Does Advance Care Planning Make a Difference at the End of Life in ...
Does Advance Care Planning Make a Difference at the End of Life in ...
Does Advance Care Planning Make a Difference at the End of Life in ...
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La Crosse <strong>Advance</strong>d Directive Study II:<br />
<strong>Does</strong> <strong>Advance</strong> <strong>Care</strong> <strong>Plann<strong>in</strong>g</strong><br />
<strong>Make</strong> a <strong>Difference</strong><br />
<strong>at</strong> <strong>the</strong> <strong>End</strong> <strong>of</strong> <strong>Life</strong> <strong>in</strong> La Crosse<br />
County?<br />
Bud Hammes, PhD & Brenda<br />
Rooney, PhD<br />
Jake Gundrum, MS<br />
© Copyright 2009 All Rights Reserved – Gundersen Lu<strong>the</strong>ran Medical Found<strong>at</strong>ion, Inc.
The failure <strong>of</strong> <strong>Advance</strong> Directives<br />
<strong>in</strong> <strong>the</strong> USA<br />
“Just complet<strong>in</strong>g a st<strong>at</strong>utory AD does not work”<br />
The prevalence <strong>of</strong> <strong>Advance</strong> Directives is low (Prevalence<br />
is 20-30% <strong>in</strong> <strong>the</strong> general pop. up to 50% for end-stage<br />
illnesses)<br />
• <strong>Advance</strong> Directives are most <strong>of</strong>ten unavailable <strong>at</strong> <strong>the</strong><br />
place <strong>of</strong> tre<strong>at</strong>ment (available to <strong>the</strong> physician only 25%<br />
<strong>of</strong> time)<br />
• <strong>Advance</strong> directives are most <strong>of</strong>ten not helpful to<br />
decision-mak<strong>in</strong>g (plann<strong>in</strong>g is too generic)<br />
• <strong>Advance</strong> directives are <strong>of</strong>ten not followed (not available,<br />
not specific, not accepted).<br />
Wilk<strong>in</strong>son A, Wenger N, Shugarman LR; U.S. Department <strong>of</strong> Health and<br />
Human Services; RAND Corpor<strong>at</strong>ion. Liter<strong>at</strong>ure Review On <strong>Advance</strong><br />
Directives. http://aspe.hhs.gov/daltcp/reports/2007/advdirlr.htm. Published<br />
June 2008.<br />
© Copyright 2009 All Rights Reserved – Gundersen Lu<strong>the</strong>ran Medical Found<strong>at</strong>ion, Inc.
ACP <strong>in</strong> La Crosse Area<br />
• In 1991 local health adm<strong>in</strong>istr<strong>at</strong>ors agreed to<br />
develop a collabor<strong>at</strong>ive effort to <strong>in</strong>crease <strong>the</strong><br />
prevalence <strong>of</strong> plann<strong>in</strong>g prior to a medical crisis<br />
• A local task force was organized to develop and<br />
implement a new program<br />
• An ACP system was developed th<strong>at</strong> <strong>in</strong>cluded:<br />
stds <strong>of</strong> care/policies, tra<strong>in</strong><strong>in</strong>g <strong>of</strong> facilit<strong>at</strong>ors and<br />
staff, pt. educ<strong>at</strong>ion m<strong>at</strong>erials, and oversight<br />
us<strong>in</strong>g QI methods<br />
• This new system was fully implemented <strong>in</strong> <strong>the</strong><br />
spr<strong>in</strong>g <strong>of</strong> 1993<br />
© Copyright 2009 All Rights Reserved – Gundersen Lu<strong>the</strong>ran Medical Found<strong>at</strong>ion, Inc.
Community ACP System Susta<strong>in</strong>ed<br />
and Improved from ’96-’08<br />
• Practices, Policies, and tra<strong>in</strong><strong>in</strong>g cont<strong>in</strong>ue<br />
with on-go<strong>in</strong>g upd<strong>at</strong>es and improvements<br />
• POAHC document revised and improved<br />
• POLST form added to system <strong>in</strong> 1997<br />
• QI monitor<strong>in</strong>g for outcomes and quality<br />
cont<strong>in</strong>ue<br />
© Copyright 2009 All Rights Reserved – Gundersen Lu<strong>the</strong>ran Medical Found<strong>at</strong>ion, Inc.
LADS I<br />
Retrospective Study <strong>of</strong> adult de<strong>at</strong>hs from 5 zip<br />
codes <strong>in</strong> La Crosse Co. over 11 months <strong>in</strong> ’95-<br />
’96 (pop approx 95,000)<br />
Eligibility<br />
• 18 or older<br />
• Mentally capable <strong>at</strong> some po<strong>in</strong>t <strong>in</strong> <strong>the</strong> previous<br />
10 years<br />
• Died under <strong>the</strong> care <strong>of</strong> a provider<br />
• Resident <strong>of</strong> La Crosse Co. for 6 mos or gre<strong>at</strong>er.<br />
Hammes BJ, Rooney BL. De<strong>at</strong>h and end-<strong>of</strong>-plann<strong>in</strong>g <strong>in</strong> one midwestern community. Arch Intern Med.<br />
1998.158:383-390.<br />
© Copyright 2009 All Rights Reserved – Gundersen Lu<strong>the</strong>ran Medical Found<strong>at</strong>ion, Inc.
LADS II<br />
A retrospective study <strong>of</strong> all adult de<strong>at</strong>hs <strong>in</strong> health<br />
care organiz<strong>at</strong>ions <strong>in</strong> La Crosse Co.<br />
Eligibility <strong>in</strong>cluded:<br />
• La Crosse county resident for > 6 months<br />
• 18 years <strong>of</strong> age or older<br />
• Mentally capable <strong>at</strong> some po<strong>in</strong>t <strong>in</strong> <strong>the</strong> last 15<br />
years <strong>of</strong> life<br />
• P<strong>at</strong>ient died under <strong>the</strong> care <strong>of</strong> a health care<br />
organiz<strong>at</strong>ion between September 1, 2007 --<br />
March 31, 2008<br />
© Copyright 2009 All Rights Reserved – Gundersen Lu<strong>the</strong>ran Medical Found<strong>at</strong>ion, Inc.
LADS-I<br />
LADS-II<br />
Demographics (n=540)<br />
Age (years)<br />
Mean<br />
80<br />
Median<br />
82.21<br />
Range<br />
20-103<br />
Sex, % M<br />
46.3<br />
Loc<strong>at</strong>ion <strong>of</strong> De<strong>at</strong>h (%)<br />
Home<br />
14<br />
LTC<br />
50<br />
Hospital<br />
36<br />
Demographics (n=400)<br />
Age (years)<br />
Mean<br />
80<br />
Median<br />
84<br />
Range<br />
31-108<br />
Sex, % M<br />
44.9<br />
Loc<strong>at</strong>ion <strong>of</strong> De<strong>at</strong>h (%)<br />
Home<br />
14<br />
LTC<br />
46<br />
Hospital<br />
30<br />
Inp<strong>at</strong>ient Hospice<br />
10<br />
© Copyright 2009 All Rights Reserved – Gundersen Lu<strong>the</strong>ran Medical Found<strong>at</strong>ion, Inc.
LADS-I<br />
LADS-II<br />
Type <strong>of</strong> AD (%)<br />
Type <strong>of</strong> AD (%)<br />
POA-HC<br />
77<br />
POA-HC<br />
90<br />
Instructive (Liv<strong>in</strong>g Will)<br />
10<br />
Instructive (Liv<strong>in</strong>g Will)<br />
8<br />
Dict<strong>at</strong>ed note<br />
13<br />
Dict<strong>at</strong>ed note<br />
33<br />
<strong>Advance</strong> Directives (n=540)<br />
Subjects with written ADs<br />
n=459 (85%)<br />
<strong>Advance</strong> Directives (n=400)<br />
Subjects with written ADs<br />
360 (90%)<br />
Subjects with AD <strong>in</strong> MR<br />
n=437 (95%)<br />
Subjects with AD <strong>in</strong> MR<br />
358 (99%)<br />
Subjects with a POLST<br />
272 (67%)<br />
Subjects with a POLST<br />
and a written AD<br />
247 (61%)<br />
Subjects with a POLST or<br />
a written AD<br />
390 (96%)<br />
© Copyright 2009 All Rights Reserved – Gundersen Lu<strong>the</strong>ran Medical Found<strong>at</strong>ion, Inc.
Honor<strong>in</strong>g preferences about hospitaliz<strong>at</strong>ion<br />
Study<br />
LADS I<br />
Prevalence <strong>of</strong><br />
plans not to<br />
hospitalize, #<br />
38<br />
% honored<br />
78%<br />
LADS II<br />
164<br />
97%<br />
© Copyright 2009 All Rights Reserved – Gundersen Lu<strong>the</strong>ran Medical Found<strong>at</strong>ion, Inc.
© Copyright 2009 All Rights Reserved – Gundersen Lu<strong>the</strong>ran Medical Found<strong>at</strong>ion, Inc.
Conclusions<br />
1. We have clearly susta<strong>in</strong>ed a high level <strong>of</strong><br />
plann<strong>in</strong>g, plans are available, and are<br />
almost always honored.<br />
2. A system<strong>at</strong>ic approach to advance care<br />
plann<strong>in</strong>g can be implemented and<br />
changes <strong>of</strong> <strong>the</strong> p<strong>at</strong>terns <strong>of</strong> p<strong>at</strong>ient care.<br />
3. A system<strong>at</strong>ic approach to advance care<br />
plann<strong>in</strong>g can reduce unwanted utiliz<strong>at</strong>ion<br />
<strong>of</strong> acute care services.<br />
© Copyright 2009 All Rights Reserved – Gundersen Lu<strong>the</strong>ran Medical Found<strong>at</strong>ion, Inc.
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