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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
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CONTEXT: Care consistent with goals is the desired outcome of advance care planning (ACP).
OBJECTIVES: To examine concordance between advance directives and proxy care preferences among nursing home residents with advanced dementia, and determine the impact of an ACP video on concordance.
METHODS: Data were from Educational Video to Improve Nursing home Care in End-stage dementia (EVINCE); a cluster randomized clinical trial conducted in 64 Boston-area facilities (32/arm) from 2013-2017. Participants included advanced dementia residents and their proxies (N=328 dyads). At 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 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: comfort, 7%; basic 49%; and intensive, 58%. When comfort care was preferred, concordance was higher in intervention versus control facilities (10.8% versus 2.5%; adjusted odds ratio, 2.48, 95% confidence interval, 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.
http://dx.doi.org/10.1016/j.jpainsymman.2018.09.018
Voir la revue «JOURNAL OF PAIN AND SYMPTOM MANAGEMENT»
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