Respecting end of life wishes: development and implementation of an evidence-based intervention to increase the completion of advance directives

Abstract

With an aging population and medical advancements people are living longer. With advanced age often come chronic conditions making it increasingly important to communicate end of life (EOL) care preferences to family, loved ones, and healthcare providers. However, despite the proven benefits that advance care planning (ACP) can provide for patients, families, and providers, it remains a challenge to initiate such conversations and advance directive (AD) completion rates remain low. The purpose of this project was to analyze the current process of discussing EOL care preferences, completing and accessing ADs in a rural family practice clinic and identify areas in need of improvement. The primary goal is to increase completion of ADs with a secondary aim to increase healthcare provider accessibility to ADs. Development and implementation of an ACP intervention consisting of a standard visit for a provider initiated ACP discussion with patients 65 years and older. Pre and post AD knowledge surveys before and after the visit, augmented with a census medical record review (MRR) were used to evaluate the intervention. A total of 26 patients, 4.42% of the eligible population chose to participate. The project found that the majority 69.23% (n=18) of the participants reported having an AD, however 55.56% (n=10) were not documented in the EMR. Further, 37.50% (3) of participants reported not having one but was found to have had a Physician Orders for Life Sustaining Treatment (POLST) during both pre and post intervention periods. The MMR found 81.72% (n= 733) of patients from both time periods did not have an AD in their electronic medical record (EMR). None of the intervention participants were found to have completed an AD following the intervention, however, it proved to be informative and somewhat influential on their thoughts surrounding EOL preferences and discussing them with others. The intervention had no effect on the completion of ADs as reflected by the proportion of ADs found in the EMR in the post intervention period. In fact, the proportion of ADs found in this period decreased. Overall, the intervention was beneficial as it further identified challenges in the current process recognizing provider accessibility to ADs as the bigger issue as well as the need for additional patient and provider education.