• Advanced Directives in Nursing Homes

      Morgan, Tracie L. (2010)
      Background: Nursing homes are becoming the place where Americans choose to live their final stages of life, providing end-of-life care for the over 65 population. Despite the focus on patient centered care and shared decision-making, three out of four people did not complete Advanced Directives in 2004. Purpose: The purpose of this study was to: I) assess the feasibility of an educational intervention on advanced directives within a Nursing Home setting; 2) evaluate if the education improves knowledge and attitudes about advanced directives; and 3) determine if attendees complete the Maryland Life-Sustaining Treatment Options (LST) form after the education. Design: A feasibility study, using quasi-experimental, pre-test/post-test, design was used. The intervention was a one day, one and half hour educational program using the End of Life Nursing Education Consortium (ELNEC) Ethics and Advanced Directives Module. Sample/Setting: A convenience sample of six patients with decisional capacity from a Maryland Nursing Home was used. Data Collection: Survey data were collected pre and post intervention. A Participant Intake Form was used to collect demographic and medical information. The Advance Directive Knowledge Assessment Survey and Advance Directive Attitudes Assessment Survey were used pre-and post-intervention to measure change in knowledge and attitudes. Additionally, a Follow up Interview was conducted to obtain additional information from participants regarding how they have used the information obtained from the Program, as well as the subsequent completion of the Maryland LST form. Results: The education program did not improve participant knowledge regarding advanced directives. There was, however an improvement in attitudes regarding advanced directives, with median score improvements from pre-intervention (Md=35.5) to post-intervention (Md= 37.5), z= -2.003, p< 0.045. In the Follow-up Interview, seven days post-educational program, 80% of participants stated, "they will use the information learned in the future," and 100% of the participants discussed the information learned within the first week, post-program, with either a family caregiver, health care provider, or Nursing Home staff. None of the participants completed a Maryland LST form. Conclusions/Implications: As a result of this Educational program, there was a marked improvement in the participants' attitudes towards advanced directives in this Maryland Nursing Home. Although there was not an improvement in the participants' knowledge regarding the same, the Follow-up Interviews suggested that the information provided during the educational program did positively impact their beliefs and did increase their awareness of the content. This allowed the participants to have repeat conversations with their family, health care providers, and Nursing Home staff. Although the study is generally feasible, consideration for future use of this study needs to be directed toward a more diverse ethnic population, the instruments used, and the inclusion of family and/or Durable Power of Attorney (DPOAs).
    • End-of-life Decision Making Among Patients and Proxies

      Hinderer, Katherine Ann; Friedmann, Erika (2010)
      Background: End-of-life (EOL) decision making, including decisions to withdraw mechanical ventilation, can be extremely difficult for patients and their proxies. Advance directives provide proxies with guidance related to EOL decisions. Proxy accuracy ranges from 58% to 79% with the average around 68% (Shalowitz et al., 2006). Patients and proxies have varying levels of trust in the decisions proxies make. Proxy experience with EOL decisions may influence future decisions. Purpose: To explore patient and proxy decisions related to EOL care and treatment preferences in scenarios representing three distinct disease trajectories. Patient and proxy decisions were explored, and compared for concordance, as they related to the different disease trajectories and directives given by the patient in each of the scenarios. Methods: This was a secondary data analysis of the "From Contract to Covenant in Advance Care Planning" study (Fins et al., 2005). Participants included 59 patients and 103 inexperienced and experienced proxies. Hypotheses were tested with correlations, crosstabulations, t-tests, repeated measures ANOVAs, and generalized estimating equations. Results: Patients' mean age was 77.1+7 years, 91.5% were female, and 96.6% were Caucasian. Inexperienced proxies' mean age was 57.6 +16 years, 56.9% were male, and 100% were Caucasian. Experienced proxies' mean age was 60.1+12.5 years, 76.9% were female, and 96.2% were Caucasian. Patient/inexperienced proxy agreement was 48-94% and was highest in the poor prognosis stroke disease trajectory. Modification to directives improved concordance in the uncertain prognosis heart failure trajectory. Proxy agreement ranged from 70.9-95%. GEE analyses revealed proxies with lower education and no history of serious illness were least likely to remove patients from the ventilator. Proxy experience and valence (do everything/do nothing) nested within disease trajectory predicted removal (p = < .05); gender and age did not. Patient trust (33.44+6.8) in proxy decisions was higher than proxy trust (30.19+5.5) in their own decisions (p = < .05). Conclusion: This study supported the importance of directives in EOL decision making. In examining agreement and differences in proxy and patient decisions within different disease trajectories, healthcare providers can better understand patient conditions where further interventions are needed. These data suggest that further research related to patients, proxies, and EOL decisions is needed.