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‘Easy to follow’ advance directives more likely to be used
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Both clinicians and patients more often utilized advance directives that were more “readable, understandable, appealing and usable,” according to findings recently published in the Journal of the American Board of Family Medicine.
“The data are that over 70% of people want to die at home, free of pain, surrounded by family and friends, yet over 70% of people die in the hospital, frequently in the ICU, as a result of withdrawal or withholding of life-sustaining treatment,” Elizabeth Wickersham, MD, MS, of the department of family and preventive medicine at the University of Oklahoma College of Medicine, told Healio Primary Care.
“We believe advance care planning and advanced directive adoption needs to improve so that we can better align the care people receive at the end of life with their wishes and desires,” she added.
Wickersham and colleagues compared the implementation of the Oklahoma Advance Directive — described by researchers as a 20-page explanatory booklet with highly technical and legal language and complicated and occasionally poorly defined medical terminology — with the similarly purposed Five Wishes form — described as written at an eighth-grade reading level and accompanied by internet- and video-based educational tools — among 2,748 patients from six primary care physicians.
They found that Five Wishes was offered in 36% of eligible patient visits and accepted 82% of the time, whereas the Oklahoma Advance Directive was offered in 33% of eligible patient visits and accepted 54% of the time.
“Many patients expressed confusion about the statements they were signing and often needed assistance with the [Oklahoma Advance Directive] form. In contrast, no Five Wishes patients demonstrated confusion about the purpose of the form’s sections. They reported that it used simple language and was easy to follow,” Wickersham and colleagues wrote.
In addition, unadjusted analyses revealed that the Five Wishes form was 3.89 times more likely than the Oklahoma Advance Directive (95% CI, 2.88-5.24) to be accepted. Logistic regression models controlling for several confounders showed that acceptance of Five Wishes was favored significantly over Oklahoma Advance Directive (OR = 1.52; 95% CI, 1.27-1.81). Only 31% of physicians said they could see the patients’ specific wishes from looking at the patients’ electronic health record — a statistic that researchers said needed improvement in order to increase the implementation rate.
Wickersham also provided a few pointers that primary care clinicians can use to help them start conversations with their patients regarding advance care planning.
“These talks need to start when patients are not acutely/emergently ill or otherwise under duress. It takes time for patients to consider what their wishes really are and how to align their advance care planning with the things that matter most to them,” she told Healio Primary Care.
“Studies demonstrate that most people want their doctor to discuss their advance care planning with them and that most people do not have this conversation. People that have these conversations as a result of writing up a will usually do not attend to the medical questions carefully. They often have no idea what they actually put on the forms and whether or not they align with their values and beliefs. These conversations are best had with people who know medicine, know the patient, and know the patient’s values,” Wickersham added. – by Janel Miller
Disclosures: The authors report no relevant financial disclosures.