Fostering Preoperative End-of-life Care Discussions between Patients and Proxies. Grimaldo et al. (page 43)
Although all healthcare facilities are required under the 1991 Patient Self-Determination Act to recognize living wills and durable power of attorney for health care as advance directives, studies have shown that few patients complete advance care planning documents, and most do not have discussions with their proxies regarding their wishes about decision-making for end-of-life care. Grimaldo et al. evaluated the effectiveness of a 5- to 10-min discussion led by anesthesiologists to foster dialogue between patients and proxies regarding advance care planning.
During preoperative evaluations between September 1998 and May 1999, 307 English-speaking patients aged 65 yr or older were invited to participate in the advance care planning study. Two hundred patients who agreed to participate were randomized to either a control group or an intervention group. Patients in the control group received standard preoperative screening and counseling during their visit with one of the four anesthesiologists participating in the study. If they expressed interest in further information about advance directives, patients in this group were given an informational brochure and appropriate paperwork to designate a durable power of attorney. Patients randomized to the intervention group received a 5- to 10-min information session with one of the four anesthesiologists. Guidelines in the form of a one-page script had been furnished to the anesthesiologists beforehand. The emphasis of the intervention was to encourage patients to talk to their proxies about their wishes should they become unable to communicate. Patients were given copies of the California Durable Power of Attorney for Health Care form and shown how to fill it out. Patients in both groups completed a survey before and after surgery that was designed to assess their awareness of advance directives. In the postoperative survey, 66% of patients in the control group reported having had discussions with their proxies about end-of-life care, whereas 87% of those in the intervention group reported having had such discussions. The completion rate of durable power of attorneys was also higher in the intervention group—27% as compared with 10% in the control group. Although the study’s homogeneous sample population limits its applicability to other groups of patients (such as non–English-speaking or younger patients), it shows that the anesthesia preoperative evaluation offers an opportunity to broach this important issue and encourage patient–proxy communication.