Administrative Memos

199901

FROM: Theodore O. Will, Chief Executive Officer
DATE: Jan 19, 1999
SUBJECT: Promoting the Use of Advance Directives in New York State
IPRO CONTACTS:

Charles Stimler, M.D., M.P.H., Clinical Coordinator, Ext. 514

Enclosed please find a statewide report on "Promoting the Use of Advance Directives in New York State". This quality improvement project grew out of concerns about end-of-life care, and promotes the more widespread use of advance directives among Medicare beneficiaries.

The study documents significant room for improvement in how hospitals provide their patients with information about advance directives, and the types of advance directives being used. The project was divided into two distinct patient samples, acute emergency admissions for Congestive Heart Failure (CHF), and elective admissions for joint replacement (total hip replacement or total knee replacement), because of the hypothesis that patient and provider behavior may reflect severity of illness and patient prognosis upon admission. It was a key finding, however, that provision of information about or execution of advance directives was not related to severity of illness. In total, fifty-eight (58) hospitals collaborated with IPRO on this project, and each has received a hospital-specific report of its baseline findings.

Should you have any questions about IPRO's Advance Directives project, please feel free to contact Charles Stimler, M.D., M.P.H., Clinical Coordinator, at extension 514.

EXECUTIVE SUMMARY

IPRO has initiated a quality improvement effort to promote the use of advance directives by patients and to increase the rate at which hospitals provide information about advance directives. The Federal Patient Self Determination Act requires that hospitals provide information about advance directives upon admission, and document whether or not the patient has an advance directive executed. New York State has statutes which grant legal immunity to health care providers who honor in good faith DNR (Do Not Resuscitate) orders and health care proxy directives.

IPRO abstracted information from two samples of medical records; patients with congestive heart failure (CHF), and those admitted for an elective surgical procedure (total hip replacement or total knee replacement), hypothesizing that use of advance directives may be influenced by issues of patient disease severity. Fifty-eight hospitals voluntarily participated in either the CHF or the elective surgery portion of the project. Patients in the CHF sample, as compared with the elective surgery sample, were older by an average of 4 years, more likely to be male (41% vs. 37%), and had a longer mean length of stay (7.6 days versus 5.8 days). The key results include:

• Slightly under two-thirds of patients (63% of CHF, 64% of elective surgery) received information from hospitals regarding their right to an advance directive prior to or upon admission. This key finding was not related to the severity of the diagnosis.
• About one-third of patients in either group (CHF or elective surgery) had executed an advance directive prior to admission. This key finding was also not related to the severity of the diagnosis.
• Few (<15%) patients without an advance directive executed one during their hospitalization.
• Only about one-third of pre-existing advance directives were placed on the chart at any time during hospitalizations.
• An opportunity exists for better patient-physician communication about advance directives.
• Of the 43 patients who died in this study, 37% did not have an advance directive documented in their chart prior to death.

Suggested methods for increasing advance directives include providing educational materials to patients before admission or after discharge, using a patient representative to counsel patients as well as locate existing advance directives, and involving physicians. IPRO intends to remeasure these results in the Spring of 1999 to assess improvement.