Early intervention in planning end-of-life care with ambulatory geriatric patients - Results of a pilot trial

Background: A large discrepancy exists between the wishes of dying patients and their actual end-of-life care. However, retrospective clinical experience suggests that early advance care planning (ACP) can markedly reduce this discrepancy. This article describes a randomized trial to evaluate the short-term clinical utility of early ACP. We also assessed the feasibility of performing a larger prospective study to document long-term outcomes. Methods: Ambulatory geriatric patients (N=61) were randomized to either a control group, which received only a Massachusetts Health Care Proxy form to complete, or an intervention group, in which each patient and health care agent discussed ACP with a trained nurse facilitator. The benefits and burdens of life-sustaining treatments were discussed, and patient goals and preferences for these treatments were documented. Results: Two-month follow-up revealed that the intervention achieved higher congruence between agents and patients in their understanding of patients' end-of-life care preferences, with 76% (19/25) in complete agreement vs 55% (12/22) of the controls (effect size [ES] =-0.43). There was also a greater increase in patient knowledge about ACP in the intervention group (ES=0.22). Intervention patients became less willing to undergo life-sustaining treatments for a new serious medical problem (ES=-0.25), more willing to undergo such treatments for an incurable progressive disease (ES=0.24), and less willing to tolerate poor health states (ES=-0.78). Practical insights were gained about how to conduct a larger study more effectively. Conclusion: A facilitated discussion about end-of-life care between patients and their health care agents helps define and document the patient's wishes for both patient and agent.