For elderly patients during the last six months of hospital care, both families and hospital professionals are seeking to improve the lines of communication for desired end-of-life (EOL) practices through advance care planning (ACP). A recent study in JAMA Internal Medicine exposed the discrepancy between EOL care preferences elected by health care professionals and the patient or family members.
Researchers first evaluated ACP use and EOL preferences from the patient or family perspective, in order to measure the frequency of engagement in EOL planning. Using a sample from 12 acute care hospitals in British Columbia and Quebec, researchers used validated questionnaires to interview patients age 80 or better with an acute medical or surgical condition or related circumstance. Family members also participated in interviews to discover their role in ACP decision making, or to conduct interviews for patients who were cognitively unable to participate.
These interviews found a gap of expressed or written consent on EOL treatment between patient wishes and hospital practitioners. Although there is an increase in life-sustaining technology use, most patients expressed wanting only comfort care during the last six months. The majority of patients interviewed expressed a desire for comfort care (30.6 percent), or a mix of comfort care and full medical care without resuscitation (30.6 percent); however, these wishes were either improperly documented in medical records, or were communicated insufficiently to medical professionals involved in the patient’s EOL care. For the majority who expressed a medical care preference, only a quarter had a written order stating their medical care goals. Most notable was the discrepancy between the 28.1 percent of patients who preferred comfort care only and the mere 4.5 percent who documented their stated care goals.
Similarly, 34.8 percent of family members of EOL patients stated a preference for comfort care and 27.7 percent for a mix of care during the ACP process. For those family members, only 17 percent documented their preferred method of medical treatment.
The use of aggressive life-sustaining treatment for patients who do not want such treatment results in a poorer quality of life for patients, poorer quality of death, negative long-term consequences for the family, and higher medical expenses. Patient satisfaction during EOL requires addressing gaps in communication, decision-making, and documentation of patient goals by health care professionals. Communication with physicians only occurred in one-third of cases, and communication with other health care professionals, such as nurses, social workers, and spiritual care workers, included patient care preferences in only 10 percent of cases. Based on the knowledge-to-action model for identifying gaps between knowledge and current practices, the researchers recommend investing in ACP as the most progressive action to narrow the gap between decision makers and patients in EOL care.
Heyland, D, Barwich, D, Pichora, D, et al. Failure to engage hospitalized elderly patients and their families in advance care planning. JAMA Internal Medicine. (2013). DOI: 10.1001/jamainternmed.2013.180