Early intervention in planning end-of-life care with ambulatory geriatric patients: results of a pilot trial.
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.


CONCLUSIONS
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.
Schwartz
Carolyn E
CE
Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, MA 01742, USA. carolyn.schwartz@umassmed.edu
Wheeler
H Brownell
HB
Hammes
Bernard
B
Basque
Noreen
N
Edmunds
Jean
J
Reed
George
G
Ma
Yunsheng
Y
Li
Lynn
L
Tabloski
Patricia
P
Yanko
Julianne
J
D032722:Advance Care Planning; D016223:Advance Directives; D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care; D001294:Attitude to Health; D003657:Decision Making; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D010347:Patient Care Planning; D010353:Patient Education as Topic; D010865:Pilot Projects; D011446:Prospective Studies; D011788:Quality of Life; D013727:Terminal Care; D019452:Terminally Ill; D013997:Time Factors; D016896:Treatment Outcome