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Early Intervention in Planning End-of-Life Care With Ambulatory Geriatric Patients
Results of a Pilot Trial
Carolyn E. Schwartz, ScD;
H. Brownell Wheeler, MD;
Bernard Hammes, PhD;
Noreen Basque, RN, MA;
Jean Edmunds, MA;
George Reed, PhD;
Yunsheng Ma, MPH;
Lynn Li, MD;
Patricia Tabloski, PhD, RN;
Julianne Yanko, PhD;
and the UMass End-of-Life Working Group
Arch Intern Med. 2002;162:1611-1618.
Background A large discrepancy exists between the wishes of dying patients and
their actual end-of-life care. However, retrospective clinical experience
suggests that early advance care planning (ACP) can markedly reduce this discrepancy.
This article describes a randomized trial to evaluate the short-term clinical
utility of early ACP. We also assessed the feasibility of performing a larger
prospective study to document long-term outcomes.
Methods Ambulatory geriatric patients (N = 61) were randomized to either a control
group, which received only a Massachusetts Health Care Proxy form to complete,
or an intervention group, in which each patient and health care agent discussed
ACP with a trained nurse facilitator. The benefits and burdens of life-sustaining
treatments were discussed, and patient goals and preferences for these treatments
were documented.
Results Two-month follow-up revealed that the intervention achieved higher congruence
between agents and patients in their understanding of patients' end-of-life
care preferences, with 76% (19/25) in complete agreement vs 55% (12/22) of
the controls (effect size [ES] = -0.43). There was also a greater increase
in patient knowledge about ACP in the intervention group (ES = 0.22). Intervention
patients became less willing to undergo life-sustaining treatments for a new
serious medical problem (ES = -0.25), more willing to undergo such treatments
for an incurable progressive disease (ES = 0.24), and less willing to tolerate
poor health states (ES = -0.78). Practical insights were gained about
how to conduct a larger study more effectively.
Conclusion A facilitated discussion about end-of-life care between patients and
their health care agents helps define and document the patient's wishes for
both patient and agent.
From the Departments of Family Medicine and Community Health (Dr Schwartz)
and Surgery (Dr Wheeler), the Office of Medical Ethics (Ms Edmunds), the Department
of Medicine, Divisions of Preventive and Behavioral Medicine (Drs Schwartz,
Reed, and Yanko and Mr Ma) and General Medicine, Primary Care, and Geriatrics
(Dr Li), University of Massachusetts Medical School, Worcester; the Department
of Medical Humanities, Gundersen Lutheran Medical Foundation, La Crosse, Wis
(Dr Hammes); Visiting Nurse Association Care Network Inc, Worcester (Ms Basque);
and Boston College School of Nursing, Chestnut Hill, Mass (Dr Tabloski). Members
of the UMass End-of-Life Working Group (Worcester, Mass) are Eileen Griffin,
RN; Thomas G. Landry III, DMin; Flo Leclair, RN, BSN, CNRH; Sarah McGee, MD,
MPH; Sarah Reiff-Hekking, PhD; and Joanne Spurr, LCSW.
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