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Educational video does not affect dementia care

An advance care planning video did not impact preferences, do-not-hospitalize directives or burdensome treatments for patients with advanced dementia, according to findings published in JAMA Internal Medicine.

“Patients with advanced dementia commonly receive burdensome treatments that may be of little clinical benefit and inconsistent with care preferences,” Susan L. Mitchell, MD, MPH, from the Hebrew SeniorLife Institute for Aging Research, and colleagues wrote. “Advance care planning offers an opportunity to promote goal-directed care. However, current [advance care planning] is often inadequate; proxy counseling is inconsistent, preferences are not routinely ascertained, and advance directives may not reflect the goals of care.”

Between 2013 and 2017, Mitchell and colleagues conducted a cluster randomized clinical trial to determine if advance care planning affects advance directives, level of care preferences, goals-of-care discussions and burdensome treatments among patients with advanced dementia residing in one of 64 nursing homes, compared with usual care.

The researchers enrolled 402 residents with advanced dementia (mean age, 86.7 years; 87.1% white; 80.1% women) and their proxies. Participants were randomly assigned to the intervention arm (n = 211) or control arm (n = 189) and were evaluated every 3 months for 1 year. Proxies in the intervention group watched a 12-minute advance care planning video then informed the primary care team of their preferred level of care (comfort, basic or intensive).

Results showed that there was no difference in do-not-hospitalize directives among both groups (63% in both arms; adjusted OR = 1.08; 95% CI, 0.69-1.69). There was also no difference between the groups in preferences for comfort care, directives to withhold IV hydration and burdensome treatments.

Directives for no tube-feeding at 6 months were more likely in participants in the intervention group than the control group (70.1% vs. 61.9%; aOR = 1.79; 95% CI, 1.13-2.82). This was also true for all other time periods.

Residents in the intervention group were also more likely to have documented goals-of-care discussions at 3 months (16.1% vs. 7.9%; aOR = 2.58; 95%CI, 1.20-5.54). Do-not-hospitalize and no tube-feeding directives occurred more often in the intervention group than the control group when comfort care was preferred (72.2% vs. 52.8%; aOR = 2.68; 95% CI, 2.68-5.85).

“While the findings suggest that advance care planning videos do not alter care preferences, they do suggest that the video promotes alignment of proxy preferences with advance care directives,” Mitchell said in a press release.

In an accompanying editorial, Nathan E. Goldstein, MD, and Harriet Mather, MD, MSc, both from the Icahn School of Medicine at Mount Sinai, point out that dementia affects millions of patients and is expected to affect even more as the baby-boomer generation continues to age.

“Mitchell and colleagues’ outstanding work in this study demonstrates just how complicated advance care planning is in this population and how we must continue to work to improve the care of these individuals to ensure that the treatments they receive optimize quality of life and are ultimately aligned with their values, goals and preferences,” they wrote. – by Alaina Tedesco

Disclosure: The authors report no relevant financial disclosures.