Documentation of Advance Care Planning for Community-Dwelling Elders

Abstract

Background: Advance planning for end-of-life care has gained acceptance, but actual end-of-life care is often incongruent with patients' previously stated goals. We assessed the flow of advance care planning information from patients to medical records in a community sample of older adults to better understand why advance care planning is not more successful. Methods: Our study used structured interview and medical record data from community-dwelling older patients in two previous studies: Assessing Care of Vulnerable Elders (ACOVE)-1 (245 patients age 65 years and screened for high risk of death/functional decline in 1998-1999) and ACOVE-2 (566 patients age 75 who screened positive for falls/mobility disorders, incontinence, and/or dementia in [2002][2003]. We compared interview data on patients' preferences, advance directives, and surrogate decision-makers with findings from the medical record. Results: In ACOVE-1, 38% of surveyed patients had thought about limiting the aggressiveness of medical care; 24% of surveyed patients stated that they had spoken to their doctor about this. The vast majority of patients (88%-93%) preferred to die rather than remain permanently in a coma, on a ventilator, or tube fed. Regardless of patients' specific preferences, 15%-22% of patients had preference information in their medical record. Among patients who reported that they had completed an advance directive and had given it to their health-care provider, 15% (ACOVE-1) and 47% (ACOVE-2) had advance directive information in the medical record. Among patients who had not completed an advance directive but had given surrogate decision-maker information to their provider, 0% (ACOVE-1) and 16% (ACOVE-2) had documentation of a surrogate decision-maker in the medical record. Conclusions: Community-dwelling elders' preferences for end-of-life care are not consistent with documentation in their medical records. Electronic health records and standardized data collection for end-of-life care could begin to ameliorate this problem.

Documentation and Discussion of Preferences for Care Among Patients With Advanced Cancer

“…In contrast to prior work among older adults at increased risk for death or functional decline, which demonstrated that pa- tient preferences for care are often not available within the medical record, 17 we found that most patients with stage IV cancer had had their preferences for care documented, although documentation appeared more often in clinician notes than in a formal AD. Many patients had more than one note describing their preferences documented in the medical record, with the first documentation of preferences appearing on average 2 months after diagnosis of advanced cancer and within 5 months of death.…”

Impact of a Care Directives Activity Tab in the Electronic Health Record on Documentation of Advance Care Planning

“…8 Similar findings among community-dwelling vulnerable elders were obtained in a secondary analysis of data from 2 related studies; only 15% to 47% of 800 elders who reported completing an advance directive and giving it to a health care clinician had corresponding documentation in the medical record. 9 Agreement between expressed and documented preferences may be affected by the fact that a substantial proportion of older adults completing advance directives may not fully understand these documents. 10,11 Advanced care documentation must be readily accessible to clinicians.…”

Nurses' knowledge and comfort levels using the Physician Orders for Life-sustaining Treatment (POLST) form in the progressive care unit

“…9 Even when these discussions occur, a patient's wish might not be documented or followed through by other health care providers in a different health care setting. 8,10 The Physician Orders for Life-sustaining Treatment (POLST) form complements an advanced directive to ensure the patient's preferences about end-of-life care are followed in any health care setting. The purpose of this evidence-based education program was to increase progressive care unit (PCU) registered nurses' (RNs') knowledge and comfort levels using the POLST form.…”