Assessing Quality in Advance Care Planning Documentation: A Survey of Current Methods

Background High-quality advance care planning (ACP) documentation facilitates the communication of patients’ wishes as they progress in their disease course and travel between health care settings. No consensus exists regarding evaluation of documentation quality, and diverse strategies for assessing quality have been adopted in clinical ACP studies. Methodology We conducted a literature review in PubMed and via manual search to identify clinical studies that assessed ACP quality or completeness as an outcome measure over a 5-year period. Studies that treated ACP as a binary outcome variable (present or absent), studies that took place outside of the US, and studies in pediatric populations were excluded from review. Results We identified 11 studies for inclusion in our review. Across study methodologies, the following 8 quality domains were identified: discussion frequency, documentation accessibility, discussion timing, health care proxy, health goals or values, scope of treatment/code status, prognosis/illness understanding, and end of life (EOL) care planning. Each study assessed between 2 and 6 domains. Divergent methods for assessing quality domains were utilized, including manual qualitative analysis and natural language processing techniques. Conclusion Defining and measuring the quality of documentation is critical to developing ACP programs that improve patient care. Our review provides an adaptable framework centered around quality domains.

How to plan for the progression of dementia

As your loved one begins to experience more problems with thinking and memory, they will need help managing their health care, finances, and other aspects of daily living. They may need to leave their home in order to receive the amount or type of care they require. Preparing legal documents such as a will, power of attorney, and health care proxy is an important step in planning for the future. Having conversations with your loved one early after a diagnosis ensures that they can participate in future planning as much as possible, easing your burden as increased care is required. Even if they don’t want to participate, you can still explore options so you will be ready when a crisis occurs.

Clinical Issues

VSED requires a decisionally capable, seriously ill patient who makes an informed choice to intentionally hasten death because of unacceptable current suffering or fear of imminent future suffering. In addition to being well informed and determined, patients must have access to ongoing caregiving support and a committed clinician partner. The treating clinician must carefully evaluate the reasons for the patient’s request and her decision-making capacity. Most patients who forgo all oral intake, food and liquids, die peacefully from dehydration within ten to fourteen days. Difficult symptoms of thirst and dry mouth can be adequately relieved with good oral care and access to medications to relieve additional distress. Many patients will be reassured by awareness of the option of VSED even if they never actually exercise it. Completion of advance directives (both health care proxy and instructional) as well as MOLST forms are recommended for anyone initiating VSED, as many patients lose decision-making capacity late in the process.

How to plan for the progression of dementia

As your loved one begins to experience more problems with thinking and memory, they will need help managing their health care, finances, and other aspects of daily living. They may need to leave their home in order to receive the amount or type of care they require. Preparing legal documents such as a will, power of attorney, and health care proxy is an important step in planning for the future. Having conversations with your loved one early after a diagnosis ensures that they can participate in future planning as much as possible, easing your burden as increased care is required. Even if they don’t want to participate, you can still explore options so you will be ready when a crisis occurs.

Impact of Age on Consent in a Geriatric Orthopaedic Trauma Patient Population

Introduction: Persistent misconceptions of frailty and dementia in geriatric patients impact physician-patient communication and leave patients vulnerable to disempowerment. Physicians may inappropriately focus the discussion of treatment options to health care proxies instead of patients. Our study explores the consenting process in a decision-making capable orthogeriatric trauma patient population to determine if there is a relationship between increased patient age and surgical consent by health care proxy. Methods: Patients aged 65 and older who underwent operative orthopaedic fracture fixation between 1 of 2 Level 1 Trauma Centers were retrospectively reviewed. Decision-making capable status was defined as an absence of patient history of cognitive impairment and a negative patient pre-surgical Confusion Assessment Method (CAM) and Mini-Cog Assessment screen. Provider of surgical consent was the main outcome and was determined by signature on the consent form. Results: 510 patients were included, and 276 (54.1%) patients were deemed capable of consent. In 27 (9.8%) of 276 decision-capable patients, physicians obtained consent from health care proxies. 20 of these 27 patients (74.1%) were 80 years of age or older. However, in patients aged 70 to 79, only 7 health care proxies provided consent. (p = 0.07). For every unit increase in age, the log odds of proxy consent increased by .0008 (p < 0.001). Age (p < 0.001), income level (p = 0.03), and physical presence of proxy at consult (p < 0.001) were factors associated with significantly increased utilization of health care proxy provided consent. Language other than English was a significant predictor of proxy-provided consent (p = 0.035). 48 (22%) decision-making incapable patients provided their own surgical consent. Discussion: The positive linear association between age and health care proxy provided consent in cognitively intact geriatric orthopaedic patients indicates that increased patient age impacts the consenting process. Increased physician vigilance and adoption of institutional consenting guidelines can reinforce appropriate respect of geriatric patients’ consenting capacity.

Religiosity, Cognition, and Engagement in Advance Care Planning Among Older Adults

Advance care planning (ACP) is an important process of discussion and documentation that may help older adults receive the end-of-life care they prefer. Although existing literature predominantly finds greater self-reported religiosity to decrease the rates of ACP, a clear consensus is not yet evident. Data from 3,182 adults aged 55 and older participating in the 2012 wave of the Health and Retirement Study were used to investigate this association and examine the moderating role of cognition. Participants reporting at least one of two ACP behaviors (written instructions and assigning a health care proxy) were categorized as formal planning only, engaging in only informal discussions was categorized as informal planning, and those who completed both or none were categorized accordingly. Cognition was measured using self-reported memory change over the last two years and with objective cognitive testing scores. Using multinomial logistic regression, three forms of ACP behaviors were regressed on a religiosity/spirituality scale, the two cognition measures, and demographic and psychosocial covariates. Greater religiosity was associated with a lower likelihood of engaging in both plans compared to none (OR=0.91, 95%CI=0.84-0.97), however this effect was no longer significant with the inclusion of race. Higher cognitive scores were associated with greater odds of engaging in informal-only (OR=1.07, 95%CI=1.04-1.10) and both plans (OR=1.04, 95%CI=1.01-1.06); subjective memory change was not associated with ACP. Neither cognitive measure significantly moderated the negative association of religiosity on ACP, suggesting that the awareness of worsening memory does not undermine the tendency to avoid planning among the highly religious.

What Predicts Advance Care Planning Among Older Adults: Perceived Health or the Number of Chronic Conditions?

Advance care planning (ACP) is associated with improved quality of death and better end-of-life care. Studies have found that both health status and chronic illness influence rates of ACP. However, little is known about the relative association of each factor with engaging in ACP. This study aims to identify the extent to which the number of chronic conditions and self-rated health predict engaging in ACP. We used data from the Health and Retirement Study, a nationally-representative longitudinal survey of older adults. The sample consisted of 2016 core interview respondents. We conducted logistic regression models to examine the association between self-rated health and the number of self-reported chronic conditions with three dependent variables: (1) ACP engagement (n=687), (2) AD completion (n=1671), and (3) assignment of health care proxy (n=1668), while controlling for demographic characteristics,. Samples were weighted. Analysis revealed that reporting more chronic conditions was associated with higher odds of advance directive completion (OR:1.21, p&lt;.001), ACP engagement (OR: 1.26, p&lt;.05), and assigning medical proxies (OR: 1.32, p&lt;.001). However, better self-reported health was associated with higher odds of having an AD (OR: 1.20, p&lt;.05) and assigning medical proxies (OR: 1.27, p&lt;.01). These findings suggest that greater number of chronic conditions increased the odds of having an AD, engaging in ACP and in assigning medical proxies; however, those reporting better health were more likely to have an AD and a medical proxy. Findings from this study point suggest that individuals with multi-morbidities may be more open to engaging in ACP discussions and activities.

Chinese Americans’ Priorities and Practices for Designating a Healthcare Proxy

Many Americans need decision-making from someone else due to cognitive impairment. Chinese comprises the largest Asian group in the U.S.; few studies have investigated factors influencing Chinese Americans’ health care proxy (HCP) designation. The aim of this study was to examine factors associated with Chinese Americans’ HCP designation, using Andersen’s Behavioral Model as a lens. Data were from the 2015 Asian American Quality of Life Survey. Hierarchical logistic regression analyses were conducted to test the incremental predictive power of predisposing, enabling, and needs factors. We found that age, marital status, religious affiliation, health insurance, acculturation, and self-rated health were predictors for HCP designation. The odds of having an HCP designation were 1.96 times higher for those aged 65 and above, compared to those aged 18-64 (p=0.045); The odds were 2.40 times higher for those who were married (p=0.006); The odds were 1.79 times higher for Protestants (p=0.042) and 2.25 times higher for Buddhists (p=0.025), compared to those with no religious affiliation; Having a health insurance increased the odds of having an HCP designation by 2.23 (p=0.022); For each additional unit in acculturation score, the odds of having an HCP designation increased by 0.65 (p=0.011); Compared to those who rated their health as excellent/very good/good, those rating health as fair/poor had a 2.97 times higher odds of HCP designation (p=0.001). We concluded that various factors influence Chinese Americans’ HCP designation, and appropriate and innovative practices should be used to assist HCP discussion and designation among Chinese and other ethnic minority populations.

Reframing the End Stage of Renal Disease: How Age Matters

End Stage Renal Disease (ESRD) conveys high symptom burden, multimorbidity and the greater likelihood of hospital death than other serious illnesses. Increases in people with ESRD occurred most sharply among adults age 75+. Despite high mortality risk, few with ESRD consider end-of-life preferences or discuss with a physician. The purpose of this study was to explore the nature of advance care planning in ESRD. The study utilized mixed methods and both qualitative and quantitative data was collected during in-depth chairside interviews with 31 people while they were on hemodialysis. Participants ranged in age from 29-85; Mage=60; (N=13 [40%/)60). The data was divided above and below the Mage, and distinct differences were found in the nature of advanced care planning by age group. Greater numbers of people &gt;60 (N=11[61%]) were not considering a transplant while (N=9[69%]) of those under 60 had a failed transplant and were again on the waiting list. Although the majority of participants had a health care proxy (N=27[87%]), more who were &gt;60 had a proxy who knew their wishes (N=14[78%]) compared with (N=9[69%]) who were 60 compared with none &lt;60. The qualitative data illuminated these age-differentiated responses in themes: Older age and (1) Multimorbidity; (2) Frequency/intensity of hospitalization; (3) Diminished hope of transplantation; and (4) More acute death awareness. The need for disease-specific advance care planning—with hopes and expectations about transplant--and attention to the influence of age and decline cannot be overstated.

Medicolegal Implications of Mild Neurocognitive Disorder

Introduction: The syndromes of mild cognitive impairment (MCI) or mild neurocognitive disorder (MiND), often prodromal to dementia (Major Neurocognitive Disorder), are characterized by acquired clinically significant changes in one or more cognitive domains despite preserved independence. Mild impairment has significant medicolegal consequences for an affected person and their care system. We review the more common etiologies of MiND and provide a systematic review of its medicolegal implications. Methods: We conducted a systematic review of the peer-reviewed English literature on medicolegal aspects of MCI or MiND using comprehensive search terms and expanding our review to include sources cited by these reports. Results: Impairment of memory, executive function, social cognition, judgment, insight or abstraction can alter an individual’s abilities in a variety of areas that include decision making, informed consent, designation of a surrogate decision-maker such as a health care proxy, understanding and management of financial affairs, execution of a will, or safe driving. Conclusion: Even mild cognitive impairment can have significant behavioral consequences. Clinicians can assist care partners and persons with MCI or MiND by alerting them to the medicolegal concerns that often accompany cognitive decline. Early recognition and discussion can help a care system manage medicolegal risk more effectively and promote thoughtful advance planning.