Engaging in advance-care-planning discussions with their physicians or having advance directives filed in their medical records resulted in no significant difference in survival time for patients at three Colorado hospitals, according to a report in the Journal of Hospital Medicine.1
A total of 458 adult patients admitted to general IM services at the hospitals were asked whether they’d had discussions with their physicians about advance directives, which are legal documents allowing patients to spell out treatment preferences (including a desire for more aggressive treatment) in advance of situations in which they are no longer able to communicate them. Charts were reviewed for the presence of advance directives, and the patients were then stratified based on low, medium, or high risk of death within a year. The high-risk patients were excluded from the study, and those in the low- and medium-risk groups were followed from 2003 to 2009.
“In regard to the current national debate about the merits of advance-care planning, this study suggests that honoring patients’ wishes to engage in advance directive discussions and documentation does not lead to harm,” the study concludes.
Lead author Stacy Fischer, MD, of the University of Colorado Denver says that it is striking how few hospitalized patients have actually engaged in these conversations, even though the population is quite ill. “So often, the conversation happens too late,” she says, “and then not with the patient but with a surrogate.”
Dr. Fischer encourages hospitalists to view the hospital admission as an important opportunity to start conversations with patients about their future care preferences. When patients come into the hospital, they must be asked about advance directives, but that process tends to be cursory, she says. At a minimum, hospitalists should clarify who the surrogate decision maker is, who would speak for the patient at a time of incapacity.
What should the hospitalist’s role be in end-of-life discussions? “That’s a complicated question in the current environment, where nobody seems to think it’s their role,” Dr. Fischer says. “I believe we all need to help move the conversation along. If [advance directive] forms can be available on the floor and if patients express interest in them, then encouraging them would be important.”
Larry Beresford is a freelance writer in Oakland, Calif.
- Fischer SM, Min SJ, Sauaia A, Kutner JS. “They’re going to unplug grandma”: Advance directive discussions and documentation do not decrease survival in patients at baseline lower risk of death. J Hosp Med. 2012;7:3-7.