Promoting the Use of Advanced Directives Amongst Our Patients

1. Malik M. McDaniel, RN NU 442.03 Advanced Concepts of Nursing Leadership Thomas Jefferson University Promoting the Use of Advanced Directives Amongst Our Patients

2. To provide educational support amongst Osler 8/ Polk unit (HIV specialty) nursing staff • To discover perceptions and attitudes related to the use of Advance Directives in our patient population • To assist staff in the development of strategies that will increase the use of AD’s amongst our patient population Purpose

3. To advocate for our patients by helping them understand the full benefit and consequence of their decision making To promote the best quality of care in an end of life event Rationale

4. A legal document that conveys a patients wishes about end of life Allows the patient to appoint a proxy, someone to make medical decisions for the patient, in an event where the patient is unable to “Advance Directives are about getting people better quality care at the end of life” (2011, Estate) What is an Advanced Directive?

5. Living Will Durable Power of Attorney DNR Health Care Surrogate Health Care Proxy End of Life Decision Maker Types of advance directives

6. Snapshot of AD’s used at johns hopkins

7. Readability - (12th grade level) • Limited Choices – care providers cannot be surrogate • Legitimizing – signatures, witnesses, notarizing (N/A in MD) • Patient’s Preference – not individualized enough, religious issues, patient may change mind • State Based – may not be recognized across states • Legal Restrictions – no same sex partners (N/A in MD) Some Problems with Advanced Directives

8. Homeless • IV Drug users • Poorly Educated • Non English Speaking • Unstable Family Situations • Depressed, Fearful, Stressed Patients • African American and Latino patients(least likely ethnic groups) Challenges In Our Patient Population

9. Understanding the Document (Translation) • 40% of the population reads at a 8th grade level(Benjamin, A., 2011) • Stressful Hospital Stay (time when AD is introduced) • Mistrust of health care system or provider • Social Support, Unresolved Family Conflict • Perception of who introduces AD • Patients ability to communicate • View of death, dying and suffering • Religious or Cultural Beliefs • Lack of Knowledge • Some see as promotion of death Obstacles

10. Literature Review

11. A conducted study showed 96% of patients preferred completing AD’s when healthy • Results showed that patients with an AD had less stress in their family when compared to those without • A controlled study group of African American patients showed 50% of the participants believed they would be treated differently if they had a LW • No differences shown in the variables of gender, marital status, education, occupation in utilizing AD’s Nolan, M., & Bruder, M.,(2005).

12. African-Americans are generally less likely to have created an advance directive. However, in hospice care, 80% of AA patients created an advance directive A study showed 65% of nursing home patients have some kind of AD Additionally, 28% of patient receiving home health have AD’s. Llyod, J., (2011). Study: Blacks less likely to have living wills, medical directives

13. Half of all people infected with HIV make life decisions without any discussion with their health care practioner Black and Latino patients were less likely to communicate their end of life wishes, but also less likely to be approached by a healthcare practioner The study showed programs designed with clinical interventions work best for AA and Latino patients The Journal of the American Medical Association (2001). End of Life Discussions and Preferences Among Patients with HIV

14. Both political parties have realized and expressed the importance and benefit in increasing the use of AD’s Something We can All Agree ON!!!

15. In 2011, President Obama announced a regulation that gives doctors reimbursement for counseling patients on end of life planning (Norton, A., & Lies, E., 2011) • In 2009, The Senate suggested that patients who are involved in advance planning be rewarded with reduced insurance premium (Rozovsky, F, 2010) • In 2009, The Advance Planning and Compassionate Care Act authorized Medicare and Medicaid to reimburse for advanced care planning (Rozovsky, F, 2010) • In 2008, Sarah Pailin urged healthcare professionals and lawyers to volunteer their time to improve public knowledge and increase the number of Alaskans with AD’s (Leopald, J, 2009) National Strategies

16. A study showed AD completion rates increased by 29% when homeless patients received guidance in the completion of AD versus a self-guided completion. (Parker, S,F., 2008) Since 1996 rates of AD completion in nursing homes having increased 17% (American Journal of Hospice and Pallative Care Medicine, 2008) A study amongst HIV patient showed completion of AD’s were more likely when their physician and practioner discussed it with them. (JAMA, 2001) Intervention Yields Results

17. Vary the presenter • Get physicians involved • Reduce patients stress levels • Discuss at well patient visit • Find out why your patient refused an AD • Educational Seminars to staff and patients • Provide trends and data to patients, present cultural awareness • Present AD at different times throughout hospital stay including EXIT WHAT can we do?

18. What are you perceptions of AD’s? • Have you heard of the terms AD, living will, or durable power of attorney for health care? • If you were ill or incapacitated with no hope for recovery, what decisions would you want your family to make? • If there is no LW, and family members and healthcare providers disagree over treatment, how would you want this situation handled? Some Probing Questions to Ask Patients (Ramsey, C., 2005)

19. God is control, he holds my time clock • I will not be placed on a machine and lie there • AD’s are for when you get old • I don’t know what an AD is • My wife will make those decision • I would not want my family to go through stress • My family knows my decision and I want them to act on my decision • My family will respect my choice • I am too healthy to need one Some Common Response to Anticipate (Ramsey, C., 2005)

20. Understand – invest time in the patients response and concern. Explore and Relate to their perceptions. Be Sincere TurnAround – After understanding their concerns, uselogic to turn their perception around Repeat the Benefits – this is done to rebuild the value of AD’s Repeat the Completion Process if Necessary Responding to a Patients Concerns

21. Increase the amount of opportunities the patient will have to be educated about AD’s All RN’s on Osler 8/Polk will familiarize themselves with AD forms used on the unit All RN’s on the unit will develop a comfort level in explaining the benefits to the patient All RN’s will be aware of their patient’s AD status Goals of UNIT Project

22. In addition to social work’s introduction, All RN’s will assess their patients knowledge of AD In the middle of their hospital stay and during time of discharge, patients will be re-educated and reoffered the chance to fill out an AD Objectives

23. When to Introduce AD’s

24. Self Evaluation Tool

25. Morning RN staff familiarized themselves with current AD forms used on the unit Am staff engaged in role playing sessions designed to simulate patient presented challenges RN staff was provided with information and guidance in the event they are unsure about AD policies Current Outcomes

26. Varying approaches towards encouraging AD use amongst patients will result in increased usage • Unit’s RN staff will have increased understanding of AD’s, including the process, issues, and usage data • Continuous Trending, Discussion, and Education will lead to additional strategies that promote increased usage of AD’s in our patient population Anticipated Outcomes

27. Provide an across the board practice in encouraging the use of AD’s on the unit, including evening and weekend staff Introduce the rationale to all RN’s and extend training/discussions where needed Verbalize AD status during report from one RN to another and determine a strategy for that patient if needed Recommendation

28. Reevaluate the units perception and the effectiveness of this project every 3 months Trend the percent of patients completing AD versus those who are not Briefly reiterate the rationale to unit staff, accompanied by recent data and issues related to AD Recommendation (Every 3 Months)

29. Not everyone Will Agree with the idea of an Advance directive

30. American Journal of Hospice and Pallative Care Medicine, (2008). Retrieved from http://aahsa.org/article.aspx?id=5776 Benjamin, A. (2011). Keep It Simple. Retrieved from http://www.rtmagazine.com/issues/articles/2011-02_07.asp End of Life Discussions and Preferences Among Persons With HIV. Retrieved from http://jama.ama-assn.org/content/285/22/2880.full Leopald, J. (2009). Pailin Backed End-of-Life Counseling As Alaska Governor. Retreived from http://www.pubrecord.org/politics/3560/pailin-backed-end-of- life-counseling References

31. Llyod, J. (2011). Study: African-Americans Less Likely To Create Advance Directive. Retrieved from http://www.estateplanningnewyork.com/2011/01/study- african-americans- less-likely-to-create-advance-directive.shtml Norton, A., & Lies, E. (2011). U.S. Laws A Barrier For Advance Directives: Study. Retrieved from http://www.reuters.com/article/2011/01/18/us-directives- idustre70h0c620110118 Parker, S,F.,(2008). Homeless People: Advance Directives and Hospice-Pallative Care. Retrieved from http://hospiceandnursinghomes.blogspot.com/2008/10/ homeless-people-advance-directives-and.html References (Cont..)

32. Ramsey, P, C., (2005), Advance Directives: Young Adult African American Family Member’s Perception, Knowledge, Attitudes, and Utilization. Retrieved on March 31, 2011 from http://www.sti.iupui.edu/pp07/congress10/ramsey_c.pdf Rozovsky, F. (2010), Improving the Use of Advance Directives. Retrieved on March 24, 2011 from http://www.hhnmag.com/hhnmag_app/jsp/articledisplay.jsp?dcrpath =HHNMAG/Article/data/01JAN2010/100119HHN_Weekly_Rozovsky& domain=HHNMAG The Journal of the American Medical Association. (2001). Retrieved on April 02, 2011 from http://jama.ama- assn.org/content/285/22/2880.abstract References (Cont..)