Elsevier

Journal of Professional Nursing

Volume 20, Issue 1, January–February 2004, Pages 47-58
Journal of Professional Nursing

Patient-centered advance care planning in special patient populations: a pilot study

https://doi.org/10.1016/j.profnurs.2003.12.001Get rights and content

Abstract

The purpose of this study was to assess the feasibility of a patient-centered advance care planning (PC-ACP) approach to patients with chronic illnesses and their surrogates with respect to promotion of shared decision-making outcomes—congruence between patient and surrogate, patient’s decisional conflict, and knowledge of advance care planning. An experimental design was used. The settings were the heart failure, renal dialysis, and cardiovascular surgery clinics at Gundersen Lutheran Medical Center in La Crosse, WI. Twenty-seven patient-surrogate pairs participated. A 1-hour PC-ACP interview was provided to the experimental group. Only usual care was delivered to participants in the control group. Comparison of the composite scores of a Statement of Treatment Preferences indicated that congruence in decision-making for future medical treatment in patient-surrogate pairs in the treatment group was significantly higher than in the control group. Greater satisfaction with the decision-making process and less decisional conflict were demonstrated in the treatment group. The PC-ACP interview can be effective in promoting shared decision-making between patients and their surrogates and in producing greater satisfaction with the process of decision-making and less decisional conflict.

Section snippets

Theoretical framework

The PC-ACP interview was constructed by integrating the familiar and effective advance care planning facilitation skills embedded in the nationally recognized program Respecting Choices (Hammes & Briggs, 2000) with two social science theories: the interactive decision-making model (Pierce & Hicks, 2001) and the representational approach to patient education (Donovan & Ward, 2001).

The interactive decision-making model, which originates from several economic principles and decision theories, has

Design

An experimental design was used in this study. Patients were paired with their surrogates and assigned to one of three disease conditions to receive either the intervention or the usual care (Fig 1).

Sample and setting

Participants were recruited from the heart failure clinic, renal dialysis unit, and cardiovascular surgery clinic at Gundersen Lutheran Medical Foundation in La Crosse, Wisconsin, a 325-bed clinically affiliated organization that has participated in the development of the community-based Respecting

Sample characteristics

Most patients were 61 to 70 years old (M = 68.7, SD = 9.2). All patients and their surrogates were white. Approximately 62 percent of the patients in the experimental group were women. About 80 percent of patients in the control group were men (Table 2). Most surrogates were women in both groups (≥ 71 percent). Surrogates had a mean age of 50 ± 14.8 years. Children accounted for 76.9 percent of surrogates in the experimental group; spouses accounted for 50 percent of surrogates in the control

Discussion

The approach tested in this pilot study, the PC-ACP interview, shows that this unique intervention to promote shared decision-making might contribute to improvement in care at the end of life. The PC-ACP interview appeared to be acceptable to most participating patients and their surrogates. The most important finding was that the interview could result in higher congruence between the patient and surrogate and at the same time decrease the patient’s decisional conflict. This result contradicts

Conclusions

Findings of this study suggest that the PC-ACP interview can enhance surrogates’ understanding of patients’ preferences for future medical treatment and surrogates’ roles in decision-making for the patient. It is expected that increasing the surrogate’s understanding of the patient’s wishes improves the congruence between the patient and surrogate in medical decision-making; this understanding can empower the surrogate to speak for the patient when the patient becomes incapacitated. To create

∗Assistant Director for Advance Care Planning, Gundersen Lutheran Medical Foundation, La Crosse, WI.

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    ∗Assistant Director for Advance Care Planning, Gundersen Lutheran Medical Foundation, La Crosse, WI.

    †Rodefer Chair and Professor, University of Wisconsin-Madison School of Nursing, Madison, WI.

    ‡Director of Medical Humanities, Gundersen Lutheran Medical Foundation, La Crosse, WI.

    §Doctoral candidate, University of Wisconsin-Madison School of Nursing, Madison, WI.

    ¶IRB and Ethics Committee Coordinator, Gundersen Lutheran Medical Foundation, La Crosse, WI.

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