Managed Death in a PACE: Pathways in Present and Advance Directives

Objectives

To test the effect of an innovative method of documenting present and advance health care wishes on the rates of completion and the qualitative choices of health care wishes.

Design

Interventional prospective cohort (pre- and post-).

Setting

Program for All-inclusive Care of the Elderly (PACE) site in St. Louis, MO.

Participants

Enrolled PACE participants.

Intervention

A documentation tool that captures both present and advance directives in a framework of “pathways,” blending goals of care with typical procedure-oriented directives.

Measurements

Data from medical records to calculate rates of health care wishes (HCW) completion, proportions of qualitative choices, and compliance with wishes at death.

Results

Baseline prevalences of present directives (PD) and advance directives (AD) were 77% and 36%, respectively, while Do Not Resuscitate (DNR) wishes were documented in 48% of PD and 26% of AD. After implementation of the Pathways Tool, completion rates increased to 99% for both PD and AD. Documented DNR wishes decreased to 38% of PD and increased to 66% of AD. Qualitative choices for care (Longevity vs Function vs Palliation) changed toward a palliation pathway for AD (from 9% to 53%). The rate of dying at home increased from 24% to 65%. Compliance with end-of-life wishes increased from 72% to 96%. These are statistically significant.

Conclusion

Introduction of a novel pathways method of documenting HCW in a PACE site was associated with increased completion, preferences toward less invasive levels of care at life’s end, and increased compliance with participants’ wishes and deaths at home. Future research to validate the methodology employed in this intervention should be conducted in other long-term care settings.

Keywords:  End-of-life , advance directives , health care wishes , present directives , pathways