End-of-life care in hospital: current practice and potentials for improvement

From July until September 2004, all deaths were registered prospectively in all departments of Freiburg University Hospital, Germany, a large teaching hospital with approximately 55,000 inpatient admissions per year. A retrospective chart review was done for all patients who died during this time period using a tool validated in two American and Australian projects. Main outcome measures were patients' identification as dying by medical staff, Do-Not-Resuscitate (DNR) orders, and the presence of comfort care plans. The cohort comprised 226 consecutive death events. Seven percent of patients had a written advance directive. DNR orders were available for 65% of patients and were entered into the charts on average 5.9 days prior to death. Thirty-eight percent of charts had evidence that staff recognized that the patients were dying. This prognosis was noted on average 3.8 days prior to death. According to chart notes, clinicians documented cancer patients as dying more frequently than patients with cardiovascular disease (P = 0.029). In the chart entries, comfort care plans were completed fully for 14% and partially for 27% of patients. On average, comfort care plans were put in place nine days prior to death. Cancer patients had significantly more frequent comfort care plans than patients with cardiovascular diseases (P < 0.001). In 59% of medical charts, there was no evidence of a comfort plan. Approximately one-third of dying patients received active life-sustaining treatment at time of death. These data highlight the need for systematic strategies to monitor patients' needs and to improve quality of care, especially during the last four days before death.     

Advance Directives in Hospitalized Patients: A Retrospective Cohort Study

The purpose of this study was to examine processes for advance directives (ADs) in hospitalized patients to inform improvements in practice and policy. This was a retrospective study examining electronic records of 5,330 inpatients admitted over a 3-month period. During admission, 63.5% of patients were queried, with 37.2% of patients having ADs and only 14.4% available in the record. Older age and Medicare insurance were associated with having ADs. Opportunities exist for nurse practitioners to change structure and processes related to ADs improving completion and availability.     

An Interventional Study for the Early Identification of Patients With Palliative Care Needs and the Promotion of Advance Care Planning and Advance Directives

ContextPrograms identifying patients needing palliative care and promoting advance care planning (ACP) are rare in Asia.ObjectivesThis interventional cohort study aimed to identify hospitalized patients with palliative care needs using a validated palliative care screening tool (PCST), examine the ability of the PCST to predict mortality, and explore effects of a pragmatic ACP program targeted by PCST on the utilization of life-sustaining treatment during the last three months of life.MethodsIn this prospective study, we used PCST to evaluate patients' palliative care needs between 2015 and 2016 and followed patients for three months. ACP with advance directives (ADs) was systematically offered to all patients with PCST score ≥4.ResultsOf 47,153 hospitalized patients, 10.4% had PCST score ≥4. During follow-up, 2121 individuals died within three months of palliative care screening: 1225 (25.0%) with PCST score ≥4 and 896 (2.1%) with PCST score <4. After controlling for covariates, PCST score ≥4 was significantly associated with a higher mortality within three months of screening (adjusted odds ratio [AOR] 6.86; 95% CI 6.16–7.63). Moreover, ACP consultation (AOR 0.78; 95% CI 0.66–0.92) and AD completion (AOR 0.49; 95% CI 0.36–0.65) were associated with a lower likelihood of receiving life-sustaining treatments during the last three months of life.ConclusionWe demonstrated the feasibility of implementing a comprehensive palliative care program to identify patients with palliative care needs and promote ACP and AD in Eastern Asia. ACP consultation and AD completion were associated with reduced utilization of life-sustaining treatments during the last three months of life.     

医护患对实施预立医疗照护计划的态度及影响因素调查

目的调查粤北地区某三级甲等医院医护人员、恶性肿瘤患者及家属对实施预立医疗照护计划的态度及影响因素。方法采用自行设计的问卷,调查本院210名医护人员、105名恶性肿瘤患者家属及103例恶性肿瘤患者对预立医疗照护计划的态度及影响因素。结果医护人员、家属及患者对预立医疗照护计划的认知率分别为16.7%、9.5%及6.8%;赞同实施率分别为85.7%、51.4%及88.3%。不同文化程度、宗教信仰、住院经历及丧亲原因的家属对预立医疗照护计划的态度差异有统计学意义(P0.05)。医护人员、家属及患者支持实施预立医疗照护计划原因不一,其中选择较多原因为疾病长期折磨、临终时应减轻痛苦等;不支持实施预立医疗照护计划的原因医护人员选择较多为没有法律支持、应救死扶伤,家属选择较多为伦理道德问题,患者选择较多为有事未了。结论不同地区医护人员、患者及家属对预立医疗照护计划认知程度可能不同,医护人员及患者对实施预立医疗照护计划态度较家属更认可和支持,多因素影响实施预立医疗照护计划态度,实施时需综合考虑社会道德观念及法律等问题。     

Are Emergency Department Patients Thinking about Advance Directives?

Objectives : To assess the percentage of adult patients presenting to an urban ED who have a written advance directive (AD) and to determine whether age, sex, a patient's perception of his or her health status, and having a regular physician are associated with the patient's having an AD.
Methods : This was a cross-sectional patient survey performed at a community teaching hospital ED. Surveys were completed by 511 adult ED patients during representative shifts over a 3-month period. The questions included age, sex, "self-reported" health status, whether the patient had a "regular" physician, a patient-generated list of medical problems, and whether the patient had a written AD. For this study, ADs included health care proxies, living wills, and do-not-attempt-resuscitation (DNAR) orders.
Results : Of the patients surveyed, 27% reported having an AD. Males and females were equally likely to have an AD. Factors associated with an increased likelihood of having an AD were older age, having a "regular" physician, and the patient's perception of his or her health status as ill. Most patients who had an AD (82%) discussed it with their families, but only 48% discussed it with their physicians.
Conclusion : Only 27% of the adult patients presenting to the ED had an AD. Older age, the patient's perception of his or her health status as ill, and having a "regular" physician increased the likelihood of having an AD.     

Perspectives of Elderly People on Advance Directives in Japan

PURPOSE: To examine perspectives of Japanese elderly people on advance directives (ADs) and factors related to positive attitudes toward ADs. METHOD: The data were collected by a structured questionnaire from 313 of 565 older adult members of senior citizens' centers in two cities in Japan. Survey items pertained to demographic characteristics, terminal care preferences, and personal values, including autonomy, family function, and religious piety. FINDINGS: Of the 313 elderly people who completed questionnaires, 72.9% had positive preferences for executing living wills. With regard to durable power of attorney for health care, 62.2% approved of it. The supporters of ADs were more likely to have had discussions about terminal care with family members or physicians, experience of a family member hospitalized for terminal illness or injury, preferences for life-sustaining treatments that were self-determined, and personal values such as religious piety. The relationship between positive preferences toward durable power of attorney for health care and sex, marital status, and living arrangements were significant. CONCLUSIONS: Most Japanese older adults in this study approved of ADs, and family structure was important to the acceptance of designating a proxy. Discussion about end-of-life care and respect for life-sustaining treatment preferences are important decisions, about the end of life.     

Advance Directives,Medical Conditions,and Preferences for End-of-Life Care Among Physicians: 12-year Follow-Up of the Johns Hopkins Precursors Study

Context

Stability of preferences for life-sustaining treatment may vary depending on personal characteristics.

Advance Directives in Skilled Nursing Facility Residents Transferred to Emergency Departments

OBJECTIVE: Ten years have passed since Congress enacted the Patient Self-Determination Act to promote the use of advance directives (ADs). This study was performed to determine the frequency, type, demographic distribution, and utility of ADs that accompany residents of skilled nursing facilities (SNFs) transferred to emergency departments (EDs). METHODS: This was an observational, cross-sectional cohort of SNF residents, transferred to two urban, academic EDs. Chart review and physician interviews were conducted on consecutive patients arriving during 12-hour data collection shifts. RESULTS: Among 715 patients entered, 315 [44%, 95% confidence interval (95% CI) = 40% to 48%] had an AD. Advance directives were significantly more prevalent among white (50%) than African American (34%) or Hispanic (39%) patients (p < 0.001), and varied from 0% to 94% among SNFs. Of the 315 patients with ADs, do-not-resuscitate (DNR) orders were the most prevalent (65%, 95% CI = 58% to 69%). Although 75% (95% CI = 69% to 81%) of the DNR orders addressed cardiopulmonary resuscitation (CPR), only 12% (95% CI = 8% to 16%) addressed intubation. Among 39 patients who required intubation or CPR, 44% had ADs, 82% (95% CI = 57% to 96%) of which were deemed useful. CONCLUSIONS: Despite a decade of legislation promoting their use, ADs are lacking in most SNF residents transferred to EDs for evaluation and in most settings in which a clinical indication exists for intubation or CPR. Variation in their prevalence appears to be associated with both ethnicity and SNF origin. Although about three-fourths of DNR ADs addressed CPR, only about one in ten offered guidance regarding intubation. When available, ADs are used in most instances to guide emergency care.     

Nurses Preparation for Advanced Directives: An Integrative Review

Although nurses have a legal and ethical responsibility to educate and help patients complete advance directives, few nurses have a clear understanding of their role. This review integrates 19 studies published between 1990 and 2018 of the knowledge or confidence of nurses and nursing students regarding advance directives or of education on advance directives in nursing curricula. Fewer than half of working nurses demonstrated knowledge, confidence, or both regarding advance directives, and nursing programs which cover advance directives at all typically devote only 1.5?h or less to this legal document which potentially has impact on patient care and outcomes. Nurses with greater confidence regarding advance directives did not always have accurate knowledge about them. Nursing programs need more education specifically about advance directives, and more research is needed to determine what education methods can successfully address nurses' knowledge and confidence deficits.     

Concordance Between Proxy Level of Care Preference and Advance Directives Among Nursing Home Residents With Advanced Dementia: A Cluster Randomized Clinical Trial

Context

Care consistent with goals is the desired outcome of advance care planning (ACP).

Dying in Hospital: Medical Failure or Natural Outcome?

The purpose of this study was to describe patterns of medical and nursing practice in the care of patients dying of oncological and hematological malignancies in the acute care setting in Australia. A tool validated in a similar American study was used to study the medical records of 100 consecutive patients who died of oncological or hematological malignancies before August 1999 at The Canberra Hospital in the Australian Capital Territory. The three major indicators of patterns of end-of-life care were documentation of Do Not Resuscitate (DNR) orders, evidence that the patient was considered dying, and the presence of a palliative care intention. Findings were that 88 patients were documented DNR, 63 patients' records suggested that the patient was dying, and 74 patients had evidence of a palliative care plan. Forty-six patients were documented DNR 2 days or less prior to death and, of these, 12 were documented the day of death. Similar patterns emerged for days between considered dying and death, and between palliative care goals and death. Sixty patients had active treatment in progress at the time of death. The late implementation of end-of-life management plans and the lack of consistency within these plans suggested that patients were subjected to medical interventions and investigations up to the time of death. Implications for palliative care teams include the need to educate health care staff and to plan and implement policy regarding the management of dying patients in the acute care setting. Although the health care system in Australia has cultural differences when compared to the American context, this research suggests that the treatment imperative to prolong life is similar to that found in American-based studies.     

Advance directives in the primary care setting

Advance directives have been available for more than 20 years, yet only 2% of patients report having had a discussion about them with their physician. Physicians and patients appear to be reluctant to bring up the subject despite evidence that patients not only want help with advance directives, but report more satisfaction with their health care when the topic is addressed. The primary care setting is particularly well-suited to the establishment of advance directives. A clearer understanding of the benefits of advance directives to physicians and their patients can hopefully increase the use of this important health care resource.