New study evaluates the concept of "advance care planning"

February 12, 2014, Ludwig Maximilian University of Munich

For the first time in Germany, a new study evaluates the concept of "advance care planning", a regional approach that helps individuals to develop, articulate and document wishes regarding the limits of medical treatment in future medical situations when they are no longer able to make decisions themselves.

Would I want to be resuscitated in the event of acute organ failure? Would I wish to be kept alive in an intensive-care unit in the case of severe brain damage? For patients who are suffering from life-threatening diseases, issues like these are of crucial importance. However, in such a situation, the patient's wishes are rarely known. Despite legal regulation, advanced directives are not widely used in Germany and, even when such a "living will" is available it is often not relevant and not honored by the medical personnel. "So far, the whole spectrum of available life-sustaining treatment is automatically started when an old and severely ill patient is admitted to a hospital. The traditional advanced directive currently used in Germany has failed," says Professor Georg Marckmann, Chairman of the Institute for the Ethics, History and Theory of Medicine at LMU.

A lifelong process

But there is an alternative to the present unsatisfactory situation: In collaboration with a team of colleagues led by local general practitioner Jürgen in der Schmitten of the University of Düsseldorf, Marckmann has adapted the American concept of advance care planning to the German context and implemented it in a pilot project in the State of North Rhine-Westphalia. "The concept represents a paradigm shift, because it views advance care planning as a lifelong communicative process, which is supported by specially trained health professionals ("facilitators"), and results in the formulation of a detailed, individual plan for future medical situations," says Marckmann. In contrast, the conventional approach to advance directives has left their formulation entirely to the respective individual.

For the pilot project, the researchers developed a program entitled "beizeiten begleiten", which was implemented in three nursing homes in North Rhine-Westphalia, and its impact was studied over a period of 16 months. Caregivers at the three institutions were trained to initiate advance care planning conversations with the nursing home residents. In addition, the residents' general practitioners received information on the topic, and seminars were arranged for the nursing staff, clinical and emergency doctors, paramedical teams and professional guardians. The researchers also developed standardized forms for advanced directives, as well as a form for documentation of physician orders for life-sustaining treatment (POLST), which gives directives to doctors, first-aid personnel and nursing staff for the case of a life-threatening emergency.

More and better directives

"Using this integrated approach, we were able to increase the number of directives and, even more importantly, we achieved a significant improvement in their quality, i.e. their clarity and relevance," Marckmann reports. At the end of the 16-month study, over 50% of the residents of the three nursing homes had completed an advanced health-care directive. Of these declarations, nearly 94% had been signed by a physician and almost all of them designated a health-care proxy. Likewise 98% contained instructions as to how medical personnel should proceed in administering emergency care, and 95% contained specific directions regarding cardio-pulmonary resuscitation. These numbers were significantly higher compared to a control region in which the advance care program had not been implemented.

The feedback received by the researchers from both nursing-home residents and their caregivers was also very positive. "The participants were pleased that someone had finally taken the time to talk to them about the topic of death and terminal care," says Marckmann. And in personal conversations with the aged, the facilitators were able to correct many misconceptions – e.g. regarding the success rates of resuscitation attempts (which are generally low for nursing-home residents).

Dying with dignity

"Advance care planning programs make it possible to systematically ascertain the wishes of elderly and chronically ill people regarding future medical situations, and ensure that these wishes will be honored in emergency situations," says Marckmann. "Instead of engaging in debates about organized physician assisted suicide, we should rather be thinking about how we can widely implement advance care planning on a regional basis. After all, the goal of advance care planning is to enable people to die with dignity, as they would wish their lives to end."

The researchers' next goal is to make the concept of advance care planning an integral part of regular medical care. "Our study shows for the first time that a regional advance care planning program can be successfully implemented in Germany, and it demonstrates how effective such a program can be," Marckmann says. In the area around the city of La Crosse in Wisconsin in the American Midwest, for example, which served as the model for the pilot project, assistance with planning is offered to all elderly in the course of their routine medical check-ups.

Explore further: Advance directives manage end of life care issues and reduce end of life medical costs

Related Stories

Advance directives manage end of life care issues and reduce end of life medical costs

May 8, 2013
A new article available online in the American Journal of Public Health by two Johns Hopkins Bloomberg School of Public Health faculty makes a compelling case that end-of-life care issues need to become an integral part of ...

Majority of Americans avoid addressing end-of-life issues, new study finds

December 10, 2013
During the past two decades, high-profile legal cases surrounding end-of-life decisions have received widespread attention in the United States, prompting increased media focus and numerous debates on the subject.

Experimental care program keeps people with dementia at home longer, study shows

February 10, 2014
An 18-month pilot program that brought resources and counselors to elderly Baltimore residents with dementia and other memory disorders significantly increased the length of time they lived successfully at home, according ...

Hospitals and nursing homes can learn much from hospice care

January 22, 2014
There is much value in training hospital and nursing home staff in the basics of palliative care to make the last days of a dying patient's life as comfortable and dignified as possible. So says F. Amos Bailey of the Birmingham ...

An end-of-life 'conversation guide' for physicians to speak with patients

July 15, 2013
How does a doctor tackle the delicate issue of end-of-life care planning with a patient?

Recommended for you

Wine is good for you—to a point

January 18, 2018
The Mediterranean diet has become synonymous with healthy eating, but there's one thing in it that stands out: It's cool to drink wine.

Sleep better, lose weight?

January 17, 2018
(HealthDay)—Sleeplessness could cost you when it's time to stand on your bathroom scale, a new British study suggests.

Who uses phone apps to track sleep habits? Mostly the healthy and wealthy in US

January 16, 2018
The profile of most Americans who use popular mobile phone apps that track sleep habits is that they are relatively affluent, claim to eat well, and say they are in good health, even if some of them tend to smoke.

Improvements in mortality rates are slowed by rise in obesity in the United States

January 15, 2018
With countless medical advances and efforts to curb smoking, one might expect that life expectancy in the United States would improve. Yet according to recent studies, there's been a reduction in the rate of improvement in ...

Teens likely to crave junk food after watching TV ads

January 15, 2018
Teenagers who watch more than three hours of commercial TV a day are more likely to eat hundreds of extra junk food snacks, according to a report by Cancer Research UK.

Can muesli help against arthritis?

January 15, 2018
It is well known that healthy eating increases a general sense of wellbeing. Researchers at Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU) have now discovered that a fibre-rich diet can have a positive influence ...

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.