Patient Advance Directives in Practice

Abstract

ceptually or in practice. This verdict, though harsh, is justified. It also corresponds with my own experience of providing advice on advance directives.As an alternative, the authors (1) propose the system of advance care planning (ACP), first developed in the 1990s. In the ACP concept advance planning of health care is seen as a lifelong process, involving professional facilitation, which ensures the availability and implementation of advance directives that will pass the test of practice.The authors report the results of their prospective, inter-regionally controlled, nonrandomized study of the effects of the implementation of a regional ACP program that they themselves developed for use in German nursing homes. The intervention comprised the following:• Conversations between nursing home residents and professional facilitators to draw up valid advance directives using standardized forms • Intensive training of nonmedical facilitators • Training of cooperating primary care physicians • An information event for nursing staff from the nursing homes. Jürgen in der Schmitten and his co-authors present a comprehensive concept for advance health care planning and test its value on a regional basis: the advance directives of the intervention region were compared to those of the control region with regard to number, clarity, and validity. The comparison embraced the (personal and proxy) directives from 136 residents of three intervention nursing homes and 439 residents of ten nursing homes in the control region.The observation time of 16.5 months was sufficiently long to permit conclusions regarding the suitability of the advance directives in practice. During this period 49 (36%) residents in the intervention group wrote new advance directives, 30 of which were proxy directives, compared with 18 (4.1%) new directives, 10 of them proxy directives, in the control group. Representatives were named in 94.7% and 50.0% of cases, respectively. Directives were signed by a third party in 95.9% versus 77.8%, by a physician in 93.9% versus 16.7% of cases. An emergency information sheet was present in 98.0% versus 44.4% of cases. There were clear instructions with regard to resuscitation in 95.9% and 38.9% of cases, respectively.The average time that each resident spent with a facilitator was 100 minutes, spread over an average of 2.5 conversations. The difficulty in finding this amount