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An Initial Evaluation

Henry J. Silverman, MD; Pamela Tuma, BSN; Monica H. Schaeffer, PhD; Betsy Singh, PhD

Arch Intern Med. 1995;155(5):502-510.

Abstract
Background
The Patient Self-Determination Act aims to enhance patient awareness of advance directives by requiring health-care institutions to ask patients whether they have advance directives and to inform patients of their rights to prepare these documents. We investigated the following: (1) compliance of the hospital staff with implementing this act, (2) the effects of this act on the extent to which patients discuss and prepare advance directives, and (3) variables that might influence patient discussions on advance planning and preparation of advance directives.

Methods
We surveyed 219 patients from a university hospital that implemented a nurse-dependent advance directive program. We also conducted a telephone interview with 57% of these patients at least 6 months after hospital discharge.

Results
Nurses asked 70% of the patients about the existence of an advance directive and of these patients, only 57% remembered the inquiry. Only 57% of the patients received the brochure on advance directives and of these patients, only 55% read the brochure. Only 2% of the patients requested to receive additional information on advance directives. Less than one quarter of the patients had discussions on advance planning while in the hospital and of those patients who were contacted within 6 months after hospital discharge, 39% had discussions on advance planning and 15% prepared an advance directive. Race was an independent predictor for hospital discussions, and educational level was an independent predictor for discussions and preparation of advance directives after hospital discharge.

Conclusions
To enhance the effectiveness of a nurse-dependent advance directive program, hospitals may need (1) to strengthen the quality of the patient-nurse encounter in which the issue of advance directives is raised to more effectively promote patient interest, discussions, and preparation of advance directives and (2) to account for the social diversity of their patient population.

(Arch Intern Med. 1995;155:502-510)

Author Affiliations
From the Department of Medicine, Pulmonary and Critical Care Division (Dr Silverman and Ms Tuma) and Survey Research and Development Center, Department of Epidemiology and Preventive Medicine (Dr Singh), University of Maryland School of Medicine, Baltimore. Dr Schaeffer is an independent consultant in health psychology, Potomac, Md.

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