Why hospital patients do and do not execute an advance directive

Do Healthy People Engage With Education About Death, Dying and Advance Care Planning? An Early Evaluation of the Omega Course

Background: Death can be difficult to address personally, to discuss and to plan for. Since 2016 The Omega Course (Omega) has educated local people in Kenilworth, UK, about death and dying; broaching these issues and teaching communication skills whilst enabling social interaction. It aspires to produce practical outcomes with positive implications for end of life (EoL) planning and future neighbourhood care within the town. Aim: To investigate the impact of Omega on the attitudes and actions of participants. Method: Anonymous questionnaires, distributed by Qualtrics, or by post if preferred, were sent to 62 participants of Omega aged 22-94 two and a half years post course institution. Thematic analysis and inferential statistics were used. Results: 23 replies (37%) scored changes across 4 areas; barriers to discussion, ease discussing death, fears about death and future planning capability. All showed a significant beneficial change using a Paired Sample t-test (P< .01). Respondents noted common fears of death and dying, barriers to discussing the topic and planning for it. The course helped to allay fear, enabled discussion and encouraged planning for death and EoL. Respondents rated the course as 9.1/10 for achieving its aims. They appreciated discussing death and dying in a supportive environment and found the approach effective in developing their skills and changing attitudes. Conclusion: Omega has the potential to change attitudes towards death; promoting discussion, planning, and tackling misconceptions.

Discussing end of life wishes - the impact of community interventions?

Background

Many people do not discuss end of life preferences with those closest to them, although this can be beneficial to the individual and wider population. This study evaluated a community intervention to promote end of life preparation and discussion among people who are currently well.

Methods

A series of presentations and workshops (the intervention) were delivered to community groups and people working within health and social care. Participants were invited to complete a three-stage follow-up survey at Baseline, Post intervention and at three months' follow-up.

Results

Baseline questionnaires were completed by 498 individuals. Overall, 51% reported talking with close family or friends about their end of life care and 58% reported talking about what they would like to happen after their death. There was a significant positive relationship between increasing age group and having talked about end of life wishes. The majority of participants were already comfortable in talking about end of life (overall mean score 8.28/10). Post intervention, 73% stated that they planned to take action including 61% who planned a specific conversation and 55% who planned another action. At follow-up 64% reported that they had taken some action due to the intervention, including 43% who had talked about their own end of life preferences and 39% who had taken some other action.

Conclusions

Well-designed community-based interventions can be successful in prompting people to consider and discuss their end of life preferences.

Electronic supplementary material

The online version of this article (10.1186/s12904-019-0407-8) contains supplementary material, which is available to authorized users.

Factors that influence advance directives completion amongst terminally ill patients at a tertiary hospital in Kenya

Background

An advance directive (AD) is a written or verbal document that legally stipulates a person’s health care preference while they are competent to make decisions for themselves and is used to guide decisions on life-sustaining treatment in the event that they become incapacitated. AD can take the form of a living will, a limitation of care document, a do-not-resuscitate order, or an appointment of a surrogate by durable power of attorney. The completion rate of AD varies from region to region, and it is influenced by multiple factors. The objectives of this study were to determine the proportion of terminally ill patients with AD and to identify the factors that influence the completion of AD amongst terminally ill patients at a tertiary hospital in Kenya.

Methods

The study was a retrospective survey. All available records of terminally ill patients seen at Aga Khan University Hospital, Nairobi, between July 2010 and December 2015, and that met the inclusion criteria were included in the study.

Results

In total, 216 records of terminally ill patients were analyzed: 89 records were of patients that had AD and 127 records were of patients that did not have AD. The proportion of terminally ill patients that had completed AD was 41.2%. The factors that were associated with the completion of AD on bivariate analysis were history of ICU admission, history of endotracheal intubation, functional status of the patient, the medical specialty taking care of the patient, patient’s caregiver discussing the AD with the patient, and a palliative specialist review. On multivariate regression analysis, discussion of AD with a caregiver and patient’s functional impairment were the factors with statistically significant association with completion of AD.

Conclusions

The proportion of terminally ill patients that had AD in their medical records was significant. However, most terminally ill patients did not have AD. Our data, perhaps the first on the subject in East Africa, suggest that most of the factors associated with AD completion mirrored those seen in other regions of the world. Discussion between patient and their physician and patient’s functional impairment were the factors independently associated with completion of AD. Therefore, physicians need to be aware of the importance of discussions of AD with their patients.

Communicating End-of-Life Preferences

The purpose of this survey was to explore how adults communicate their end-of-life preferences. Face-to-face interviews were conducted with 119 community-dwelling adults who had previously engaged in conversations about their end-of-life preferences. Factors that made it easier to initiate the discussion included having personal experience with illness or death (24.4%), being straightforward (24.4%), or having someone else facilitate the discussion (11.8%). Most described vague end-of-life preferences such as not wanting any machines (41.2%) or heroics (34.5%). Although 22.7% reported using a living will to make their preferences clear, only 5.9% mentioned repeating or reinforcing their preferences. In all, 21% had discussed their end-of-life preferences with their physicians. These findings show discussions about end-of-life preferences frequently lack the clarity and detail needed by significant others and health care providers to honor the preferences. Routine dialogue with health care providers and significant others about end-of-life preferences might provide greater clarity and comfort.

Knowledge, Attitudes, and Predictors of Advance Directive Discussions of Registered Nurses

The purpose of this study was to describe nurses’ knowledge, attitudes, and experiences regarding advance directives. A secondary purpose was to examine predictors of advance directive discussions between nurses and patients. Seven-hundred and nineteen respondents, randomly selected from a list of registered nurses in the state of Ohio, completed mailed questionnaires. Descriptive t test, chi-square, and logistic regression statistics were used in the data analyses. The respondents were knowledgeable and possessed positive attitudes about advance directives. Higher self-perceived confidence in advance directive discussion skills and the experience of caring for at least one patient with a current advance directive were found to be significant predictors of advance directive discussions. These findings suggest that experience with advance directives documents is critical for nurses’ comfort and that developing interventions to further nurses’ confidence in their discussion skills may increase advance directive discussions.

Older Adults Making End of Life Decisions: An Application of Roy's Adaptation Model

Purpose. The purpose of this study was to identify variables that influenced completion of advanced directives in the context of adaptation from national data in older adults. Knowledge gained from this study would help us identify factors that might influence end of life discussions and shed light on strategies on effective communication on advance care planning. Design and Method. A model-testing design and path analysis were used to examine secondary data from 938 participants. Items were extracted from the data set to correspond to variables for this study. Scales were constructed and reliabilities were tested. Results. The final path model showed that physical impairment, self-rated health, continuing to work, and family structure had direct and indirect effects on completion of advanced directives. Five percent of the variance was accounted for by the path analysis. Conclusion. The variance accounted for by the model was small. This could have been due to the use of secondary data and limitations imposed for measurement. However, health care providers and families should explore patient's perception of self-health as well as their family and work situation in order to strategize a motivational discussion on advance directive or end of life care planning.

Advance directives, control, and quality of life for persons with disabilities

BACKGROUND

Personal control over end-of-life (EOL) care via advance care planning is a key component of high-quality care. Although this desire for control has been well documented in some populations, EOL care issues are not well understood within the disabilities community.

OBJECTIVE

The objective for this study was to describe the relationships between individual demographic characteristics, health-related quality of life, health locus of control, and attitudes toward advance directives (ADs) in individuals who are disabilities activists.

METHODS

We surveyed 55 participants attending a disability conference. Instruments included a demographic data sheet, the Advance Directive Attitude Survey (ADAS), the Multidimensional Health Locus of Control scale, and the Functional Assessment of Non-Life Threatening Conditions quality of life (QOL) scale.

RESULTS

Most participants were Hispanic females with some college education. About 46% had a disability. Group means revealed a high level of QOL (M=75.72, SD=19.09) and a positive attitude about ADs (M=66.49, SD=8.03). On the Opportunities for Treatment Choices subscale of the ADAS, activists without disabilities (M=14.23) were more positive about their control over EOL decisions than were the activists with disabilities (M=12.97) [t(2,52)=2.116, p<0.05].

CONCLUSIONS

Although participants were positive about ADs, differences in attitudes about control over opportunities for treatment choices between the nondisabled and disabled groups support previous findings that people with disabilities may have concerns regarding undertreatment for serious health conditions. Further study of EOL care issues for persons with disabilities is warranted.

Planning for Serious Illness amongst Community-Dwelling Older Adults

Older adults have long been encouraged to maintain their autonomy by expressing their wishes for health care before they become too ill to meaningfully participate in decision making. This study explored the manner in which community-dwelling adults aged 55 and older plan for serious illness. An online survey was conducted within the province of Saskatchewan, Canada, with 283 adults ranging in age from 55 to 88 years. Planning for future medical care was important for the majority (78.4%) of respondents, although only 25.4% possessed a written advance care plan and 41.5% had designated a substitute decision maker. Sixty percent of respondents reported conversations about their treatment wishes; nearly half had discussed unacceptable states of health. Associations between key predictor variables and planning behaviors (discussions about treatment wishes or unacceptable states of health; designation of a substitute decision maker; preparation of a written advance care plan) were assessed using binary logistic regression. After controlling for all predictor variables, self-reported knowledge about advance care planning was the key variable significantly associated with all four planning behaviors. The efforts of nurses to educate older adults regarding the process of advance care planning can play an important role in enhancing autonomy.

Advance directives among Korean American older adults: knowledge, attitudes, and behavior

The study objective was to explore knowledge, attitudes, and behavior about advance directives and how cultural values influence these beliefs. Three focus groups with 23 Korean American older adults were conducted. Advance directives were seen as helpful for ensuring that preferences for unwanted end-of-life treatment are honored and for relieving the decision-making burden on family members. However, some viewed completing advance directives as contrary to focusing on living. Culturally competent education about advance directives for Korean American older adults is necessary to help them make informed decisions about end-of-life care and informing family and health care providers of these preferences.

Coping styles, health status and advance care planning in patients with hematologic malignancies

This study evaluated whether measures of psychological well-being, including coping style, are associated with advance care planning (ACP). Data were from the Hematology Communications Study (HEMA-COMM), a prospective observational study of physician-patient communication in patients with hematologic malignancies. ACP was defined as having a living will, having a health care proxy, discussing life support with family or friends and discussing life support with a doctor or nurse. A total of 293 patients participated: only 45 (15%) had all the elements of ACP; 215 (73%) had at least one element of ACP, while 33 (11%) did not engage in ACP. In multivariate analysis, specific coping styles but not other measures of psychosocial well-being were associated with having written ACP. Verbal ACP was associated with patient-reported health and physician estimate of life expectancy. Our study suggests that tailoring ACP discussions to a patient's coping style may increase engagement in ACP.

Factors influencing older adults to complete advance directives

Objective:

The purpose of this study was to determine the factors which influence advance directive (AD) completion among older adults.

Method:

Direct interviews of hospitalized and community-dwelling cognitively intact patients >65 years of age were conducted in three tertiary teaching settings in New York. Analysis of AD completion focused on its correlation with demographics, personal beliefs, knowledge, attitudes, and exposure to educational media initiatives. We identified five variables with loadings of at least 0.30 in absolute value, along with five demographic variables (significant in the univariate analyses) for multiple logistic regression. The backward elimination method was used to select the final set of jointly significant predictor variables.

Results:

Of the 200 subjects consenting to an interview, 125 subjects (63%) had completed ADs. In comparing groups with and without ADs, gender (p < 0.0002), age (p < 0.0161), race (p < 0.0001), education (p < 0.0039), and religion (p < 0.0104) were significantly associated with having an AD. Factors predicting AD completion are: thinking an AD will help in the relief of suffering at the end of life, (OR 76.3,p < 0.0001), being asked to complete ADs/ or receiving explanation about ADs (OR 55.2,p < 0.0001), having undergone major surgery (OR 6.3,p < 0.0017), female gender (OR 11.1,p < 0.0001) and increasing age (76–85vs.59–75: OR 3.4,p < 0.0543; <85vs. 59–75: OR 6.3,p < 0.0263).

Significance of results:

This study suggests that among older adults, the probability of completing ADs is related to personal requests by health care providers, educational level, and exposure to advance care planning media campaigns.

Completion of Advance Directives Among Korean American and Non-Hispanic White Older Adults

This study examines completion of advance directives, highlighting ethnic differences between Korean and non-Hispanic White older adults in relation to health beliefs and knowledge. In this study, 217 community-dwelling older adults (112 Korean Americans and 105 non-Hispanic Whites) were interviewed using structured questionnaires. As compared to only 5.4% ( n = 6) of Korean American older adults, more than half of non-Hispanic White older adults (59.2%, n = 61) had completed advance directives. Health beliefs, but not knowledge, significantly mediated the relationship between ethnicity and completion of advance directives; Korean Americans had lower levels of health beliefs toward advance care planning than non-Hispanic Whites, and this in turn led to relatively lower rates of completing advance directives. Thus, it is advised that health care practice needs to encompass older adults’ health beliefs, which may be uniquely represented among different ethnic groups.

Outcomes After Hematopoietic Stem-Cell Transplantation for Hematologic Malignancies in Patients With or Without Advance Care Planning

Purpose

Engagement in advance care planning (ACP) is viewed as a way to prepare for possible death. In patients undergoing hematopoietic stem-cell transplantation (HSCT), an aggressive but possibly curative procedure for cancer, encouraging engagement in ACP is difficult. We conducted this analysis to determine if engagement in ACP among patients who undergo HSCT is associated with adverse outcomes.

Patients and Methods

Adult patients who were undergoing their first HSCT for hematologic malignancies between 2001 and 2003 were included. ACP was defined as having a living will, a power of attorney for health care, or life-support instructions. Outcomes assessed included the length of hospital stay, in-hospital mortality, and overall survival.

Results

Of the 343 patients, 172 did not have ACP, whereas 171 did have ACP, and 127 of those were reviewable. Of those with reviewable ACP, 28 patients (22%) completed ACP before cancer diagnosis, 87 (68%) completed ACP after the cancer diagnosis but before HSCT, and 12 (10%) engaged in ACP after HSCT. Patients without ACP before HSCT had a significantly greater risk of death compared with patients with ACP (hazard ratio, 2.11; 95% CI, 1.34 to 3.33; P = .001) while adjusting for statistically significant factors.

Conclusion

Our study demonstrated that lack of engagement in ACP is associated with adverse outcomes after HSCT. Thus, the patients least likely to have planned for poor outcomes are the ones most likely to face them. Additional studies should evaluate the nature of this association and should seek modifiable explanatory factors that could be the target of interventions.

Advance directives among health care professionals at a community-based cancer center

OBJECTIVE

To determine the proportion of health care professionals at our community-based cancer center who had completed advance directives (ADs) and to identify barriers to their doing so.

PARTICIPANTS AND METHODS

On October 11, 2005, we sent a Web-based survey via e-mail to 170 health care professionals who have face-to-face contacts with patients at our institution. These health care professionals included medical (physicians, n=15), associate (physician assistants and nurse practitioners, n=7), and support (nurses, radiation therapists, medical or nurse assistants, social workers, nutritionists, geneticist, chaplain, family counselor, and patient liaisons; n=148) staff members. The survey ended on October 31, 2005. For the purpose of this survey, having a written AD was defined as having both a living will and a power of attorney for health care. Key outcome measures of our study were existence of ADs, placement of ADs in the medical record, communication of ADs with loved ones and primary care physician, and factors that influenced the decision to have an AD. Statistical tests included the chi2 and Fisher exact tests.

RESULTS

Of the 170 health care professionals to whom the survey was sent, 134 (79%) responded. Although 83% reported that they had discussed their wishes regarding future life-sustaining medical care with those closest to them, only 35% had a written AD (58% of medical staff, 50% of associate staff, and 32% of support staff). Among those with ADs, 66% had informed their primary care physician, and 71% were certain that their ADs were in their medical records. Older age (P less than .001), role as medical or associate staff (P=.05), and more years of work experience with patients with cancer (P=.05) were associated with having an AD, whereas sex, marital or partnership status, and number of children were not. Perceived lack of time was the most common barrier cited (45%). Among those without an AD, 75% reported having end-of-life discussions with family members or loved ones.

CONCLUSION

Despite work experience with patients who have a high mortality rate, health care professionals at our cancer center do not adequately communicate (via a written AD) end-of-life planning decisions to their own primary care physicians.

Developing a Parsimonious Model for Predicting Completion of Advance Directives

PURPOSE

To develop a theory-based model to assist nurses in promoting self-determination for completion of an advance directive (AD).

DESIGN AND METHODS

This descriptive study included data from a convenience sample of 118 community-dwelling older adults in Tennessee, USA. Multinomial logistic regression was used to estimate the influence of 15 factors and covariates on completion of an AD.

FINDINGS

The parsimonious model had three significant factors: receiving AD information; attitude index; and health literacy score. Participants were highly likely to complete ADs if they had positive attitudes toward ADs and had received information on ADs. As health literacy increased, the likelihood that participants completed ADs was reduced. This model explained 25% of the variation in AD completion. Chi-square fit for the parsimonious model was highly significant.

CONCLUSIONS

Of 15 factors and covariates that could influence completion of an AD, only receiving information about ADs, having positive attitudes toward ADs, and health literacy significantly affected the likelihood of participants completing ADs. More study is needed on this model and how nurses can assist patients with end-of-life decisions.

Developmental and contextual correlates of elders' anticipated end-of-life treatment decisions

The purpose of this study was to gain insight into developmental and contextual correlates of the aggressiveness in treatment that community-based elders anticipate they will desire at the end of life. Elders completed questionnaires to measure 4 developmental factors (integrated moral reasoning, self-transcendence, past experience with life-threatening illness, and age) and five contextual factors (education level, gender, ethnicity, current health status, and completion of a living will). The variance in desired aggressiveness in treatment was explained by both developmental and contextual correlates. Integrated moral reasoning emerged as a new variable to consider in gaining understanding of the process of end-of-life decisions.

Attitudes of Critically Ill Filipino Patients and Their Families Toward Advance Directives

• Background Advance directives are important but often underused tools in critical care. Healthcare professionals’ understanding of how culture influences attitudes toward advance directives can improve knowledge and completion of these documents.

• Objective To understand the attitudes of critically ill Filipino American patients and their families toward advance directives.

• Methods A descriptive, correlational, cross-sectional study with a convenience sample of 22 Filipino American patients and 22 Filipino American family members at a West Coast medical center. All patients were admitted for cardiac surgery or cardiac interventions. Participants were interviewed with the Advance Directive Attitude Survey and A Short Acculturation Scale for Filipino Americans.

• Results Family members’ scores were significantly more positive than patients’ scores on the attitude survey (P = .01). Family members were more American acculturated than were patients (P = .001). Family members with more education had more positive attitudes toward advance directives (P = .02). Only 2 patients (and no family members) had completed an advance directive before the study. Only 27.3% of family members had prior knowledge of advance directives.

• Conclusion Overall attitudes toward advance directives were positive; however, the completion rate and knowledge of advance directives were low. Participants may have been saying what they thought the researcher wanted to hear in order to avoid disagreement. Such behavior could partly explain the positive attitudes of the Filipino Americans toward advance directives. Further research is warranted to understand how to increase completion rates for advance directives among Filipino Americans.

The Personal and Social Context of Planning for End-of-Life Care

OBJECTIVES

To examine the potential facilitators of or deterrents to end-of-life planning for community-dwelling older adults, including personal (health-related and sociodemographic) and social (physician and family) influences.

DESIGN

In-person interviews with older adults, telephone interviews with physicians and family members.

SETTING

Cleveland, Ohio.

PARTICIPANTS

Two hundred thirty-one adults aged 65 to 99 who were aging in place, 99 of their primary care physicians, and 127 of their family members.

MEASUREMENTS

Questions assessing older adults' discussions with others about end-of-life plans, implementation of advance directives, and physical (Older American Resources and Services) illness index and mental (Short Portable Mental Status Questionnaire) health status.

RESULTS

Just fewer than half of older adults had executed an advance directive and discussed their wishes with others. Only personal characteristics of elderly individuals were related to end-of-life plans, with whites, unmarried individuals, and younger adults more likely to have made preparations. Older adults' health status, as evaluated by the patient, physician, and caregiver, did not relate to the tendency to have made advance care plans. Older adults' family members were much more likely to report knowledge of advance care plans than were physicians.

CONCLUSION

These findings suggest that many physicians are not talking with their patients about their end-of-life wishes. Furthermore, the propensity to have such discussions may relate more to the personal preferences and level of comfort of patients, physicians, and family members than on the health status of the older adult.

Legal and ethical issues in end-of-life care

Advances in medical technology during the past 3 decades altered the scenarios of our dying. It is now possible to prolong life, with the frightening reality that we also can extend death. This paper examines challenges to dying well in America, defines key end-of-life dilemmas faced by critical care nurses, and examines legal and ethical issues related to dying persons' care. These issues include patients' decision-making capacity and right to refuse treatment; withholding and withdrawing life-sustaining treatment, including nutrition and hydration; "no code" decisions; medical futility; and assisted suicide. Implications for critical care practice, education, research and public policy are identified.

Perceptions about advance directives by nurses in a community hospital

Despite the legal mandate for hospitals to comply with the Patient Self-Determination Act and recommendations by the American Nurses' Association for nurses to advocate for the participation of patients in end-of-life decisions, nurses' compliance has been less than enthusiastic. This study used an exploratory descriptive design and a 10-item self-reported questionnaire, which included both multiple-choice and open-ended questions. This study examined nurses' knowledge and comfort with the implementation of the Patient Self-Determination Act. An analysis of this research shows that two major themes emerged: a need for more education involving advance directives and a desire to have other healthcare workers involved in informing patients about advance directives.