Advance directives in the cardiac care unit

doi:10.1016/j.ahj.2007.05.011

American Heart Journal

Volume 154, Issue 3, September 2007, Pages 477-481

https://doi.org/10.1016/j.ahj.2007.05.011 Get rights and content

Background

Despite effective therapies, mortality for many cardiovascular diseases remains higher than for many cancers and is difficult to predict. Guidelines recommend discussing advance directives (AD), including living wills and durable powers of attorney, with heart failure patients. The Patient Self-Determination Act mandates such discussions with all hospitalized patients. Little data are available on AD prevalence in patients with serious cardiac disease.

Methods

Patients admitted to a cardiac care unit (CCU) were surveyed regarding demographics, medical history, prevalence of AD, and interest in obtaining more information about AD. Histories of life-threatening cardiac diagnoses were tabulated. Prevalence of AD and interest in obtaining more information about AD were obtained via chart review from patients on an oncology (ONC) floor at the same hospital.

Results

One hundred twelve CCU (average age 58 ± 16 years, 47 women) and 105 ONC (average age 58 ± 14 years, 32 women) patients were enrolled. Prevalence of AD was not different between CCU and ONC patients (26% vs 31%, P = .37). Among CCU patients with prior hospitalizations but no AD, 21 of 64 did not recall being asked about AD. Cardiac care unit patients with heart failure and pulmonary hypertension were more likely to report being asked about AD in the past (39 of 54, P = .03 and 7 of 9, P = .008, respectively), but only heart failure patients were more likely to want more information about AD (P = .005). Of patients without AD, 83% from CCU and 18% from ONC wanted more information on AD (P < .001).

Conclusions

Prevalence of AD in the CCU was low, and many patients did not recall prior AD discussions. The CCU patients without AD were more likely to want information about AD than the ONC patients. A renewed emphasis on AD discussions with cardiovascular patients is needed and would be welcomed. Advance directives should be emphasized in cardiovascular training programs.

Section snippets

Methods

This study was approved by the local institutional review board. Patients able to participate in an interview in English who had been admitted to a cardiac care unit (CCU) at an academic medical center were recruited from May 2005 to May 2006. Patients were approached without regard for diagnosis or length of stay. The brief survey instrument included questions on demographics, medical history, outpatient physicians, whether the patient had executed an AD, and whether the patient recalled being

Results

Of 118 patients approached in the CCU, 112 agreed to participate (response rate = 95%). The average age was 58 ± 16 years, with 47 women (42%) (Table I). There were 73 African Americans, 29 whites, and 4 Hispanics. Racial determination was unavailable for 6 patients. The highest level of education attained was junior high for 8 (7%), high school for 56 (50%), at least college for 47 (42%), and unknown for 1 (<1%). Seventy (63%) patients reported having a primary care physician (internist,

Main findings

Our study found a low prevalence of AD among patients admitted to a CCU, comparable with that among patients admitted with oncologic/hematologic diagnoses. Almost one third of CCU patients had no recollection of prior AD discussions, despite a record of multiple hospitalizations. Patients with serious cardiac disease were more likely to indicate an interest in more information about AD than were patients with cancer.

Advanced care planning in cardiology

The development of lifesaving cardiovascular technologies and medications in

References (26)

J.E. Heffner et al.
End-of-life care preferences of patients enrolled in cardiovascular rehabilitation programs
Chest
(2000)
S.A. Hunt et al.
ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure)
Circulation
(2005)
Patient Self-Determination Act, 42 USC 1395cc, 1396a...
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)
J. Lynn et al.
Prognoses of seriously ill hospitalized patients on the days before death: implications for patient care and public policy
New Horiz
(1997)
R.E. Lane et al.
Prediction and prevention of sudden cardiac death in heart failure
Heart
(2005)
L.L. Emanuel et al.
Advance directives for medical care—a case for greater use
N Engl J Med
(1991)
H.M. Krumholz et al.
Resuscitation preferences among patients with severe congestive heart failure: results from the SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments) project
Circulation
(1998)
Z.R. Haydar et al.
Differences in end-of-life preferences between congestive heart failure and dementia in a medical house calls program
J Am Geriatr Soc
(2004)
F. Formiga et al.
End-of-life preferences in elderly patients admitted for heart failure
Q J Med
(2004)

D. High

Advance directives and the elderly: a study of interventional strategies to increase their use

Gerontologist

(1993)

K.L. Stetler et al.

Living will completion in older adults

Arch Intern Med

(1992)

D.M. High

Why are elderly people not using advance directives?

J Aging Health

(1993)

Cited by (31)

Advance directive screening among veterans with incident heart failure: Comparisons among people aging with and without HIV
2023, Heart and Lung
Heart failure (HF) is common among people aging with HIV (PWH) and without HIV (PWoH). Despite the poor prognosis for HF, advance directives (AD) completion is low but has not been compared among PWH and PWoH.
Determine the prevalence and predictors of AD screening among PWH and PWoH with incident HF.
We included Veterans with an incident HF diagnosis code from 2013–2018 in the Veterans Aging Cohort Study (VACS) without prior AD screening. Health records were reviewed for AD screening note titles within -30 days to 1-year post-HF diagnosis. Analyses were stratified by HIV status. Trends in annual AD screening were evaluated with the Cochran-Mantel-Haenszel test. The associations of AD screening with demographics, disease severity (Charlson Comorbidity Index, VACS 2.0 Index), and healthcare encounters (cardiology, palliative care, hospitalization) were evaluated with Cox proportional hazards regression.
HF was diagnosed in 4516 Veterans (28.2% PWH, 71.8% PWoH). Annual AD screening rates increased in both groups (P_trend<0.0001) and aggregate rates were higher among PWH than PWoH (53.5% vs. 48.2%, p=.001). In both groups, the likelihood of AD screening increased with greater disease severity, palliative care contact, and hospitalization (HR range=1.04–3.32, all p≤.02) but not with cardiology contact (p≥.53).
AD screening rates after incident HF remain suboptimal but increased over time and were higher in PWH. Future quality improvement and implementation efforts should aim for universal AD screening with incident HF diagnosis, initiated by providers skilled in discussing AD, including in the cardiology subspecialty setting.
Advance Care Planning and Goals of Care Communication in Older Adults with Cardiovascular Disease and Multi-Morbidity
2016, Clinics in Geriatric Medicine
Citation Excerpt :
A recent review found that absent, delayed, or inadequate ACP communication was associated with negative outcomes, including poor quality of life and anxiety, family distress, prolongation of the dying process, undesired hospitalization, patient mistrust of the health care system, physician burnout, and high costs.9 Furthermore, there are low rates of advance directive completion in patients with heart failure (41%), severe aortic stenosis (47%), or individuals admitted to a cardiac care unit (26%).21–23 Even when an advance directive exists, there is still poor correlation between what individuals state in an advance directive, what is documented in the medical record, and the care received.
How to discuss goals of care with patients
2016, Trends in Cardiovascular Medicine
Effective communication with patients and their caregivers continues to form the basis of a constructive clinician–patient relationship and is critical to provide patient-centered care. Engaging patients in meaningful, empathic communication not only fulfills an ethical imperative for our work as clinicians but also leads to increased patient satisfaction with their own care and improved clinical outcomes. While these same imperatives and benefits exist for discussing goals of care and end-of-life, communicating with patients about these topics can be particularly daunting. While clinicians receive extensive training on how to identify and treat illness, communication techniques, especially those centering around emotion-laden topics such as end-of-life care, receive short shrift medical education. Fortunately, communication techniques can be taught and learned through deliberate practice, and in this article, we seek to discuss a framework, drawn from published literature and our own experience, for approaching goals-of-care discussions in patients with cardiovascular disease.
Advance directives among hospitalized patients with heart failure
2015, JACC: Heart Failure
The purpose of this study was to assess the frequency and correlates of documented advance directives (ADs) among patients hospitalized for heart failure (HF).
Discussing ADs with patients with HF is critical for identifying treatment goals consistent with patients’ values and preferences and for facilitating health care team communication.
We retrospectively identified electronic medical records of adult patients admitted to 2 large tertiary care hospitals with either the primary or secondary discharge diagnosis of HF from September 2008 to August 2013 to assess the presence of ADs in electronic medical records. We performed analyses including HF as either the primary or secondary admission diagnosis and HF as the primary admission diagnosis only. Multivariable models were constructed to investigate independent predictors of documented ADs.
Data included 44,768 admissions from 24,291 individual patients over 5 years. Mean age of patients at admission was 64.8 ± 15.9 years; 47.9% of these patients were female, 51.8% were black. The median length of stay for all admissions was 5 (3 to 10) days; 12.7% of patients had documented ADs. Older age, female sex, white race, higher socioeconomic status, higher risk for adverse in-hospital outcomes, length of stay ≥5 days, hospice discharge, palliative care consultation, and a do-not-resuscitate order were all associated with a significantly higher chance of having documented ADs. A significant increase in ADs over time was noted, but more than 80% of patients did not have ADs in medical records at the end of the study period.
In a diverse population of hospitalized patients with HF, most did not have a documented AD in the medical records. Although several factors were associated with a higher probability, major opportunities exist for all subgroups of patients with HF to improve documentation of ADs.
Con: Patient's desire for termination of destination LVAD therapy should be respected
2013, Journal of Cardiothoracic and Vascular Anesthesia
Ethics Priorities in Adult Congenital Heart Disease
2012, Progress in Cardiovascular Diseases
The success of modern therapies in congenital heart disease has produced a large and growing population of adults with congenital heart disease as a chronic condition. Such success increasingly raises a host of ethical issues, from resource utilization to end of life decision-making. The importance of a multidisciplinary approach to the care of adult congenital heart disease (ACHD) patients has been emphasized for some time, but addressing the challenges in this population requires a broad range of ethical expertise as well. This paper is based on a conference entitled “Ethical and Policy Challenges in Pediatric and Adult Congenital Heart Disease” held in March of 2012. Herein, we present a compilation of the ethics priorities in ACHD discussed at the conference, including ethical aspects of clinical care, ethics research and policy development in the areas of providing clinical care for challenging ACHD patients, improving transitions from pediatric to adult healthcare systems, advance care planning, and addressing costs.

View all citing articles on Scopus

: Data presented in poster formats at the American College of Cardiology Scientific Sessions, Atlanta, GA, March 14, 2006, and at the Seventh Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke, Washington, DC, May 8, 2006.

: This study involved no external funding, sponsorship, or grant support.

View full text

Clinical InvestigationAcute Ischemic Heart DiseaseAdvance directives in the cardiac care unit

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Main findings

Advanced care planning in cardiology

Chest

Circulation

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

Prognoses of seriously ill hospitalized patients on the days before death: implications for patient care and public policy

New Horiz

Prediction and prevention of sudden cardiac death in heart failure

Heart

Advance directives for medical care—a case for greater use

N Engl J Med

Resuscitation preferences among patients with severe congestive heart failure: results from the SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments) project

Circulation

Differences in end-of-life preferences between congestive heart failure and dementia in a medical house calls program

J Am Geriatr Soc

End-of-life preferences in elderly patients admitted for heart failure

Q J Med

Advance directives and the elderly: a study of interventional strategies to increase their use

Gerontologist

Living will completion in older adults

Arch Intern Med

Why are elderly people not using advance directives?

J Aging Health

Clinical Investigation
Acute Ischemic Heart Disease
Advance directives in the cardiac care unit