Hospital and Program Description

The Palliative Care Unit (PalCU) at Orlando Regional Lucerne Hospital was an 8-bed, geographically-distinct acute inpatient facility, part of Orlando Regional Healthcare’s 1780-bed, multi-hospital healthcare system in Central Florida.

Problem

Despite laws requiring hospitals to offer patients opportunities to learn about and express treatment preferences with advance directives,1,2 many inpatients with severe or terminal illnesses lacked documentation of their life support preferences.3,4

Process to Resolve Problem

We designed a specialized counseling intervention, including an individualized multidimensional suffering assessment, to improve advance directive documentation in patients admitted to the PalCU.5,6 Each patient admitted to the PalCU between January 1, 2002, and April 30, 2006, received interdisciplinary palliative care according to accepted standards. Those admitted before October 1, 2003, received the specialized counseling intervention. We defined a documented advance directive as a written notation in the inpatient medical record about surrogate decision-making and/or life support preferences.

Outcomes

The study group included 1,281 patients with a mean age of 65.5 years. Only 355 patients (27.7%) had documented advance directives before admission, while 902 patients (70.6%) had documented advance directives at the time of discharge from the unit (P < 0.01). We identified no statistically significant relationships between documentation of advance directives and the patients’ primary diagnosis, age, gender, and length of stay. Notably, 95% (407/428) of those who received the specialized counseling intervention had documented advance directives, compared to 58% (495/853) who had not received the intervention (P < 0.01).

Lessons Learned

Admission to an inpatient palliative care unit significantly improved advance directive documentation, but patients who received a specialized counseling intervention during their stay in the PalCU exhibited even higher rates of documentation. Specialized counseling with individualized attention to the multidimensional components of suffering proved effective in improving advance directive documentation.

References

1. Florida Statutes 2005, Title XLIV, Chapter 765, Sections 102 and 1103. URL: http://www.flsenate.gov/Statutes/index.cfm.
2. Omnibus Budget Reconciliation Act of 1990 (OBRA-90), Pub L 101-508, Sections 4206 and 4751 (Medicare and Medicaid, respectively), 42 USC Sections 1395cc(a)(I)(Q), 1395mm (c)(8), 1395cc(f), 1396a(a)(57), 1396a(a)(58), and 1396a(w)(suppl 1991).
3. The SUPPORT Principal Investigators. A Controlled Trial to Improve Care for Seriously Ill Hospitalized Patients: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). JAMA 1995;274(20):1591-1598.
4. Last Acts. Means to a Better End: A Report on Dying in America. November 2002.
5. Boyer-Kollas B, Kollas CD. A Palliative Care Intervention for Assuring Patient Self-Determination. J. Palliative Med 2004;7(1):175-183.
6. Boyer-Kollas B, Kollas CD. Innovative Teaching Tools in Palliative Care: The Support Care Specialist. J. Palliative Med 2001;4(4):525-548.