Interventions for promoting the use of advance directives for end-of-life decisions in adults (protocol)

To assess the effects of interventions for promoting the use of advance directives (ADs) about end-of-life decisions of adults

Advance directives and the impact of timing. A qualitative study with Swiss general practitioners.

PRINCIPLES: Advance directives are seen as an important tool for documenting the wishes of patients who are no longer competent to make decisions in regards to their medical care. Due to their nature, approaching the subject of advance directives with a patient can be difficult for both the medical care provider and the patient. This paper focuses on general practitioners' perspectives regarding the timing at which this discussion should take place, as well as the advantages and disadvantages of the different moments. METHODS: In 2013, 23 semi-structured face-to-face interviews were performed with Swiss general practitioners. Interviews were analysed using qualitative content analysis. RESULTS: In our sample, 23 general practitioners provided different options that they felt were appropriate moments: either (a) when the patient is still healthy, (b) when illness becomes predominant, or (c) when a patient has been transferred to a long-term care facility. Furthermore, general practitioners reported uncertainty and discomfort regarding initiating the discussion. CONCLUSION: The distinct approaches, perspectives and rationales show that there is no well-defined or "right" moment. However, participants often associated advance directives with death. This link caused discomfort and uncertainty, which led to hesitation and delay on the part of general practitioners. Therefore we recommend further training on how to professionally initiate a conversation about advance directives. Furthermore, based on our results and experience, we recommend an early approach with healthy patients paired with later regular updates as it seems to be the most effective way to inform patients about their end-of-life care options.

Advance directives based cognitive therapy in bipolar disorder

Background and Aims: Mental Health Advance Directives (ADs) are potentially useful for bipolar patients due to the episodic characteristic of their disease. An advanced directives based cognitive therapy (ADCBT) involving the self-determination model for adherence, the cognitive representation of illness model, and the concordance model is studied on this article. The aim of the study is to evaluate ADBCT's impact on the number and duration of hospitalization as well as commitment and seclusion procedures. Methods: Charts of all patients who have written their ADs following an ADBCT intervention since at least 24 months were included in the study. Number and duration of psychiatric hospitalization for a mood or a psychotic episode as well as commitment and seclusion procedures were recorded for each patient two years before ADBCT and during a follow up of at least 24 months. Results: Number of hospitalizations, number of commitment procedures and number of days spent in psychiatric hospital reduced significantly after ADCBT in comparison of the two years who preceded the intervention. Conclusions: ADBCT seems to be effective in patients with compliance and coercion problems in this retrospective study. Its effect remains however to be confirmed in large prospective studies.

Advance directives as autonomy enhancers: reality or myth?

In the last few decades there has been a wealth of literature and legislation on advance directives. As you all know, it is an instrument by which a person can express their wishes as regards what treatmentthey should be given or, more to the point, not to be given, when he is in a situation when he can not do so himself.Regulations in the western world seem to promote advance directives as a way to enhance patient¿s autonomy in thecontext of human rights, and the media has presented advance directives as another milestone in this era of selfdetermination.However, if we look closely at some of thoseregulations we will see that there are a few elements which may undermine their efficacy, shattering this nicely presentedpicture. I will focus on two elements. First, formal requirements, and secondly, certain limits or what I like to call "escape clauses".

Advance directives as autonomy enhancers: reality or myth?

In the last few decades there has been a wealth of literature and legislation on advance directives. As you all know, it is an instrument by which a person can express their wishes as regards what treatmentthey should be given or, more to the point, not to be given, when he is in a situation when he can not do so himself.Regulations in the western world seem to promote advance directives as a way to enhance patient¿s autonomy in thecontext of human rights, and the media has presented advance directives as another milestone in this era of selfdetermination.However, if we look closely at some of thoseregulations we will see that there are a few elements which may undermine their efficacy, shattering this nicely presentedpicture. I will focus on two elements. First, formal requirements, and secondly, certain limits or what I like to call "escape clauses".

Advance directives as autonomy enhancers: reality or myth?

In the last few decades there has been a wealth of literature and legislation on advance directives. As you all know, it is an instrument by which a person can express their wishes as regards what treatmentthey should be given or, more to the point, not to be given, when he is in a situation when he can not do so himself.Regulations in the western world seem to promote advance directives as a way to enhance patient¿s autonomy in thecontext of human rights, and the media has presented advance directives as another milestone in this era of selfdetermination.However, if we look closely at some of thoseregulations we will see that there are a few elements which may undermine their efficacy, shattering this nicely presentedpicture. I will focus on two elements. First, formal requirements, and secondly, certain limits or what I like to call "escape clauses".

The feasibility of self-report advance directives among elderly patients with cognitive impairment

The central objective of this dissertation was to determine the feasibility of self-completed advance directives (AD) in older persons suffering from mild and moderate stages of dementia. This was accomplished by identifying differences in ability to complete AD among elderly subjects with increasing degrees of dementia and cognitive incompetence. Secondary objectives were to describe and compare advance directives completed by elders and identified proxy decision makers. Secondary objectives were accomplished by measuring the agreement between advance directives completed by proxy and elder, and comparing that agreement across groups defined by the elder's cognitive status. This cross-sectional study employed a structured interview to elicit AD, followed by a similar interview with a proxy decision maker identified by the elder. A stratified sampling scheme recruited elders with normal cognition, mild, and moderate forms of dementia using the Mini Mental-State Exam (MMSE). The Hopkins Competency Assessment Test (HCAT) was used for evaluation of competency to make medical decisions. Analysis was conducted on "between group" (non-demented $\leftrightarrow$ mild dementia $\leftrightarrow$ moderate dementia, and competent $\leftrightarrow$ incompetent) and "within group" (elder $\leftrightarrow$ family member) variation.^ The 118 elderly subjects interviewed were generally male, Caucasian, and of low socioeconomic status. Mean age was 77. Overall, elders preferred a "trial of therapy" regarding AD rather than to "always receive the therapy". No intervention was refused outright more often than it was accepted. A test-retest of elders' AD revealed stable responses. Eleven logic checks measured appropriateness of AD responses independent of preference. No difference was found in logic error rates between elders grouped by MMSE or HCAT. Agreement between proxy and elder responses showed significant dissimilarity, indicating that proxies were not making the same medical decisions as the elders.^ Conclusions based on these data are: (1) Self reporting AD is feasible among elders showing signs of cognitive impairment and they should be given all opportunities to complete advance directives, (2) variation in preferences for advance directives in cognitively impaired elders should not be assumed to be the effects of their impairment alone, (3) proxies do not appear to forego life-prolonging interventions in the face of increasing impairment in their ward, however, their advance directives choices are frequently not those of the elder they represent. ^

Effects of two intervention strategies on the behavior of nurses and nurse students related to advance directives

Advance directives are one mechanism for preserving the rights of individuals to exercise some control over their health care when serious illness may prevent them from direct participation. Nurses, as the health care providers with the closest and most sustained contact with critically ill and dying patients, are positioned to assist patients to plan for future health care needs. Although a majority of nurses favor the concept of advance directives for their patients and for themselves, they have not played a significant role in facilitating advance health care planning with their patients nor implemented advance health care planning for themselves.^ Research has also shown that differing forms of education and counseling increase the completion rates for advance directives in selected populations, mostly the elderly and seriously ill. Not yet developed are effective educational strategies to assist nurses and nurse students to make optimal contributions in assisting their clients' plans for future health care decision-making. This study sought to determine whether specific learning strategies (a) increased the involvement of nurses and nurse students in facilitating advance care planning with patients and (b) increased the percentage of the nurses' and nurse students' own personal advance care planning activities.^ The study compared two learning interventions and two populations, nurses and nurse students. The participants were randomly assigned to one of the two learning interventions, L1 or L2. Participants in L1 received a lecture, discussion and exploration of the forces impacting on advance directive behavior. Participants in L2 received the same intervention components with the additional component of group practice completing advance directives.^ Analysis of the data by chi-square and logistic regression did not support the hypotheses that the practice component would make a difference in the participants' facilitation of advance care planning with patients or in their own personal advance care planning activities. There were significant differences in post-intervention behavior between the nurse and nurse student groups. The nurses in the study did significantly more facilitation of advance care planning with patients and completed significantly more advance care documents than the nurse students post-intervention. However, the nurse students held more post-intervention family discussions than did the nurses. ^

Nurses' knowledge of advance directives and perceived confidence in end-of-life care: a cross-sectional study in five countries

Nurses' knowledge regarding advance directives may affect their administration and completion in end-of-life care. Confidence among nurses is a barrier to the provision of quality end-of-life care. This study investigated nurses' knowledge of advance directives and perceived confidence in end-of-life care, in Hong Kong, Ireland, Israel, Italy and the USA using a cross-sectional descriptive design (n = 1089). In all countries, older nurses and those who had more professional experience felt more confident managing patients' symptoms at end-of-life and more comfortable stopping preventive medications at end-of-life. Nurses in the USA reported that they have more knowledge and experience of advance directives compared with other countries. In addition, they reported the highest levels of confidence and comfort in dealing with end-of-life care. Although legislation for advance directives does not yet exist in Ireland, nurses reported high levels of confidence in end-of-life care.

A guide to making an advance health care directive

This guide helps people residing in Andalucía to fill in their Advance Health Care Directives, also known as a Living Will. This document allows you to make known in advance and in writing your wishes and preferences about the health care that you wish to receive when you are unable to communicate because of illness. This guide gives simple and rapid information about how to fill in the document and how to express your wishes. It also contains additional information on Advance Health Care Directives and information onthe Andalusian Registry of Advance Health Care Directives.

Advance care planning for institutionalised older people: an integrative review of the literature.

BACKGROUND: This integrative review of the literature describes the evolution in knowledge and the paradigm shift that is necessary to switch from advance directives to advance care planning. AIMS AND OBJECTIVES: It presents an analysis of concepts, trends, models and experiments that enables identification of the best treatment strategies, particularly for older people living in nursing homes. DESIGN: Based on 23 articles published between 1999 and 2012, this review distinguishes theoretical from empirical research and presents a classification of studies based on their methodological robustness (descriptive, qualitative, associative or experimental). RESULTS: It thus provides nursing professionals with evidence-based information in the form of a synthetic vision and conceptual framework to support the development of innovative care practices in the end-of-life context. While theoretical work places particular emphasis on the impact of changes in practice on the quality of care received by residents, empirical research highlights the importance of communication between the different persons involved about care preferences at the end of life and the need for agreement between them. CONCLUSIONS: The concept of quality of life and the dimensions and factors that compose it form the basis of Advance care planning (ACP) and enable the identification of the similarities and differences between various actors. They inform professionals of the need to ease off the biomedical approach to consider the attributes prioritised by those concerned, whether patients or families, so as to improve the quality of care at the end of life. IMPLICATIONS FOR PRACTICE: It is particularly recommended that all professionals involved take into account key stakeholders' expectations concerning what is essential at the end of life, to enable enhanced communication and decision-making when faced with this difficult subject.

Literature review on advance care planning of nursing home residents

Aim: Conduct a search and analytic review of literature regarding attributes of Advance Care Planning (ACP) and Advance Directive in order to identify the experiences and the best care strategies for older adults resident in nursing homes or long term institutions. Methodology: An extensive electronic search was undertaken in the following databases: Pubmed (via Ovid search), Cumulative Index of Nursing and Allied Health (CINAHL, via EBHOST), psychINFO and Cochrane. After analyzing and eliminating duplicates and professional's point of view (19), 144 titles were considered relevant: 28 opinion papers, 94 descriptive/qualitative studies or predictive studies, 17 experimental and five systematic reviews. Most of them were produced in North America and only 10 were in French. Results: With regard to European experiences, studies are scarce and further research could benefit from North American evidence. Contrary to Europe, nurses in North America play a major role in the process of care planning. The major findings were related to the poor efficacy of the completion of Advance Directives, even in presence of a substantial variety of implementation strategies. The evidence supports interventions that conceptualize ACP as a process, with an emphasis on the ascertainment of patients' values and beliefs and the necessity to include the family or loved ones from the beginning of the process in order to favor the expression and sharing of one's life perspectives and priorities in care. The most relevant findings were associated with the conceptualization of the ACP as a change in health behaviors which needs an involvement in different stages to overcome a variety of barriers. Conclusion: Rigorous research in ACP for the older adults in Swiss nursing homes that promote respect and dignity in this frail population is needed. How to best achieve patients and families goals should be the focus of nursing intervention and research in this domain.