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Advance care planning

A comparison of values statements and treatment preferences

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Abstract

BACKGROUND: Advance directives (AD) with specific treatment preferences can be difficult to apply in actual clinical situations. As an alternative, advance directives that outline patient goals and values have been advocated.

OBJECTIVE: To compare patient reactions to values-based and treatment-based advance directive forms.

SETTING: Two academic general medicine outpatient clinics in Pittsburgh, Pa.

METHODS: Outpatients age 55 or older who did not have an AD and were not demented were randomly assigned to complete either Emanuel’s Medical Directive (EMD) or Pearlman’s values history (PVH) form.

MEASUREMENTS: Length of time to complete and number of questions asked about the AD forms; proportions of patients discussing the AD with family, designating a surrogate, returning the AD by mail, and desiring to have the AD in the medical record; patient ratings of AD by telephone interview; physician report of patient-initiated AD discussions.

RESULTS: Of the 275 patients approached, 143 refused, 69 already had an AD, 63 patients were enrolled, and 25 in each group completed the telephone interview. A majority of individuals in both groups had conversations with others about the AD (60% EMD, 56% PVH; P=.77). All PVH forms designated a surrogate, whereas 79% of EMD forms did so (P=.02). One patient in each group initiated a conversation with his or her physician about AD following study completion. Both forms were thought to be a good first step in planning care at the end of life (92% EMD vs 84% PVH totally or mostly agree; P=.06). Patients completing the EMD thought it would give them control over the way their doctor cared for them at the end of their lives more than did the PVH group (84% EMD vs 48% PVH totally or mostly agree; P=.02). More patients completing the EMD form worried that it would be difficult to change answers on the form if they later changed their minds (20% EMD vs 4% PVH totally or mostly agree; P=.02).

CONCLUSIONS: Both the values-based and treatment-based AD forms were rated favorably overall. Patients thought the treatment-based directive would give them more control over their care. Patients completing the values history form were more likely to designate a surrogate. Patients are likely to discuss both types of AD with family, but neither form alone is likely to lead to AD conversations with physicians.

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References

  1. The Support Principal Investigators. A controlled trial to improve care for seriously ill hospitalized patients: the study to understand prognoses and preferences of outcomes and risks of treatments (SUPPORT). JAMA. 1995;274:1591–8.

    Article  Google Scholar 

  2. Teno JM, Licks S, Lynn J, et al. Do advance directives provide instructions that direct care? SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. J Am Geriatr Soc. 1997;45:508–12.

    PubMed  CAS  Google Scholar 

  3. Teno J, Lynn J, Wenger N, et al. Advance directives for seriously ill hospitalized patients: effectiveness with the patient self-determination act and the SUPPORT intervention. J Am Geriatr Soc. 1997;45:500–7.

    PubMed  CAS  Google Scholar 

  4. Teno JM, Stevens M, Spernak S, Lynn J. Role of written advance directives in decision-making: insights from qualitative and quantitative data. J Gen Intern Med. 1998;13:439–46.

    Article  PubMed  CAS  Google Scholar 

  5. Brett AS. Limitations of listing specific medical interventions in advance directives. JAMA. 1991;266:825–8.

    Article  PubMed  CAS  Google Scholar 

  6. Hanson LC, Tulsky JA, Danis M. Can clinical interventions change care at the end of life? Ann Intern Med. 1997;126:381–88.

    PubMed  CAS  Google Scholar 

  7. Danis M, Southerland LI, Garrett JM, et al. A prospective study of advance directives for life-sustaining care. N Engl J Med. 1991;324:882–8

    Article  PubMed  CAS  Google Scholar 

  8. Doukas DJ, McCullough LB. The values history. The evaluation of the patient’s values and advance directives. J Fam Pract. 1991;32:145–53.

    PubMed  CAS  Google Scholar 

  9. Doukas DJ, Gorenflo DW. Analyzing the values history: an evaluation of patient medical values and advance directives. J Clin Ethics. 1993;4:41–5.

    PubMed  CAS  Google Scholar 

  10. Mold JW, Looney SW, Viviani NJ, Quiggins PA. Predicting the health-related values and preferences of geriatric patients. J Fam Pract. 1994;39:461–7.

    PubMed  CAS  Google Scholar 

  11. Fischer GS, Alpert HR, Stoeckle JD, Emanuel LL. Can goals of care be used to predict intervention preferences in an advance directive? Arch Intern Med. 1997;157:801–7.

    Article  PubMed  CAS  Google Scholar 

  12. Teno JM, Lynn J. Putting advance-care planning into action. J Clin Ethics. 1996;7:205–13.

    PubMed  CAS  Google Scholar 

  13. Reinders M, Singer PA. Which advance directive do patients prefer? J Gen Intern Med. 1994;9:49–51.

    Article  PubMed  CAS  Google Scholar 

  14. Heun R, Papassotiropoulos A, Jennssen F. The validity of psychometric instruments for detection of dementia in the elderly general population. Int J Geriatr Psychiatry. 1998;13:368–80.

    Article  PubMed  CAS  Google Scholar 

  15. Emanuel LL, Emanuel EJ. The medical directive: a new comprehensive advance care document. JAMA. 1989;261:3288–93.

    Article  PubMed  CAS  Google Scholar 

  16. Emanuel LL, Barry MJ, Stoeckle JD, Ettlelson LM, Emanuel EJ. Advance directives for medical care—a case for greater use. New Engl J Med. 1991;324:889–95.

    Article  PubMed  CAS  Google Scholar 

  17. Pearlman R, Starks H, Cain K, Rosengren D, Patrick D. Your Life, Your Choices—Planning for Future Medical Decisions: How to Prepare a Personalized Living Will. Springfield, Va: U.S. Department of Commerce; 1998. National Technical Information Service PB#98159437.

    Google Scholar 

  18. Kolarik RC, Arnold RM, Fischer GS, Tulsky JA. Clarifying objectives for advance care planning. J Palliat Med. In press.

  19. Edinger W, Smucker DR. Outpatients’ attitudes regarding advance directives. J Fam Pract. 1992;35:650–3.

    PubMed  CAS  Google Scholar 

  20. Tierney WM, Dexter PR, Gramelspacher GP, Perkins AJ, Zhou XH, Wolinsky FD. The effect of discussions about advance directives on patients’ satisfaction with primary care. J Gen Intern Med. 2001;16:32–40.

    Article  PubMed  CAS  Google Scholar 

  21. Singer PA, Martin DK, Lavery JV, Thiel EC, Kelner M, Mendelssohn DC. Reconceptualizing advance care planning from the patient’s perspective. Arch Intern Med. 1998;158:879–84.

    Article  PubMed  CAS  Google Scholar 

  22. Sachs GA, Stocking CB, Miles SH. Empowerment of the older patient. A randomized, controlled trial to increase discussion and use of advance directives. J Am Geriatr Soc. 1992;40:269–73.

    PubMed  CAS  Google Scholar 

  23. Reily BM, Wagner W, Ross J, Magnussen CR, Papa L, Ash J. Promoting completion of health care proxies following hospitalization. Arch Intern Med. 1995;155:2202–6.

    Article  Google Scholar 

  24. Rubin SM, Strull WM, Fialkow MF, Weiss SJ, Lo B. Increasing the completion of the durable power of attorney for health care—a randomized, controlled trial. JAMA. 1994;271:209–12.

    Article  PubMed  CAS  Google Scholar 

  25. Meier DE, Fuss BR, O’Rourke D, Baskin SA, Lewis M, Morrison S. Marked improvement in recognition and improvement of health care proxies—a randomized controlled trial of counseling by hospital patient representatives. Arch Intern Med. 1996;156:1227–32.

    Article  PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. the Division of General Internal Medicine and General Academic Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pa

    Russ C. Kolarik MD

  2. the Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pa

    Robert M. Arnold MD & Gary S. Fischer MD

  3. Center for Bioethics and Health Law, University of Pittsburgh School of Medicine, Pittsburgh, Pa

    Russ C. Kolarik MD, Robert M. Arnold MD & Gary S. Fischer MD

  4. The Institute for Performance Improvement, University of Pittsburgh School of Medicine, Pittsburgh, Pa

    Robert M. Arnold MD

  5. the Center for Research on Healthcare, University of Pittsburgh School of Medicine, Pittsburgh, Pa

    Barbara H. Hanusa PhD

Authors
  1. Russ C. Kolarik MD
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  2. Robert M. Arnold MD
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  3. Gary S. Fischer MD
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  4. Barbara H. Hanusa PhD
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Corresponding author

Correspondence to Russ C. Kolarik MD.

Additional information

Dr. Arnold is supported by the Project on Death in America Faculty Scholars Program, the Greenwall Foundation, Ladies Hospital Aid Society of Western Pennsylvania, and the LAS Trust Foundation.

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Kolarik, R.C., Arnold, R.M., Fischer, G.S. et al. Advance care planning. J GEN INTERN MED 17, 618–624 (2002). https://doi.org/10.1046/j.1525-1497.2002.10933.x

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  • DOI: https://doi.org/10.1046/j.1525-1497.2002.10933.x

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