Assessment of advance care planning documentation for residents of residential aged care facilities presenting to the emergency department
Tzy Harn Chua A , Jessica Ru-Jia Foong A , Ryan Renxin Tan A , Princess Natsai Rukasha A and Carolyn Hullick
A B C D
+ Author Affiliations
- Author Affiliations
A School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia. Email: tzyharn.chua@uon.edu.au; jessica.foong@uon.edu.au; ryanrenxin.tan@uon.edu.au; princess.rukasha@uon.edu.au
B Hunter Medical Research Institute, Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia.
C Belmont Hospital, Croudace Bay Road, Belmont, NSW 2280, Australia.
D Corresponding author. Email: carolyn.hullick@health.nsw.gov.au
Australian Health Review 44(6) 847-852 https://doi.org/10.1071/AH19238
Submitted: 21 October 2019 Accepted: 12 February 2020 Published: 20 November 2020
Abstract
Objective This study assessed the availability and quality of advance care planning (ACP) documentation among older residential aged care facility (RACF) residents who presented to the emergency department (ED).
Methods A prospective review of the medical records of RACF residents aged ≥75 years who presented to the ED from May to June 2018 was conducted. Availability of ACP was determined based on the presence of an ACP document inclusive of an advance care directive (ACD) in the medical record. The quality of ACP documentation was determined based on the presence of nine key components.
Results In all, 48.8% of patients presented to the ED with either ACP or an ACD. However, only a mean total of 3.8 (out of 9) ACP components were documented in these documents.
Conclusions Just under half (48.8%) of RACF residents presented to the ED with ACP documentation. There was limited coverage of core ACP components needed to guide clinical decision making.
What is known about the topic? RACF residents are in the last years of their life and commonly lack capacity to make decisions regarding health care. Residents are at high risk of dying when acutely unwell in hospital. ACP documentation, when readily available, helps provide appropriate end-of-life care and improves both patient and family satisfaction.
What does this paper add? Less than half the residents reporting to the ED from an RACF had ACP documentation available for clinicians. For those who presented to the ED with ACP documentation, most lacked sufficient information needed to provide care in full accordance with the patient’s preferences.
What are the implications for practitioners? There is a need to encourage, initiate, actively engage and develop systems for ACP conversations, documentation and availability when acutely unwell for people living in RACFs to provide sufficient information to guide clinical decision making. Without quality ACP, the provision of patient-centred health care may be compromised.
References
[1] Australian Institute of Health and Welfare (AIHW). People using aged care. Cat. no. AGE 85a. Canberra: AIHW; 2018. Available at: https://www.aihw.gov.au/reports/aged-care/gen-people-using-aged-care/contents/summary [verified 17 August 2020].[2] Arendts G, Dickson C, Howard K, Quine S. Transfer from residential aged care to emergency departments: an analysis of patient outcomes. Intern Med J 2012; 42 75–82.
| Transfer from residential aged care to emergency departments: an analysis of patient outcomes.Crossref | GoogleScholarGoogle Scholar | 20298507PubMed |
[3] Australian Bureau of Statistics (ABS). Disability, ageing and carers, Australia: summary of findings, 2015. Canberra: ABS; 2016.
[4] Broad JB, Gott M, Kim H, Boyd M, Chen H, Connolly MJ. Where do people die? An international comparison of the percentage of deaths occurring in hospital and residential aged care settings in 45 populations, using published and available statistics. Int J Public Health 2013; 58 257–67.
| Where do people die? An international comparison of the percentage of deaths occurring in hospital and residential aged care settings in 45 populations, using published and available statistics.Crossref | GoogleScholarGoogle Scholar | 22892713PubMed |
[5] Burkett E, Martin-Khan MG, Scott J, Samanta M, Gray LC. Trends and predicted trends in presentations of older people to Australian emergency departments: effects of demand growth, population aging and climate change. Aust Health Rev 2017; 41 246–53.
| Trends and predicted trends in presentations of older people to Australian emergency departments: effects of demand growth, population aging and climate change.Crossref | GoogleScholarGoogle Scholar | 27466861PubMed |
[6] Singal BM, Hedges JR, Rousseau EW, Sanders AB, Berstein E, McNamara RM, Hogan TM. Geriatric patient emergency visits. Part I: comparison of visits by geriatric and younger patients. Ann Emerg Med 1992; 21 802–7.
| Geriatric patient emergency visits. Part I: comparison of visits by geriatric and younger patients.Crossref | GoogleScholarGoogle Scholar | 1610036PubMed |
[7] Aminzadeh F, Dalziel WB. Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions. Ann Emerg Med 2002; 39 238–47.
| Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions.Crossref | GoogleScholarGoogle Scholar | 11867975PubMed |
[8] Ingarfield SL, Finn JC, Jacobs IG, Gibson NP, Holman CDJ, Jelinek GA, Flicker L. Use of emergency departments by older people from residential care: a population based study. Age Ageing 2009; 38 314–8.
| Use of emergency departments by older people from residential care: a population based study.Crossref | GoogleScholarGoogle Scholar | 19286676PubMed |
[9] Finn JC, Flicker L, Mackenzie E, Jacobs IG, Fatovich DM, Drummond S, Harris M, Holman DCDJ, Sprivulis P. Interface between residential aged care facilities and a teaching hospital emergency department in Western Australia. Med J Aust 2006; 184 432–5.
| Interface between residential aged care facilities and a teaching hospital emergency department in Western Australia.Crossref | GoogleScholarGoogle Scholar | 16646741PubMed |
[10] Jones JS, Dwyer PR, White LJ, Firman R. Patient transfer from nursing home to emergency department: outcomes and policy implications. Acad Emerg Med 1997; 4 908–15.
| Patient transfer from nursing home to emergency department: outcomes and policy implications.Crossref | GoogleScholarGoogle Scholar | 9305434PubMed |
[11] Finucane PM, Wundke R, Whitehead C, Williamson L, Baggoley CJ. Profile of people referred to an emergency department from residential care. Aust N Z J Med 1999; 29 494–9.
| Profile of people referred to an emergency department from residential care.Crossref | GoogleScholarGoogle Scholar | 10868526PubMed |
[12] Graverholt B, Riise T, Jamtvedt G, Ranhoff AH, Kruger K, Nortvedt MW. Acute hospital admissions among nursing home residents: a population-based observational study. BMC Health Serv Res 2011; 11 126
| Acute hospital admissions among nursing home residents: a population-based observational study.Crossref | GoogleScholarGoogle Scholar | 21615911PubMed |
[13] Department of Health and Ageing. Palliative care – advance care planning. Canberra: Department of Health; 2017.
[14] NSW Ministry of Health. Advance planning for quality care at end of life: action plan 2013–2018. Sydney: NSW Ministry of Health; 2013.
[15] Office of the Public Advocate. Advance care directive. Melbourne: Office of the Public Advocate; 2018.
[16] Detering KM, Hancock AD, Reade MC, Silvester WJB. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ 2010; 340 c1345
| The impact of advance care planning on end of life care in elderly patients: randomised controlled trial.Crossref | GoogleScholarGoogle Scholar | 20332506PubMed |
[17] Weathers E, O’Caoimh R, Cornally N, Fitzgerald C, Kearns T, Coffey A, Daly E, O’Sullivan R, McGlade C, Molloy DW. Advance care planning: a systematic review of randomised controlled trials conducted with older adults. Maturitas 2016; 91 101–9.
| Advance care planning: a systematic review of randomised controlled trials conducted with older adults.Crossref | GoogleScholarGoogle Scholar | 27451328PubMed |
[18] Auret K, Sinclair C, Averill B, Evans S. Advance care planning and end-of-life care in a network of rural Western Australian hospitals. Aust J Rural Health 2015; 23 195–200.
| Advance care planning and end-of-life care in a network of rural Western Australian hospitals.Crossref | GoogleScholarGoogle Scholar | 26131742PubMed |
[19] White B, Tilse C, Wilson J, Rosenman L, Strub T, Feeney R, Silvester W. Prevalence and predictors of advance directives in Australia. Intern Med J 2014; 44 975–80.
| Prevalence and predictors of advance directives in Australia.Crossref | GoogleScholarGoogle Scholar | 25109226PubMed |
[20] Arendts G, Quine S, Howard K, International G.. Decision to transfer to an emergency department from residential aged care: a systematic review of qualitative research. Geriatr Gerontol Int 2013; 13 825–33.
| Decision to transfer to an emergency department from residential aged care: a systematic review of qualitative research.Crossref | GoogleScholarGoogle Scholar | 23506079PubMed |
[21] Street M, Ottmann G, Johnstone MJ, Considine J, Livingston PM. Advance care planning for older people in Australia presenting to the emergency department from the community or residential aged care facilities. Health Soc Care Community 2015; 23 513–22.
| Advance care planning for older people in Australia presenting to the emergency department from the community or residential aged care facilities.Crossref | GoogleScholarGoogle Scholar | 25443161PubMed |
[22] Friedewald MI, Cleasby PA. Advance care directive documentation: issues for clinicians in New South Wales. Aust Health Rev 2018; 42 89–92.
| Advance care directive documentation: issues for clinicians in New South Wales.Crossref | GoogleScholarGoogle Scholar | 28147212PubMed |
[23] Platts-Mills TF, Richmond NL, LeFebvre EM, Mangipudi SA, Hollowell AG, Travers D, Biese K, Hanson LC, Volandes AE. Availability of advance care planning documentation for older emergency department patients: a cross-sectional study. J Palliat Med 2017; 20 74–8.
| Availability of advance care planning documentation for older emergency department patients: a cross-sectional study.Crossref | GoogleScholarGoogle Scholar | 27622294PubMed |
[24] Magaziner J, German P, Zimmerman SI, Hebel JR, Burton L, Gruber-Baldini AL, May C, Kittner S. The prevalence of dementia in a statewide sample of new nursing home admissions aged 65 and older: diagnosis by expert panel. Gerontologist 2000; 40 663–72.
| The prevalence of dementia in a statewide sample of new nursing home admissions aged 65 and older: diagnosis by expert panel.Crossref | GoogleScholarGoogle Scholar | 11131083PubMed |
[25] Hullick C, Conway J, Higgins I, Hewitt J, Dilworth S, Holliday E, Attia J. Emergency department transfers and hospital admissions from residential aged care facilities: a controlled pre-post design study. BMC Geriatr 2016; 16 102
| Emergency department transfers and hospital admissions from residential aged care facilities: a controlled pre-post design study.Crossref | GoogleScholarGoogle Scholar | 27175921PubMed |
[26] Ling R, Searles A, Hewitt J, Considine R, Turner C, Thomas S, Thomas K, Drinkwater K, Higgins I, Best K, Conway J, Hullick C. Cost analysis of an integrated aged care program for residential aged care facilities. Aust Health Rev 2019; 43 261–7.
| Cost analysis of an integrated aged care program for residential aged care facilities.Crossref | GoogleScholarGoogle Scholar | 29386096PubMed |
[27] Australasian College for Emergency Medicine. Guidelines on the implementation of the Australasian Triage Scale in emergency departments. 2016. Available at: https://acem.org.au/getmedia/51dc74f7-9ff0-42ce-872a-0437f3db640a/G24_04_Guidelines_on_Implementation_of_ATS_Jul-16.aspx [verified 17 August 2020].
[28] Silvester W, Fullam RS, Parslow RA, Lewis VJ, Sjanta R, Jackson L, White V, Gilchrist J. Quality of advance care planning policy and practice in residential aged care facilities in Australia. BMJ Support Palliat Care 2013; 3 349–57.
| Quality of advance care planning policy and practice in residential aged care facilities in Australia.Crossref | GoogleScholarGoogle Scholar | 24644755PubMed |
[29] Bollig G, Gjengedal E, Rosland JH. They know! – Do they? A qualitative study of residents and relatives views on advance care planning, end-of-life care, and decision-making in nursing homes. Palliat Med 2016; 30 456–70.
| They know! – Do they? A qualitative study of residents and relatives views on advance care planning, end-of-life care, and decision-making in nursing homes.Crossref | GoogleScholarGoogle Scholar | 26396227PubMed |
[30] Bezzina AJ. Prevalence of advance care directives in aged care facilities of the Northern Illawarra. Emerg Med Australas 2009; 21 379–85.
| 19840087PubMed |
[31] Shanley C, Whitmore E, Khoo A, Cartwright C, Walker A, Cumming RG. Understanding how advance care planning is approached in the residential aged care setting: a continuum model of practice as an explanatory device. Australas J Ageing 2009; 28 211–15.
| Understanding how advance care planning is approached in the residential aged care setting: a continuum model of practice as an explanatory device.Crossref | GoogleScholarGoogle Scholar | 19951344PubMed |
[32] Rhee JJ, Zwar NA, Kemp LA. Uptake and implementation of advance care planning in Australia: findings of key informant interviews. Aust Health Rev 2012; 36 98–104.
| Uptake and implementation of advance care planning in Australia: findings of key informant interviews.Crossref | GoogleScholarGoogle Scholar | 22513028PubMed |
[33] Cheang F, Finnegan T, Stewart C, Hession A, Clayton JM. Single-centre cross-sectional analysis of advance care planning among elderly inpatients. Intern Med J 2014; 44 967–74.
| Single-centre cross-sectional analysis of advance care planning among elderly inpatients.Crossref | GoogleScholarGoogle Scholar | 25109312PubMed |
[34] Vandervoort A, Houttekier D, Van den Block L, van der Steen JT, Vander Stichele R, Deliens L. Advance care planning and physician orders in nursing home residents with dementia: a nationwide retrospective study among professional caregivers and relatives. J Pain Symptom Manage 2014; 47 245–56.
| Advance care planning and physician orders in nursing home residents with dementia: a nationwide retrospective study among professional caregivers and relatives.Crossref | GoogleScholarGoogle Scholar | 23796587PubMed |
[35] Galambos C, Starr J, Rantz MJ, Petroski GF. Analysis of advance directive documentation to support palliative care activities in nursing homes. Health Soc Work 2016; 41 228–34.
| Analysis of advance directive documentation to support palliative care activities in nursing homes.Crossref | GoogleScholarGoogle Scholar | 29206978PubMed |
[36] Weinick RM, Wilcox SR, Park ER, Griffey RT, Weissman JS. Use of advance directives for nursing home residents in the emergency department. Am J Hosp Palliat Care 2008; 25 179–83.
| Use of advance directives for nursing home residents in the emergency department.Crossref | GoogleScholarGoogle Scholar | 18403576PubMed |
[37] Grudzen CR, Richardson LD, Johnson PN, Hu M, Wang B, Ortiz JM, Kistler EA, Chen A, Morrison RS. Emergency department-initiated palliative care in advanced cancer: a randomized clinical trial. JAMA Oncol 2016; 2 591–8.
| Emergency department-initiated palliative care in advanced cancer: a randomized clinical trial.Crossref | GoogleScholarGoogle Scholar | 26768772PubMed |
[38] Sørensen L, Foldspang A, Gulmann NC, Munk-Jørgensen P. Assessment of dementia in nursing home residents by nurses and assistants: criteria validity and determinants. Int J Geriatr Psychiatry 2001; 16 615–21.
| Assessment of dementia in nursing home residents by nurses and assistants: criteria validity and determinants.Crossref | GoogleScholarGoogle Scholar | 11424171PubMed |
[39] Lovell A, Yates P. Advance care planning in palliative care: a systematic literature review of the contextual factors influencing its uptake 2008–2012. Palliat Med 2014; 28 1026–35.
| Advance care planning in palliative care: a systematic literature review of the contextual factors influencing its uptake 2008–2012.Crossref | GoogleScholarGoogle Scholar | 24821708PubMed |
[40] Leong LJP, Crawford GB. Residential aged care residents and components of end of life care in an Australian hospital. BMC Palliat Care 2018; 17 84
| Residential aged care residents and components of end of life care in an Australian hospital.Crossref | GoogleScholarGoogle Scholar | 29885669PubMed |
[41] Wendler D, Rid A. Systematic review: the effect on surrogates of making treatment decisions for others. Ann Intern Med 2011; 154 336–46.
| Systematic review: the effect on surrogates of making treatment decisions for others.Crossref | GoogleScholarGoogle Scholar | 21357911PubMed |
[42] Carr D, Moorman SM, Boerner K. End-of-life planning in a family context: does relationship quality affect whether (and with whom) older adults plan? J Gerontol B Psychol Sci Soc Sci 2013; 68 586–92.
| End-of-life planning in a family context: does relationship quality affect whether (and with whom) older adults plan?Crossref | GoogleScholarGoogle Scholar | 23689997PubMed |
[43] Garand L, Dew MA, Lingler JH, DeKosky ST. Incidence and predictors of advance care planning among persons with cognitive impairment. Am J Geriatr Psychiatry 2011; 19 712–20.
| Incidence and predictors of advance care planning among persons with cognitive impairment.Crossref | GoogleScholarGoogle Scholar | 21785291PubMed |
