For dying patients, early plans can improve quality of life
Careful documentation of a hospice patient's end-of-life wishes—and prominently noting that information in health records early—could prevent unwanted hospitalizations and medical interventions, a new study suggests.
Researchers at The Ohio State University analyzed the health records of 1,185 cancer patients who had been referred to hospice and found that a verified do-not-resuscitate order, or DNR, before the last 30 days of life reduced the odds of hospitalization. A prominent note in the electronic health record indicating advanced care planning (for example, discussions with providers on legal directives, a living will or a health care power of attorney) also reduced the chances of admission—especially if that note was made at least six months prior to death.
Once a terminally ill patient transitions into hospice care, the goal is to avoid hospitalizations and procedures that are unnecessary and unwanted, said Laura Prater, the study's lead author and a postdoctoral researcher in the Division of General Internal Medicine at Ohio State's College of Medicine.
"Our research supports the importance of sharing your wishes with your physician and your family, and suggests that doing that earlier can prevent unwanted procedures and hospitalizations that don't align with your priorities and deteriorate your quality of life," Prater said.
The study was recently published online in the American Journal of Hospice & Palliative Medicine.
It's important for physicians and others on a patient's care team to have conversations that address that person's values and goals, including what to do if his or her illness is no longer treatable, said Seuli Bose-Brill, the study's senior author and an Ohio State Wexner Medical Center primary care physician who specializes in internal medicine and pediatrics.
"These study results really support the idea that earlier is better for documenting these wishes. Those who had advanced care planning notes in their health records six months or more before a hospital trip were significantly less likely to be admitted," Prater said.
Specifically, the researchers looked at the "problem list" on the medical record—an easy-to-spot synopsis of that person's health status. When advanced care planning was noted there more than six months before the final month of life, hospitalization was least likely.
Previous studies have found that only 13 to 44 percent of terminally ill patients have documentation of advanced care planning in their electronic health records and that the location and ease of finding that documentation is inconsistent.
In times of crisis, hospice patients often are not in a position to advocate their own priorities and family members can be unsure, afraid or in disagreement about those wishes, complicating matters. When the medical team can easily see in the electronic health record that the patient has documented his or her wishes, it eases their ability to act in the patient's best interest, Bose-Brill said.
"I think everyone in medicine is aware that we need to do a better job documenting end-of-life wishes, but as a nation we haven't figured out how best to do that," she said.
Prater said this study could prompt discussions within medical practices and hospitals about how to consistently discuss and document advanced care planning for patients.
"It's important to make this part of the process, to look for ways to make sure that these conversations are happening consistently, early and often, even though they are complex and difficult conversations to have," Prater said.
And the topic shouldn't only come up when transitioning to hospice, Bose-Brill said, because that is a time that can be particularly fraught with emotion and grief and not always the best opportunity to broach the subject.
"The earlier we start this process, the more it normalizes it," she said.
"There are so many opportunities to explore these issues that patients and families are grappling with and we in health care need to not absolve ourselves of our responsibility to talk about these things."