Status of Advance Directive and Goals‐of‐Care Discussions in a University‐Affiliated Community Hospital

Background:

The New York State Palliative Care Information Act, passed in 2011, mandates that physicians offer terminally ill patients information and counseling on palliative care and end‐of‐life options. The Allen Hospital of New York Presbyterian serves a population of generally elderly, ethnically diverse patients with multiple comorbidities, many of whom would benefit from discussion about advance directives and goals of care. This study was designed to collect baseline data in preparation for interventions to improve the quality and increase the number of conversations about advance directives and goals of care in this population.

Methods:

All patients older than age 70 admitted to medical teams at the Allen over a 1‐month period in the summer of 2012 were included in a chart review. Data were collected including demographic information, comorbidities, functional status, code status, functional status, and documentation of any discussion about prognosis or goals of care. A survey was distributed to providers about experiences and previous training on advance directive conversations. A sample of patients was interviewed about their experiences discussing code status, goals of care, and their wishes for the context and content of these conversations with their providers.

Results:

Two hundred sixty patient charts were reviewed. Twenty‐four percent had do‐not‐resuscitate (DNR) orders in the medical record, and 21.5% had documentation of a conversation about prognosis, goals of care, or code status. Higher frequency of DNR orders was seen in patients residing in nursing homes (46%) and those with a documented diagnosis of dementia (38%). Goals‐of‐care conversations were documented at higher rates in patients with complete functional dependence (39%) and patients who spent time in the ICU (55%). Physician surveys revealed that 96% (23 of 24) believed it was “very important” or “absolutely necessary” to address advance directives with patients. They identified obstacles including language barriers and time limitation. Patient interviews revealed emphasis on quality of life, misinformation about the definition of a DNR order, and recognition that physicians' time is limited

Conclusions:

This study provided quantitative and qualitative data about the status of advance directives and code status discussions at this community hospital. The data revealed an overall low rate of DNR orders and documented goals of care conversations with variation based on patient characteristics and factors related to the hospitalization. Patient wishes and physician obstacles were further clarified with surveys and interviews. The data will be collected again after physician education and compared with this baseline data to measure the effect of the intervention.

Chart review (n = 260): Percentage of patients with DNR status and percentage of patients with documented conversations in medical record about prognosis or goals of care.