Honoring Patient Choices With Advance Care Planning

Michelle Cantillo, RN; Amy Corliss, MD; Melinda Ashton, MD; Chieko Kimata, PhD, MPH, MBA; Jaclynn Ruiz, AA

Disclosures

Journal of Hospice and Palliative Nursing. 2017;19(4):304-311. 

In This Article

Abstract and Introduction

Abstract

Patients in Hawai'i are spending their dying days in the hospital and the intensive care unit. In Hawai'i, as of 2014, inpatient spending during the hospitalization in which death occurred was $5518, and US national average was $3802; 18.5% died in the intensive care unit compared with the US national average of 14.4%. Hawai'i has a high elder population who frequently have longer length of stays and are being readmitted to our facilities; 26.7% of deaths occur in Hawai'i hospitals versus the national average of 21.0% from 2003 to 2014. Furthermore, these patients are often not receiving the care that they would choose if informed of their options. The objective of this quality improvement project was to develop, implement, and evaluate the usefulness of an advance care planning (ACP) approach to assist clinicians in identifying and honoring patient choices. A target patient population ("Last Stages") was identified for the project, and an ACP registry was created. Retrospective chart review showed that, for Last Stages patients, ACP documentation increased from 28.90% to 87.03%, and Provider Orders for Life-Sustaining Treatment completion rates rose from 12.89% to 53.90% after implementation of the ACP approach. Of the patients admitted to the hospital with Provider Orders for Life-Sustaining Treatment, 94% of these patients' documented wishes were honored. Advance care planning processes did improve clinician adherence to patient choices, reducing the risk of patients receiving unwanted care.

Introduction

Patients in Hawai'i are spending their dying days in the hospital and the intensive care unit (ICU). In Hawai'i, as of 2014, inpatient spending during the hospitalization in which death occurred was $5518, and US national average was $3802; 18.5% of Hawai'i patients died in the ICU compared with the US national average of 14.4%.[1] Hawai'i has a large elder population, and its residents frequently have longer length of stays and are being readmitted to hospitals. Furthermore, 26.7% of deaths occur in Hawai'i hospitals versus the national average of 21.0% from 2003 to 2014.[2]

Many patients at the end of life (EOL) will receive unwanted care. Research has shown that 70% of Americans prefer to die at home; however, 70% die in institutions, with many receiving invasive medical interventions associated with higher length of stay and death in the ICU.[3]

Patient wishes may be unknown, and it may be challenging for clinicians to discuss wishes with patient and families.[3] An advance directive (AD), also known as a living will, is a set of written health care instructions (recognized under state law) for an individual's wishes at the EOL or when he/she is incapacitated.[4] As of 2013, only 26.3% of Americans had an AD.[5]

In 2015, the Institute of Medicine report Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life addressed many systemic barriers to ADs.[6] Barriers can create a disconnect between the patient's wishes and the actual care received at the EOL. When patients are admitted to the hospital, critical decisions have to be made in crisis mode. If the AD is not present and available to the clinical team caring for the patient in the early crisis period, care may be provided that is not consistent with choices the patient would have made if he/she were able. One of the barriers is the accessibility of ADs in hospitals at the time the patient presents for care.[6] Patients may not share the document with their family or physicians. Even if an AD is shared with a patient's physician, it may not have been sent to the hospital to be on file in the medical record. In addition, if the AD is present in the hospital chart but not easily accessible for a new admission, it is likely to be overlooked. It may also be difficult to anticipate which hospital(s) should receive the AD information. Advance directives may not be suitable for the current acute medical decisions. An AD is not a medical order.[7]

Many people presenting with an acute medical situation at the EOL may lack capacity to make their own medical decisions. Hospitalized patients often receive care from physicians who may not know their preferences.[7] These barriers prevent the clinical team from following patient wishes when acutely ill patients are admitted to the emergency department or hospital with no written directives. In this situation, the default mode is life-sustaining care. As noted in Dying in America, many people prefer to choose care to relieve pain and suffering at the EOL. The goal for planning is to ensure patient preferences are honored.[6]

In July 2009, the Physician Orders for Life-Sustaining Treatment (POLST) form was legalized in Hawai'i. Expanded signing privileges were authorized for advance practice registered nurses in July 2014, and the name was revised to Provider Orders for Life-Sustaining Treatment.[8] The POLST is a set of portable medical orders that allows the patient to designate choices such as cardiopulmonary resuscitation or do not attempt resuscitation preferences. It also includes treatment choices for medical interventions including intensive care treatment (eg, intubation and mechanical ventilation), less aggressive care on a medical ward (eg, noninvasive breathing machine), or nonaggressive care focused on comfort to relieve pain and suffering. The POLST is recommended for patients with advanced, progressive illness and/or frailty or when clinicians would not be surprised if their patients died in the next year.[9] In the areas where the POLST paradigm has been approved, there is a standard, identifiable, and brightly colored form that can be easily recognized by clinicians. Studies show that health care providers agree that the POLST is an effective medical order to guide patient care. Hospice and emergency medical services personnel have determined that POLST is useful in preventing unwanted resuscitation and avoiding unwanted hospitalization.[10]

Advance care planning (ACP) is an ongoing process to elicit patient health care goals for current and future EOL wishes. Patient priorities and values and goals of care discussions with patient should also involve patient's health care agent, family, and friends. Advance care planning may include the completion of ACP documents stating patient wishes.[11] Structured ACP programs can help to improve this communication and ensure adherence to patients' documented wishes.

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