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How well is the Patient Self-Determination Act working?: an early assessment.
Am J Med. 1993 Dec; 95(6):619-28.AJ

Abstract

OBJECTIVES

To assess the association between implementation of the Patient Self-Determination Act (PSDA) and (1) the use of formal, written advance directives, (2) the use of informal advance care arrangements, and (3) discussions between patients and their physicians and proxies an advance care planning and end-of-life treatment preferences.

DESIGN

A time-sequence study in which patients discharged from acute care hospitals 1 month before the implementation of the PSDA and 5 months after implementation of the PSDA were interviewed.

SETTING

Two medical school-affiliated, major teaching hospitals with more than 500 beds and 3 nonteaching community hospitals with fewer than 400 beds in eastern Massachusetts.

PATIENTS

A total of 579 adult patients were interviewed: 258 patients discharged before the implementation of the PSDA (pre-PSDA) and 321 patients discharged 5 months after implementation of the PSDA (post-PSDA).

MEASUREMENTS

Patients were asked about their formal, written or informal advance care planning arrangements, about the frequency of inquiries and information provided on advance care planning by the hospitals, and about their discussions of advance care planning and end-of-life treatment preferences with physicians and their proxies.

RESULTS

In the pre-PSDA cohort, 60.9% of the patients had some kind of advance care planning, whereas in the post-PSDA cohort, 72.6% did (p = 0.01). However, there was not a significant increase in the proportion of patients who had advance care planning "in a written document" (19.8% of the pre-PSDA cohort compared with 25.5% of the post-PSDA cohort, p = 0.11). The increase in written advance care planning was concentrated in the community, nonteaching hospitals (10.7% pre-PSDA versus 23.7% post-PSDA). Overall, 41.4% of patients recalled inquiries or information about advance care planning during their hospitalization. Implementation of the PSDA was not associated with a significant change in the proportion of patients who discussed advance care planning or end-of-life issues with their physicians (13.6% pre-PSDA versus 17.1% post-PSDA, p = 0.25). However, there was an increase in the proportion of patients with poorer health who spoke with their physicians (15.4% pre-PSDA versus 24.8% post-PSDA). Implementation of the PSDA was associated with an increase in the proportion of patients who had general discussions with proxies about end-of-life issues (61.8% pre-PSDA versus 73.0% post-PSDA, p = 0.024). However, 33.6% of pre-PSDA and 33.2% of post-PSDA patients had detailed discussions with their proxy about specific interventions such as mechanical ventilation or artificial nutrition. Patients with formal proxies had detailed discussions significantly more frequently than other patients (50.0% versus 26.8%, p < 0.0001).

CONCLUSIONS

The PSDA was associated with significant effects on general advance care planning issues, increasing the proportion of patients who had (1) some kind of advance care arrangements and (2) general discussions of end-of-life issues with their proxies. However, the PSDA did not appear associated with significant increases (1) in the use of formal, written advance care documents, (2) in the frequency of discussions between patients and their physicians on advance care documents or end-of-life issues, or (3) in the frequency of discussions about specific treatment preferences between patients and their proxies.

Authors+Show Affiliations

Division of Cancer Epidemiology and Control, Dana-Farber Cancer Institute, Boston, MA.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

8259779

Citation

Emanuel, E J., et al. "How Well Is the Patient Self-Determination Act Working?: an Early Assessment." The American Journal of Medicine, vol. 95, no. 6, 1993, pp. 619-28.
Emanuel EJ, Weinberg DS, Gonin R, et al. How well is the Patient Self-Determination Act working?: an early assessment. Am J Med. 1993;95(6):619-28.
Emanuel, E. J., Weinberg, D. S., Gonin, R., Hummel, L. R., & Emanuel, L. L. (1993). How well is the Patient Self-Determination Act working?: an early assessment. The American Journal of Medicine, 95(6), 619-28.
Emanuel EJ, et al. How Well Is the Patient Self-Determination Act Working?: an Early Assessment. Am J Med. 1993;95(6):619-28. PubMed PMID: 8259779.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - How well is the Patient Self-Determination Act working?: an early assessment. AU - Emanuel,E J, AU - Weinberg,D S, AU - Gonin,R, AU - Hummel,L R, AU - Emanuel,L L, PY - 1993/12/1/pubmed PY - 1993/12/1/medline PY - 1993/12/1/entrez KW - Death and Euthanasia KW - Empirical Approach KW - Legal Approach SP - 619 EP - 28 JF - The American journal of medicine JO - Am. J. Med. VL - 95 IS - 6 N2 - OBJECTIVES: To assess the association between implementation of the Patient Self-Determination Act (PSDA) and (1) the use of formal, written advance directives, (2) the use of informal advance care arrangements, and (3) discussions between patients and their physicians and proxies an advance care planning and end-of-life treatment preferences. DESIGN: A time-sequence study in which patients discharged from acute care hospitals 1 month before the implementation of the PSDA and 5 months after implementation of the PSDA were interviewed. SETTING: Two medical school-affiliated, major teaching hospitals with more than 500 beds and 3 nonteaching community hospitals with fewer than 400 beds in eastern Massachusetts. PATIENTS: A total of 579 adult patients were interviewed: 258 patients discharged before the implementation of the PSDA (pre-PSDA) and 321 patients discharged 5 months after implementation of the PSDA (post-PSDA). MEASUREMENTS: Patients were asked about their formal, written or informal advance care planning arrangements, about the frequency of inquiries and information provided on advance care planning by the hospitals, and about their discussions of advance care planning and end-of-life treatment preferences with physicians and their proxies. RESULTS: In the pre-PSDA cohort, 60.9% of the patients had some kind of advance care planning, whereas in the post-PSDA cohort, 72.6% did (p = 0.01). However, there was not a significant increase in the proportion of patients who had advance care planning "in a written document" (19.8% of the pre-PSDA cohort compared with 25.5% of the post-PSDA cohort, p = 0.11). The increase in written advance care planning was concentrated in the community, nonteaching hospitals (10.7% pre-PSDA versus 23.7% post-PSDA). Overall, 41.4% of patients recalled inquiries or information about advance care planning during their hospitalization. Implementation of the PSDA was not associated with a significant change in the proportion of patients who discussed advance care planning or end-of-life issues with their physicians (13.6% pre-PSDA versus 17.1% post-PSDA, p = 0.25). However, there was an increase in the proportion of patients with poorer health who spoke with their physicians (15.4% pre-PSDA versus 24.8% post-PSDA). Implementation of the PSDA was associated with an increase in the proportion of patients who had general discussions with proxies about end-of-life issues (61.8% pre-PSDA versus 73.0% post-PSDA, p = 0.024). However, 33.6% of pre-PSDA and 33.2% of post-PSDA patients had detailed discussions with their proxy about specific interventions such as mechanical ventilation or artificial nutrition. Patients with formal proxies had detailed discussions significantly more frequently than other patients (50.0% versus 26.8%, p < 0.0001). CONCLUSIONS: The PSDA was associated with significant effects on general advance care planning issues, increasing the proportion of patients who had (1) some kind of advance care arrangements and (2) general discussions of end-of-life issues with their proxies. However, the PSDA did not appear associated with significant increases (1) in the use of formal, written advance care documents, (2) in the frequency of discussions between patients and their physicians on advance care documents or end-of-life issues, or (3) in the frequency of discussions about specific treatment preferences between patients and their proxies. SN - 0002-9343 UR - https://www.unboundmedicine.com/medline/citation/8259779/How_well_is_the_Patient_Self_Determination_Act_working:_an_early_assessment_ L2 - https://linkinghub.elsevier.com/retrieve/pii/0002-9343(93)90358-V DB - PRIME DP - Unbound Medicine ER -