Since the implementation of the Patient Self Determination Act of 1991, research on advance directives has been disappointing. There still exists a significant number of adults who have not completed an advance directive, although many express interest in doing so. Many researchers have studied the types of educational interventions that might motivate adults to complete plans for care at the end-of-life, with mixed results. The types of interventions that have been studied include the distribution of patient educational materials; altering the timing of the distribution of these materials, physician education, training advance care planning facilitators; instituting chart and computer based reminders as well as multimodal approaches. Some of these interventions have resulted in the increased completion of documents, while others have not. Moreover, when other important outcomes are studied, such as whether the documents are available when needed; if they are known by the physician, or if they are available during transfer of the patient, the results are less than optimal. Organizational structures and processes are major determinants of these inadequacies. Even when advance directives are completed and recorded, there is little evidence the information included affects treatment decisions. They are often too vague, confusing or the designated surrogate has not had meaningful conversations to be able to know what the patient would have wanted. Since clinicians remain uncomfortable and unskilled in having end-of-life discussions, patients and families are often disatisfied with the lack of inititation by their health provider, and the quantity and quality of the discussions. Additionally, lack of sensitivity to cultural or religious differences pose barriers to initiation of discussions among certain patient populations.
It is not surprising that attention has turned toward the development and testing of improved models of planning and decision-making that will result in more informed choices and increased satisfaction with the dying experience.
However, improved models of planning must integrate more than simply a new form, or a place in the medical record to store the new form. An effective Advance Care Planning Program will ideally encompass a systems approach if it is to have long lasting impact and produce positive outcomes. A useful framework for developing such a program is one that makes promises in several domains. The Respecting Choices Advance Care Planning Program in La Crosse, WI., uses the following Five Promises of Advance Care Planning to assist organizations and communities to evaluate their current efforts in advance care planning. Does your community/organization address the multiple components of advance care planning and create an effective system that truly honors individual preferences for future health care?
Initiate conversations
Provide assistance
Plans are clear
Plans are available
Plans are followed
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This content is provided by Gundersen Lutheran Medical Foundation. Citation: Hammes, Bernard J., Briggs, Linda, "Respecting Choices Advance Care Planning Facilitators Manual," Gundersen Lutheran Programs for Improving
End-of-Life Care, Gundersen Lutheran Medical Foundation, 2000. http://www.gundluth.org/eolprograms