Completing an Advance Directive in the Primary Care Setting: What Do We Need for Success?

Ramsaroop, Sharda; Reid, M. Carrington; Adelman, Ronald D.

doi:10.1111/j.1532-5415.2007.01065.x

Cited by 220 publications

(243 citation statements)

References 30 publications

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“…Numerous approaches to sharing ACDs have been investigated both in Australia and internationally, but there has been limited universal uptake due to a lack of systematic processes for embedding them into routine practice at an institutional level and across health jurisdictions. 18 Furthermore, advance care planning needs to be normalised in all health settings. To date, the greatest hope for embedding ACDs across services and jurisdictions is the electronic medical record, which is an important facilitator of advance care planning.…”

Section: Discussionmentioning

confidence: 99%

Palliative care health professionals’ experiences of caring for patients with advance care directives

Johnson

Singer

Masso³

et al. 2015

Aust. Health Review

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Objective. To explore the health professionals' (HPs) perceptions and experiences of advance care directives (ACDs) and advance care planning in Australian palliative care services.Methods. A nationwide survey of 105 palliative care services was conducted, with two HPs from each service invited to participate. A qualitative analysis of open responses about advance care planning was undertaken.Results. Sixty questionnaires were returned with open responses. Most responders were nurses (75%), aged 40 years (80%) and with a mean of 12 years palliative care experience. Data were grouped into four key themes: (1) the ACD; (2) the process of developing ACDs; (3) the process of using ACDs; and (4) the consequences of having ACDs. Participants were positive about advance care planning, commenting that ongoing communication about end-of-life care ensures mutual understanding between patients, family and HPs. Provision of care was considered easier and more efficient with an ACD in place. ACDs were perceived to reduce distrust and conflict between family, friends and HPs, and promote communication. Suboptimal documentation, clarity and explicitness limited the usefulness of ACDs when they were available.Conclusions. Advance care planning benefits HPs, patients and their family. To maximise these benefits, ACDs need to be clear, comprehensive, medically relevant and transportable documents.What is known about the topic? Ideally, advance care planning encompasses the identification and documentation of a person's preferences for future medical treatments and care in preparation for an occasion when the person cannot express their values and wishes. The uptake and practice of advance care planning is inconsistent, and the extent to which it is used by health professionals and patients is variable. Many people are cared for at the end of life in specialist palliative care services, but the intersection between palliative care and advance care planning remains under-researched. What does this paper adds? ACDs facilitate communication and advance care planning; help establish trust between health professionals, patients and their families; and make multiple aspects of care easier for HPs. Processes surrounding ACDs, particularly inadequate documentation, limit adherence and application. What are the implications for practitioners? Clear communication is necessary for effective ACD development and application. The presence of an ACD makes communication and advance care planning easier, and improves trust between HPs, patients and their family. To be useful, ACDs must be clear, comprehensive, medically relevant, transportable documents.

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Section: Discussionmentioning

confidence: 99%

Palliative care health professionals’ experiences of caring for patients with advance care directives

Johnson

Singer

Masso³

et al. 2015

Aust. Health Review

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“…Linking the patient incentive with PCP encouragement may be helpful, because we found that a patient incentive combined with PCP encouragement was more powerful than either PCP encouragement or patient incentive alone. Future research should focus on strategies to overcome barriers to ACP-related best practice by PCPs, 27 experiment with alternative incentive designs (e.g., incentive size, target recipient), and engage different patient and provider populations.…”

Section: Discussionmentioning

confidence: 99%

“…For the providerdelivered patient incentive study, assuming an intra-class correlation of 0.05 26 and a rate of provider-reported ACP discussion of 10% in the control arm, we calculated that 20 PCPs per arm and 10 patients per PCP (n ¼ 200 per group) would provide 92% power at a two-sided alpha of 0.05 to detect a 15-percentage point absolute difference 27 between intervention and control groups. We used an intention-to-treat approach using generalized linear mixed models with a logit link and fixed effect for the intervention and practice type with a random effect for provider for the dichotomous outcomes.…”

Section: Study Design and Ethical Approvalmentioning

confidence: 99%

Financial Incentives to Increase Advance Care Planning Among Medicaid Beneficiaries: Lessons Learned From Two Pragmatic Randomized Trials

Barnato

Moore

et al. 2017

Journal of Pain and Symptom Management

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Context. Medicaid populations have low rates of advance care planning (ACP). Potential policy interventions include financial incentives.Objective. To test the effectiveness of patient plus provider financial incentive compared with provider financial incentive alone for increasing ACP discussions among Medicaid patients.Methods. Between April 2014 and July 2015, we conducted two sequential assessor-blinded pragmatic randomized trials in a health plan that pays primary care providers (PCPs) $100 to discuss ACP: 1) a parallel cluster trial ( provider-delivered patient incentive) and 2) an individual-level trial (mail-delivered patient incentive). Control and intervention arms included encouragement to complete ACP, instructions for using an online ACP tool, and (in the intervention arm) $50 for completing the online ACP tool and a small probability of $1000 (i.e., lottery) for discussing ACP with their PCP. The primary outcome was provider-reported ACP discussion within three months.Results. In the provider-delivered patient incentive study, 38 PCPs were randomized to the intervention (n ¼ 18) or control (n ¼ 20) and given 10 patient packets each to distribute. Using an intention-to-treat analysis, there were 27 of 180 ACP discussions (15%) in the intervention group and 5 of 200 (2.5%) in the control group (P ¼ .0391). In the mail-delivered patient incentive study, there were 5 of 187 ACP discussions (2.7%) in the intervention group and 5 of 189 (2.6%) in the control group (P ¼ .99).Conclusion. ACP rates were low despite an existing provider financial incentive. Adding a provider-delivered patient financial incentive, but not a mail-delivered patient incentive, modestly increased ACP discussions. PCP encouragement combined with a patient incentive may be more powerful than either encouragement or incentive alone. J Pain Symptom Manage 2017;-:-e-. Ó

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“…One group systematically reviewed studies designed to increase advance directive completion in primary care and identified a number of common themes in terms of barriers. 34 Physicians tended to blame 'lack of time', 'low health literacy of patients', 'lack of necessary skills', 'lack of privacy for discussion' and 'patients not sick enough' for lack of success in implementing ACP, while patients cited 'deferring decisions to physicians or family', 'inconsistency with religious beliefs', 'too distressing to discuss', 'documents too complicated' and 'plan to do it later'.…”

Section: Barriers To Acpmentioning

confidence: 99%

“…Primary care gives the opportunity for ACP to be an ongoing process, rather than a single event, with the potential for multiple appointments giving time for accurate assessment as well as true understanding to develop between patient and doctor. A systematic review of studies aimed at increasing completion of advance directives 34 found that the most successful interventions were those that incorporated direct patient-healthcare professional interaction over multiple visits.…”

Section: Why Primary Care?mentioning

confidence: 99%

Advance care planning under the Mental Capacity Act 2005 in primary care

Hayhoe

Howe

2011

Br J Gen Pract

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Completing an Advance Directive in the Primary Care Setting: What Do We Need for Success?

Cited by 220 publications

References 30 publications

Palliative care health professionals’ experiences of caring for patients with advance care directives

Palliative care health professionals’ experiences of caring for patients with advance care directives

Financial Incentives to Increase Advance Care Planning Among Medicaid Beneficiaries: Lessons Learned From Two Pragmatic Randomized Trials

Advance care planning under the Mental Capacity Act 2005 in primary care

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