Advance care planning in nursing homes: correlates of capacity and possession of advance directives.
OBJECTIVE
The identification of nursing home residents who can continue to participate in advance care planning about end-of-life care is a critical clinical and bioethical issue. This study uses high quality observational research to identify correlates of advance care planning in nursing homes, including objective measurement of capacity.


METHODS
The authors used cross-sectional, cohort study between 1997 and 1999. Seventy-eight residents (M age = 83.97, SD = 8.2) and their proxies (M age = 59.23, SD = 11.77) were included across five nursing homes. The authors obtained data via chart review, proxy interviews, resident assessments, survey completion by certified nursing assistants, and direct observation of residents' daily behaviors.


RESULTS
Capacity assessments revealed that most residents could state a simple treatment preference (82.4%), but a sizable number did not retain capacity to understand treatment alternatives or appreciate the consequences of their choice. Global cognitive ability (Mini-Mental State Examination score) was related to understanding and appreciation. When the authors removed the effects of global cognitive ability, understanding and appreciation were related to time spent by residents in verbal interaction with others. Residents were more likely to possess advance directives when proxies possessed advance directives, proxies were less religious, and residents were socially engaged.


CONCLUSIONS
Assessment of proxy beliefs and direct determination of residents' decisional capacity and social engagement may help nursing home staff identify families who may participate in advance planning for end-of-life medical care. Measures of global cognitive ability offer limited information about resident capacity for decision making. Decisional capacity assessments should enhance the verbal ability of individuals with dementia by reducing reliance on memory in the assessment process. Interventions to engage residents and families in structured discussions for end-of-life planning are needed.
Allen
Rebecca S
RS
Department of Psychology, The University of Alabama, Tuscaloosa 35487, USA. rsallen@bama.ua.edu
DeLaine
Shermetra R
SR
Chaplin
William F
WF
Marson
Daniel C
DC
Bourgeois
Michelle S
MS
Dijkstra
Katinka
K
Burgio
Louis D
LD
D032722:Advance Care Planning / Q000706:statistics & numerical data*; D016223:Advance Directives / Q000706:statistics & numerical data*; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D003430:Cross-Sectional Studies; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006707:Homes for the Aged / Q000706:statistics & numerical data*; D006801:Humans; D007258:Informed Consent / Q000592:standards; D008297:Male; D016743:Mental Competency / Q000592:standards; D008875:Middle Aged; D009735:Nursing Homes / Q000706:statistics & numerical data*; D019727:Proxy / Q000706:statistics & numerical data; D012067:Religion; D015203:Reproducibility of Results; D014481:United States