| Learning Objective #1: Understand advance care planning within the context of routine health maintenance visits | |||
| Learning Objective #2: Engage patients in on-going dialogue about end-of-life issues so that crisis can be averted at the time of critical illness |
In an effort to improve end-of-life care in this country and safeguard peoples' rights during critical illness and decisional incapacity, advance directives (ADs) have gained wide acceptance as a mechanism by which people can formally document their wishes and values regarding future medical care. The rate of AD completion has remained low despite the 1990 federal mandate that they be addressed with every patient upon admission to a medical facility. Many studies have been conducted in the outpatient setting to determine effective strategies which promote advance care planning with patients during times of relative wellness, before the onset of a medical crisis or loss of cognitive functioning. This randomized, controlled trial with 133 outpatient veterans sought to address many of the presumed barriers to the AD process. An intensive educational intervention with lecture, videotape, and interactive dialogue to supplement written information about ADs, had no appreciable impact on veterans' execution of ADs (p=0.774) or subsequent discussions about end-of-life care (p=0.402). There was a statistically significant relationship between first-time AD completion and self-reported health status. No association was found between the veterans' age, gender, ethnicity, family structure, educational level, cognitive functioning, financial status, degree of religiosity, personal experience with critical illness, number of days hospitalized in the past year, prior discussions about future treatment preferences, or previous exposure to ADs; and the outcomes of AD completion and initiation of advance care discussions. Veterans with baseline ADs (n=31) had statistically significant differences from those without (n=100) with regards to age, days hospitalized in the past year, previous exposure to ADs, and discussions about ADs. Successful advance care planning is a complex and perplexing process and may depend in large part on primary care providers engaging patients in on-going, meaningful discussions about end-of-life care.
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