1. Allen, RS; DeLaine, SR; Chaplin, WF; Marson, DC; Bourgeois, MS; Dijkstra, K; Burgio, LD. Advance Care Planning in Nursing Homes: Correlates of Capacity and Possession of Advance Directives. The Gerontologist; 2003; 43:3:309-317.[Annotation]
This observational, cross section cohort study was designed to identify residents with the cognitive ability to participate in their own advance care planning. Seventy-eight residents and their proxies participated from five nursing homes. Data was collected from chart review, proxy interviews, resident assessment using a decision capacity assessment tool, direct observation of behavior, and certified nursing assistant surveys. Capacity assessment showed 84.4% of the residents could state a simple treatment preference but could not understand treatment alternatives or appreciate the implication of their choice. Proxies were generally less religious than residents. Fifty percent of the African-American residents were dropped from the study because of lack of familial proxy, as compared with 11.5% of white residents. Residents were more likely to possess advance directives if proxies possessed advance directives. It was concluded that decisional capacity assessments should be designed which would enhance the verbal ability of the resident with dementia by reducing reliance on memory, thus giving the resident a part in his/her end-of-life planning.[Pub Med]
2. Cohen-Mansfield, J; Libin, A; Lipson, S. Differences in Presenting Advance Directives in the Chart, in the Minimum Data Set, and through the Staff’s Perceptions. The Gerontologist; 2003; 43:3:302-308.[Annotation]
Ability to quickly access directives regarding end-of-life care of the individual resident depends on where the directive is located within the chart and whether there is discrepancy between the chart cover information and what is contained in the advanced directive, the MDS, and other sources. This study proposed to clarify how advanced directives are summarized and how physicians view these directives. The charts of 122 residents from a large 587-bed nursing home were reviewed, looking at advance directives from the front cover, the MDS, and inside the chart. Results show a higher agreement of information between the inside of the chart and the front cover than between the MDS and either the front cover or inside the chart. This study suggests that the care of a patient may be determined by the location of the advance directive information, the source, and the quality of the chart. Disagreement was also found between the physician’s reports and data found from the inside and front cover of the chart. Much of the discrepancies lie in the frequency of updating the chart. [Pub Med]
3. Gillick, MR. Adapting Advance Medical Planning for the Nursing Home. Innovations in End-of-Life Care; 2003; 5:3:www.edc.org/lastacts.[Annotation]
The author argues that advance care planning in nursing homes, although improved since 1991, is lacking comprehensive levels of care planning which would address a range between supportive therapy and maximal medical care. Many nursing homes have adopted the designation of a health care proxy and/or institution of a do-not-resuscitate order but lack a comprehensive care plan. Nursing homes offering “levels of care” have been generally accepted by residents and family, but these levels are often hierarchical and intervention-specific which does not allow for individualized decision making. The author suggests three goals--maximizing comfort, maintaining function, and prolonging life--and argues that patients and families need to be asked to prioritize these goals. Barriers to goal planning include the need to interpret a goal-based plan (vs. following intervention-specific directives) and the occurrence of a “must happen” conversation among resident, family, staff and physician. Strategies for making advance care planning effective are: 1) build on the “levels of care” approach by linking it to a resident’s care goals, 2) create a process to advance medical planning consistent with the culture and organization of the nursing home, and 3) make recommendations to families and residents regarding an appropriate level of care in order to facilitate the planning process regarding levels of care and patient’s health status.[Pub Med]
4. Happ, MB; Capezuti, E; Strumpf, NE; Wagner, L; Cunningham, S; Evans, L; Maislin, G. Advance Care Planning and End-of-Life Care for Hospitalized Nursing Home Residents. Journal of the American Geriatrics Society; 2002; 50:829-835.[Annotation]
The authors described advance care planning and end-of-life care for 43 nursing home residents hospitalized in the last 6 weeks of life. Trained nurses utilized a constant comparative method to review data from patients’ records and advance practice field notes. Results reveal distinct characteristics and transition points for frail nursing home residents in advance care planning and end-of-life care. These transition points include nursing home admission, hospitalization, acute illness, and decline toward death. Two major trajectories were revealed--a slow decline with more rapid progression near end-of-life and a rapid, steady decline over a 3 month period. Both were brought on by an acute event. Although 29 residents formally rejected CPR, few had “comfort care only” designations before hospitalization. Case histories are included. The authors conclude that there are critical junctures within the residents nursing home stay when advance care planning can be pursued and future interventions targeted.[Pub Med]
5. McAuley WJ; Travis, SS. Advance Care Planning among Residents in Long-Term Care. American Journal of Hospice and Palliative Care; 2003; 20:5:353-359.[Annotation]
This study focused on 2 types of advance care directives: basic (i.e., a living will or do-not-resuscitate order) and progressive (i.e., do-not-hospitalize order or orders restricting feeding, medication, or other treatments). The basic advance directive is defined as an order triggered by knowledge of the disease and it’s course which would have no immediate impact on the care of the resident. The progressive order is based on a person’s futility assessment and would have direct impact on treatment. Results show that 60% of nursing home residents have some type of advance directive, with 59% having a basic advance directive and 9% having at least one of the more progressive advance directive (with or without a basic advance directive). The authors note that African Americans and residents with mental impairment usually do not have progressive advance directives.[Pub Med]
6. Molloy, DW; Guyatt, GH; Russo, R; Goeree, R; O’Brien, BJ; Bédard, M; Willan, A; Watson, J; Patterson, C; Harrison, C; Standish, T; Strang, D; Darzins, PJ; Smith, S; Dubois, S. Systematic Implementation of an Advance Directive Program in Nursing Homes: A Randomized Controlled Trial. The Journal of the American Medical Association; 2000; 283:11:1437-1444.[Annotation]
This randomized control trial examines the effect of systematically implementing advance directives in nursing homes based on 1,292 residents of six 100-plus-bed nursing homes in Ontario. The six homes were pair-matched on key characteristics, and one home per pair was randomly selected to take part. Satisfaction with care, cost, and mortality are measured. No special directions were given, and each nursing home continued its usual policy. The data suggest that systematic implementation of advance directives reduces health care services utilization without affecting satisfaction or mortality.[Pub Med]
7. Volicer, L; Cantor, MD; Derse, AR; Edwards, DM; Prudhomme, AM; Gregory, DCR; Reagan, JE; Tulsky, JA; Fox, E. Advance Care Planning by Proxy for Residents of Long-Term Care Facilities who Lack Decision-Making Capacity. Journal of the American Geriatrics Society; 2002; 50:761-767.[Annotation]
The focus of this study examines progressive advance care planning and whether long-term care facilities should seek proxies for residents lacking the decision-making capacity to implement such planning. A “proxy” is defined as the person who is best qualified to speak for the resident. The article discusses families, state statutes, case law, and current practices in several Veterans Health Administration (VHA) nursing homes. The authors describe “the Oregon Experience,” an effort to develop and implement Physician’s Orders for Life Sustaining Treatment (POLST) in long-term care facilities. Three focus groups involving 20 healthcare providers from 10 Veterans Administration facilities met regarding current proxy planning practices. The authors report that none of the focus group members knew of any VHA policies supporting an advance plan by proxy. Results also show that signatures of proxy decision makers were rarely required. The authors recommend an 11-point minimum criteria for initiating a process of developing an advance care plan for residents of long-term care who lack capacity to make decisions.[Pub Med]
