Decision Making – Aligned or Discordant

Frailty assessments help identify risk in order to avoid as much decline as possible and to provide information that helps to align patient/family priorities with realistic possibilities. At the same time, highlighting the increased risk associated with some treatments can help patients and families make an informed choices.  From literature review, we know that treatment decisions not in keeping with the patient’s goals increase medical costs and prolong end-of-life difficulties. Discussion and documentation is the key and failure to follow documented wishes is considered a serious medical error.

We all have experienced crisis decision-making and been uncomfortable with those choices. We have also likely been aware of surrogate decision-making when there has been no discussion of wishes or priorities, yet a significant decision must be made. We have also read articles where documented wishes were not available or followed and treatment decisions were discordant with the patient’s goals. We want to disrupt this pattern for the sake of our patients and their families. 

The Good News

A recent study, prompted by COVID-19, produced beneficial results for the completion of advance care planning (ACP) documents. Anticipating the potential for decline, providers had ≥1 ACP conversation with 963 nursing home residents/surrogates and to discuss any changes in their goals, code status, and hospitalization preferences. 

  • Before the ACP discussion: 361 were full code status; 602 were Out of Hospital Do Not Resuscitate; 188 with Out of Hospital DNR were also Do Not Hospitalize
  • After the ACP discussion: 88 changed from full code status to Out of Hospital DNR (Up 63% to 72%) 

Takeaway message: Resident’s priorities, preferences and willingness to discuss sensitive issues may change over time. Reviewing their documents on a regular schedule is a worthwhile practice and one clearly demonstrated in this study.

Another study, asked whether end-of-life wishes were followed. The study sample included 2281 deceased patients aged ≥65 years. The authors found:

  • 82.6% had discussed end-of-life care and families said they were familiar with the patient’s goals.
  • 84.1% had completed an advance directive
  • 88.9% received treatment concordant with their end-of-life wishes
  • 5.9% received an unwanted treatment (CPR, artificial feeding, ventilator)
  • 13.5% did not receive a desired treatment
  • 65% had discussed their wishes with their physician or other medical staff
  • Only 57.1% of the 88% patients wishing to die at home did so

Takeaway message: It is possible for patients to receive end-of-life care in keeping with their goals and wishes. While there is still room for improvement, this study is encouraging and a reminder for all of us to discuss advance care plans early and often, including the preferred location for end-of-life care, and to ask about specific treatment options that may or may not align with the patient’s wishes. 

More on these issues…

These reports can help guide practitioners, especially those who are uncomfortable or feel unprepared to have these ACP and end-of-life conversations. 

  1. Dying in America: A study of the current state of health care for persons of all ages who are nearing the end of life.

https://www.nap.edu/catalog/18748/dying-in-america-improving-quality-and-honoring-individual-preferences-near

  1. Clinical Practice Guidelines for Quality Palliative Care, 4th edition: A consensus response to the report above, emphasizing an interdisciplinary approach to caring for those with serial illnesses. 

https://www.nationalcoalitionhpc.org/wp-content/uploads/2020/07/NCHPC-NCPGuidelines_4thED_web_FINAL.pdf

For more guidance on completion of advance care documents and framing discussions based on the risk of frailty, please contact us at PatientPattern.com.