Systematic Implementation of an Advance Directive Program in Nursing Homes: A Randomized Controlled Trial
Molloy, D. William
Guyatt, Gordon H.
O'Brien, Bernie J.
Darzins, Peteris J.
JAMA. 2000 Mar 15; 283(11): 1437-1444.
CONTEXT: Although advance directives are commonly used in the community, little is known about the effects of their systematic implementation. OBJECTIVES: To examine the effect of systematically implementing an advance directive in nursing homes on patient and family satisfaction with involvement in decision making and on health care costs. DESIGN: Randomized controlled trial conducted June 1, 1994, to August 31, 1998. SETTING AND PARTICIPANTS: A total of 1292 residents in 6 Ontario nursing homes with more than 100 residents each. INTERVENTION: The Let Me Decide advance directive program included educating staff in local hospitals and nursing homes, residents, and families about advance directives and offering competent residents or next-of-kin of mentally incompetent residents an advance directive that provided a range of health care choices for life-threatening illness, cardiac arrest, and nutrition. The 6 nursing homes were pair-matched on key characteristics, and 1 home per pair was randomized to take part in the program. Control nursing homes continued with prior policies concerning advance directives. MAIN OUTCOME MEASURES: Residents' and families' satisfaction with health care and health care services utilization over 18 months, compared between intervention and control nursing homes. RESULTS: Of 527 participating residents in intervention nursing homes, 49% of competent residents and 78% of families of incompetent residents completed advance directives. Satisfaction was not significantly different in intervention and control nursing homes. The mean difference (scale, 1-7) between intervention and control homes was -0.16 (95 % confidence interval [CI], -0.41 to 0.10) for competent residents and 0.07 (95% CI, -0.08 to 0.23) for families of incompetent residents. Intervention nursing homes reported fewer hospitalizations per resident (mean, 0.27 vs 0.48; P = .001) and less resource use (average total cost per patient, Can $3490 vs Can $5239; P = .01) than control nursing homes. Proportion of deaths in intervention (24%) and control (28%) nursing homes were similar (P = .20). CONCLUSION: Our data suggest that systematic implementation of a program to increase use of advance directives reduces health care services utilization without affecting satisfaction or mortality.
Advance Directives; Aged; Allowing to Die; Competence; Consent; Decision Making; Economics; Education; Evaluation; Evaluation Studies; Family Members; Health; Health Care; Health Personnel; Hospitals; Institutional Policies; Illness; Life; Mortality; Nursing Homes; Nutrition; Patient Care; Patient Participation; Patient Satisfaction; Program Descriptions; Prolongation of Life; Statistics; Third Party Consent; Time Factors;
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Systematic Implementation of an Advance Directive Program in Nursing Homes: A Randomized Controlled Trial Molloy, D. William; Guyatt, Gordon H.; Russo, Rosalie; Goeree, Ron; O'Brien, Bernie J.; Bedard, Michel; Willan, Andy; Watson, Jan; Patterson, Christine; Harrison, Christine; Standish, Tim; Strang, David; Darzins, Peteris J.; Smith, Stephanie; Dubois, Sacha (2000-03-15)