Original Research

Importance of Early Initiation of Advance Care Planning

Fed Pract. 2015 March;32(3):30-34

References

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One life-limiting nononcologic disease is COPD. Chronic obstructive pulmonary disease remains a major public health problem. It is the fourth leading cause of chronic morbidity and mortality in the U.S. and is projected to rank fifth in 2020 in disease burden worldwide.⁷ Given its prevalence, COPD is found in all adult health care settings.

Among hospitalized veterans in the VHA in 2005, COPD was the fourth most common discharge diagnosis.⁸ In the veteran population, a high prevalence for developing COPD also exists due to high-risk factors including tobacco use in the military. According to a study conducted at the Cincinnati VAMC in Ohio, a 40% greater prevalence of COPD existed in this veteran population than in the general U.S. population.⁸

Another nononcologic, life-limiting disease is CHF. Both the prevalence and hospitalization rates for CHF show an upward trend since the 1970s, resulting in a continued increase in CHF death rates.⁹ According to 2008 estimates from the National Institutes of Health, there are 5 million CHF patients in the U.S. and hospitalization rates approach 1 million per year.⁹ Congestive heart failure affects 2.4% of the adult population and > 11% of the expanding population aged > 80 years. Existing care may slow the progression of the disease but can rarely reverse it, which usually results in a prolonged period of advanced illness. As a result of the increasing prevalence, there remains a high symptom burden for patients living with advanced CHF.¹⁰

In managing the high symptom burden of CHF and COPD, patient-centered care must be acknowledged and used. Patient-centered care mandates that beneficial therapies and recommended guidelines be offered and discussed with the patient, giving attention to patient preferences.¹⁰

Study Design

The theoretical framework for the development and implementation of this project is based on Ruland and Moore’s Peaceful End of Life Theory.¹¹ This theory is based on 2 assumptions. The first is that each person’s approach to EOL is personal. The second is that nursing care plays a major role in making EOL a peaceful experience. The 5 outcome measures include: (1) not experiencing pain; (2) the experience of comfort; (3) the experience of dignity and respect; (4) being at peace; and (5) closeness to significant others or other caring persons.

The outcome indicator of the Peaceful End of Life Theory— experience of dignity/respect with its related criteria and prescriptors—provided structure for the development and implementation of this project. The prescriptors related to the experience of dignity/respect include involving the patient and significant others in decision making; treating the patient with dignity, empathy, and respect; and being attentive to the patient’s expressed needs, wishes, and preferences.¹¹

Due to the increased prevalence of chronic illnesses in the VA system, veterans need encouragement to complete ADs. The VA instituted a national directive guiding education and implementation of an AD.¹²These discussions occur at the first contact a veteran has with the system and at other times when appropriate. The purpose of the directive is to allow veterans to guide the course of their treatment and to assure that they are aware of the ability to refuse treatment at any time.¹²

Inconsistencies in Advance Directive Completion

Inconsistencies were noted with how ADs were completed at the VA Northern Indiana Health Care System in Muncie. For outpatients, the clinic nursing staff received an electronic medical record (EMR) reminder if the veteran did not have an AD. This reminder prompted the nurse to ask the veteran about completing an AD. If the veteran agreed, a social work consult was initiated by nursing. Of concern, the social worker is usually responsible for several clinics so it is unlikely the process of completing the AD would be accomplished on the day the veteran was already in the clinic.

Discussions in the inpatient setting included a physician, a nurse practitioner, or a social worker and were often disease specific and patient oriented. However, in an acute hospitalization, it was less likely that patients initiated ADs due to acute illness and rapid nature of treatment.

Another concern was related to the amount of clinical knowledge the social worker had about the specifics of each patient’s case. Without specifics, a social worker can make the AD discussion very broad. Patients want information regarding disease progression and prognosis specific to their own condition to be able to make an informed choice regarding ADs.¹³

A study population with the diagnoses of CHF and COPD was selected due to the prevalence in the facility and at the request of facility leadership.