Advance directives are important clinical tools for assuring that patient’s end-of-life goals are met. Earlier referrals to palliative and hospice care through health care planning could better assist Vermonters in attaining their care goals. This project sought to improve advance directive completion in Vermont, increase awareness of health care planning among patients, and aid discussion between patients and providers in the clinic.https://scholarworks.uvm.edu/fmclerk/1483/thumbnail.jp

Petrow, Eva

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University of VermontScholarWorks @ UVMFamily Medicine Clerkship Student Projects Larner College of Medicine2018Motivating Patients to Complete AdvanceDirectivesEva PetrowUVM Larner College of MedicineFollow this and additional works at: https://scholarworks.uvm.edu/fmclerkPart of the Medical Education Commons, and the Primary Care 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 CitationPetrow, Eva, "Motivating Patients to Complete Advance Directives" (2018). Family Medicine Clerkship Student Projects. 409.https://scholarworks.uvm.edu/fmclerk/409  Motivating Patients to Complete Advance Directives   Charlotte, VT Eva Petrow, MS3 Rotation #2 (May 7th– June 15th, 2018) Project Mentor: Andrea Regan, MD 1 Background   Advance directives are important clinical tools for assuring that patient’s end-of-life goals are met, and are associated with several positive outcomes:    One multisite prospective study of  332 patients with advanced cancer demonstrated lower rates of  aggressive interventions at the end of  life and earlier hospice care referrals.1    90% of  people say that it is important to talk to their loved ones about end-of-life care, but only 27% have had such a conversation.3   80 percent of  Vermonters would prefer to die at home, but in actuality 50 percent die in a hospital and 27 percent die in a nursing home. Earlier referrals to hospice care could better assist Vermonters in attaining their end-of-life goals. Among those enrolled in hospice, 76 percent die at home.2   Only 26.3% of  Americans have completed an advance directive.4   Patients often have difficulty completing advance directives for a variety of  reasons, including negative perception of  advance care planning by some, difficulty formulating personal preferences, and bureaucratic fatigue.  2 Cost Benefits   25.1% of  Medicare spending is used in the last year of  a patient’s life.5   Lower levels of  Medicare spending have been associated with use of  advance directives specifying limitations on interventions.6    Studies suggest that hospice and advance directives can save 25% to 40% of  health care costs during the last month of  life.7   We should encourage patients to utilize hospice care and advanced care planning, as they are cost effective options which encourage patient participation in health care decisions at the end-of-life.7  3 Community Perspectives   Community experts discussed potential barriers and strategies for motivating patients to complete advance directives:    Cindy Bruzzese, Executive Director and Clinical Ethicist, the Vermont Ethics Network:    “I think it is worth mentioning that people can undertake this process in steps (and frankly that is what is recommended—use the tool/form that is right for you and where you are in the Advance Care Planning process)…you need not complete every section of  the form.  People can customize it to meet their needs.”    [Name Withheld], Legal Nursing Consultant, Clinical Ethics Department, the University of Vermont Medical Center:    “It helps your husband, wife, and kids get an idea of  what you want. I would stress the fact that it doesn’t need to be completely filled out. You only need to include the parts you think are important to you or important to your kids. You can leave parts blank and can fill out more later if  you want to. Patients often have questions they don’t know the answer to. They can think about it, talk about it and come back to it later. It’s one less thing for your family to worry about as you work on getting better.”   Carolyn Kulik, Director, Charlotte Senior Center:    In discussing a need for advance directive discussions in the community, Ms. Kulik stated “I am sure some could benefit” and that currently the Charlotte Senior Center does “not specifically” offer health-related programming to seniors. Ms. Kulik suggested that a future survey of  Charlotte seniors may best assess their educational needs on the topic of  health care planning.   4 Intervention   A single-paged double-sided educational pamphlet for patients was provided at each routine wellness visit. This pamphlet contained both educational information as well as motivational guidance for completing advance directives.    Educational topics included: the purpose and content of  the advance directive, where to find blank templates, who should receive copies of  a patient’s advance directive, and other frequently asked questions.   Motivational points included: expression of  personal preferences, decreasing stress and conflict among loved ones in deciding health care, making decisions about what matters the most to patients, and having important conversations with loved ones that can bring them closer together.   A 2-3 minute introductory conversation about advance directives was offered in conjunction with the pamphlet, which explained the purpose of  the document.    Patients were given blank advance directive “short form” to complete at home.    5 Response   This intervention increased awareness of  health care planning among patients and highlighted the importance of  completing these forms at home.    Clinicians at Charlotte Family Health Center expressed positive responses to this intervention. They felt the pamphlet aided in streamlining visit flow and provided additional resources and information for patients that could not be covered within the time constraints of  the standard wellness visit. Quotes from Patients at the Charlotte Family Health Center:   “It’s never too early to start writing an [advance directive]. It settles any possible confusion.”    “You need to think about someone’s life choices as a medical decision as well as a deeply personal and family decision.”   “Having a doctor who asks the right questions at the right time can really empower the family to plan for end of  life decisions.”   6 Effectiveness and Limitations   Brochures are easy to read at an average educational level, contain minimal medical language, and are presented in an inviting format.   Combining a provider conversation with an educational pamphlet increases the overall effectiveness of  this intervention.   Limiting factors include brevity of  provider conversation, limited distribution of  brochures and lack of  established follow-up after initial advance directive conversation.  7 Recommendations for Future Interventions   Following the success of  this limited intervention, pamphlets could be more widely distributed to multiple clinics throughout Chittenden County, Vermont.    Continue to assess the utility of  this measure through focused patient interviews pre-intervention and post-intervention. Incorporate useful patient feedback into future versions of  this pamphlet.    Educate providers about how and when to begin discussing hospice care with patients who are nearing the end of  life, in conjunction with advance directive use.   8 References 1.  Wright AA, Zhang B, Ray A, et al. Associations Between End-of-Life Discussions, Patient Mental Health, Medical Care Near Death, and Caregiver Bereavement Adjustment. JAMA. 2008;300(14):1665-1673. doi:10.1001/jama.300.14.1665. 2.  Vermont General Assembly. No. 60. An act relating to hospice and palliative care, http://www.leg.state.vt.us/DOCS/2012/ACTS/ACT060.PDF. 3.  The Conversation Project National Survey. 2013. theconversationproject.org. 4.  Rao JK, Anderson LA, Lin F, Laux JP. Completion of advance directives among U.S. consumers. Am J Prev Med. 2014 Jan; 46(1): 65-70. 5.  Riley GF, Lubitz JD. Long-term trends in Medicare payments in the last year of life. Health Serv Res. 2010 Apr; 45(2):565–76. 6.  Nicholas LH, Langa KM, Iwashyna TJ, Weir DR. Regional variation in the association between advance directives and end-of-life Medicare expenditures. JAMA. 2011 Oct; 306(13):1447-53. 7.  Emanuel EJ. Cost savings at the end of life What do the data show?. JAMA. 1996 Jun 26;275(24):1907-14. PubMed PMID: 8648872.  9 

Motivating Patients to Complete Advance Directives

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Motivating Patients to Complete Advance Directives

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