Implementation of program does not affect satisfaction or mortality
CHICAGO - Implementation of a systematic program in which nursing home residents or their families decide in advance about the type of care the resident wishes to receive in difficult medical circumstances reduces the number of hospitalizations and use of healthcare resources without affecting satisfaction or mortality, according to an article in the March 15 issue of The Journal of the American Medical Association (JAMA).
D. William Molloy, MRCP, FRCPC, from McMaster University, Hamilton, Ontario, and colleagues evaluated use of "advanced directives" -- written indications of a patient's wishes about their medical care in six nursing homes in Ontario, Canada. Three of the nursing homes enacted a systematic advanced directives program using the "Let Me Decide" advanced directive tool. A registered nurse from each of the homes attended a two-day workshop to train as health care facilitators. They learned a specific approach to educating hospital staff, nursing home staff, residents, and families about directives and measuring a person's capacity to complete directives, then put this program into action. The other three nursing homes continued their usual policies for advance directives.
The authors found that nursing homes using the advanced directives program reported fewer hospitalizations per resident and less resource use resulting in an average savings of $1,200 U.S. per patient. The proportion of deaths that occurred in the two groups of nursing homes were similar, as were satisfaction levels with the quality of care received.
"Systematic application of the 'Let Me Decide' advance directives in nursing homes can reduce costs substantially by reducing hospitalizations," the authors write. "Replications of this study, with exploration of generalizability in different settings, would greatly strengthen the case for a widespread program of systematic implementation of certain kinds of advance directives in nursing homes."
Competent residents and proxies for incompetent residents had the opportunity to complete advance directives. The program provided a range of health care choices for life-threatening illness, cardiac arrest, and feeding. Individuals or proxies could choose different levels of care for life-threatening illness (from intensive to palliative), nutrition (from intubation to basic), and cardiopulmonary resuscitation (resuscitation or no resuscitation) if they were in a "reversible" condition with an "acceptable" quality of life or an "irreversible" condition with an "unacceptable" quality of life. This unacceptable condition was described in a personal statement.
Competent residents and relatives of competent residents at all six nursing homes completed satisfaction questionnaires about the care provided at the start of the study and six, 12 and 18 months thereafter.
"We anticipated that systematic application of 'Let Me Decide' would decrease overall resource utilization because staff would follow the wishes of acutely ill residents and their families and allow these residents to remain in the home," the authors write. "Without 'Let Me Decide,' staff in the control homes would transfer more residents to the hospital."
"The results may have implications for training of nursing home personnel," the authors also write. "The workers in many nursing homes are not educated about advance directives, and the homes are not equipped to provide symptom relief and palliative care to residents at the end of life. It is likely that the systematic application of advance directives will increase the need for effective palliative care in nursing homes."
(JAMA. 2000;283:1437-1444)
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