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Concordance Between Proxy Level of Care Preference and Advance Directives Among Nursing Home Residents With Advanced Dementia: A Cluster Randomized Clinical Trial.
J Pain Symptom Manage. 2019 01; 57(1):37-46.e1.JP

Abstract

CONTEXT

Care consistent with goals is the desired outcome of advance care planning (ACP).

OBJECTIVES

The objectives of this study were to examine concordance between advance directives and proxy care preferences among nursing home residents with advanced dementia and to determine the impact of an ACP video on concordance.

METHODS

Data were from Educational Video to Improve Nursing home Care in End-stage dementia, a cluster randomized clinical trial conducted in 64 Boston-area facilities (32/arm) from 2013 to 2017. Participants included advanced dementia residents and their proxies (N = 328 dyads). At the baseline and quarterly (up to 12 months), proxies stated their preferred level of care for the resident (comfort, basic, or intensive) and advance directives for specific treatments (resuscitation, hospitalization, tube-feeding, intravenous hydration, antibiotics) were abstracted from the charts. At the baseline, proxies in intervention facilities viewed an ACP video. Their care preferences after viewing it were shared via a written communication with the primary care team. At each assessment, concordance between directives and proxy preferences was determined.

RESULTS

Among the residents (mean age, 86.6 years; 19.5% male), the most prevalent directive was DNR (89.3%) and foregoing antibiotics was least common (parenteral, 8.2%; any type, 4.0%). Concordance between directives and each level of care preference was as follows: comfort, 7%; basic, 49%; and intensive, 58%. When comfort care was preferred, concordance was higher in intervention versus control facilities (10.8% vs. 2.5%; adjusted odds ratio, 2.48; 95% CI, 1.01-6.09).

CONCLUSION

Better alignment between preferences for comfort-focused care and advance directives is needed in advanced dementia. An ACP video may help achieve that goal.

Authors+Show Affiliations

Hebrew SeniorLife Institute for Aging Research, Boston, Massachusetts, USA.Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.Department of Statistics, University of Washington, Seattle, Washington, USA.Division of Geriatric Medicine, Cecil G. Sheps Center for Health Services Research and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.Hebrew SeniorLife Institute for Aging Research, Boston, Massachusetts, USA.Hebrew SeniorLife Institute for Aging Research, Boston, Massachusetts, USA; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA. Electronic address: smitchell@hsl.harvard.edu.

Pub Type(s)

Journal Article
Randomized Controlled Trial
Research Support, N.I.H., Extramural

Language

eng

PubMed ID

30273717

Citation

Cohen, Simon M., et al. "Concordance Between Proxy Level of Care Preference and Advance Directives Among Nursing Home Residents With Advanced Dementia: a Cluster Randomized Clinical Trial." Journal of Pain and Symptom Management, vol. 57, no. 1, 2019, pp. 37-46.e1.
Cohen SM, Volandes AE, Shaffer ML, et al. Concordance Between Proxy Level of Care Preference and Advance Directives Among Nursing Home Residents With Advanced Dementia: A Cluster Randomized Clinical Trial. J Pain Symptom Manage. 2019;57(1):37-46.e1.
Cohen, S. M., Volandes, A. E., Shaffer, M. L., Hanson, L. C., Habtemariam, D., & Mitchell, S. L. (2019). Concordance Between Proxy Level of Care Preference and Advance Directives Among Nursing Home Residents With Advanced Dementia: A Cluster Randomized Clinical Trial. Journal of Pain and Symptom Management, 57(1), 37-e1. https://doi.org/10.1016/j.jpainsymman.2018.09.018
Cohen SM, et al. Concordance Between Proxy Level of Care Preference and Advance Directives Among Nursing Home Residents With Advanced Dementia: a Cluster Randomized Clinical Trial. J Pain Symptom Manage. 2019;57(1):37-46.e1. PubMed PMID: 30273717.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Concordance Between Proxy Level of Care Preference and Advance Directives Among Nursing Home Residents With Advanced Dementia: A Cluster Randomized Clinical Trial. AU - Cohen,Simon M, AU - Volandes,Angelo E, AU - Shaffer,Michele L, AU - Hanson,Laura C, AU - Habtemariam,Daniel, AU - Mitchell,Susan L, Y1 - 2018/09/29/ PY - 2018/05/16/received PY - 2018/09/14/revised PY - 2018/09/20/accepted PY - 2018/10/3/pubmed PY - 2019/6/19/medline PY - 2018/10/2/entrez KW - Dementia KW - advance care planning KW - advance directives KW - cluster randomized clinical trial KW - nursing home KW - preferences SP - 37 EP - 46.e1 JF - Journal of pain and symptom management JO - J Pain Symptom Manage VL - 57 IS - 1 N2 - CONTEXT: Care consistent with goals is the desired outcome of advance care planning (ACP). OBJECTIVES: The objectives of this study were to examine concordance between advance directives and proxy care preferences among nursing home residents with advanced dementia and to determine the impact of an ACP video on concordance. METHODS: Data were from Educational Video to Improve Nursing home Care in End-stage dementia, a cluster randomized clinical trial conducted in 64 Boston-area facilities (32/arm) from 2013 to 2017. Participants included advanced dementia residents and their proxies (N = 328 dyads). At the baseline and quarterly (up to 12 months), proxies stated their preferred level of care for the resident (comfort, basic, or intensive) and advance directives for specific treatments (resuscitation, hospitalization, tube-feeding, intravenous hydration, antibiotics) were abstracted from the charts. At the baseline, proxies in intervention facilities viewed an ACP video. Their care preferences after viewing it were shared via a written communication with the primary care team. At each assessment, concordance between directives and proxy preferences was determined. RESULTS: Among the residents (mean age, 86.6 years; 19.5% male), the most prevalent directive was DNR (89.3%) and foregoing antibiotics was least common (parenteral, 8.2%; any type, 4.0%). Concordance between directives and each level of care preference was as follows: comfort, 7%; basic, 49%; and intensive, 58%. When comfort care was preferred, concordance was higher in intervention versus control facilities (10.8% vs. 2.5%; adjusted odds ratio, 2.48; 95% CI, 1.01-6.09). CONCLUSION: Better alignment between preferences for comfort-focused care and advance directives is needed in advanced dementia. An ACP video may help achieve that goal. SN - 1873-6513 UR - https://www.unboundmedicine.com/medline/citation/30273717/Concordance_Between_Proxy_Level_of_Care_Preference_and_Advance_Directives_Among_Nursing_Home_Residents_With_Advanced_Dementia:_A_Cluster_Randomized_Clinical_Trial_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0885-3924(18)30502-5 DB - PRIME DP - Unbound Medicine ER -