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

Carolyn E. Schwartz, University of Massachusetts Medical School
H. Brownell Wheeler, University of Massachusetts Medical School
Bernard Hammes
Noreen Basque
Jean Edmunds, University of Massachusetts Medical School
George W. Reed, University of Massachusetts Medical School
Yunsheng Ma, University of Massachusetts Medical School
Lynn Li, University of Massachusetts Medical School
Patricia Tabloski
Julianne Yanko

Abstract

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.