Concordance Between Proxy Level of Care Preference and Advance Directives Among Nursing Home Residents With Advanced Dementia: A Cluster Randomized Clinical Trial

Simon M. Cohen, Angelo E. Volandes, Michele L. Shaffer, Laura C Hanson, Daniel Habtemariam, Susan L. Mitchell

Research output: Contribution to journalArticle

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Abstract

Context: Care consistent with goals is the desired outcome of advance care planning (ACP). Objectives: The objectives of this study were to examine concordance between advance directives and proxy care preferences among nursing home residents with advanced dementia and to determine the impact of an ACP video on concordance. Methods: Data were from Educational Video to Improve Nursing home Care in End-stage dementia, a cluster randomized clinical trial conducted in 64 Boston-area facilities (32/arm) from 2013 to 2017. Participants included advanced dementia residents and their proxies (N = 328 dyads). At the baseline and quarterly (up to 12 months), proxies stated their preferred level of care for the resident (comfort, basic, or intensive) and advance directives for specific treatments (resuscitation, hospitalization, tube-feeding, intravenous hydration, antibiotics) were abstracted from the charts. At the baseline, proxies in intervention facilities viewed an ACP video. Their care preferences after viewing it were shared via a written communication with the primary care team. At each assessment, concordance between directives and proxy preferences was determined. Results: Among the residents (mean age, 86.6 years; 19.5% male), the most prevalent directive was DNR (89.3%) and foregoing antibiotics was least common (parenteral, 8.2%; any type, 4.0%). Concordance between directives and each level of care preference was as follows: comfort, 7%; basic, 49%; and intensive, 58%. When comfort care was preferred, concordance was higher in intervention versus control facilities (10.8% vs. 2.5%; adjusted odds ratio, 2.48; 95% CI, 1.01–6.09). Conclusion: Better alignment between preferences for comfort-focused care and advance directives is needed in advanced dementia. An ACP video may help achieve that goal.

LanguageEnglish (US)
Pages37-46.e1
JournalJournal of Pain and Symptom Management
Volume57
Issue number1
DOIs
StatePublished - Jan 1 2019

Fingerprint

Advance Directives
Advance Care Planning
Proxy
Nursing Homes
Dementia
Randomized Controlled Trials
Facility Regulation and Control
Anti-Bacterial Agents
Enteral Nutrition
Home Care Services
Nursing Care
Resuscitation
Primary Health Care
Hospitalization
Odds Ratio
Communication
Patient Comfort

Keywords

  • Dementia
  • advance care planning
  • advance directives
  • cluster randomized clinical trial
  • nursing home
  • preferences

ASJC Scopus subject areas

  • Nursing(all)
  • Clinical Neurology
  • Anesthesiology and Pain Medicine

Cite this

Concordance Between Proxy Level of Care Preference and Advance Directives Among Nursing Home Residents With Advanced Dementia : A Cluster Randomized Clinical Trial. / Cohen, Simon M.; Volandes, Angelo E.; Shaffer, Michele L.; Hanson, Laura C; Habtemariam, Daniel; Mitchell, Susan L.

In: Journal of Pain and Symptom Management, Vol. 57, No. 1, 01.01.2019, p. 37-46.e1.

Research output: Contribution to journalArticle

Cohen, Simon M. ; Volandes, Angelo E. ; Shaffer, Michele L. ; Hanson, Laura C ; Habtemariam, Daniel ; Mitchell, Susan L. / Concordance Between Proxy Level of Care Preference and Advance Directives Among Nursing Home Residents With Advanced Dementia : A Cluster Randomized Clinical Trial. In: Journal of Pain and Symptom Management. 2019 ; Vol. 57, No. 1. pp. 37-46.e1.
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abstract = "Context: Care consistent with goals is the desired outcome of advance care planning (ACP). Objectives: The objectives of this study were to examine concordance between advance directives and proxy care preferences among nursing home residents with advanced dementia and to determine the impact of an ACP video on concordance. Methods: Data were from Educational Video to Improve Nursing home Care in End-stage dementia, a cluster randomized clinical trial conducted in 64 Boston-area facilities (32/arm) from 2013 to 2017. Participants included advanced dementia residents and their proxies (N = 328 dyads). At the baseline and quarterly (up to 12 months), proxies stated their preferred level of care for the resident (comfort, basic, or intensive) and advance directives for specific treatments (resuscitation, hospitalization, tube-feeding, intravenous hydration, antibiotics) were abstracted from the charts. At the baseline, proxies in intervention facilities viewed an ACP video. Their care preferences after viewing it were shared via a written communication with the primary care team. At each assessment, concordance between directives and proxy preferences was determined. Results: Among the residents (mean age, 86.6 years; 19.5{\%} male), the most prevalent directive was DNR (89.3{\%}) and foregoing antibiotics was least common (parenteral, 8.2{\%}; any type, 4.0{\%}). Concordance between directives and each level of care preference was as follows: comfort, 7{\%}; basic, 49{\%}; and intensive, 58{\%}. When comfort care was preferred, concordance was higher in intervention versus control facilities (10.8{\%} vs. 2.5{\%}; adjusted odds ratio, 2.48; 95{\%} CI, 1.01–6.09). Conclusion: Better alignment between preferences for comfort-focused care and advance directives is needed in advanced dementia. An ACP video may help achieve that goal.",
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AB - Context: Care consistent with goals is the desired outcome of advance care planning (ACP). Objectives: The objectives of this study were to examine concordance between advance directives and proxy care preferences among nursing home residents with advanced dementia and to determine the impact of an ACP video on concordance. Methods: Data were from Educational Video to Improve Nursing home Care in End-stage dementia, a cluster randomized clinical trial conducted in 64 Boston-area facilities (32/arm) from 2013 to 2017. Participants included advanced dementia residents and their proxies (N = 328 dyads). At the baseline and quarterly (up to 12 months), proxies stated their preferred level of care for the resident (comfort, basic, or intensive) and advance directives for specific treatments (resuscitation, hospitalization, tube-feeding, intravenous hydration, antibiotics) were abstracted from the charts. At the baseline, proxies in intervention facilities viewed an ACP video. Their care preferences after viewing it were shared via a written communication with the primary care team. At each assessment, concordance between directives and proxy preferences was determined. Results: Among the residents (mean age, 86.6 years; 19.5% male), the most prevalent directive was DNR (89.3%) and foregoing antibiotics was least common (parenteral, 8.2%; any type, 4.0%). Concordance between directives and each level of care preference was as follows: comfort, 7%; basic, 49%; and intensive, 58%. When comfort care was preferred, concordance was higher in intervention versus control facilities (10.8% vs. 2.5%; adjusted odds ratio, 2.48; 95% CI, 1.01–6.09). Conclusion: Better alignment between preferences for comfort-focused care and advance directives is needed in advanced dementia. An ACP video may help achieve that goal.

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