The majority of hospitalised elderly people at high risk of dying have thought about end-of-life care, though documentation of preferences in medical records may be lacking
- Correspondence to: Dr Sarah Jeong, School of Nursing and Midwifery, University of Newcastle, PO Box 127, Ourimbah, NSW 2258, Australia;
Commentary on Google Scholar
Implications for practice and research
Nurses are provided with empirical evidence on how they can improve satisfaction with end-of-life experiences and implementing expressed preference for care.
Further research should be undertaken to investigate nurses’ current involvement in advanced care planning (ACP) to benefit future activities in acute hospital settings.
Further investigation of the roles nurses play in pursuing high levels of engagement in ACP in non-hospital settings is necessary to provide practical guidance to nurses who would like to increase levels of engagement in ACP in various settings.
Since the emergence of advanced care planning (ACP), numerous studies have focused on the difficulties associated with implementing this in various healthcare settings. One difficulty is initiating conversations relating to the potential use of ACP. Other difficulties include negotiating the complexity and intricacy associated with writing advance care plans and the question of whether they can be adequately implemented.1 ,2
In this prospective study, 278 patients who were at high risk of dying in the next 6 months and 225 family members were identified from 12 acute care hospitals in Canada by screening hospital records or by a referral from a member of the patient's healthcare team. Following a 48–120 h period to allow for the abatement of symptoms present at admission, separate face-to-face interviews with patients and family members using a validated questionnaire were conducted. The medical records of the patients were reviewed immediately after the interviews by the study nurse to determine the level of congruence between the medical record and personal preferences. Data were analysed using statistical analysis software. Mean, SD and percentile with 95% CIswere used to report the results.
The results show high levels of patients’ and family members’ engagement in ACP: 47.9% of participating patients and 52.2% of family members reported completion of written ACP prior to hospitalisation. However, only 24.8% of patients and 31.7% of family members had been asked about ACP at the time of admission. When preferences were documented in medical notes, the concordance between the documented goals-of-care and patients’ and family members’ expressed preferences was 30.2% and 31.4%, respectively. Only 11.9% of patients and 14.7% of family members preferred life-prolonging medical care, including resuscitation in case of deterioration. The mean satisfaction score (out of 100) for end-of-life communication and decision-making was 69.1 for patients and 61 for family members.
This study attempts to capture a comprehensive picture of the difficulties in relation to applying ACP in healthcare settings. Clear efforts are made to determine whether prescribed levels of care in the medical record reflect expressed preferences for care. It is commendable that the study was conducted in acute hospital settings, where reluctance from patients and families to talk about issues can arise as a result of the physical and emotional stresses they may encounter.
The data collection methods used in this study were appropriate and the tools used are valid. The authors acknowledge that the generalisability of the results is limited to a white, English-speaking population in hospital settings in Canada. The documented goals-of-care may not necessarily align with what is delivered. Therefore, the low levels of concordance between expressed preferences for care and documented goals-of-care requires careful interpretation.
Questions which emerge about the analysis and interpretation of the results: what is meant by ‘expressed preference for care’ and how many patients and family members ‘expressed preference for the care’? It is stated in p.783 that 276 patients and 224 family members had expressed a preference for care. Does this mean that all participating patients (n=278) and family members (n=225), excluding the missing data (2 patients and 1 family member) had expressed a preference for care? However, 88.7% (n=166.7) of 188 patients and 88.1% (n=140) of 159 family members had discussed future care wishes with someone. Or should the authors refer to 76.3% (n=210) of 276 patients and 81.7% (n=183) of 224 family members who had thought about future care for themselves or their loved one? As a consequence, the discordance between expressed preference for care and documented goals-of-care reported in this study may not accurately reflect if expressed preference for care is implemented in practice and requires further analysis and investigation.