Study of the factors influencing the preparation of advance directives

The aim of the study is to analyze the factors influencing the decision to prepare advance directives (AD) related to socio-demographic situation, health status, degree of dependence, healthcare characteristics and psychosocial aspects. This is a case-control study conducted using a personal interview. We compared 123 subjects who had completed AD with 123 subjects who had not and who belonged to two health centers in the Albacete Health District. Study variables included self-perceived health, functional status, morbidity, socio-demographic characteristics, use of health services, attitudes toward AD and psychosocial aspects. We found a predominance of women (64.2%) among those who prepared AD, with a mean age of 53.3 years. Preparing AD was associated with secondary or higher education (OR = 2.5), a lifestyle other than living with a partner and with children (OR = 2.5), chronic medication use (OR = 3.2), higher than average number of specialist visits (OR = 4.0), a longer-term relationship with the family physician (OR = 3.5), a family history of having AD (OR = 17.3) and with lower levels of social interaction (OR = 3.0). The results suggest that several factors, resulting from both the socio-demographic situation and health or functional status, can affect the decision to formalize AD.     

Timing and facilitation of advanced directives in Japan

ObjectivesThis study aimed to reveal Japanese elders' perspective on optimal timing and method of receiving unified guidance about advance directives (AD).MethodsWe convened 202 elders (average age 66) to learn about end-of-life at Kyoto University. They listened to a presentation and viewed two videos on advance care planning and AD; then 167 completed detailed questionnaires about unified timing and methods of providing such information.ResultsA majority of Japanese elders (79%) agreed with unified guidance in combination with the issue of health insurance cards at age 65 or 75. The most preferred method for receiving information was video presentation.ConclusionsJapanese elders appear to welcome the idea of receiving information about AD when they are issued health insurance cards at age 65 or 75. Use of video materials holds great promise for educating elderly Japanese about their choices on AD.     

Medical decision making for older adults: an international perspective comparing the United States and India

There has been a significant decline in cardiovascular morbidity and mortality amidst pervasive advances in care, including percutaneous revascularization, mechanical circulatory support, and transcatheter valvular therapies. While advancing therapies may add significant longevity, they also bring about new end-of-life decision-making challenges for patients and their families who also must weigh the advantages of reduced mortality to the possibility of longer lives consisting of high morbidity, frailty, pain, and poor quality of living. Advance care entails options of withholding or withdrawing therapies, and has become a familiar part of cardiovascular care for older patients in Western countries. However, as advanced cardiovascular practices extend to developing countries, the interrelated concept of advance care is rarely straight forward as it is affected by local cultural traditions and mores, and can lead to very different inferences and use. This paper discusses the concepts of advance care planning, surrogate decision-making, orders for resuscitation and futility in patients with cardiac disease with comparisons of West to East, focusing particularly on the United States versus India.     

Knowledge regarding advance care planning: A systematic review

BackgroundLack of knowledge is one of the main reasons for the low rates of completion of Advance Care Planning (ACP).ObjectiveThe purpose of this study was to systematically review the existing literature on knowledge regarding Advance Care Planning.MethodsA systematic search of the literature was made in CINHAL, AgeLine, PubMed, PsyINFO and SocINDEX, from 1994 till May 2016.ResultsWe identified 37 articles that satisfied the inclusion criteria: 35 were quantitative, one was qualitative and one used mixed methods. Most of the studies (n = 23) were conducted in the United States and participants in most of the studies (n = 22) were professionals. A variety of aspects of ACP were examined, regarding subjective and objective knowledge. Seventeen studies found that participants knew some aspects of ACP, but didn’t know others. Inconsistencies were found in the types of instruments and the number of items used to assess knowledge.ConclusionsMore effort should be invested in increasing knowledge regarding ACP among professionals and lay people. Developing validated tools to measure objective and subjective knowledge in both populations might be a first step in this direction.     

End‐of‐life communication in Korean older adults: With focus on advance care planning and advance directives

The present article aimed to provide a comprehensive review of current status of end‐of‐life (EOL) care and sociocultural considerations in Korea, with focus on the EOL communication and use of advance directives (AD) in elderly Koreans. Through literature review, we discuss the current status of EOL care and sociocultural considerations in Korea, and provide a look‐ahead. In Korea, patients often receive life‐sustaining treatment until the very end of life. Advance care planning is rare, and most do‐not‐resuscitate decisions are made between the family and physician at the very end of patient's life. Koreans, influenced mainly by Confucian tradition, prefer a natural death and discontinuation of life‐sustaining treatment. Although Koreans generally believe that death is natural and unavoidable, they tend not to think about or discuss death, and regard preparation for death as unnecessary. As a result, AD are completed by just 4.7% of the general adult population. This situation can be explained by several sociocultural characteristics including opting for natural death, wish not to burden others, preference for family involvement and trust in doctor, avoidance of talking about death, and filial piety. Patients often receive life‐sustaining treatment until the very EOL, advance care planning and the use of AD is not common in Korea. This was related to unique sociocultural characteristics of Korea. A more active role of physicians, development of a more deliberate EOL discussion process, development of culturally appropriate AD and promotion of advance care planning might be required to provide good EOL care in Korea. Geriatr Gerontol Int 2016; 16: 407‐415.     

Completion of advance directives by older health maintenance organization members: the role of attitudes and beliefs regarding life-sustaining treatment

OBJECTIVES: This study examined whether older health maintenance organization (HMO) members' attitudes and beliefs regarding life-sustaining treatment were associated with their completion of advance directives (ADs). DESIGN: A mailed survey of 1,247 subjects, aged 75 and older, participating in a randomized trial comparing two educational interventions designed to increase AD completion: mailed written materials versus written materials plus a videotape. AD completion was documented by medical record review. SETTING: The initial trial took place in October 1994 at a large group-model HMO in the Denver metropolitan area. The survey was mailed to participants 3 months after the trial. PARTICIPANTS: All HMO members aged 75 and older who received medical care at one of the medical offices (n = 1247) were mailed the survey. Participants were the 735 members who returned the survey. MEASUREMENTS: AD completers were compared with noncompleters on survey items pertaining to attitudes and beliefs regarding life-sustaining treatment. RESULTS: Of survey respondents, AD completers (n = 313) differed from noncompleters (n = 422) in their agreement with the following attitudinal/belief statements: (1) Putting my wishes for life-sustaining treatment in writing is too binding (completers = 12, noncompleters = 35); (2) I prefer that my family decide what kind of medical care is best for me if I should become unable to communicate my wishes (completers = 69, noncompleters = 88); and (3) My physician clearly understands my wishes for life-sustaining treatment (completers = 76, noncompleters = 43; all values, P< .0001). CONCLUSIONS: Completers were more likely to believe that their physicians understood their wishes and less likely to think that ADs are too binding. More noncompleters wanted their family to decide, even though an AD would increase their families' ability to do so. AD completion rates might increase if they were characterized as a way to preserve flexibility in a complex medical system, help families reach amicable decisions on behalf of their loved ones, and increase patients' confidence that their physician understands their wishes for life-sustaining treatment.     

From advance directives to advance care planning: current legal status, ethical rationales and a new research agenda

This paper uses a case example to review the current legal status of advance directives, as well as their ethical rationale. We draw attention to ongoing efforts to institutionalize advance directives, and to some of the tractable and intractable reasons why advance directives are ineffective. We then introduce the concept of advance care planning, and argue that we should not assume that advance care directives have a place in this process. We conclude by offering three reasons why this assumption may operate, and by suggesting that contingency and uncertainty may sometimes overwhelm all rational approaches to medical care.     

A comparison of preferences of elderly patients for end-of-life period and their relatives' perceptions in Thailand

BackgroundGoal of palliative care is to experience a good death. Understanding the perceptions of elderly patients and their relatives about this issue should provide healthcare professionals with practical guidance in order to achieve this goal.ObjectivesTo determine and compare the perceptions of elderly patients and relatives regarding wishes during their end-of-life(EOL) period.MethodsThis was a cross-sectional study conducted at Siriraj and Srinagarind Hospital in Thailand from September 2017 to February 2018. A questionnaire was given to elderly patients and the relatives of them. The patients were asked to respond to the questions as though they were terminally-ill patients, and relatives were asked to imagine how elderly people would respond to the questions.ResultsWe recruited 608 elderly patients and 607 relatives. The most important issue in both groups was“receiving the full truth about their illnesses”. The perceptions of the patients and relatives differed significantly in 8/13 areas covered in the questionnaire. Independent factors associated with preference for home death were elderly from Khon Kaen (adjusted odds ratio (AOR) 2.6;95%CI 1.7,4.1), previous self-employed/general work compared to individuals who did not work (AOR 0.5;95%CI 0.3,0.9), low educational level (AOR 2.3;95%CI 1.3,4.0), low income (AOR 1.7;95%CI 1.1,2.5), greater family size (AOR 1.7;95%CI 1.1,2.6) and dissatisfaction in life (AOR 2.5;95%CI 1.1,5.4).ConclusionReceiving the full truth about their illnesses was the most important issue for participants in both groups. The major differences between the two groups had to do with autonomy. Factors influencing place of death were location of patients, previous occupation, educational level, family income, family size and dissatisfaction in life.     

Hospital resource utilization and presence of advance directives at the end of life for adults with congenital heart disease

Objective: Overall health care resource utilization by adults with congenital heart disease has increased dramatically in the past two decades, yet little is known about utilization patterns at the end of life. The objective of this study is to better under‐ stand the patterns and influences on end‐of‐life care intensity for adults with con‐ genital heart disease.
Methods: We identified a sample of adults with congenital heart disease (n = 65), cancer (n = 10 784), or heart failure (n = 3809) who died between January 2010 and December 2015, cared for in one multi‐hospital health care system. We used multi‐ variate analysis to evaluate markers of resource utilization, location of death, and documentation of advance care planning among patients with congenital heart dis‐ ease versus those with cancer and those with heart failure.
Results: Approximately 40% of adults with congenital heart disease experienced in‐ patient and intensive care unit (ICU) hospitalizations in the last 30 days of life; 64% died in the hospital. Compared to patients with cancer, patients with adult congenital heart disease (ACHD) were more likely to have inpatient (adjusted risk ratio 1.57; 95% CI 1.12‐2.18) and ICU admissions in the last 30 days of life (adjusted risk ratio 2.56; 95% CI 1.83‐3.61), more likely to die in the hospital (adjusted risk ratio 1.75; 95% CI 1.43‐2.13), and more likely to have documentation of advance care planning (adjusted risk ratio 1.46; 95% CI 1.09‐1.96). Compared to patients with heart failure (HF), patients with ACHD were less likely to have an ICU admission in the last 30 days of life (adjusted risk ratio 0.73; 95% CI 0.54‐0.99).
Conclusions: Adults with congenital heart disease have significant hospital resource utilization near the end of life compared to patients with cancer, notable for more hospitalizations and a higher likelihood of death in the hospital. This population rep‐ resents an important opportunity for the application of palliative and supportive care.     

Initiating advance care planning on end-of-life issues in dementia: Ambiguity among UK and Dutch physicians

BackgroundIn dementia, advance care planning (ACP) of end-of-life issues may start as early as possible in view of the patient’s decreasing ability to participate in decision making. We aimed to assess whether practicing physicians in the Netherlands and the United Kingdom who provide most of the end-of-life care, differ in finding that ACP in dementia should start at diagnosis.MethodsIn a cross-sectional study, we surveyed 188 Dutch elderly care physicians who are on the staff of nursing homes and 133 general practitioners from Northern Ireland. We compared difference by country in the outcome (perception of ACP timing), rated on a 1–5 agreement scale. Regression analyses examined whether a country difference can be explained by contrasts in demographics, presence, exposure and role perceptions.ResultsThere was wide variability in agreement with the initiation of ACP at dementia diagnosis, in particular in the UK but also in the Netherlands (60.8% agreed, 25.3% disagreed and 14.0% neither agreed, nor disagreed). Large differences in physician characteristics (Dutch physicians being more present, exposed and adopting a stronger role perception) hardly explained the modest country difference. The perception that the physician should take the initiative was independently associated with agreeing with ACP at diagnosis.ConclusionsThere is considerable ambiguity about initiating ACP in dementia at diagnosis among physicians practicing in two different European health care systems and caring for different patient populations. ACP strategies should accommodate not only variations in readiness to engage in ACP early among patient and families, but also among physicians.     

Improving health care student attitudes toward older adults through educational interventions: A systematic review

ABSTRACT

Educational institutions should aim to positively influence the attitudes of future health care practitioners toward older patients to ensure the provision of quality patient care. This systematic review of the literature aims to determine the effectiveness of educational interventions designed to improve health care student behaviors and/or attitudes toward older people. The 29 studies included in this review utilized a variety of interventions, methods, and measurement tools. The most common type of educational intervention incorporated interaction with real patients. Few studies evaluated the impact of interventions on behavior; therefore, more observational studies are required. Overall interventions incorporating interactions with real patients who are independently living had a positive impact on student attitudes toward older adults. Clinically focused placements with patients who are ill may still have a place in the development of the patient-centered interview and assessment skills, along with improving confidence and competence, despite not having a favorable impact on attitudes.