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Promoting Inpatient Directives About Life-Sustaining Treatments in a Community Hospital: Results of a 3-Year Time-Series Intervention Trial

Promoting Inpatient Directives About Life-Sustaining Treatments in a Community Hospital: Results... Abstract Background: Hospitalization presents an opportunity for physicians to discuss advance directives with patients and to encourage completion of health care proxies. Objective: To prospectively promote discussion and documentation of treatment-specific directives about life-sustaining interventions (cardiopulmonary resuscitation, admission to critical care units, mechanical ventilation, electrical cardioversion, and vasopressor therapy) among unselected medical inpatients in a community teaching hospital. Methods: We conducted a time-series intervention trial from January 1,1991, through June 30 1993, divided into three phases. During the education phase, we provided reminders, education, and feedback to attending physicians; during the intervention phase, we promoted a new documentation form for directives to be used by attending physicians; during the control phase, no interventions occurred. We studied consecutive patients (N=1780) admitted to the hospital acute medical service in each of the following 10 periods: three in the education phase (n=598), three in the intervention phase (n=826), and four in the control phase (n=356). The primary outcome measures were the frequency and content of directives documented by attending physicians in their patients' hospital charts. Secondary outcome measures included physicians' and patients' attitudes about directives, surveyed repeatedly. Results: The proportion of inpatients with directives increased significantly during the intervention phase (62.5% vs 23.6% during the education phase and 25.3% during the control period, P<.001, Pearson χ2 test). During the final intervention phase, 227 (83.2%) of 273 inpatients had directives documented in the hospital chart. Increases in clinically important ("impact") directives usually involved intensive care, not do-not-resuscitate status. Overall, 366 (86.7%) of 422 physician-attested directives agreed with the treatment preferences of interviewed patients (κ ranges, 0.53 to 0.79). Physicians' attitudes about and interest in directives improved. Conclusions: Institutional interventions can facilitate attending physicians' documentation of treatment-specific directives about life-sustaining care for most medical inpatients. More research is needed to confirm the effect of these efforts on quality and cost of hospital care, patients' autonomy, and their eventual execution of durable directives and proxies.(Arch Intern Med. 1995;155:2317-2323) References 1. Emanuel LL, Barry MJ, Stoeckle JD, Ettelson LM, Emanuel EJ. Advance directives for medical care. N Engl J Med . 1991;324:889-895.Crossref 2. Haas JS, Weissman JS, Cleary PD, et al. Discussion of preferences for life-sustaining care by persons with AIDS. Arch Intern Med . 1993;153:1241-1248.Crossref 3. Holley JL, Nespor S, Rault R. Chronic in-center hemodialysis patients' attitudes, knowledge and behavior toward advance directives. J Am Soc Nephrol . 1993;3:1405-1408. 4. Steinbrook R, Lo B, Moulton J, Saika G, Hollander H, Volberding PA. Preferences of homosexual men with AIDS for life-sustaining treatment. N Engl J Med . 1986;314:457-460.Crossref 5. Owen C, Tennant C, Levi J, Jones M. Resuscitation: patient and staff attitudes in the context of cancer. Gen Hosp Psychiatry . 1992;14:327-333.Crossref 6. Sachs GA. Caring for older cancer patients. Oncology . 1992;6( (suppl) ):131-135. 7. Broadwell AW, Boisaubin EV, Dunn JK, Engelhardt HT Jr. Advance directives on hospital admission: a survey of patient attitudes. South Med J . 1993;86:165-168.Crossref 8. Frankl D, Oye RK, Bellamy PE. Attitudes of hospitalized patients toward life support. Am J Med . 1989;86:645-648.Crossref 9. Reilly BM, Magnussen CR, Ross J, Ash J, Papa L, Wagner M. Can we talk? inpatient discussions about advance directives in a community hospital. Arch Intern Med . 1994;154:2299-2308.Crossref 10. Steiber SR. Right to die: public balks at deciding for others. Hospitals . 1987; 61:72. 11. Brennan TA. Ethics committees and decisions to limit care. JAMA . 1988;260: 803-807.Crossref 12. Emanuel EJ, Weinberg DS, Gonin R, Hummel LR, Emanuel LL. How well is the Patient Self-Determination Act working? Am J Med . 1993;95:619-628.Crossref 13. Damato AN, Reddy TK, Rusche P, et al. Advance directives for the elderly: a survey. N J Med . 1993;90:215-220. 14. Ebell MH, Smith MA, Seifert KG, Polsinelli K. The do-not-resuscitate order: outpatient preferences and decision-making. J Earn Pract . 1990;31:630-636. 15. Edinger W, Smucker DR. Outpatients' attitudes regarding advance directives. J Earn Pract . 1992;35:650-653. 16. Finucane TE, Shumway JM, Powers RL, D'Alessandri RM. Planning with elderly outpatients for contingencies of severe illness: a survey and clinical trial. J Gen Intern Med . 1988;3:322-325.Crossref 17. Lo B, McLeod G, Saika G. Patient attitudes toward discussing life-sustaining treatment. Arch Intern Med . 1986;146:1613-1615.Crossref 18. Schmerling RH, Bedell SE, Lilienfeld A, Delbanco TL. Discussing cardiopulmonary resuscitation: a study of elderly outpatients. J Gen Intern Med . 1988;3:317-321.Crossref 19. Emanuel LL. Does the DNR order need life-sustaining intervention? time for comprehensive advance directives. Am J Med . 1989;86:87-90.Crossref 20. Wenger NS, Zensky MF, Oye RK, et al. Readmission resuscitation status after hospitalization with a do-not-resuscitate order. J Gen Intern Med . 1994;9 ( (suppl 2) ):100. Abstract.Crossref 21. Reilly BM, Ross J, Magnussen CR, Wagner M, Papa L, Ash J. Promoting completion of health care proxies following hospitalization. Arch Intern Med . In press. 22. Cohen-Mansfield J, Droge JA, Billig N. The utilization of the durable power of attorney for health care among hospitalized elderly patients. J Am Geriatr Soc . 1991;39:1174-1178. 23. Teno JM, Lynn J, Phillips RS, et al. Do formal advance directives affect resuscitation decisions and the use of resources for seriously ill adults? J Clin Ethics . 1994;5:23-30. 24. Bedell S, Delbanco TL. Choices about cardiopulmonary resuscitation: when do physicians talk to patients? N Engl J Med . 1984;310:1089-1093.Crossref 25. Mittelberger JA, Lo B, Martin D, Uhlmann RF. Impact of a procedure-specific do-not-resuscitate order form on documentation of do-not-resuscitate orders. Arch Intern Med . 1993;153:228-232.Crossref 26. Silverman HJ, Tuma P, Schaeffer MH, Singh B. Implementation of the Patient Self-Determination Act in a hospital setting. Arch Intern Med . 1995;155:502-510.Crossref 27. Emanuel LL, Emanuel EJ, Stoeckle JD, Hummel LR, Barry MJ. Advance directives: stability of patients' treatment choices. Arch Intern Med . 1994;154:209-217.Crossref 28. Stephens RL. 'DNR' orders. JAMA . 1986;255:240-241.Crossref 29. Pearlman RA, Cain KC, Patrick DL, et al. Insights pertaining to patient assessments of status worth than death. J Clin Ethics . 1993;4:33-41. 30. Lo B, Jonsen AR. Clinical decisions to limit treatment. Ann Intern Med . 1980; 93:764-768.Crossref 31. Omnibus Reconciliation Act of 1990. Pub L No. 101-508, 4206 Stat 4751. 32. Greco PJ, Schulman KA, Lavizzo-Moury R, Hansen-Flaschen J. The Patient Self-Determination Act and the future of advance directives. Ann Intern Med . 1991;115:639-643.Crossref 33. Emanuel LL, Emanuel EJ. The medical directive. JAMA . 1989;261:3288-3293.Crossref 34. Lynn J, Teno JM. After the Patient Self-Determination Act: the need for empirical research on formal advance directives. Hastings Cent Rep . 1993:20-24. 35. Maksoud A, Jahnigen DW, Skibinski CI. Do-not-resuscitate orders and the cost of death. Arch Intern Med . 1993;153:1249-1253.Crossref 36. Murphy DJ, Finucane TE. New DNR policies. Arch Intern Med . 1993;153:1641-1648.Crossref 37. Chambers CV, Diamond JJ, Perkel RL, Lasch LA. Relationship of advance directives to hospital charges in a Medicare population. Arch Intern Med . 1994; 154:541-547.Crossref 38. Teno JM, Hakim RB, Knaus WA, et al. Preferences for cardiopulmonary resuscitation. J Gen Intern Med . 1995;10:179-186.Crossref 39. Emanuel EJ, Emanuel LL. The economics of dying. N Engl J Med . 1994;330: 540-544.Crossref 40. Schneiderman LJ, Kronick R, Kaplan RM, Anderson JP, Langer RD. Effects of offering advance directives on medical treatment and cost. Ann Intern Med . 1992;117:599-606.Crossref 41. Brett AS. Limitations of listing specific medical interventions in advance directives. JAMA . 1991;266:825-828.Crossref 42. Emanuel EJ, Brett AS. Managed competition and the patient-physician relationship. N Engl J Med . 1993;329:879-882.Crossref 43. Cammer-Paris BE, Carrion VG, Meditch JS, Capello CF, Mulvihill MN. Roadblocks to DNR orders. Arch Intern Med . 1993;153:1689-1695.Crossref 44. Brunetti LJ, Carperos SD, Westlund RE. Physicians' attitudes toward living wills and CPR. J Gen Intern Med . 1991;6:323-329.Crossref 45. Mower WR, Baraff LJ. Advance directives. Arch Intern Med . 1993;153:375-381.Crossref 46. Malloy TR, Wigton RS, Meeske J, Tape TG. The influence of treatment descriptions on advance medical directive decisions. J Am Geriatr Soc . 1992; 40:1255-1260. 47. Schneiderman LJ, Pearlman RA, Kaplan RM, Anderson JP, Rosenberg EM. Relationship of general advance directive instructions to specific life-sustaining treatment preferences in patients with serious illness. Arch Intern Med . 1992;152:2114-2122.Crossref 48. Sachs GA, Stocking CB, Miles SH. Empowerment of the older patient? J Am Geriatr Soc . 1992;40:269-273. 49. Morrison RS, Morrison EW, Glickman DF. Physician reluctance to discuss advance directives. J Gen Intern Med . 1994;9( (suppl 2) ):61. Abstract.Crossref 50. Hare J, Nelson C. Will outpatients complete living wills? J Gen Intern Med . 1991;6:41-46.Crossref 51. Sulmasy DP, Haller K, Terry PB. More talk, less paper. Am J Med . 1994;96: 432-438.Crossref 52. Murphy DJ, Burrows D, Santilli S, et al. The influence of the probability of survival on patients' preferences regarding CPR. N Engl J Med . 1994;330:545-549.Crossref 53. Cohen-Mansfield J, Droge JA, Billig N. Factors influencing hospital patients' preferences in the utilization of life-sustaining treatments. Gerontologist . 1992; 32:89-95.Crossref 54. Donkas DJ, Gorenflo DW. Analyzing the values history. J Clin Ethics . 1993;4: 41-45. 55. Schneiderman LJ, Kaplan RM, Pearlman RA, Teetzael H. Do physicians' own preferences for life-sustaining treatments influence their perception of patients' preferences? J Clin Ethics . 1993;4:28-33. 56. Davidson KW, Hackler C, Caradine R, McCord RS. Physicians' attitudes on advance directives. JAMA . 1989;262:2415-2419.Crossref 57. Ebell M, Doukas DJ, Smith MA. The do-not-resuscitate order. Am J Med . 1991;91:255-260.Crossref 58. Miller DL, Gorbien MJ, Simbartl LA, Jahnigen DW. Factors influencing physicians in recommending in-hospital CPR. Arch Intern Med . 1993;153:1999-2003.Crossref 59. Gillick MR, Hesse K, Mazzapiza N. Medical technology at the end of life. Arch Intern Med . 1993;153:2542-2547.Crossref 60. Tulsky JA, Chesney MA, Lo B. 'See one, do one, teach one' fails in discussion about resuscitation. J Gen Intern Med . 1994;9( (suppl 2) ):83. Abstract. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Promoting Inpatient Directives About Life-Sustaining Treatments in a Community Hospital: Results of a 3-Year Time-Series Intervention Trial

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References (84)

Publisher
American Medical Association
Copyright
Copyright © 1995 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1995.00430210067010
Publisher site
See Article on Publisher Site

Abstract

Abstract Background: Hospitalization presents an opportunity for physicians to discuss advance directives with patients and to encourage completion of health care proxies. Objective: To prospectively promote discussion and documentation of treatment-specific directives about life-sustaining interventions (cardiopulmonary resuscitation, admission to critical care units, mechanical ventilation, electrical cardioversion, and vasopressor therapy) among unselected medical inpatients in a community teaching hospital. Methods: We conducted a time-series intervention trial from January 1,1991, through June 30 1993, divided into three phases. During the education phase, we provided reminders, education, and feedback to attending physicians; during the intervention phase, we promoted a new documentation form for directives to be used by attending physicians; during the control phase, no interventions occurred. We studied consecutive patients (N=1780) admitted to the hospital acute medical service in each of the following 10 periods: three in the education phase (n=598), three in the intervention phase (n=826), and four in the control phase (n=356). The primary outcome measures were the frequency and content of directives documented by attending physicians in their patients' hospital charts. Secondary outcome measures included physicians' and patients' attitudes about directives, surveyed repeatedly. Results: The proportion of inpatients with directives increased significantly during the intervention phase (62.5% vs 23.6% during the education phase and 25.3% during the control period, P<.001, Pearson χ2 test). During the final intervention phase, 227 (83.2%) of 273 inpatients had directives documented in the hospital chart. Increases in clinically important ("impact") directives usually involved intensive care, not do-not-resuscitate status. Overall, 366 (86.7%) of 422 physician-attested directives agreed with the treatment preferences of interviewed patients (κ ranges, 0.53 to 0.79). Physicians' attitudes about and interest in directives improved. Conclusions: Institutional interventions can facilitate attending physicians' documentation of treatment-specific directives about life-sustaining care for most medical inpatients. More research is needed to confirm the effect of these efforts on quality and cost of hospital care, patients' autonomy, and their eventual execution of durable directives and proxies.(Arch Intern Med. 1995;155:2317-2323) References 1. Emanuel LL, Barry MJ, Stoeckle JD, Ettelson LM, Emanuel EJ. Advance directives for medical care. N Engl J Med . 1991;324:889-895.Crossref 2. Haas JS, Weissman JS, Cleary PD, et al. Discussion of preferences for life-sustaining care by persons with AIDS. Arch Intern Med . 1993;153:1241-1248.Crossref 3. Holley JL, Nespor S, Rault R. Chronic in-center hemodialysis patients' attitudes, knowledge and behavior toward advance directives. J Am Soc Nephrol . 1993;3:1405-1408. 4. Steinbrook R, Lo B, Moulton J, Saika G, Hollander H, Volberding PA. Preferences of homosexual men with AIDS for life-sustaining treatment. N Engl J Med . 1986;314:457-460.Crossref 5. Owen C, Tennant C, Levi J, Jones M. Resuscitation: patient and staff attitudes in the context of cancer. Gen Hosp Psychiatry . 1992;14:327-333.Crossref 6. Sachs GA. Caring for older cancer patients. Oncology . 1992;6( (suppl) ):131-135. 7. Broadwell AW, Boisaubin EV, Dunn JK, Engelhardt HT Jr. Advance directives on hospital admission: a survey of patient attitudes. South Med J . 1993;86:165-168.Crossref 8. Frankl D, Oye RK, Bellamy PE. Attitudes of hospitalized patients toward life support. Am J Med . 1989;86:645-648.Crossref 9. Reilly BM, Magnussen CR, Ross J, Ash J, Papa L, Wagner M. Can we talk? inpatient discussions about advance directives in a community hospital. Arch Intern Med . 1994;154:2299-2308.Crossref 10. Steiber SR. Right to die: public balks at deciding for others. Hospitals . 1987; 61:72. 11. Brennan TA. Ethics committees and decisions to limit care. JAMA . 1988;260: 803-807.Crossref 12. Emanuel EJ, Weinberg DS, Gonin R, Hummel LR, Emanuel LL. How well is the Patient Self-Determination Act working? Am J Med . 1993;95:619-628.Crossref 13. Damato AN, Reddy TK, Rusche P, et al. Advance directives for the elderly: a survey. N J Med . 1993;90:215-220. 14. Ebell MH, Smith MA, Seifert KG, Polsinelli K. The do-not-resuscitate order: outpatient preferences and decision-making. J Earn Pract . 1990;31:630-636. 15. Edinger W, Smucker DR. Outpatients' attitudes regarding advance directives. J Earn Pract . 1992;35:650-653. 16. Finucane TE, Shumway JM, Powers RL, D'Alessandri RM. Planning with elderly outpatients for contingencies of severe illness: a survey and clinical trial. J Gen Intern Med . 1988;3:322-325.Crossref 17. Lo B, McLeod G, Saika G. Patient attitudes toward discussing life-sustaining treatment. Arch Intern Med . 1986;146:1613-1615.Crossref 18. Schmerling RH, Bedell SE, Lilienfeld A, Delbanco TL. Discussing cardiopulmonary resuscitation: a study of elderly outpatients. J Gen Intern Med . 1988;3:317-321.Crossref 19. Emanuel LL. Does the DNR order need life-sustaining intervention? time for comprehensive advance directives. Am J Med . 1989;86:87-90.Crossref 20. Wenger NS, Zensky MF, Oye RK, et al. Readmission resuscitation status after hospitalization with a do-not-resuscitate order. J Gen Intern Med . 1994;9 ( (suppl 2) ):100. Abstract.Crossref 21. Reilly BM, Ross J, Magnussen CR, Wagner M, Papa L, Ash J. Promoting completion of health care proxies following hospitalization. Arch Intern Med . In press. 22. Cohen-Mansfield J, Droge JA, Billig N. The utilization of the durable power of attorney for health care among hospitalized elderly patients. J Am Geriatr Soc . 1991;39:1174-1178. 23. Teno JM, Lynn J, Phillips RS, et al. Do formal advance directives affect resuscitation decisions and the use of resources for seriously ill adults? J Clin Ethics . 1994;5:23-30. 24. Bedell S, Delbanco TL. Choices about cardiopulmonary resuscitation: when do physicians talk to patients? N Engl J Med . 1984;310:1089-1093.Crossref 25. Mittelberger JA, Lo B, Martin D, Uhlmann RF. Impact of a procedure-specific do-not-resuscitate order form on documentation of do-not-resuscitate orders. Arch Intern Med . 1993;153:228-232.Crossref 26. Silverman HJ, Tuma P, Schaeffer MH, Singh B. Implementation of the Patient Self-Determination Act in a hospital setting. Arch Intern Med . 1995;155:502-510.Crossref 27. Emanuel LL, Emanuel EJ, Stoeckle JD, Hummel LR, Barry MJ. Advance directives: stability of patients' treatment choices. Arch Intern Med . 1994;154:209-217.Crossref 28. Stephens RL. 'DNR' orders. JAMA . 1986;255:240-241.Crossref 29. Pearlman RA, Cain KC, Patrick DL, et al. Insights pertaining to patient assessments of status worth than death. J Clin Ethics . 1993;4:33-41. 30. Lo B, Jonsen AR. Clinical decisions to limit treatment. Ann Intern Med . 1980; 93:764-768.Crossref 31. Omnibus Reconciliation Act of 1990. Pub L No. 101-508, 4206 Stat 4751. 32. Greco PJ, Schulman KA, Lavizzo-Moury R, Hansen-Flaschen J. The Patient Self-Determination Act and the future of advance directives. Ann Intern Med . 1991;115:639-643.Crossref 33. Emanuel LL, Emanuel EJ. The medical directive. JAMA . 1989;261:3288-3293.Crossref 34. Lynn J, Teno JM. After the Patient Self-Determination Act: the need for empirical research on formal advance directives. Hastings Cent Rep . 1993:20-24. 35. Maksoud A, Jahnigen DW, Skibinski CI. Do-not-resuscitate orders and the cost of death. Arch Intern Med . 1993;153:1249-1253.Crossref 36. Murphy DJ, Finucane TE. New DNR policies. Arch Intern Med . 1993;153:1641-1648.Crossref 37. Chambers CV, Diamond JJ, Perkel RL, Lasch LA. Relationship of advance directives to hospital charges in a Medicare population. Arch Intern Med . 1994; 154:541-547.Crossref 38. Teno JM, Hakim RB, Knaus WA, et al. Preferences for cardiopulmonary resuscitation. J Gen Intern Med . 1995;10:179-186.Crossref 39. Emanuel EJ, Emanuel LL. The economics of dying. N Engl J Med . 1994;330: 540-544.Crossref 40. Schneiderman LJ, Kronick R, Kaplan RM, Anderson JP, Langer RD. Effects of offering advance directives on medical treatment and cost. Ann Intern Med . 1992;117:599-606.Crossref 41. Brett AS. Limitations of listing specific medical interventions in advance directives. JAMA . 1991;266:825-828.Crossref 42. Emanuel EJ, Brett AS. Managed competition and the patient-physician relationship. N Engl J Med . 1993;329:879-882.Crossref 43. Cammer-Paris BE, Carrion VG, Meditch JS, Capello CF, Mulvihill MN. Roadblocks to DNR orders. Arch Intern Med . 1993;153:1689-1695.Crossref 44. Brunetti LJ, Carperos SD, Westlund RE. Physicians' attitudes toward living wills and CPR. J Gen Intern Med . 1991;6:323-329.Crossref 45. Mower WR, Baraff LJ. Advance directives. Arch Intern Med . 1993;153:375-381.Crossref 46. Malloy TR, Wigton RS, Meeske J, Tape TG. The influence of treatment descriptions on advance medical directive decisions. J Am Geriatr Soc . 1992; 40:1255-1260. 47. Schneiderman LJ, Pearlman RA, Kaplan RM, Anderson JP, Rosenberg EM. Relationship of general advance directive instructions to specific life-sustaining treatment preferences in patients with serious illness. Arch Intern Med . 1992;152:2114-2122.Crossref 48. Sachs GA, Stocking CB, Miles SH. Empowerment of the older patient? J Am Geriatr Soc . 1992;40:269-273. 49. Morrison RS, Morrison EW, Glickman DF. Physician reluctance to discuss advance directives. J Gen Intern Med . 1994;9( (suppl 2) ):61. Abstract.Crossref 50. Hare J, Nelson C. Will outpatients complete living wills? J Gen Intern Med . 1991;6:41-46.Crossref 51. Sulmasy DP, Haller K, Terry PB. More talk, less paper. Am J Med . 1994;96: 432-438.Crossref 52. Murphy DJ, Burrows D, Santilli S, et al. The influence of the probability of survival on patients' preferences regarding CPR. N Engl J Med . 1994;330:545-549.Crossref 53. Cohen-Mansfield J, Droge JA, Billig N. Factors influencing hospital patients' preferences in the utilization of life-sustaining treatments. Gerontologist . 1992; 32:89-95.Crossref 54. Donkas DJ, Gorenflo DW. Analyzing the values history. J Clin Ethics . 1993;4: 41-45. 55. Schneiderman LJ, Kaplan RM, Pearlman RA, Teetzael H. Do physicians' own preferences for life-sustaining treatments influence their perception of patients' preferences? J Clin Ethics . 1993;4:28-33. 56. Davidson KW, Hackler C, Caradine R, McCord RS. Physicians' attitudes on advance directives. JAMA . 1989;262:2415-2419.Crossref 57. Ebell M, Doukas DJ, Smith MA. The do-not-resuscitate order. Am J Med . 1991;91:255-260.Crossref 58. Miller DL, Gorbien MJ, Simbartl LA, Jahnigen DW. Factors influencing physicians in recommending in-hospital CPR. Arch Intern Med . 1993;153:1999-2003.Crossref 59. Gillick MR, Hesse K, Mazzapiza N. Medical technology at the end of life. Arch Intern Med . 1993;153:2542-2547.Crossref 60. Tulsky JA, Chesney MA, Lo B. 'See one, do one, teach one' fails in discussion about resuscitation. J Gen Intern Med . 1994;9( (suppl 2) ):83. Abstract.

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Nov 27, 1995

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