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Journal of General Internal Medicine

, Volume 19, Issue 9, pp 944–951 | Cite as

Promoting advance directives among elderly primary care patients

  • Lawrence S. WissowEmail author
  • Amy Belote
  • Wade Kramer
  • Amy Compton-Phillips
  • Robert Kritzler
  • Jonathan P. Weiner
Original Articles

Abstract

OBJECTIVE: To determine efficient ways of promoting advance directives among heterogeneous populations of elderly ambulatory patients.

DESIGN: One-year quasi-experimental trial.

SETTING: Five suburban and urban health centers in one region of a large managed care organization. One additional suburban center served as a control site.

PARTICIPANTS: Individuals ages 65 and older (N=2,120) who were continuously enrolled and had a health maintenance visit with their primary care provider during the study year.

INTERVENTION: Physician education (oral and written) and physician and patient prompts to discuss advance directives.

MAIN RESULTS: Sixty-six (7.8%) of patients at the intervention centers completed new advance directives, versus 9 of 1,277 (<1%) at the comparison center (P<.001). Patients 75 and older were twice as likely (odds ratio [OR], 2.0; 95% confidence limits [CL], 1.2 to 3.3) as those 65 to 74 to file a new advance directive, and the odds were twice as great (OR, 2.6; 95% CL, 1.4 to 4.6) at centers serving communities with median household income over the state median. Gender, recent hospitalization, emergency room visits, and number of chronic conditions were not related to making new directives nor was predominant ethnicity of the center community (African-American versus white). Adjusted for these factors, the intervention resulted in a 20-fold increase (95% CL, 10.4 to 47.8) in the odds of creating a new advance directive. Doctors reported barriers of time and unwillingness to press discussions with patients.

CONCLUSIONS: A replicable intervention largely targeting doctors achieved a modest increase in advance directives among elderly ambulatory patients. Future interventions may need to target lower-income patients, “younger” elderly, and more specifically address doctors’ attitudes and comfort discussing advance directives.

Key words

advance directives primary care elderly ethnicity income 

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References

  1. 1.
    Emanuel L, Barry MJ, Stoeckle JD, Ettelson LM, Emanuel EJ. Advance directives for medical care—a case for greater use. N Engl J Med. 1991;324:889–95.PubMedCrossRefGoogle Scholar
  2. 2.
    Emanuel LL, Danis M, Pearlman RA, Singer PA. Advance care planning as a process: structuring the discussions in practice. J Am Geriatr Soc. 1995;43:440–6.PubMedGoogle Scholar
  3. 3.
    Cugliari AM, Miller T, Sobal J. Factors promoting completion of advance directives in the hospital. Arch Intern Med. 1995;155:1893–8.PubMedCrossRefGoogle Scholar
  4. 4.
    Stetler KL, Elliott BA, Bruno CA. Living will completion in older adults. Arch Intern Med. 1992;152:954–9.CrossRefGoogle Scholar
  5. 5.
    Johnston SC, Pfeifer MP, McNutt R. The discussion about advance directives: patient and physician opinions regarding when and how it should be conducted. Arch Intern Med. 1995;155:1025–30.PubMedCrossRefGoogle Scholar
  6. 6.
    Shmerling RH, Bedell SE, Lilienfeld A, Delbanco TL. Discussing cardiopulmonary resuscitation: a study of elderly outpatients. J Gen Intern Med. 1988;3:317–21.PubMedCrossRefGoogle Scholar
  7. 7.
    Kohn M, Menon G. Life prolongation: views of elderly outpatients and health care professionals. J Am Geriatr Soc. 1988;36:840–4.PubMedGoogle Scholar
  8. 8.
    Gamble ER, McDonald PJ, Lichstein PR. Knowledge, attitudes, and behavior of elderly persons regarding living wills. Arch Intern Med. 1991;151:277–80.PubMedCrossRefGoogle Scholar
  9. 9.
    Markson LJ, Fanale J, Steel K, Kern D, Annas G. Implementing advance directives in the primary care setting. Arch Intern Med. 1994;154:2321–7.PubMedCrossRefGoogle Scholar
  10. 10.
    Morrison RS, Morrison EW, Glickman DF. Physician reluctance to discuss advance directives: an empiric investigation of potential barriers. Arch Intern Med. 1994;154:2311–8.PubMedCrossRefGoogle Scholar
  11. 11.
    Gordon NP, Shade SB. Advance directives are more likely among seniors asked about end-of-life care preferences. Arch Intern Med. 1999;159:701–4.PubMedCrossRefGoogle Scholar
  12. 12.
    Rubin SM, Strull WM, Flakow MF, Weiss SJ, Lo B. Increasing the completion of the durable power of attorney for health care: a randomized controlled trial. JAMA. 1994;27:209–12.CrossRefGoogle Scholar
  13. 13.
    Waters CM. End-of-life care directives among African Americans: lessons learned—a need for community-centered discussion and education. J Community Health Nurs. 2000;17:25–37.PubMedCrossRefGoogle Scholar
  14. 14.
    Brown JB, Beck A, Boles M, Barrett P. Practical methods to increase the use of advance medical directives. J Gen Intern Med. 1999;14:21–6.PubMedCrossRefGoogle Scholar
  15. 15.
    High DM. Advance directives and the elderly: a study of intervention strategies to increase use. Gerontologist. 1993;33:342–9.PubMedGoogle Scholar
  16. 16.
    Dexter PR, Wolinsky FD, Gramelspacher GP, et al. Effectiveness of computer-generated reminders for increasing discussions about advance directives and completion of advance directive forms: a randomized, controlled trial. Ann Intern Med. 1998;128:102–10.PubMedGoogle Scholar
  17. 17.
    Hare J, Nelson C. Will outpatients complete living wills? A comparison of two interventions. J Gen Intern Med. 1991;6:41–6.PubMedCrossRefGoogle Scholar
  18. 18.
    Kao AC, Green DC, Zalslavsky AM, Koplan JP, Cleary PD. The relationship between method of physician payment and patient trust. JAMA. 1998;280:1708–14.PubMedCrossRefGoogle Scholar
  19. 19.
    Campbell DT, Stanley JC. Experimental and Quasi-experimental Designs for Research. Boston, Mass: Houghton Mifflin; 1963.Google Scholar
  20. 20.
    2000 U.S. Census. Data by Zip Code Tabulation Areas, and Profile of General Demographic Characteristics. Maryland Department of Planning. Available at: http://www.mdp.state.md.us/MSDC/. Accessed May 14, 2003.Google Scholar
  21. 21.
    Rubenstein LV, Mittman BS, Yano EM, Mulrow CD. From understanding health care provider behavior to improving health care: the QUERI framework for quality improvement. Med Care. 2000;38(6 suppl 1):H29-H41Google Scholar
  22. 22.
    Johns Hopkins University, Health Services Research and Development Center. ACG Manual. Baltimore, Md: Johns Hopkins University; 2001. Available at: http://www.acg.jhsph.edu. Accessed July 2, 2004.Google Scholar
  23. 23.
    Nutting PA, Rost K, Smith J, Werner JJ, Elliot C. Competing demands from physical problems: effect on initiating and completing depression care over 6 months. Arch Fam Med. 2000;9:1059–64.PubMedCrossRefGoogle Scholar
  24. 24.
    Olson AL, Kelleher KJ, Kemper KJ, Zuckerman BS, Hammond CS, Dietrich AJ. Primary care pediatricians’ roles and perceived responsibilities in the identification and management of depression in children and adolescents. Ambul Pediatr. 2001;1:91–8.PubMedCrossRefGoogle Scholar
  25. 25.
    Davis DA, Thomson MA, Oxman AD, Haynes RB. Evidence for the effectiveness of CME: a review of 50 randomized controlled trials. JAMA 1992;268:1111–7.PubMedCrossRefGoogle Scholar
  26. 26.
    Roter DL, Hall JA, Kern DE, Barker LR, Cole KA, Roca RP. Improving physicians’ interviewing skills and reducing patients’ emotional distress. Arch Intern Med. 1995;155:1877–84.PubMedCrossRefGoogle Scholar
  27. 27.
    Soumerai SB. Principles and uses of academic detailing to improve the management of psychiatric disorders. Int J Psychiatry Med. 1998;28:81–96.PubMedCrossRefGoogle Scholar
  28. 28.
    Collins KS, Hughes DL, Doty MM, Ives BL, Edwards JN, Tenney K. Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority Americans. New York: The Commonwealth Fund; March, 2002.Google Scholar
  29. 29.
    Doescher MP, Saver BG, Franks P, Fiscella K. Racial and ethnic disparities in perceptions of physician style and trust. Arch Fam Med. 2000;9:1156–63.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2004

Authors and Affiliations

  • Lawrence S. Wissow
    • 1
    • 4
    Email author
  • Amy Belote
    • 1
  • Wade Kramer
    • 2
  • Amy Compton-Phillips
    • 3
  • Robert Kritzler
    • 3
  • Jonathan P. Weiner
    • 1
  1. 1.the Johns Hopkins Bloomberg School of Public HealthBaltimore
  2. 2.Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.Rockville
  3. 3.Mid-Atlantic Permanente Medical GroupBaltimore
  4. 4.the Bioethics InstituteJohns Hopkins UniversityBaltimore

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