal patient outcomes including end-of-life care consistent with preferences (25%; 3/12 with improvement), quality of life (0/14 studies), mental health (21%; 4/19) and home deaths (25%; 1/4), or that it reduced healthcare use/costs (18%; 4/22 studies). However, we found more consistent evidence that ACP interventions improve proximal patient outcomes including quality of patient–physician communication (68%; 13/19), preference for comfort care (70%; 16/23), decisional conflict (64%; 9/14) and patient-caregiver congruence in preference (82%; 18/22) and that it improved ACP documentation (a process outcome; 63%; 34/54).

Conclusion

This review provides the most comprehensive evidence to date regarding the efficacy of ACP on key patient outcomes and healthcare use/costs. Findings suggest a need to rethink the main purpose and outcomes of ACP.

PROSPERO registration number

CRD42020184080.

Continuing education meetings and workshops: effects on professional practice and healthcare outcomes

BACKGROUND

Educational meetings are used widely by health personnel to provide continuing medical education and to promote implementation of innovations or translate new knowledge to change practice within healthcare systems. Previous reviews have concluded that educational meetings can result in small changes in behaviour, but that effects vary considerably. Investigations into which characteristics of educational meetings might lead to greater impact have yielded varying results, and factors that might explain heterogeneity in effects remain unclear. This is the second update of this Cochrane Review.

OBJECTIVES

• To assess the effects of educational meetings on professional practice and healthcare outcomes • To investigate factors that might explain the heterogeneity of these effects SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, ERIC, Science Citation Index Expanded (ISI Web of Knowledge), and Social Sciences Citation Index (last search in November 2016).

SELECTION CRITERIA

We sought randomised trials examining the effects of educational meetings on professional practice and patient outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. One review author assessed the certainty of evidence (GRADE) and discussed with a second review author. We included studies in the primary analysis that reported baseline data and that we judged to be at low or unclear risk of bias. For each comparison of dichotomous outcomes, we measured treatment effect as risk difference adjusted for baseline compliance. We expressed adjusted risk difference values as percentages, and we noted that values greater than zero favour educational meetings. For continuous outcomes, we measured treatment effect as per cent change relative to the control group mean post test, adjusted for baseline performance; we expressed values as percentages and noted that values greater than zero favour educational meetings. We report means and 95% confidence intervals (CIs) and, when appropriate, medians and interquartile ranges to facilitate comparisons to previous versions of this review. We analysed professional and patient outcomes separately and analysed 22 variables that were hypothesised a priori to explain heterogeneity. We explored heterogeneity by using univariate meta-regression and by inspecting violin plots.

MAIN RESULTS

We included 215 studies involving more than 28,167 health professionals, including 142 new studies for this update. Educational meetings as the single intervention or the main component of a multi-faceted intervention compared with no intervention • Probably slightly improve compliance with desired practice when compared with no intervention (65 comparisons, 7868 health professionals for dichotomous outcomes (adjusted risk difference 6.79%, 95% CI 6.62% to 6.97%; median 4.00%; interquartile range 0.29% to 13.00%); 28 comparisons, 2577 health professionals for continuous outcomes (adjusted relative percentage change 44.36%, 95% CI 41.98% to 46.75%; median 20.00%; interquartile range 6.00% to 65.00%)) • Probably slightly improve patient outcomes compared with no intervention (15 comparisons, 2530 health professionals for dichotomous outcomes (adjusted risk difference 3.30%, 95% CI 3.10% to 3.51%; median 0.10%; interquartile range 0.00% to 4.00%); 28 comparisons, 2294 health professionals for continuous outcomes (adjusted relative percentage change 8.35%, 95% CI 7.46% to 9.24%; median 2.00%; interquartile range -1.00% to 21.00%)) The certainty of evidence for this comparison is moderate. Educational meetings alone compared with other interventions • May improve compliance with desired practice when compared with other interventions (6 studies, 1402 health professionals for dichotomous outcomes (adjusted risk difference 9.99%, 95% CI 9.47% to 10.52%; median 16.5%; interquartile range 0.80% to 16.50%); 2 studies, 72 health professionals for continuous outcomes (adjusted relative percentage change 12.00%, 95% CI 9.16% to 14.84%; median 12.00%; interquartile range 0.00% to 24.00%)) No studies met the inclusion criteria for patient outcome measurements. The certainty of evidence for this comparison is low. Interactive educational meetings compared with didactic (lecture-based) educational meetings • We are uncertain of effects on compliance with desired practice (3 studies, 370 health professionals for dichotomous outcomes; 1 study, 192 health professionals for continuous outcomes) or on patient outcomes (1 study, 54 health professionals for continuous outcomes), as the certainty of evidence is very low Any other comparison of different formats and durations of educational meetings • We are uncertain of effects on compliance with desired practice (1 study, 19 health professionals for dichotomous outcomes; 1 study, 20 health professionals for continuous outcomes) or on patient outcomes (1 study, 113 health professionals for continuous outcomes), as the certainty of evidence is very low. Factors that might explain heterogeneity of effects Meta-regression suggests that larger estimates of effect are associated with studies judged to be at high risk of bias, with studies that had unit of analysis errors, and with studies in which the unit of analysis was the provider rather than the patient. Improved compliance with desired practice may be associated with: shorter meetings; poor baseline compliance; better attendance; shorter follow-up; professionals provided with additional take-home material; explicit building of educational meetings on theory; targeting of low- versus high-complexity behaviours; targeting of outcomes with high versus low importance; goal of increasing rather than decreasing behaviour; teaching by opinion leaders; and use of didactic versus interactive teaching methods. Pre-specified exploratory analyses of behaviour change techniques suggest that improved compliance with desired practice may be associated with use of a greater number of behaviour change techniques; goal-setting; provision of feedback; provision for social comparison; and provision for social support. Compliance may be decreased by the use of follow-up prompts, skills training, and barrier identification techniques.

AUTHORS' CONCLUSIONS

Compared with no intervention, educational meetings as the main component of an intervention probably slightly improve professional practice and, to a lesser extent, patient outcomes. Educational meetings may improve compliance with desired practice to a greater extent than other kinds of behaviour change interventions, such as text messages, fees, or office systems. Our findings suggest that multi-strategy approaches might positively influence the effects of educational meetings. Additional trials of educational meetings compared with no intervention are unlikely to change the review findings; therefore we will not further update this review comparison in the future. However, we note that randomised trials comparing different types of education are needed.

Advance care planning clinic: A structured clinical experience for internal medicine residents

BACKGROUND

Advance care planning (ACP) is an important step to provide medical care consistent with patients' preferences and values. Nationally, rates of ACP completion are low, and internal medicine residency clinics face additional barriers. To address this need, we implemented an ACP clinic for internal medicine residents.

METHODS

An ACP clinical experience was created for PGY2 residents beginning in 2018, with 6 total sessions, consisting of consolidated didactics, protected time to identify, outreach, and schedule patients, and two half days of dedicated ACP visits. Residents were surveyed before (end of PGY1) and after (end of PGY2) the intervention. The preceding residency class, serving as a historic control, only received the curriculum and were surveyed at the end of their PGY2 year. Electronic medical record (EMR) data was accessed to track ACP documentation.

RESULTS

The overall survey response rate was 124/134 (93%). Comparing the intervention cohort before and after the intervention, there was a significant increase in self-assessed confidence in completing ACP (2.1/4.0 vs 3.5/4.0, p < 0.01). Comparing the intervention and historic cohorts (end of PGY2), the intervention was associated with improved confidence in ability to complete ACP for their patients (3.5/4.0 vs 2.7/4.0, p < 0.01). The historic control had no increase in ACP documentation rates over time, while the intervention cohort had a 13.9% absolute increase in ACP documentation for their patients over the course of residency (p < 0.01).

CONCLUSION

The creation of an ACP-specific clinical experience, in conjunction with existing curricula, resulted in significant improvements in knowledge, self-assessed skills and behavior, and EMR documentation.

Continuing Education Outcomes for Advance Care Planning: A Systematic Review of the Literature

INTRODUCTION

Advance care planning (ACP) is a process of considering future health and care needs for a time when a person may be unable to speak for themselves. Health professional continuing education programs have been proposed for facilitating patient participation in ACP; however, their impacts on participants, patient and clinical outcomes, and organizational approaches to ACP are not well understood.

METHODS

This systematic literature review examined interventional studies of education programs conducted with health professionals and care staff across a broad range of settings. Five electronic databases were searched up to June 2020, and a manual search of reference lists was conducted. The quality of studies was appraised by the first, second, and third authors.

RESULTS

Of the 7993 articles identified, 45 articles met the inclusion criteria. Program participants were predominantly medical, nursing, and social work staff, and students. Interventions were reported to improve participants' self-perceived confidence, knowledge, and skills; however, objectively measured improvements were limited. Multimodal programs that combined initial didactic teaching and role-play simulation tasks with additional activities were most effective in producing increased ACP activity in medical records. Evidence for improved clinical outcomes was limited.

DISCUSSION

Further studies that use rigorous methodological approaches would provide further evidence about what produces improved patient and clinical outcomes. Needs analyses and quality indicators could be considered to determine the most appropriate and effective education resources and monitor their impacts. The potential contribution of a broader range of health professionals and interprofessional learning approaches could be considered to ultimately improve patient care.

Practicing Serious Illness Conversations in Graduate Medical Education

BACKGROUND

Physician trainees are not provided with routine practice opportunities to have a serious illness conversation, which includes a discussion of patient expectations, concerns, and preferences regarding an advancing illness.

OBJECTIVE

To test the acceptability of incorporating a serious illness conversation into routine trainee practice.

METHODS

Residents in an internal medicine program conducted a serious illness conversation in the ambulatory care setting with the assistance of a conversation guide. Semi-structured interviews determined trainees' perceptions of the educational intervention. Patients were surveyed to understand their experience.

RESULTS

Twenty-one trainees had at least one opportunity to practice having a serious illness conversation and completed a majority of the conversation elements. In semi-structured interviews, trainees expressed the belief that the serious illness conversation should be an important component of routine patient care, understood that patients are willing to have these conversations, discovered that patients did not have a clear understanding of their prognosis, and said that time is the main barrier to having these conversations more consistently. Patients found the conversation to be important (92%), reassuring (83%), and of higher quality than the communication of a usual doctor visit (83%).

CONCLUSIONS

With preparation, time, and a conversation guide, trainees completed the elements of a serious illness conversation and found it to be an important addition to their routine practice. Patients found the conversation to be important, reassuring, and of better quality than their usual visits.

Housestaff perceptions on training and discussing the Maryland Orders for Life Sustaining Treatment Form (MOLST)

Background

On-line tutorials are being increasingly used in medical education, including in teaching housestaff skills regarding end of life care. Recently an on-line tutorial incorporating interactive clinical vignettes and communication skills was used to prepare housestaff at Johns Hopkins Hospital to use the Maryland Orders for Life Sustaining Treatment (MOLST) form, which documents patient preferences regarding end of life care. 40% of housestaff who viewed the module felt less than comfortable discussing choices on the MOLST with patients. We sought to understand factors beyond knowledge that contributed to housestaff discomfort in MOLST discussions despite successfully completing an on-line tutorial.

Methods

We conducted semi-structured telephone interviews with 18 housestaff who completed the on-line MOLST training module. Housestaff participants demonstrated good knowledge of legal and regulatory issues related to the MOLST compared to their peers, but reported feeling less than comfortable discussing the MOLST with patients. Transcripts of interviews were coded using thematic analysis to describe barriers to using the MOLST and suggestions for improving housestaff education about end of life care discussions.

Results

Qualitative analysis showed three major factors contributing to lack of housestaff comfort completing the MOLST form: [1] physician barriers to completion of the MOLST, [2] perceived patient barriers to completion of the MOLST, and [3] design characteristics of the MOLST form. Housestaff recommended a number of adaptations for improvement, including in-person training to improve their skills conducting conversations regarding end of life preferences with patients.

Conclusions

Some housestaff who scored highly on knowledge tests after completing a formal on-line curriculum on the MOLST form reported barriers to using a mandated form despite receiving training. On-line modules may be insufficient for teaching communication skills to housestaff. Additional training opportunities including in-person training mechanisms should be incorporated into housestaff communication skills training related to end of life care.

Korean Medical Professionals' Attitudes and Experiences on Advance Care Planning for Noncancerous Disease

Background

Advance care planning (ACP) allows patients to declare their preferences for life-sustaining and hospice palliative care. However, the perception of ACP remains low in Korea. The present study assessed the attitudes and status of medical professionals in relation to end-of-life care decisions in older and noncancerous patients.

Methods

This descriptive correlation study was performed to understand the attitudes regarding and status of ACP and advance directives (AD). For this purpose, we conducted a survey of members who attended the Spring Conference of the Korean Geriatrics Society in May 2015 using a questionnaire that included questions on experiences related to AD, opinions on disturbance factors and improvement measures, and questions about the status of their medical institutions.

Results

All of 181 respondents were doctors. Among the respondents, 21.7% had the experience of treating patients who had completed an AD. Medical professionals saw AD use as appropriate for terminal patients with less than 6 months of life expectancy, as well as those with degenerative neurological disorders such as amyotrophic lateral sclerosis, chronic diseases such as chronic renal disease, and early stages of Alzheimer's disease.

Conclusion

The results showed that geriatrics medical professionals agreed with the necessity for AD in noncancerous terminal diseases and that consideration of a family-centered decision-making culture, legal protection for medical professionals, and education of the general public and medical professionals will be helpful for the popularization of AD.

Goals of Care Ambulatory Resident Education: Training Residents in Advance Care Planning Conversations in the Outpatient Setting

BACKGROUND

Advance care planning (ACP) discussions often occur in the inpatient setting when patients are too ill to participate in decision making. Although the outpatient setting is the preferred time to begin these discussions, few physicians do so in practice. Many internal medicine (IM) residents report inadequate training as a barrier to having outpatient ACP discussions.

OBJECTIVE

To assess whether a novel curriculum entitled Goals of Care Ambulatory Resident Education (GOCARE) improved resident physicians' understanding of and preparedness for conducting ACP discussions in the outpatient setting.

DESIGN

The curriculum was delivered over four weekly three-hour small group sessions to IM residents. Each session included didactics, a demonstration of skills, and a simulated patient communication laboratory that emphasized deliberate practice.

SETTING/SUBJECTS

IM residents from an urban, academic ambulatory care practice.

MEASUREMENTS

Impact of the intervention was evaluated using a retrospective pre-post design. Residents completed surveys immediately after the course and six months later.

RESULTS

Forty-two residents participated in the curriculum and 95% completed the postcourse survey. Residents' self-rated level of preparedness increased for ACP discussions overall (4.0 pre vs. 5.2 post on 7-point Likert scale) and for communication steps involved in ACP (p < 0.001). Fifty-nine percent of participants completed the six-month follow-up survey. Residents' self-rated preparedness to engage in outpatient ACP discussions remained high (4.5 pre vs. 5.5 post at six months p < 0.001). Residents also reported increased use of ACP communication skills (p < 0.001) six months later.

CONCLUSIONS

The GOCARE curriculum provides an alternative model of communication training that can be integrated into residency training and improve residents' skills in outpatient ACP discussions.

Failure of the Current Advance Care Planning Paradigm: Advocating for a Communications-Based Approach

The purpose of advance care planning (ACP) is to allow an individual to maintain autonomy in end-of-life (EOL) medical decision-making even when incapacitated by disease or terminal illness. The intersection of EOL medical technology, ethics of EOL care, and state and federal law has driven the development of the legal framework for advance directives (ADs). However, from an ethical perspective the current legal framework is inadequate to make ADs an effective EOL planning tool. One response to this flawed AD process has been the development of Physician Orders for Life Sustaining Treatment (POLST). POLST has been described as a paradigm shift to address the inadequacies of ADs. However, POLST has failed to bridge the gap between patients and their autonomous, preferred EOL care decisions. Analysis of ADs and POLST reveals that future policy should focus on a communications-based approach to ACP that emphasizes ongoing interactions between healthcare providers and patients to optimize EOL medical care to the individual patient.

Communication Tools for End-of-Life Decision-Making in Ambulatory Care Settings: A Systematic Review and Meta-Analysis

BACKGROUND

Patients with serious illness, and their families, state that better communication and decision-making with healthcare providers is a high priority to improve the quality of end-of-life care. Numerous communication tools to assist patients, family members, and clinicians in end-of-life decision-making have been published, but their effectiveness remains unclear.

OBJECTIVES

To determine, amongst adults in ambulatory care settings, the effect of structured communication tools for end-of-life decision-making on completion of advance care planning.

METHODS

We searched for relevant randomized controlled trials (RCTs) or non-randomized intervention studies in MEDLINE, EMBASE, CINAHL, ERIC, and the Cochrane Database of Randomized Controlled Trials from database inception until July 2014. Two reviewers independently screened articles for eligibility, extracted data, and assessed risk of bias. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to evaluate the quality of evidence for each of the primary and secondary outcomes.

RESULTS

Sixty-seven studies, including 46 RCTs, were found. The majority evaluated communication tools in older patients (age >50) with no specific medical condition, but many specifically evaluated populations with cancer, lung, heart, neurologic, or renal disease. Most studies compared the use of communication tools against usual care, but several compared the tools to less-intensive advance care planning tools. The use of structured communication tools increased: the frequency of advance care planning discussions/discussions about advance directives (RR 2.31, 95% CI 1.25-4.26, p = 0.007, low quality evidence) and the completion of advance directives (ADs) (RR 1.92, 95% CI 1.43-2.59, p<0.001, low quality evidence); concordance between AD preferences and subsequent medical orders for use or non-use of life supporting treatment (RR 1.19, 95% CI 1.01-1.39, p = 0.028, very low quality evidence, 1 observational study); and concordance between the care desired and care received by patients (RR 1.17, 95% CI 1.05-1.30, p = 0.004, low quality evidence, 2 RCTs).

CONCLUSIONS

The use of structured communication tools may increase the frequency of discussions about and completion of advance directives, and concordance between the care desired and the care received by patients. The use of structured communication tools rather than an ad-hoc approach to end-of-life decision-making should be considered, and the selection and implementation of such tools should be tailored to address local needs and context.

REGISTRATION

PROSPERO CRD42014012913.

Multimedia decision support intervention: a promising approach to enhance the intention to complete an advance directive among hospitalized adults

PURPOSE

We examined the acceptability and initial efficacy of a multimedia decision support (MDS) intervention to improve intention to complete an advanced directive (AD) among hospitalized adults following an episode of critical illness.

DATA SOURCES

We used comparative quasi-experimental posttest only design. Forty-nine hospitalized adults, recovering from a critical illness, received either MDS or AD educational brochure. Demographic characteristics and self-report measures of AD knowledge were captured at baseline and used as covariates. Helpfulness of the intervention (acceptability) and the outcome variable, intention to complete an AD decision, were assessed after exposure to the MDS intervention or educational brochure (information-only control condition).

CONCLUSIONS

The MDS was a more acceptable form of education compared to a brochure. After adjusting for covariates, participants exposed to the MDS intervention were 24.7 times more likely to intend to complete an AD compared to those who were assigned to the information-only control condition.

IMPLICATIONS FOR PRACTICE

This pilot study establishes the acceptability and initial efficacy of the MDS intervention among individuals with critical illness, who are at high risk for hospital readmission life-sustaining treatment. This study illuminates a teachable moment in which patients are more receptive to interventions to complete an AD.

Efficacy of advance care planning: a systematic review and meta-analysis

OBJECTIVE

To systematically review the efficacy of advance care planning (ACP) interventions in different adult patient populations.

DESIGN

Systematic review and meta-analyses.

DATA SOURCES

Medline/PubMed, Cochrane Central Register of Controlled Trials (1966 to September 2013), and reference lists.

STUDY SELECTION

Randomized controlled trials that describe original data on the efficacy of ACP interventions in adult populations and were written in English.

DATA EXTRACTION AND SYNTHESIS

Fifty-five studies were identified. Study details were recorded using a predefined data abstraction form. Methodological quality was assessed using the PEDro scale by 2 independent reviewers. Meta-analytic techniques were conducted using a random effects model. Analyses were stratified for type of intervention: 'advance directives' and 'communication.'

MAIN OUTCOMES AND MEASURES

Primary outcome measures were completion of advance directives and occurrence of end-of-life discussions. Secondary outcomes were concordance between preferences for care and delivered care, knowledge of ACP, end-of-life care preferences, quality of communication, satisfaction with healthcare, decisional conflict, use of healthcare services, and symptoms.

RESULTS

Interventions focusing on advance directives as well as interventions that also included communication about end-of-life care increased the completion of advance directives and the occurrence of end-of-life care discussions between patients and healthcare professionals. In addition, interventions that also included communication about ACP, improved concordance between preferences for care and delivered care and may improve other outcomes, such as quality of communication.

CONCLUSIONS

ACP interventions increase the completion of advance directives, occurrence of discussions about ACP, concordance between preferences for care and delivered care, and are likely to improve other outcomes for patients and their loved ones in different adult populations. Future studies are necessary to reveal the effective elements of ACP and should focus on the best way to implement structured ACP in standard care.

Improved Resident Physician Confidence With Advance Care Planning After an Ambulatory Clinic Intervention

Many primary care providers feel uncomfortable discussing end-of-life care. The aim of this intervention was to assess internal medicine residents’ advance care planning (ACP) practices and improve residents’ ACP confidence. Residents participated in a facilitated ACP quality improvement workshop, which included an interactive presentation and chart audit of their own patients. Pre- and postintervention surveys assessed resident ACP-related confidence. Only 24% of the audited patients had an advance directive (AD), and 28% of the ACP-documentation was of no clinical utility. Terminally ill patients (odds ratio 2.8, P < .001) were more likely to have an AD. Patients requiring an interpreter were less likely to have participated in ACP. Residents reported significantly improved confidence with ACP and identified important training gaps. Future studies examining the impact on ACP quality are needed.

What factors are associated with having an advance directive among older adults who are new to long term care services?

OBJECTIVES

To explore differences in having an advance directive among older adults newly transitioned to long term services and support (LTSS) settings (ie, nursing homes [NHs]; assisted living facilities [ALFs]; home and community-based services).

DESIGN

Cross sectional survey.

SETTING

LTSS in New York and Pennsylvania.

PARTICIPANTS

Participants were 470 older adults who recently started receiving LTSS. Included in this analyses, N = 442 (ALF: n = 153; NH: n = 145; home and community-based services: n = 144).

MEASUREMENTS

Interviews consisted of questions about advance directives (living will and health care power of attorney), significant health changes in the 6 months before the start of long term care support services, Mini-Mental State Examination, and basic demographics.

RESULTS

Sixty-one percent (270/442) of older adults receiving LTSS reported having either a living will and/or an health care power of attorney. ALF residents reported having an advance directive more frequently than NH residents and older adults receiving LTSS in their own home (living will: χ(2)[2]= 120.9; P < .001; health care power of attorney: χ(2)[2]= 69.1; P < .001). In multivariate logistic regression models, receiving LTSS at an ALF (OR = 5.01; P < .001), being white (OR = 2.87; P < .001), having more than 12 years of education (OR = 2.50; P < .001), and experiencing a significant health change in past 6 months (OR = 1.97; P = .007) were predictive of having a living will. Receiving LTSS at an ALF (OR = 4.16; P < .001), having more than 12 years of education (OR = 1.74, P = .022), and having had a significant change in health in the last 6 months (OR = 1.61; P = .037) were predictive in having an health care power of attorney in this population of LTSS recipients.

CONCLUSIONS

These data provide insight into advance directives and older adults new to LTSS. Future research is needed to better understand the barriers to completing advance directives before and during enrollment in LTSS as well as to assess advance directive completion changes over time for this population of older adults.

Clinical Decision Support Technology to Increase Advance Care Planning in the Primary Care Setting

Physicians are often unable to guide patients through the advance care planning (ACP) process due to cost and time constraints. We conducted a retrospective analysis in the primary care setting targeting older adults without an advance medical directive (AMD). An ACP educational packet was sent to intervention patients before their health maintenance examination (HME). Additionally, their physicians had access to a computerized clinical decision support system on AMD completion at the time of the HME. Control participants’ physicians had access to the computerized decision support system and traditional resources only. All participants who received the packet were sent a follow-up survey. In all, 21.6% of intervention participants completed an AMD, compared with 4.1% of control participants. Combining clinical decision support systems and standardized processes enhances the ACP process.

Enhancing competency in professionalism: targeting resident advance directive education

BACKGROUND

Education about advance directives typically is incorporated into medical school curricula and is not commonly offered in residency. Residents' experiences with advance directives are generally random, nonstandardized, and difficult to assess. In 2008, an advance directive curriculum was developed by the Scott & White/Texas A&M University System Health Science Center College of Medicine (S&W/Texas A&M) internal medicine residency program and the hospital's legal department. A pilot study examining residents' attitudes and experiences regarding advance directives was carried out at 2 medical schools.

METHODS

In 2009, 59 internal medicine and family medicine residents (postgraduate year 2-3 [PGY-2, 3]) completed questionnaires at S&W/Texas A&M (n  =  32) and The University of Texas Medical School at Houston (n  =  27) during a validation study of knowledge about advance directives. The questionnaire contained Likert-response items assessing attitudes and practices surrounding advance directives. Our analysis included descriptive statistics and analysis of variance (ANOVA) to compare responses across categories.

RESULTS

While 53% of residents agreed/strongly agreed they had "sufficient knowledge of advance directives, given my years of training," 47% disagreed/strongly disagreed with that statement. Most (93%) agreed/strongly agreed that "didactic sessions on advance directives should be offered by my hospital, residency program, or medical school." A test of responses across residency years with ANOVA showed a significant difference between ratings by PGY-2 and PGY-3 residents on 3 items: "Advance directives should only be discussed with patients over 60," "I have sufficient knowledge of advance directives, given my years of training," and "I believe my experience with advance directives is adequate for the situations I routinely encounter."

CONCLUSION

Our study highlighted the continuing need for advance directive resident curricula. Medical school curricula alone do not appear to be sufficient for residents' needs in this area.

Resident education and management of end-of-life care: the resident's perspective

BACKGROUND

Twenty percent of Americans die in the intensive care unit of our nation's hospitals. Many of those individuals die after life-sustaining therapy has been withdrawn or withheld. Surgeons should be competent in discussing the withholding and withdrawal of life sustaining therapy (WWLST) with their patients. We surveyed surgical residents to learn their perspectives and training experience with discussing end-of-life care and WWLST with patients.

METHODS

We mailed a survey to residents in all accredited surgical residency programs in New England. Nonresponders were contacted by mail at 3 and 6 weeks after the initial mailing.

RESULTS

Nineteen of 20 (95%) programs participated in this study. Three hundred thirty-five residents were surveyed and 141 residents responded (response rate, 42%). Ninety-two percent (n = 129) of respondents had cared for patients where WWLST had occurred, and 74% (n = 104) had initiated a discussion about WWLST themselves. Most (n = 81, 60%) respondents felt competent to discuss WWLST, whereas 14% rarely (n = 13) or never (n = 6) felt comfortable discussing WWLST. Most (n = 119, 85%) respondents believed that they would be adequately trained at the end of their residencies; however, 39% (n = 53) felt they were inadequately trained in this area. Graduates before 2002 were significantly more likely to agree strongly or generally that they would be well trained in managing WWLST when they completed residency (p = 0.006).

CONCLUSION

Almost all surgical residents will have to discuss WWLST with patients and their families, yet a significant number feel inadequately trained to do so. Steps should be taken to ensure that surgical residents can discuss WWLST as part of their core competencies, and this training should be reinforced throughout residency.

Advance care planning in the primary care setting: a comparison of attending staff and resident barriers

Advance directive completion rates remain poor in the ambulatory setting. The purpose of this study was to explore and contrast staff provider and resident physicians' experiences with advance care planning (ACP) and to identify barriers to this process in the primary care setting. A 17-item survey was administered to staff primary care providers and categorical internal medicine residents. Staff providers were more likely to discuss ACP after prompting from patients' family members (P < .02) or after a change in health status (P < .02) and were more likely to believe that non-physician members of the care team should counsel patients about ACP. The majority of respondents cited system-based barriers as major obstacles to ACP. Strategies aimed at systematizing the ACP process for both patients and providers are needed.

Continuing education meetings and workshops: effects on professional practice and health care outcomes

BACKGROUND

Educational meetings are widely used for continuing medical education. Previous reviews found that interactive workshops resulted in moderately large improvements in professional practice, whereas didactic sessions did not.

OBJECTIVES

To assess the effects of educational meetings on professional practice and healthcare outcomes.

SEARCH STRATEGY

We updated previous searches by searching the Cochrane Effective Practice and Organisation of Care Group Trials Register and pending file, from 1999 to March 2006.

SELECTION CRITERIA

Randomised controlled trials of educational meetings that reported an objective measure of professional practice or healthcare outcomes.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed study quality. Studies with a low or moderate risk of bias and that reported baseline data were included in the primary analysis. They were weighted according to the number of health professionals participating. For each comparison, we calculated the risk difference (RD) for dichotomous outcomes, adjusted for baseline compliance; and for continuous outcomes the percentage change relative to the control group average after the intervention, adjusted for baseline performance. Professional and patient outcomes were analysed separately. We considered 10 factors to explain heterogeneity of effect estimates using weighted meta-regression supplemented by visual analysis of bubble and box plots.

MAIN RESULTS

In updating the review, 49 new studies were identified for inclusion. A total of 81 trials involving more than 11,000 health professionals are now included in the review. Based on 30 trials (36 comparisons), the median adjusted RD in compliance with desired practice was 6% (interquartile range 1.8 to 15.9) when any intervention in which educational meetings were a component was compared to no intervention. Educational meetings alone had similar effects (median adjusted RD 6%, interquartile range 2.9 to 15.3; based on 21 comparisons in 19 trials). For continuous outcomes the median adjusted percentage change relative to control was 10% (interquartile range 8 to 32%; 5 trials). For patient outcomes the median adjusted RD in achievement of treatment goals was 3.0 (interquartile range 0.1 to 4.0; 5 trials). Based on univariate meta-regression analyses of the 36 comparisons with dichotomous outcomes for professional practice, higher attendance at the educational meetings was associated with larger adjusted RDs (P < 0.01); mixed interactive and didactic education meetings (median adjusted RD 13.6) were more effective than either didactic meetings (RD 6.9) or interactive meetings (RD 3.0). Educational meetings did not appear to be effective for complex behaviours (adjusted RD -0.3) compared to less complex behaviours; they appeared to be less effective for less serious outcomes (RD 2.9) than for more serious outcomes.

AUTHORS' CONCLUSIONS

Educational meetings alone or combined with other interventions, can improve professional practice and healthcare outcomes for the patients. The effect is most likely to be small and similar to other types of continuing medical education, such as audit and feedback, and educational outreach visits. Strategies to increase attendance at educational meetings, using mixed interactive and didactic formats, and focusing on outcomes that are likely to be perceived as serious may increase the effectiveness of educational meetings. Educational meetings alone are not likely to be effective for changing complex behaviours.

Engagement in multiple steps of the advance care planning process: a descriptive study of diverse older adults

OBJECTIVES

To assess engagement in multiple steps of the advance care planning (ACP) process 6 months after exposure to an advance directive. In this study, ACP is conceptualized similarly to the behavior change model.

DESIGN

Descriptive study.

SETTINGS

County general medicine clinic in San Francisco.

PARTICIPANTS

One hundred seventy-three English or Spanish speakers, aged 50 and older (mean 61) given a standard (12th-grade reading level) and an easy-to-read (5th-grade reading level) advance directive.

MEASUREMENTS

Six months after exposure to two advance directives, self-reported ACP contemplation; discussions with family, friends discussions with clinicians; and documentation were measured. Associations were examined between ACP steps and between subject characteristics ACP engagement.

RESULTS

Most participants (73%) were nonwhite and 31% had less than a high school education. Sixty-one percent contemplated ACP, 56% discussed ACP with family or friends, 22% discussed ACP with clinicians, and 13% documented ACP wishes. Subjects who had discussed ACP with their family or friends were more likely to discuss ACP with their clinicians (36% vs 2%, P<.001) and document ACP wishes (18% vs 4%, P=.009) than those who had not. Latinos and subjects with less than a high school education discussed ACP more often with family or friends (P<.06) and clinicians (P<.03) than other ethnic groups and subjects with more education.

CONCLUSIONS

ACP involves distinct steps including contemplation, discussions, and documentation. The ACP paradigm should be broadened to include contemplation and discussions. Promoting discussions with family and friends may be one of the most important targets for ACP interventions, and literacy- and language-appropriate advance directives may help reverse patterns of sociodemographic disparities in ACP.

Documentation of code status and discussion of goals of care in gravely ill hospitalized patients

BACKGROUND

Timely discussions about goals of care in critically ill patients have been shown to be important.

METHODS

We conducted a retrospective chart review over 2 years (2003-2004) of patients admitted to our medical service who were classified as "expected to die." Charts were evaluated for do-not-resuscitate (DNR) documentation and discussions of goals of care. Detailed chart reviews for demographic information, cause of death, site of death, length of stay, and duration of resuscitation attempt were performed.

RESULTS

Of 497 charts identified, 434 (87.3%) had a DNR on file at the time of death. After exclusion of patients who died in less than 24 hours, 18 no-DNR charts remained. Seven noted a decision to continue aggressive care and 11 had no code status discussion documented. Younger patients and patients with cardiovascular disease were less likely to have a DNR. Resuscitation times were longer in the no-discussion group. All patients who died without a DNR died in the intensive care unit. Seventy-six percent of discussions were done by medicine housestaff.

CONCLUSIONS

Although the overall rate of DNR documentation was high, several trends emerged. Medicine housestaff in the intensive care unit would be a logical group to target for an educational intervention to address these discrepancies.

Residency Training in Advance Care Planning: Can It Be Done in the Outpatient Clinic?

Resident physicians are expected to assist their outpatients to understand and complete advance directives, but their efficacy in doing so remains uncertain. After receiving educational training, internal medicine residents identified at-risk patients and solicited them about advance directives. Residents completed pretest and posttest questionnaires that assessed their knowledge, skills, attitude, and comfort with advance directives. Patients were also surveyed about their attitudes regarding advance directives. Ten internal medicine residents and 88 patients participated. Residents' self-assessed knowledge rose from 6.0 to 9.2 on a 10-point Likert scale. Skills using advance directives increased from 4.0 to 7.9, attitudes improved from 6.0 to 8.4, and comfort rose from 5.4 to 8.9. Eighty-four percent of patients expressed interest in completing advance directives, and 16% actually completed documents. An educational intervention improved knowledge, skills, attitudes, and comfort with advance directives among internal medicine residents practicing in the outpatient setting. Meanwhile, patients demonstrated a strong interest in completing advance directives.

An electronic medical record intervention increased nursing home advance directive orders and documentation

OBJECTIVES

To develop an electronic medical record intervention to improve documentation of patient preferences about life-sustaining care, detail of resuscitation and treatment-limiting orders, and concordance between these orders and patient preferences.

DESIGN

Prospective before-after intervention trial.

SETTING

Veterans Affairs nursing home with an electronic medical record for all clinical information, including clinician orders.

PARTICIPANTS

All 224 nursing home admissions from May 1 to October 31, 2004.

MEASUREMENTS

Completion of an advance directive discussion note by the primary clinician, clinician orders about resuscitation and other life-sustaining treatments, and concordance between these orders and documented patient preferences.

INTERVENTION

The electronic medical record was modified so that an admission order would specify resuscitation status. Additionally, the intervention alerted the primary clinician to complete a templated advance directive discussion note for documentation of life-sustaining treatment preferences.

RESULTS

Primary clinicians completed an advance directive discussion note for five of 117 (4%) admissions pre-intervention and 67 of 107 (63%) admissions post-intervention (P<.001). In multivariate analysis, the intervention was independently associated with advance directive discussion note completion (odds ratio=42, 95% confidence interval=15-120). Of patients who preferred do-not-resuscitate (DNR) status, a DNR order was written for 86% pre-intervention versus 98% post-intervention (P=.07); orders to limit other life-sustaining treatments were written for 16% and 40%, respectively (P=.01).

CONCLUSIONS

A targeted electronic medical record intervention increased completion of advance directive discussion notes in seriously ill patients. For patients who preferred DNR status, the intervention also increased the frequency of DNR orders and of orders to limit other life-sustaining treatments.

Interventions before consultations for helping patients address their information needs

BACKGROUND

Patients often do not get the information they require from doctors and nurses. To address this problem, interventions directed at patients to help them gather information in their healthcare consultations have been proposed and tested.

OBJECTIVES

To assess the effects on patients, clinicians and the healthcare system of interventions which are delivered before consultations, and which have been designed to help patients (and/or their representatives) address their information needs within consultations.

SEARCH STRATEGY

We searched: the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library (issue 3 2006); MEDLINE (1966 to September 2006); EMBASE (1980 to September 2006); PsycINFO (1985 to September 2006); and other databases, with no language restriction. We also searched reference lists of articles and related reviews, and handsearched Patient Education and Counseling (1986 to September 2006).

SELECTION CRITERIA

Randomised controlled trials of interventions before consultations designed to encourage question asking and information gathering by the patient.

DATA COLLECTION AND ANALYSIS

Two researchers assessed the search output independently to identify potentially-relevant studies, selected studies for inclusion, and extracted data. We conducted a narrative synthesis of the included trials, and meta-analyses of five outcomes.

MAIN RESULTS

We identified 33 randomised controlled trials, from 6 countries and in a range of settings. A total of 8244 patients was randomised and entered into studies. The most common interventions were question checklists and patient coaching. Most interventions were delivered immediately before the consultations.Commonly-occurring outcomes were: question asking, patient participation, patient anxiety, knowledge, satisfaction and consultation length. A minority of studies showed positive effects for these outcomes. Meta-analyses, however, showed small and statistically significant increases for question asking (standardised mean difference (SMD) 0.27 (95% confidence interval (CI) 0.19 to 0.36)) and patient satisfaction (SMD 0.09 (95% CI 0.03 to 0.16)). There was a notable but not statistically significant decrease in patient anxiety before consultations (weighted mean difference (WMD) -1.56 (95% CI -7.10 to 3.97)). There were small and not statistically significant changes in patient anxiety after consultations (reduced) (SMD -0.08 (95%CI -0.22 to 0.06)), patient knowledge (reduced) (SMD -0.34 (95% CI -0.94 to 0.25)), and consultation length (increased) (SMD 0.10 (95% CI -0.05 to 0.25)). Further analyses showed that both coaching and written materials produced similar effects on question asking but that coaching produced a smaller increase in consultation length and a larger increase in patient satisfaction. Interventions immediately before consultations led to a small and statistically significant increase in consultation length, whereas those implemented some time before the consultation had no effect. Both interventions immediately before the consultation and those some time before it led to small increases in patient satisfaction, but this was only statistically significant for those immediately before the consultation. There appear to be no clear benefits from clinician training in addition to patient interventions, although the evidence is limited.

AUTHORS' CONCLUSIONS

Interventions before consultations designed to help patients address their information needs within consultations produce limited benefits to patients. Further research could explore whether the quality of questions is increased, whether anxiety before consultations is reduced, the effects on other outcomes and the impact of training and the timing of interventions. More studies need to consider the timing of interventions and possibly the type of training provided to clinicians.

The effectiveness of interventions to increase advance directive completion rates

OBJECTIVE

Despite federal and state laws governing advance directives (ADs), interventions to increase rates of legally completed ADs have not produced significant results. This study synthesizes the state of the science regarding effectiveness of interventions to increase AD completion rates.

METHODS

Garrard's method for conducting a systematic literature review was followed. In all, 25 studies meeting inclusion criteria were reviewed. Interventions fell into two types: (a) didactic-information distributed through an educational program or clinical encounter or by a mailing and (b) interactive-person-to-person interaction where participants had the opportunity to ask questions and/or receive assistance completing the forms.

RESULTS

Postintervention rates of AD completion were: didactic = no change to 34% increase; interactive = 23% to 71% increase.

DISCUSSION

Education without the ability to ask questions does not significantly increase the AD completion rate. Didactic interventions did not usually increase completion rates higher than the predicted average rate for the general population.

Completing an advance directive in the primary care setting: what do we need for success?

OBJECTIVES

To systematically review studies designed to increase advance directive completion in the primary care setting and employ meta-analytic techniques to quantify their effects.

DESIGN

Extensive bibliographic searches of English-language literature published from January 1991 through July 2005 were conducted. Investigators abstracted prespecified information (e.g., design, study duration, types of interventions employed) and advance directive completion rates for intervention and control arms in each investigation and calculated absolute rate differences (i.e., difference in completion rates between the two groups) for each study. Individual study and pooled-effect sizes were also calculated, along with 95% confidence intervals (CIs).

SETTING

Literature review.

RESULTS

Eighteen studies were retained in the final sample. Most studies employed multimodal interventions. The most common approach consisted of educational materials directed at patients (through mailing or at visit) coupled with a patient-healthcare provider interaction in a group or individual setting (n=7). Absolute differences in completion rates varied from a high of 44% (favors intervention) to a low of -2% (favors control). Effect sizes could be calculated for 15 of the 18 studies. The pooled effect size was 0.50 (95% CI=0.17-0.83), indicating a moderate overall effect in favor of the intervention.

CONCLUSION

The majority of studies demonstrated statistically significant effects associated with the advance directive intervention. The most successful interventions incorporated direct patient-healthcare professional interactions over multiple visits. Passive education of patients using written materials (without direct counseling) was a relatively ineffective method for increasing advance directive completion rates in the primary care setting.

Evaluation of an Educational Intervention To Encourage Advance Directive Discussions between Medicine Residents and Patients

INTRODUCTION

Most medical schools are remiss in preparing physicians in end-of-life communication skills. As a result, many residents are uncomfortable with approaching the patient, have not developed the skills required to discuss the patients' wishes, and avoid end-of-life conversations.

OBJECTIVE

To evaluate an educational intervention focused on teaching residents skills to discuss advance directives.

METHODS

Medicine Residents attended a morning report consisting of both didactic training and participation in a role-play exercise. Charts of inpatients were audited ten days prior to and five days subsequent to the intervention to ascertain if there was a documented do-not-resuscitate (DNR) discussion.

RESULTS

Seventy-nine records of patients assigned to eight physicians who attended the intervention and who were responsible for patients before and after the intervention were reviewed. Of the patients assigned to these residents before the intervention, 32% had a documented DNR discussion. Thirty-four (34%) of the physicians had discussions after the intervention, demonstrating only minimal improvement.

CONCLUSIONS

A single intervention may be inadequate to affect physician practices related to DNR discussions. Physicians may need more interactive, experiential learning opportunities and related supervision over the course of their training in order to improve these communication skills. A chart review that only records if a DNR discussion was documented in the medical record may not be the best tool to evaluate the success of this educational intervention. Improvement in attitudes and knowledge were not able to be measured.

Discussing resuscitation preferences with patients: challenges and rewards

Discussing preferences regarding resuscitation is a challenging and important task for any physician. Understanding patients' wishes at the end of life allows physicians to provide the type of care patients want, to avoid unwanted interventions, and to promote patient autonomy and dignity. Hospitalists face an even greater challenge because they are often meeting a patient for the first time in a crisis situation. Despite the frequency with which clinicians have these conversations, they typically fall short when discussing code status with patients. In this evidence-based review, we discuss physician barriers to conducting effective discussions, offer a variety of approaches to enhancing these conversations, and review important communication techniques.

A practical tool to identify patients who may benefit from a palliative approach: the CARING criteria

Palliative care is often offered only late in the course of disease after curative measures have been exhausted. To provide timelier symptom management, advance care planning, and spiritual support, we propose a simple set of prognostic criteria that identifies persons near the end of life. In this retrospective cohort study of five prognostic indicators, the CARING criteria (Cancer, Admissions > or = 2, Residence in a nursing home, Intensive care unit admit with multiorgan failure, > or = 2 Noncancer hospice Guidelines), logistic regression modeling demonstrated high sensitivity and specificity for mortality at 1 year (c statistic > 0.8). A simple set of clinically relevant criteria applied at the time of hospital admission can identify seriously ill persons who have a high likelihood of death in 1 year and, therefore, may benefit the most from incorporating palliative measures into the plan of care.

Interventions to Enhance Communication among Patients, Providers, and Families

Whether patient suffering is caused by physical symptoms, unwanted medical intervention, or spiritual crisis, the common pathway to relief is through a provider who is able to elicit these concerns and is equipped to help the patient and family address them. This paper reviews the current state of knowledge in communication at the end of life, organized according to a framework of information gathering, information giving, and relationship building; and then focuses on interventions to enhance communication among patients, providers, and families. Several observations emerge from the existing literature. Patients have highly individualized desires for information and we cannot predict patient preferences. Communication coding methodology has advanced significantly yet the current systems remain poorly understood and largely inaccessible. Physicians and other health care providers do not discuss sufficiently treatment options, quality of life or respond to emotional cues from patients, and there is plenty of room for improvement. On the positive side, we have also learned that physicians and other health care providers can be taught to communicate better through intensive communication courses, and that communication interventions can improve some patient outcomes. Finally, huge gaps remain in our current knowledge, particularly with regard to understanding the relationship between communication style and outcomes. These findings suggest several recommendations. We should create larger and more diverse datasets; improve upon the analysis of recorded communication data; increase our knowledge about patient preferences for information; establish a stronger link between specific communication behaviors and outcomes; and identify more efficient ways to teach providers communication skills.

Residents' end-of-life decision making with adult hospitalized patients: a review of the literature

PURPOSE

The authors performed a structured literature review to understand residents' experiences with end-of-life (EOL) decision making with adult hospitalized patients, specifically regarding decisions to withhold or withdraw advanced life-support measures.

METHOD

An Ovid-based strategy was used to search Medline, ERIC, PsychINFO, and CINHAL databases for articles published between 1966 and February 2005, combining the domains of "resuscitation orders," "decision making," and "internship and residency." All quantitative and qualitative studies examining residents' EOL decision making with adult hospitalized patients were included. The authors developed and applied a scoring system for relevance and quality, performed data abstraction and quality assessment independently and in duplicate, then met to collate findings and identify factors in residents' EOL decision making.

RESULTS

The searches yielded 884 articles, of which 26 were included. Variable methodologies precluded meta-analysis. In these studies, residents felt unprepared to handle patient EOL decision making, although exposure to EOL discussions helped them gain confidence. Residents' attitudes, skills, and knowledge were key determinants of whether EOL decisions were addressed. Many misinterpreted the terms "DNR" and "futility." Residents' understanding of the patient EOL decision-making process could be extremely variable, and their do-not-resuscitate discussions suboptimal. Residents' lived practice experience of the patient EOL decision-making process was often at odds with what they were taught in formal curricula.

CONCLUSIONS

Educational strategies aimed at changing residents' knowledge, skills and attitude should address the hidden curriculum for the patient EOL decision-making process that is part of the experienced culture of every day practice. Future studies of this experienced culture would inform specific educational interventions.

Paradoxes in cancer patients' advance care planning

PURPOSE

To determine the frequency of advance care planning (ACP) in hospitalized cancer patients and to assess their reactions to a proposed policy in which medical housestaff would offer to discuss ACP at the time of hospital admission.

METHODS

Structured interviews with 111 consecutively admitted cancer patients on the oncology inpatient service of a tertiary care medical center.

RESULTS

We found that 69% (77/111) of patients had discussed their advance care preferences with someone, usually a family member, and 33% (37/111) had completed at least one formal advance directive (e.g., a living will or durable power of attorney for health care); 32% (36/111) had done both; and 30% (33/111) had done neither. However, only 9% (10/111) of patients reported having discussed their advance care preferences with their clinic oncologists and only 23% (23/101) of the remaining patients stated that they wished to do so. By contrast, 58% (64/110) of patients supported a policy in which medical housestaff would offer to discuss these advance care preferences as a part of the admission history.

CONCLUSIONS

Our data suggest that while oncology inpatients frequently have ACPs that they discuss with family and/or document in formal advance directives, they rarely discuss or wish to discuss these ACPs with clinic oncologists. We also show that most of the reticent patients would nevertheless consider discussing the same ACPs with admitting housestaff on the day of hospital admission.

Improving completion of advance directives in the primary care setting: a randomized controlled trial

BACKGROUND

Since 1991, hospitals have asked patients whether they have advance directives, but few patients complete these documents. We assessed two simple interventions to improve completion of advance directives among elderly or chronically ill outpatients.

METHODS

We conducted a cluster randomized controlled trial involving 1079 patients from five general medicine clinics that were affiliated with an academic medical center. Patients were either > or =70 years of age or > or =50 years old with a chronic illness. The study comprised three arms: physician reminders recommending documentation of advance directives, physician reminders plus mailing advance directives to patients together with educational literature, or neither intervention (control). The main outcome measure was completion of an advance directive.

RESULTS

After 28 weeks, 1.5% (5/332) of patients in the physician reminder group, 14% (38/277) in the physician reminder plus patient mailing group, and 1.8% (5/286) in the control group had completed advance directives. In multivariate analyses, patients in the physician reminder plus patient mailing group were much more likely than controls to have completed advance directives (odds ratio [OR] = 5.9; 95% confidence interval [CI]: 1.5 to 22), whereas patients in the physician reminder-only group were no more likely than controls to have completed advance directives (OR = 0.88; 95% CI: 0.21 to 3.7).

CONCLUSION

Mailing health care proxy and living will forms and literature to patients before an appointment at which their physicians received a reminder about advance directives yielded a small but significant improvement in completion of these documents. A physician reminder alone did not have an effect.

Influencing advance directive completion rates in non-terminally ill patients: a systematic review

PURPOSE

To conduct a systematic review of educational advance care planning interventions directed at patients without terminal illness to determine their influence on the completion rate of advance directives (AD).

MATERIALS AND METHODS

We searched MEDLINE; Cochrane Library, and reference lists of all pertinent retrieved articles for randomized trials (RCTs), restricted to English language and adults > or =18 years. Two investigators independently and in duplicate determined trial eligibility. We included published RCTs evaluating an educational intervention comprised of at least one of; written, audio, or video materials, or direct counseling, and if an outcome included AD completion rate.

RESULTS

Nine RCTs (N=3,206) were included. Overall, methodologic quality and reporting transparency were poor. The median composite quality score was 5 (range, 0-10). The odds ratios for AD completion rates ranged from 0.41 to 106.0 across the trials (test of heterogeneity P <.001). The summary odds ratio for these educational interventions was 3.71 (95% C.I. 1.46, 9.40). Trials with greater methodologic rigor and reporting transparency produced a more conservative estimate of effect, 2.42 [0.96, 6.10] versus 28.69 [5.08, 162.06] for less rigorous and poorly reported trials (P =.013).

CONCLUSIONS

Advance directive completion rates documenting patient preferences for end-of-life care may be increased by simple patient-directed educational interventions.

Advance care planning: does patient gender make a difference?

BACKGROUND

Although it has received little study, gender may significantly affect patients' attitudes about advance care planning.

METHODS

We asked 26 Mexican American (14 male, 12 female), 18 European American (7 male, 11 female), and 14 African American (7 male, 7 female) inpatients for their attitudes about advance care planning and dying. Coders of different ethnicities and genders performed independent, blinded content analyses of responses.

RESULTS

The interviews identified 40 themes. Five, including "Advance directives (ADs) improve the chances a patient's wishes will be followed," characterized both genders of all 3 ethnic groups. Although no individual themes distinguished the genders across ethnic groups, 3 meta-themes--or clusters of related themes--did. Men's end-of-life wishes addressed functional outcome alone, but women's wishes addressed other factors, too. Men felt disempowered by the health system, but women felt empowered. Men feared harm from the system, but women anticipated benefit. Each ethnic group expressed these gender differences uniquely. For example, most Mexican American men preferred death to disability, believed "the health care system controls treatment," and wanted no "futile" life support. In contrast, most Mexican American women expressed wishes only about care other than life support (especially about when and where they wanted to die), believed ADs "help staff know...(such) wishes," and trusted the system to "honor (written) ADs."

CONCLUSION

Core cultural attitudes observed in both genders of 3 ethnic groups may extend to all Americans. Although core attitudes may support advance care planning for many Americans, health professionals should consider tailoring it to other, ethnic- and gender-specific attitudes.

Palliative Care Education: An Intervention to Improve Medical Residents' Knowledge and Attitudes

BACKGROUND

Medical care at the end of life remains poor. One approach to improving end-of-life care is through education of medical trainees. However, evidence regarding the structure of an ideal educational intervention is sparse.

OBJECTIVE

To test an innovative curriculum designed to improve medical resident knowledge and decrease anxiety surrounding end-of-life care.

METHODS

Quasiexperimental study of medical trainees in a large academic internal medicine residency. Attitudes and knowledge were measured at baseline and at completion of a 1-month clinical ward rotation for both control (n = 40) and intervention groups (n = 30) using the Collett-Lester Death Anxiety Scale (C-LDAS), the Semantic Differential Scale (SDS), and a 16-question knowledge-based test. Residents in the intervention group completed four 1-hour sessions focused on end-of-life issues.

RESULTS

Baseline anxiety levels were high while knowledge scores were poor. Linear regression modeling demonstrated that pretest scores were the strongest predictor of post-test scores for all three measures. Additional significant predictors for the knowledge test were prior palliative care experience and year of training (p = 0.02), while prior palliative care experience alone contributed to the SDS model (p = 0.06). No significant improvements on the SDS, C-LDAS, or knowledge test occurred after the curriculum intervention.

CONCLUSIONS

Our classroom intervention had no significant effect on residents' attitudes towards or knowledge of end-of-life care. The fact that prior palliative care experience affects baseline scores provides a strong argument for continued research for an effective curriculum for end-of-life education, perhaps focusing on clinical rather than didactic experiences in palliative care.

Advance directive group education in a VA outpatient clinic

Advance directive education is an important social work role in many medical settings. Despite its obvious benefit in terms of time-effectiveness, group education around advance directives has received little previous attention in the social work research literature. In a retrospective cohort (n = 13,913), we compared three education strategies in an attempt to evaluate their effectiveness on advance directive completion: (1) participation in a group session, (2) one or more individual sessions with a social worker, and (3) no advance directive education. Social work education of any kind resulted in an overall completion rate of 20% versus 2.1% in the non-intervention group. Group education was twice as effective as an individual social work session, and as effective as multiple sessions, but less time consuming. Our study confirmed previous findings that older patients are more likely to complete advance directives independent of education strategy. Participants in the group sessions were also older than the rest of the cohort, leading us to hypothesize about the particular appeal of group education to older patients. We conclude that group education is an effective as well as time- and cost-efficient social work tool for facilitating completion of advance medical directives, particularly among older patients.

Education, ethics, and end-of-life decisions in the intensive care unit

OBJECTIVE

To examine the influence of education and clinical experience on residents' attitudes toward withdrawal of life support.

DESIGN

Self-administered survey.

SETTING

Four Canadian teaching hospitals.

SUBJECTS

Residents rotating through four intensive care units.

MEASUREMENTS AND MAIN RESULTS

The survey examined ethics education and experience regarding end-of-life care, importance of factors influencing withdrawal of life support, confidence in decisions, and recommendations for enhancing end-of-life education. The response rate was 83.9% (52 of 62). A minority of residents reported an appropriate amount of formal teaching on ethical principles (17.3%), patient-centered education (28.8%), and informal discussion (28.8%) before their intensive care unit rotation. During their rotation, most residents cared for patients in whom withdrawal of life support was considered. Although they usually attended family meetings, residents were never (34.6%) or rarely (42.3%) the primary discussant. Before the intensive care unit rotation, confidence in withdrawal decisions was related to male sex (p =.001) and previous patient-centered ethics education (p =.02). At the end of the intensive care unit rotation, only resident involvement in family meetings (p =.02) and being the primary discussant at such meetings (p =.01) were associated with confidence. After we adjusted for pre-rotation confidence in withdrawal of life support decision-making, the only predictor of post-rotation confidence was family meeting involvement (p <.001). Residents recommended more patient-centered discussion, observation of attending physicians discussing end-of-life issues, and opportunity to lead family meetings.

CONCLUSIONS

Experiential, case-based, patient-centered curricula are associated with resident confidence in withdrawal of life support decisions in the intensive care unit.

Completion of advance directives by older health maintenance organization members: the role of attitudes and beliefs regarding life-sustaining treatment

OBJECTIVES

This study examined whether older health maintenance organization (HMO) members' attitudes and beliefs regarding life-sustaining treatment were associated with their completion of advance directives (ADs).

DESIGN

A mailed survey of 1,247 subjects, aged 75 and older, participating in a randomized trial comparing two educational interventions designed to increase AD completion: mailed written materials versus written materials plus a videotape. AD completion was documented by medical record review.

SETTING

The initial trial took place in October 1994 at a large group-model HMO in the Denver metropolitan area. The survey was mailed to participants 3 months after the trial.

PARTICIPANTS

All HMO members aged 75 and older who received medical care at one of the medical offices (n = 1247) were mailed the survey. Participants were the 735 members who returned the survey.

MEASUREMENTS

AD completers were compared with noncompleters on survey items pertaining to attitudes and beliefs regarding life-sustaining treatment.

RESULTS

Of survey respondents, AD completers (n = 313) differed from noncompleters (n = 422) in their agreement with the following attitudinal/belief statements: (1) Putting my wishes for life-sustaining treatment in writing is too binding (completers = 12, noncompleters = 35); (2) I prefer that my family decide what kind of medical care is best for me if I should become unable to communicate my wishes (completers = 69, noncompleters = 88); and (3) My physician clearly understands my wishes for life-sustaining treatment (completers = 76, noncompleters = 43; all values, P< .0001).

CONCLUSIONS

Completers were more likely to believe that their physicians understood their wishes and less likely to think that ADs are too binding. More noncompleters wanted their family to decide, even though an AD would increase their families' ability to do so. AD completion rates might increase if they were characterized as a way to preserve flexibility in a complex medical system, help families reach amicable decisions on behalf of their loved ones, and increase patients' confidence that their physician understands their wishes for life-sustaining treatment.

Cross-cultural similarities and differences in attitudes about advance care planning

OBJECTIVE

Culture may have an important impact on a patient's decision whether to perform advance care planning. But the cultural attitudes influencing such decisions are poorly defined. This hypothesis-generating study begins to characterize those attitudes in 3 American ethnic cultures.

DESIGN

Structured, open-ended interviews with blinded content analysis.

SETTING

Two general medicine wards in San Antonio, Texas.

PATIENTS

Purposive sampling of 26 Mexican-American, 18 Euro-American, and 14 African-American inpatients.

MEASUREMENTS AND MAIN RESULTS

The 3 groups shared some views, potentially reflecting elements of an American core culture. For example, majorities of all groups believed "the patient deserves a say in treatment," and "advance directives (ADs) improve the chances a patient's wishes will be followed." But the groups differed on other themes, likely reflecting specific ethnic cultures. For example, most Mexican Americans believed "the health system controls treatment," trusted the system "to serve patients well," believed ADs "help staff know or implement a patient's wishes," and wanted "to die when treatment is futile." Few Euro Americans believed "the system controls treatment," but most trusted the system "to serve patients well," had particular wishes about life support, other care, and acceptable outcomes, and believed ADs "help staff know or implement a patient's wishes." Most African Americans believed "the health system controls treatment," few trusted the system "to serve patients well," and most believed they should "wait until very sick to express treatment wishes."

CONCLUSION

While grounded in values that may compose part of American core culture, advance care planning may need tailoring to a patient's specific ethnic views.

Training pediatric house staff in evidence-based ethics: an exploratory controlled trial

OBJECTIVE

To evaluate an educational intervention in evidence-based ethics (emphasizing clinical knowledge, epidemiologic skills, and recognition of ethical issues) administered to house staff before rotating through our neonatal intensive care unit.

STUDY DESIGN

A controlled trial of 64 pediatric house staff assigned to alternating control and intervention rotations. Questionnaires were administered at the end of the rotation.

RESULTS

Some benefits of the intervention were observed. However, a large percentage of intervention and control house staff substantially overestimated (>1.25 correct value) predischarge mortality (23% vs. 55% of house staff; p<0.02), mortality or major morbidity (74% vs. 46% of house staff; p=0.04), and cerebral palsy rates (70% vs. 87%; p=0.12). Neither group cited many methodological criteria for evaluating follow-up studies (3.3 vs. 2.4 criteria; p=0.05) or ethical issues considered in treatment recommendations for extremely premature infants (3.1 vs. 2.8 issues; p=0.35).

CONCLUSION

Improved house staff training in evidence-based ethics is needed.

State practice variations in the use of tube feeding for nursing home residents with severe cognitive impairment

OBJECTIVE

To describe the differences in prevalence of tube feeding among states and to examine possible factors that could explain practice patterns.

DESIGN

Analysis of random samples from an interstate data bank comprised of the Minimum Data Set (MDS), a standardized, federally mandated assessment instrument for nursing home residents.

SETTING

Nursing homes in four states participating in a federal demonstration project of case mix payment plus five others with existing MDS data systems.

PARTICIPANTS

Individuals 65 years of age and older (N = 57,029), who had very severe cognitive impairment, including total dependence in eating, and who resided in nursing homes during 1994, the most recent year for which uniform data were available.

MEASUREMENTS

State-by-state differences in prevalence of tube feeding, controlling for demographic and clinical variables.

RESULTS

The prevalence of tube feeding ranged from 7.5% in Maine to 40.1% in Mississippi. Each state had a significantly elevated prevalence of tube feeding compared with Maine, with odds ratios (ORs) ranging from 1.50 to 5.83, P < .001. Specific directives not to provide tube feeding (OR 0.41, P < .001), and white race (OR 0.45, P < .001) were strongly and negatively associated with tube feeding.

CONCLUSIONS

Wide regional variations exist in the use of tube feeding of nursing home residents with equivalent impairments. Sociodemographic factors could be important, but more study is needed to determine whether physician characteristics, such as race, attitudes, or knowledge, have an impact and to clarify medical standards for the use of tube feeding in this population.

Continuing education meetings and workshops: effects on professional practice and health care outcomes

BACKGROUND

Educational meetings and printed educational materials are the two most common types of continuing education for health professionals. An important aim of continuing education is to improve professional practice so that patients can receive improved health care.

OBJECTIVES

To assess the effects of educational meetings on professional practice and health care outcomes.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, MEDLINE (from 1966), the Research and Development Resource Base in Continuing Medical Education in January 1999 and reference lists of articles.

SELECTION CRITERIA

Randomised trials or well designed quasi-experimental studies examining the effect of continuing education meetings (including lectures, workshops, and courses) on the clinical practice of health professionals or health care outcomes.

DATA COLLECTION AND ANALYSIS

Two reviewers independently applied inclusion criteria, assessed the quality of each study, and extracted study data. We attempted to collect missing data from investigators. We conducted both qualitative and quantitative analyses.

MAIN RESULTS

Thirty-two studies were included with a total of 36 comparisons. The studies involved from 13 to 411 health professionals (total N= 2995) and were judged to be of moderate or high quality, although methods were generally poorly reported. There was substantial variation in the complexity of the targeted behaviours, baseline compliance, the characteristics of the interventions and the results. The heterogeneity of the results was best explained by differences in the interventions. For 10 comparisons of interactive workshops, there were moderate or moderately large effects in six (all of which were statistically significant) and small effects in four (one of which was statistically significant). For interventions that combined workshops and didactic presentations, there were moderate or moderately large effects in 12 comparisons (eleven of which were statistically significant) and small effects in seven comparisons (one of which was statistically significant). In seven comparisons of didactic presentations, there were no statistically significant effects, with the exception of one out of four outcome measures in one study.

REVIEWER'S CONCLUSIONS

Interactive workshops can result in moderately large changes in professional practice. Didactic sessions alone are unlikely to change professional practice.

A new approach to Advance Directives

OBJECTIVE

To martial arguments for listing simplified Advance Directives on the Medicare card.

DESIGN AND MAIN RESULTS

Literature review shows that 90% of patients do not have advance directives, that patients and doctors are both remiss in discussing end-of-life issues, and that Medicare, insurance companies, and hospitals do little to remedy this lapse.

CONCLUSION

A case is made for listing simplified Advance Directives on the Medicare card.