Advance Directives (ADs) have been shown to be associated with increased patient satisfaction with end-of-life care, decreased in-hospital deaths, and decreased end-of-life costs in high-cost regions. Nationally, prevalence of ADs has increased over the last 20 years, but the majority of patients still have not completed an AD. A significant obstacle to completion is lack of awareness. A presentation to increase knowledge regarding ADs among primary care staff was created to address this.https://scholarworks.uvm.edu/fmclerk/1277/thumbnail.jp

Donnelly, Laura K

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UVM ScholarWorks

University of VermontScholarWorks @ UVMFamily Medicine Clerkship Student Projects Larner College of Medicine2017Increasing Advance Directive Knowledge amongHealthcare ProfessionalsLaura K. DonnellyFollow this and additional works at: https://scholarworks.uvm.edu/fmclerkPart of the Bioethics and Medical Ethics Commons, Community Health Commons, CommunityHealth and Preventive Medicine Commons, Family Medicine Commons, Medical EducationCommons, Palliative Care Commons, Primary Care Commons, and the Public Health Educationand Promotion CommonsThis Book is brought to you for free and open access by the Larner College of Medicine at ScholarWorks @ UVM. It has been accepted for inclusion inFamily Medicine Clerkship Student Projects by an authorized administrator of ScholarWorks @ UVM. For more information, please contactdonna.omalley@uvm.edu.Recommended CitationDonnelly, Laura K., "Increasing Advance Directive Knowledge among Healthcare Professionals" (2017). Family Medicine ClerkshipStudent Projects. 238.https://scholarworks.uvm.edu/fmclerk/238Laura Donnelly, MS3Hinesburg Family PracticeMarch 2017Mentor: Dr. Michael SiroisIncreasing Advance Directive Knowledge among Healthcare ProfessionalsNationally, Advance Directive (AD) completion rates are ~25% In a 2014 survey of 8000 community-dwelling adults, 26.3% had completed an AD 67.8% expressed concerns about end-of-life care Most frequently cited reason for not having an AD was lack of awareness Those with ADs were more likely to be more educated, have a higher income, be older, and have a regular source of care when compared with those without4Population aged >65 years is projected to increase from 43.1 million to 92.0 million from 2012-2060 Population aged >85 years is projected to increase from 5.9 million to 18.2 million by 20605University of Vermont Medical Center named increasing AD utilization as a quality measureMultiple staff members at Hinesburg Family Practice identified AD awareness as an                                                   area to be improved upon Questions included: How to access the Vermont AD online registry Whether ADs were valid across state lines Applicability of ADs in emergency situationsAdvance Directives as an Area of NeedHealthcare costs increase exponentially in last year of life1 Does this increase quality of life? Is this consistent with the patient’s goals?ADs have the potential to decrease costs by limiting expensive interventions when not desired by patients Controversial ethical concerns that cutting costs may motivate use of ADsADs have been associated with lower levels of Medicare spending and lower likelihood of in-hospital death in regions with high end-of-life costs3Review found that “advanced care planning may reduce net health expenditures—despite the costs of implementation and maintenance”2Limitations2 Costs are difficult to assess No studies account for costs accrued by family/friends in providing careMany studies exclude home care costs No prospective studiesCost“I see on an ongoing basis the need for this [ADs]…the quandaries people end up in if they were not counseled on an ongoing basis. What does it [an AD] mean, allow you to do, and what kind of decisions are okay—all these answers must be conveyed to patients.”“So much of what we do is to extend life. A lot of people don’t understand that they can decide to limit treatment. The more planning you do, the less guilt your loved one will have doing the things you wished.”--Michael Sirois, M.D.Family Medicine Physician Hinesburg Family PracticeCommunity Perspective“Advance directives are, first and foremost, one of the most important parts of healthcare information. They should be stewarded by clinicians as carefully as allergies and medical history, but it is difficult to know how to chart a medical care plan.”On who needs an AD: “Everybody over the age of 18. This is not about death and dying, it is about affirming choices and affirming life. Remember, the three most famous cases in medical ethics were young women in their 20s.”On patients’ concerns about appointing a healthcare agent: “Fear of burdening someone is a barrier. Remember, the charge of a an agent is not to make decisions, but to represent the patient’s decisions…to say what the patient would say for themselves. We’re not asking you to ‘pull the plug,’ we’re asking what the patient would want.”--Sally Bliss, MSB, RNClinical Ethicist, University of Vermont Medical CenterChair of the Vermont Ethics Network Board of DirectorsCommunity Perspective15 minute PowerPoint presentation was given to office staff at Hinesburg Family Practice on March 6, 2017One week prior to this, an email was sent by the practice manager to all staff requesting attendanceOptional anonymous pre- and post-surveys assessing staff knowledge of ADs and confidence in counseling patients were administeredPresentation was made available electronically to staff unable to attendApplication for provider access to the Vermont Advance Directive Registry was completed and submitted for Hinesburg Family PracticeInterventionSurvey given prior to presentation asked staff to rate their agreement with various statements assessing knowledge and comfort with ADs (1=strongly disagree, 2=disagree, 3=neutral, 4=agree, 5=strongly agree)Identical survey was given immediately following the presentationData were analyzed using student’s t-testsComments and questions were requestedResultsMean agreement with the below statements increased following the presentation: “I can advise patients where to find resources about ADs.” (pre mean 3.6, post 4.6, p=0.12) “I understand the difference between an AD and a Do Not Resuscitate (DNR)/Clinician Orders for Life-Sustaining Treatment (COLST).” (pre mean 4.3, post mean 5.0, p=0.32)100% of those surveyed strongly agreed with the statement “I believe that ADs are an important part of patient care and well-being.”Resultsn=7Difference in mean ratings pre- and post-presentation did not reach statistical significancePossible reasons for this: Those surveyed may have started out highly knowledgeable regarding Advance Directives Staff had been at the practice for many years Sample included a disproportionate number of physicians and fewer RNs/LPNs/LNAs, who may be less familiar with ADsSurvey method was not well-suited for the setting Presentation was given during lunch hour, and staff came and went during Surveys were completed by fewer staff members than attended Two people completed a pre-presentation survey but left prior to the endUltimately, the sample size (n=7 and 5, pre- and post-) was simply too small to draw conclusionsTime constraints did not allow for more in-depth exploration of ADsFuture proposal to assess efficacy of staff education:Provide online module/PowerPoint for staff to review when convenient Electronic surveys could then been completed, allowing for greater statistical power than was possible in my assessmentLimitationsAspects of presentation worked well:Specific questions posed by staff over prior weeks were addressedNotably, question of how to access Vermont AD Registry was answered and an access code established for the practicePresentation was made available electronically for referenceComments were positiveStaff who may not otherwise be counseling patients expressed that they felt empowered to do soStaff noted that they often felt frustrated handing patients AD forms which may ever be returned; after presentation, they observed that providing AD forms still initiated an important conversation for patients and their familiesVariance of responses decreased while mean agreement with statements increased, indicating a qualitative improvement in knowledge of and comfort with ADsEfficacyAdd AD training to onboarding for new staff Future projects could create training materials for orientationDetermination of best place in the workflow to integrate advanced care planningTrain staff to identify what patients should receive the long-form ADPatients with significant co-morbidities/terminal conditions EMR could be automated to identify these patients Too involved for office visit; organize follow-up with social worker if neededEncourage staff to complete their own Advance Directives! Increases familiarity and comfort with process—complete yours, then help othersHealth measure (receive $35 for completion)Future Interventions1. Hoover, Donald R., et al. "Medical expenditures during the last year of life: findings from the 1992–1996 Medicare current beneficiary survey." Health services research 37.6 (2002): 1625-1642.2. Klingler, Corinna, Jürgen in der Schmitten, and Georg Marckmann. "Does facilitated Advance Care Planning reduce the costs of care near the end of life? Systematic review and ethical considerations." Palliative medicine 30.5 (2016): 423-433.3. Nicholas, Lauren Hersch, et al. "Regional variation in the association between advance directives and end-of-life Medicare expenditures." Jama 306.13 (2011): 1447-1453.4. Rao, Jaya K., et al. "Completion of advance directives among US consumers." American journal of preventive medicine 46.1 (2014): 65-70.5. U.S. Census Bureau. U.S. Census Bureau projections show a slower growing, older, more diverse nation a half century from now. Washington DC: Census Bureau; 2012. http://www.census.gov.ezproxy.uvm.edu/newsroom/releases/archives/population/cb12-243.html. References

Increasing Advance Directive Knowledge among Healthcare Professionals

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Increasing Advance Directive Knowledge among Healthcare Professionals

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