Chronic Obstructive Pulmonary Disease (COPD) and Advance Directives

The purpose of this study was to determine if Chronic Obstructive Pulmonary Disease (COPD) patients use advance directives. Since the PSDA (Patient Self Determination Act) was passed in 1990, the use of advance directives has low numbers. This study utilized the model of Joyce Travelbees (Tomey & Alligood, 1998) human-to-human-relationship theory which emphasizes attaining a rapport with the patient after progressing through the original encounter, emerging identities, having sympathy and empathy. Twenty-five COPD subjects were given a quantitative cross sectional survey at a suburban hospital in Michigan, which included demographic information such as: age, gender, education, marital status and insurance. The subjects completed a self-report questionnaire about advance directives including questions such as: do you have an advance directive and who gave you information about advance directives. This study used SPSS (Statistical Package for the social sciences) for analyzing the data. The results showed that most subjects were > 65 years of age, had a high-school education, were female, and were married. Results for this study also revealed that a high number of the subjects did not have an advanced directive. Implications for theory, practice and research are related to the results. Of special importance is that healthcare workers, including nurse practitioners, should continue to support advance directives in their professional practice.Master'sSchool of Health Professions and Studies: NursingUniversity of Michiganhttp://deepblue.lib.umich.edu/bitstream/2027.42/117767/1/WilliamsMel.pd

Implementation of an Advance Directive Protocol in a Primary Care Setting

Despite the passage of the Patient Self-Determination Act in 1992, only 15% of the United States population has completed an advance directive (AD). This statistic will be exaggerated with the future growth of older adults in the year 2030, at which time this portion of the population is expected to double to 72.1 million people. Without an AD, patients lose their autonomy and may be subjected to costly, life prolonging treatments that they would never choose for themselves. The unnecessary costs and unwanted treatment are preventable with an AD, and primary care providers are in a prime position to initiate AD discussions when patients are in good health and capable of making these decisions. Evidence suggests that if primary care providers and office staff were trained in patient advance care planning (ACP) and provided an AD guideline to follow, then heath care providers would engage in patient AD discussions. Thus, the purpose of this evidence based practice (EBP) project was to determine whether an AD Engagement Protocol which focused on patient’s level of AD readiness, along with health care provider and office staff education, impacted staff attitudes and promoted engagement of AD discussion at the EBP target site. To guide this EBP project system change, the Stetler Model and the Transtheoretical Model were utilized. Patient demographic data were collected and the engaged patient’s level of readiness was assessed per provider. Attitudes were measured using the tool, A Brief Survey About Staff Attitudes Related to Advanced Directives. Data analysis was completed using descriptive statistics, and paired t-tests identified the differences in provider and staff attitudes about ADs before and after project intervention. Attitudes about ADs improved to a statistically significant level post-intervention (p = .0004). All health care providers positively engaged in ACP discussions with eligible patient participants at a rate exceeding 50%

How do general practitioners conceptualise advance care planning in their practice? : a qualitative study

Objectives : To explore how GPs conceptualise advance care planning (ACP), based on their experiences with ACP in their practice. Methods : Five focus groups were held with 36 GPs. Discussions were analysed using a constant comparative method. Results : Four overarching themes in the conceptualisations of ACP were discerned: (1) the organisation of professional care required to meet patients' needs, (2) the process of preparing for death and discussing palliative care options, (3) the discussion of care goals and treatment decisions, (4) the completion of advance directives. Within these themes, ACP was both conceptualised in terms of content of ACP and/or in terms of tasks for the GP. A specific task that was mentioned throughout the discussion of the four different themes was (5) the task of actively initiating ACP by the GP versus passively waiting for patients' initiation. Conclusions : This study illustrates that GPs have varying conceptualisations of ACP, of which some are more limited to specific aspects of ACP. A shared conceptualisation and agreement on the purpose and goals of ACP is needed to ensure successful implementation, as well as a systematic integration of ACP in routine practice that could lead to a better uptake of all the important elements of ACP

Improving Goals of Care Conversations with High Risk Heart Failure Patients

Background: Heart failure (HF) is a progressive, chronic disease that can be complicated or caused by pulmonary hypertension (PH). Goals of Care Conversations (GoCCs) are discussions to: identify a healthcare surrogate, initiate and review advance directives, and refer for palliative care consultation. Providers struggle with determining HF prognosis and initiating GoCCs. Gagne Combined Comorbidity Score prognosticates a one-year mortality risk. Purpose: Implementation of an electronic prognostication tool, Gagne Score, for clinicians to identify and increase documentation of GoCCs with high-risk HF patients. Design: Pre- and Post-intervention quality improvement (QI) project at an ambulatory clinic to evaluate use of a prognostication tool in improving documentation of GoCCs with HF patients. Methods: Prior to each clinic, providers notified of high-risk HF patients, identified using prognostication tool. Medical record data on provider documentation of four aspects of GoCCs: presence and review of advance directives, documented healthcare surrogates, and referral for palliative care consultation, collected for nine weeks pre and post intervention. Demographic and medical data on PH patients treated during pre and post intervention. Demographic, education and experience data collected by survey from provider participants. Descriptive statistics, chi square analysis, and t-tests used to compare documentation of GoCCs pre- and post-intervention. Results: Providers were female, specialized in cardiology with 26 � 8.5 years of experience, including a physician, clinical nurse specialist, and nurse practitioner. No differences existed in age, gender, ethnicity, PH diagnosis, or Gagne Score for patients treated during pre and post intervention. Documentation of GoCCs was significantly greater post intervention compared to pre-intervention (0%, n=0/47 and 88%, n=35/40 respectively, p<0.001). Documentation of each of the four aspects of GoCCs was variable with the greatest improvement in documentation of healthcare surrogate and review of advance directives. Referral for palliative care consultation remained low (0%, n=0/47 and 0%, n=0/40). Conclusion: Implementation of an electronic prognostication tool using Gagne Score was effective in increasing documentation of GoCCs in 3 criteria of GoCCs: advance directives, healthcare surrogate, and reviewing of previously completed advance directives. Referral for palliative care did not increase with this intervention and indicates an area for improvement

Integrative Review for Identifying Patients Appropriate for End-of-Life Care Interventions by

Background: End of life is defined as the last 12 months before a person dies, with 1% of the total population passing each year. Primary care providers can predict end of life and implement interventions. Early identification of patients for palliative care prevents crises, meets the needs of patients and families, and reduces the cost of healthcare. Screening for end-of-life care needs in primary care using the Gold Standards Framework (GSF) and the Prognostic Indicator Guidance (PIG) tool/surprise question will minimize risk of missed interventional opportunities. Purpose: This educational intervention served to increase provider knowledge of the GSF and PIG, and supplied providers with resources for screening patients for end-of-life care needs. Presentation and Toolkit: An educational presentation of this integrative review and resource packet was given to providers and staff in a primary care clinic. The packet contained current evidence, statistics, references, and resources available for patients and providers. The DNP student created an end-of-life care screening algorithm and an adapted screening tool, both of which were embedded in the resource packet. Outcomes/Discussion: The DNP student successfully met the desired outcomes. Pre- (100%) and post-presentation (73%) surveys revealed a 100% increase in provider knowledge regarding the GSF, PIG, surprise question, and available resources. Respondents (100%) said they would use the packet and felt confident doing so. The algorithm was deemed helpful, easy to use and satisfied the providers desire for guidance in this process. Implications/Conclusion: Implications for future practice include the effective and efficient use of the resource packet for early identification of end-of-life patients in primary care. The DNP student is available to consult and assist with implementation of the packet into practice. Keywords: Gold Standards Framework, palliative care, end of life, surprise questio

Advance Directive Advocacy: Empowering Homeless Clients to Express Their End-of-Life Wishes

abstract: As Baby Boomers age, the number of older homeless patients facing end of life is increasing. Homeless individuals die of the same diseases as their domiciled counterparts, but they have distinct barriers to equitable end-of-life care, such as lack of regular medical care, a higher likelihood of comorbid serious mental illness and substance abuse, alienation from potential healthcare proxies, and specific fears related to dying. Completion of an advance directive (AD) would address many of these barriers, as well as national goals of reducing medical costs associated with end of life care. A review of the literature indicates that homeless individuals, once educated on the purpose and significance of ADs, complete them at a higher rate than non-homeless people. Further, racial and ethnic disparities in document completion are minimized with educational interventions about an AD’s purpose. King’s Theory of Goal Attainment provides the theoretical basis for the application of such an intervention in the setting of a medical respite center and a day resource center that both serve the homeless. Thirty-seven clients of the two sites and 14 staff members were administered a pre-and post-test measuring attitudes and knowledge relating to ADs on a Likert scale, resulting in an increase in knowledge about one of the two documents that traditionally comprise an AD, while not significantly affecting attitudes. Implications for practice include an inexpensive intervention that does not require a medically trained individual to deliver, enabling a broad application to a variety of settings with the goal of empowering a traditionally disenfranchised population to make health decisions related to the most vulnerable of life passages

Comparing Engagement in Advance Care Planning Between Stages of Heart Failure

Indiana University-Purdue University Indianapolis (IUPUI)Heart failure is a terminal disease with an unpredictable trajectory. Family members of patients with heart failure are often called upon to make decisions about treatment and end of life care, sometimes with little guidance as to the patients’ wishes. Advance care planning (ACP) is an ongoing process by which patients make decisions about their future healthcare. Only about one-third of patients with heart failure have participated in ACP, which is a similar percentage to the overall population. Despite increased focus on ACP and interventions to improve it, the rates of ACP in the population remain relatively unchanged. There is a need to develop interventions that are targeted based on patient engagement in the process rather than the existing broad-based interventions. The purpose of this dissertation study is to examine the relationship between the American Heart Association stage of heart failure and readiness to engage in advance care planning. The study consisted of mailed surveys that consisted of demographic questionnaires and the Advance Care Planning Engagement Survey. Engagement was analyzed in relation to heart failure stage, heart failure class, comorbidities, perception of health status, recent hospitalizations, making healthcare decisions for others, and demographic variables. The results demonstrated that although there was no significant association between heart failure stage or class and engagement in advance care planning, there were significant associations between medical comorbidities and advance care planning engagement. Other significantly associated participant characteristics included age, gender, education, ethnicity, and income. Findings suggest that people with multiple comorbid conditions will be more likely to be ready to engage in ACP than those with fewer health conditions. The results from this study will contribute to the development of strategies to improve advance care planning that are targeted based on engagement level

Implementing Point-of-Care Tools to Increase Advance Care Planning Discussions Among Older Adults

Background: The adult population 65 years of age and older is increasing, but a lack of advance care planning discussions has led to poor completion of advance directives. Advance directives express one’s medical wishes once they are not able to make their own decisions and are approaching the end of their life. Advance directives prevent futile care that patients do not want. Problem: Lack of knowledge, lack of time, and unwillingness to discuss advance directives prevent providers from including advance care planning in their current workflow. Advance directives are important to provide in the long-term care setting, as these patients often have multiple comorbidities and are at higher risk for hospital readmission. Methods: Participants included patients aged 65 and older who are residents of a skilled nursing and rehab facility. They must be admitted for at least one week and be able to make their own medical decisions. Intervention: The DNP project leader initiated advance care discussions using the PREPARE conversation guide. Patients received an advance care discussion guide published by PREPARE and reviewed it with the DNP project leader and family members. Completion of the advance directive was measured at the time of and one week after the intervention. Results: There was a statistically significant increase in post-implementation advanced directive completion scores compared to baseline completion scores (p = .006) Conclusion: The PREPARE point-of-care tools improved completion of advance directives and aided in advance care planning discussions in older adults