To evaluate the feasibility and effectiveness of implementing a "Let Me Decide" advance directive education program among veterans living in the community, the authors studied 150 veterans in south central Ontario. Thirty-four veterans had preexisting Powers of Attorney and were removed from the analysis, leaving a total sample of 116. Two methods of systematically implementing a directive program were evaluated after the intervention period and 6 months later. Eighty-two (71%) of the 116 veterans expressed interest in receiving detailed information about the program, and 67 (82%) of the 82 interested veterans were educated. Forty-two (63%) of the 67 educated veterans completed directives. Of the 116 interested veterans, 42 (36%) completed directives. Veterans who were educated about directives were surveyed at follow-up, and 37 of 38 (97%) respondents reported that the education process was beneficial and should be offered to other veterans. This response pattern was consistent among those who completed and those who did not complete directives.
Although advance directives are commonly used in the community, little is known about the effects of their systematic implementation.
To examine the effect of systematically implementing an advance directive in nursing homes on patient and family satisfaction with involvement in decision making and on health care costs.
Randomized controlled trial conducted June 1, 1994, to August 31, 1998.
A total of 1292 residents in 6 Ontario nursing homes with more than 100 residents each.
The Let Me Decide advance directive program included educating staff in local hospitals and nursing homes, residents, and families about advance directives and offering competent residents or next-of-kin of mentally incompetent residents an advance directive that provided a range of health care choices for life-threatening illness, cardiac arrest, and nutrition. The 6 nursing homes were pair-matched on key characteristics, and 1 home per pair was randomized to take part in the program. Control nursing homes continued with prior policies concerning advance directives.
Residents' and families' satisfaction with health care and health care services utilization over 18 months, compared between intervention and control nursing homes.
Of 527 participating residents in intervention nursing homes, 49% of competent residents and 78% of families of incompetent residents completed advance directives. Satisfaction was not significantly different in intervention and control nursing homes. The mean difference (scale, 1-7) between intervention and control homes was -0.16 (95 % confidence interval [CI], -0.41 to 0.10) for competent residents and 0.07 (95% CI, -0.08 to 0.23) for families of incompetent residents. Intervention nursing homes reported fewer hospitalizations per resident (mean, 0.27 vs 0.48; P = .001) and less resource use (average total cost per patient, Can $3490 vs Can $5239; P = .01) than control nursing homes. Proportion of deaths in intervention (24%) and control (28%) nursing homes were similar (P = .20).
Our data suggest that systematic implementation of a program to increase use of advance directives reduces health care services utilization without affecting satisfaction or mortality.
Comment In: ACP J Club. 2000 Nov-Dec;133(3):85
Comment In: JAMA. 2000 Mar 15;283(11):1481-210732940