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 In addition to ensuring patients receive care that's in line with
their wishes, the study’s senior author said advanced directives
reduce the burden on family members who would otherwise make those
decisions.
“It’s really hard on loved ones to make those decisions if there has
been no planning,” said Dr. Paul Mueller, chair of general internal
medicine at the Mayo Clinic in Rochester, Minnesota.
Family members are often relieved when patients have already filled
out an advanced directive, he said. “The patient has already
articulated what he or she wants.”
There has been increasing attention in recent years toward
encouraging people to make their end-of-life preferences known,
including an annual National Health Care Decisions Day (see Reuters
Health story of April 16, 2014 here: http://reut.rs/1pW54PR) for
seven years running.
But researchers have found the message is only getting across
consistently to patients with certain diseases or under certain
circumstances, and even then the rules and paperwork are not always
clear (see Reuters Health story of July 29, 2014 here:
http://reut.rs/1obHvpu).
For the new study, Mueller and his colleagues focused on patients
with a severe condition known as aortic stenosis that occurs when
the main artery to the heart does not open all the way. The problem
causes poor circulation and can lead to death.
The condition can be treated by opening the patient’s chest and
replacing the artery, or with a less invasive procedure known as
transcatheter aortic valve replacement (TAVR), which is often
reserved for people not strong enough to have the full surgery.
In both cases, Mueller and his colleagues write in a research letter
published in JAMA Internal Medicine that patients are at risk for
death and other complications related to the surgery, such as stroke
and heart rhythm problems.
Recent studies suggest about a third of people who undergo either
procedure will die during the two years after surgery. The high
death rate suggests many people will face difficult decisions
following the procedures, Mueller said.
“We wanted to understand what kind of advanced planning people with
severe disease have,” he said.
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The study team looked at data from 251 patients who had TAVR
performed at the Mayo Clinic between January 2008 and December 2012.
About 47 percent had advanced directives. Only about a third of
those advanced directives addressed life-sustaining treatment, such
as whether the patient wanted to be resuscitated or to be fed
through a tube.
“Fortunately, most patients who had (advanced directives) listed
surrogate decision makers in their (advanced directives),” the
researchers wrote.
In the study group, most people with a designated surrogate to make
healthcare decisions chose a child or spouse and 23 percent chose
friends or other family members.
Unlike other studies, Mueller said, they did not find differences in
who did and did not have advanced directives based on other health
problems, such as heart attacks, high blood pressure and stroke.
He said it could be that they did not have enough people included in
this study to pick up on those differences.
“For physicians, we need to do a better job of talking to patients
with this type of illness (about advanced directives),” Mueller
said.
Each state differs in how they require advanced directives to be
filed, but Mueller said barriers – such as the complexity of the
documents – should be eliminated as much as possible.
SOURCE: http://bit.ly/1pW3bCJ
JAMA Internal Medicine, online August 4, 2014.
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