Advance care planning can be challenging for both patients and providers. Barriers to understanding patients’ goals of care include patient and provider discomfort with the topic, as well as family and cultural dynamics. The Stanford Letter Advance Directive (LAD) is a simple tool written at a fifth grade reading level in eight different languages that patients can use to initiate their advance directives. Earlier work includes a feasibility randomized controlled trial, which showed that diverse patients preferred the LAD, as it was easier to use compared to Traditional Advance Directives (TAD).
Purpose:
In this prospective, single center pilot study we evaluate the effect of the LAD on provider understanding of patient goals of care.
Description:
Methods: We performed a prospective, cluster-randomized, controlled trial with five general medicine ward teams in May 2016. Patients admitted to two control teams received usual care, including the standard protocol for offering TADs. In addition to usual care, patients admitted to three intervention teams were offered the LAD. Medical residents, interns, and sub-interns from each of the teams were surveyed regarding their self-assessed understanding of their patients’ goals of care as well as the usefulness of the letter. Chi square and T tests were used to compare the two groups.
Results: Providers on the control teams completed 93% (15/16) of the surveys and providers on the intervention teams completed 100% (24/24) of the surveys. On a five-point Likert scale, intervention team providers rated themselves more highly than the control providers with regards to (i) understanding of “what matters most” to their patient (mean score 3.96 versus 2.47 respectively, p<0.05) and (ii) their feeling of preparedness to guide their patient’s proxy (mean score 3.63 versus 2.67 respectively, p<0.05). Among advance care planning documents including the TAD, the providers found the LAD most helpful 92% of the time, reporting that it (i) improved understanding of goals of care; (ii) would be useful in guiding end-of-life discussions; (iii) captured end-of-life preferences in the patient’s own words; and (iv) helped clarify patient values and family dynamics. Intervention team providers were also more likely than usual care providers to report knowing their patients’ preferred site of death (79% versus 20% of responses respectively, p<0.05). No difference was seen in provider knowledge about other specific end-of-life preferences.
Conclusions:
The results of this pilot study suggest that the letter advance directive may improve provider understanding of patients’ general goals and values around end of life care compared to usual care including traditional advance directives. The LAD could potentially reduce barriers to discussion and improve shared decision-making around goals of care and advance care planning.