Attention Health Care Providers: Don't Be Afraid of Advance Directives

Initiating a sensitive conversation in the intensive care unit (ICU) can be uncomfortable, but a new analysis shows that’s exactly what patients want.

Advance directive (AD), or a written statement expressing one’s wishes regarding medical treatment, helps patients who are unable to communicate decisions in serious situations. Prashant Jagtap, MD, from the Mayo Clinic in Minnesota, and his team were able to increase the initiation of advance directive conversations soon after hospital admission. He discussed the findings during a presentation at the CHEST 2015 meeting in Montréal, Canada.

“There is some confusion regarding health care decision making,” Jagtap said during the session. It also brings along a string of questions: Who should initiate the conversation? When is the right time? Can we overcome the barriers? So the team implemented a system that would make the discussion more productive.

From September 2014 to January 2015, the team initiated interventions to health care providers which included handing out educational materials, making project members available as resources, and collecting weekly feedback in hopes that stakeholders would engage in advance directive more. The goal of this initiative was to have the conversation within the first 72 hours of admission to the ICU — and the team succeeded.

For the 128 ICU admissions in September 2014, 22% had advance directive conversations during admission, and only 12% of those discussions were documented. However, improvements were observed just three months after the interventions. From November 2014 to January 2015, there were 170 ICU admissions. Of those, 40% had the advance directive talk and 39% had them documented within 72 hours of admission. This was a 12% to 39% improvement from baseline in just three months.

“Some people are not comfortable discussing advance directive,” Jagtap noted. In a survey which included 23 providers, 30 nurses, and 12 patients, the results revealed that almost everyone thought that both physicians and allied health care staff, such as those in the ICU, should start the conversation.

Among the top reasons why clinicians do not initiate advance directive are: time constraint, would rather focus on the patient’s condition, and not comfortable discussing the topic, according to the survey. However, as it turns out the patients felt more satisfied when the conversation was brought up, Jagtap confirmed.

In order to carry out this initiation, health care providers expressed that skills, resources, and process plan were the most helpful. The team suggests educating staff and patients, appointing a lead person for the conversation, and having a back-up process.

The analysis in now in a control phase, but the team plans to continue its research to be led by mid-level ICU staff.