A nurse practitioner–led community workshop: Increasing adult participation in advance care planning

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Advance directives (ADs) include living wills (LWs), written documents used by individuals to express their preferences in guiding future medical decision‐making, and/or durable powers of attorney (POA), a person named to express wishes on an individual's behalf. Advance care planning (ACP) is an ongoing proactive process in which individuals, their healthcare providers, and their families reflect on goals, values, and beliefs to direct future medical care.
National Healthcare Decisions Day (NHDD), April 16, was developed to educate and empower the public and providers about the importance of ACP (NHDD, 2017). It is an initiative to encourage individuals to express their wishes and was introduced nationwide in 2008. Despite this initiative, the Institute of Medicine (IOM, 2012) Best Care at Lower Costs: The Path to Continuously Learning Healthcare in America reported that $750 billion or 30% of all healthcare costs were related to waste including unwanted medical treatment.
According to Van Scoy, Howrylak, Nguyen, Chen, and Sherman (2014), ADs and ACP continue to be underutilized in today's healthcare system. AD and ACP completion rates remain at an all‐time low ranging between 5% and 39% (Van Scoy et al., 2014). Three of four individuals with completed ADs share their wishes with their family members, whereas only one in three relay their wishes to their healthcare provider (Heyland et al., 2013). Current research also demonstrates that 76% of individuals will be unable to participate in some or all of their decision making at the end of life (EOL; Motley, 2013). The low percentages of AD completion rates and ACP discussions can be traced to a lack of awareness of ACP and insufficient information being provided to both individuals and healthcare providers (Heyland et al., 2013).
While lack of awareness has been reported as the number one barrier, other barriers may exist, such as individual and family member fear, concern for causing family burden, the assumption preferences about EOL wishes are already known, and willingness and/or discomfort in EOL discussions (Heyland et al., 2013; Malcomson & Bisbee, 2009). Healthcare providers cite lack of time during office visits, inadequate training, and educational resources as barriers to initiate an ACP discussion (Heyland et al., 2013; Malcomson & Bisbee, 2009; Tung & North, 2009).
Consequently, low levels of AD completion and ACP have a direct relationship resulting in higher levels of Medicare spending, higher likelihood of in‐hospital deaths, lower use of hospice care, and lower quality of life (Halpern & Emanuel, 2012; Nicholas, Langa, Iwashyna, & Weir, 2011; White & Arnold, 2011). The U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (2007) reported that 80% of deaths occur in the acute care setting, when most individuals would rather spend their last moments in their home. Other disadvantages of low ACP completion, which have no monetary value, include stress, turmoil, and anxiety among individual and family members as well as undesirable family bereavement outcomes (Morhaim & Pollack, 2013; White & Arnold, 2011).
As a result of low ACP completion, public education in the community setting to raise awareness and elevate expectations about care options has been suggested (IOM, 2015). This recommendation is based on the IOM that released a report in September 2014: Dying in America: Improving Quality and Honoring Individual Preferences near the End of Life. There are obvious major gaps that exist in care related to patient suffering near EOL because of the absence or continuity of AD and ACP (IOM, 2015). The IOM recommends key changes to be made to ensure family‐oriented and quality patient‐centered care during EOL medical treatment (IOM, 2015).
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