A WIN-WIN SOLUTION FOR
AN AILING HEALTHCARE SYSTEM
Evidence for the Benefits
of Advance Care Planning
By Steve Wardle, MBA
Edited by Elizabeth Truong, MD
OVERVIEW
1
The IHI Triple Aim
2
ADVANCE CARE PLANNING
3
Current State of ACP
5
Patient-Physician Communication Breakdown
7
REVIEWING THE EVIDENCE
9
Goal 1 – Reducing the per capita cost of healthcare
10
Goal 2 – Improving the patient experience of care
14
Goal 3 – Improving the health of populations
19
CONCLUSION
24
REFERENCES
28
OVERVIEW
The healthcare delivery system in the US has major
challenges with respect to value. Currently, there is a
U S H E A LT H C A R E
SPENDING
poor balance between the total cost of the
healthcare system and the benefits received by the
population. The US healthcare system consumes
¹
nearly 18% of the country’s GDP , and is projected to
²
increase to 20% of the GDP by 2020 .
Despite this high spending, the outcomes are mixed.
The World Health Organization’s last global
healthcare system ranking placed the US Healthcare
The Highest Per Capita
³
in the World by Nearly
50%
2.5X
The OECD Average
Spend Per Capita
System 37th in the world, behind Costa Rica4, while
the Commonwealth Fund recently ranked US
healthcare system performance last among the 11
richest OECD countries5.
OVERALL RANKING (2013)
Health Expenditures / Capita, 2011**
Overview
1
THE IHI TRIPLE AIM
Partially in response to this, the Institute for Health Improvement (IHI)
established the “Triple Aim” framework for optimizing healthcare system
performance.
When it was developed in 2007, the triple aim appeared radical and possibly
an unrealistic framework, as it called for improvements to patient expereince
and the health of populations simultaneous with a reduction in the per capita
cost of healthcare.
Today, it is mainstream, guiding provider strategic initiatives and legislative
reform agendas. A Google search for “triple aim health” returns nearly 18
million results. While the shift in mind set is positive, triple aim success stories
have been slower to emerge. One of the few healthcare initiatives available
today that can achieve the triple aim is advance care planning.
Reduce the Per Capita
Cost of Healthcare
Improve the Patient
Experience of Care
Improving the Health
of Populations
Overview
2
ADVANCE CARE PLANNING
Advance Care Planning (ACP) is a series of discussions between health
professionals and patients that provide education on disease, explores patient
goals, and ultimately documents preferences for future care in living wills or
advance directives. The discussions elicit values, spirituality, culture, and other
influencers of care as a part of the decision tree.
The process ideally includes loved ones/caregivers that may be surrogate
decision-makers in the future if the patient were to lose decision-making capacity,
these surrogates can be the legally recognized medical Power of Attorney
(MPOA). ACP has been precticed and studied for some decades, and strong
evidence exists of the benefits to the patient, their loved ones, the healthcare
delivery system, and payers.
ACP has been practiced and studied for some decades, and
strong evidence exists of the benefits to the patient, their
loved ones, the healthcare delivery system, and payers.
Advance Care Planning
3
Advanced Care Planning supports all three arms of the
IHI Triple Aim Goal.
REDUCE THE PER CAPITA COST OF HEALTHCARE
•
Reduces spending in the last years to weeks of life.
•
Reduces hospital time and ICU days.
•
Reduces post-acute care utilization.
IMPROVE THE PATIENT EXPERIENCE OF CARE
•
Improves satisfaction scores at end of life (EOL) for both
patients and caregivers.
•
Lowers frequency and degree of conflict between all involved
parties.
•
Fosters empowerment so patients receive care that is aligned
with the their wishes.
IMPROVE THE HEALTH OF POPULATIONS
•
Reduces deaths in hospitals and increases hospice utilization.
•
Improves quality of life and extends length of life.
•
Reduces distressing symptoms of deppression and pain for
patients and caregiver.
Advance Care Planning
4
CURRENT STATE OF ACP
Despite the benefits, ACP has yet to emerge in the
mainstream or be widely available.
6
A 2015 Poll by Kaiser Health Found
. . . However
9 out of 10 Adults Feel Doctors Should
Only 2 out of 10 Adults
Discuss End-of-Life Care With Patients
Reported Being Able To
An observational study7 of physicians practicing at two prominent academic
hospitals found a surprising lack of both incidence and quality of communication
between physicians and seriously ill patients. Reaffirming the September 2015
Kaiser Health Tracking Poll, 66% of serious ill patients had no end-of-life care
discussions. When discussions did occur, the discussions were abstract, medical
jargon was used, patient’s life goals were not discussed, and no recommendations
or evidence-based predictions of outcome were offered.
Advance Care Planning
5
CURRENT STATE OF ACP
1
Minute Average
Time Spent
on Code Status
1out of 80
Encounters Involved a
Physician-led Discussion
on Prognosis with
Code Status
In a study8 of elderly patients at high risk of dying in the next 6 months
being treated at 12 different acute care hospitals, communication with
healthcare providers was inadequate. Only 30.3% of elderly patients, with
a mean age of 80 years old, reported having an advance care plan
discussion with their physician.
Only 30% of medical
records of elderly
patients had
documentation of care
preferences in chart.
Advance Care Planning
6
PATIENT-PHYSICIAN COMMUNICATION BREAKDOWN
ACP currently has low adoption rates in the US, despite the strong evidence
of benefits to and demand from patients. A variety of reasons exist as to why
ACP is not more widely adopted by physicians. The breakdown in patientphysician communication has been explored by a number of researchers, and
two recent reports from IOM9 and California Healthcare Foundation (CHCF)10
had very similar findings on this. They are summarized below and discussed in
more detail on the following page.
LACK OF TIME
LACK OF TRAINING
DESIRE TO MAINTAIN HOPE
DIFFICULTY IN REMAINING OBJECTIVE
UNSUPPORTIVE SYSTEM
Advance Care Planning
7
The main drivers of patient-physician communication breakdowns around ACP
from the IOM and CHCF reports are discussed below:
LACK OF TIME
The IOM report cited insufficient time as the most significant
contributing factor, with two thirds of physicians citing this as a
serious barrier. Since ACP takes hours to deliver, lack of time is likely
to remain an issue for the physician-driven model in addition to the
lack of reimbursement to physicians for ACP.
LACK OF TRAINING
The CHCF study found that 71% of physicians had no formal training
in discussing end-of-life wishes with patients or families. Having
uncomfortable discussions on future care requires specialized training
and practice with facilitation and communication techniques.
DESIRE TO MAINTAIN HOPE
Nearly half of the doctors in the CHCF study felt that their primary role
with the patient is to treat. They have significant concerns that having
ACP discussions will signal to the patient that they are “giving up”.
The IOM report supported the same findings.
DIFFICULTY IN REMAINING OBJECTIVE
In a study of 343 doctors providing estimates on 468 terminally ill
patients, 63% overestimated survival time, and the average
overestimation was 530% too high. Only about 33% of estimates were
considered accurate. The stronger the relationship was between the
patient and physician, and the higher likelihood that the prognosis
would be overestimated.
UNSUPPORTIVE SYSTEM
According to CHCF, 71% of physicians reported not having a formal
system for analyzing goals of care and end-of-life wishes, and 24%
reported having no location within their EHR to insert ACP documents
for future reference.
Advance Care Planning
8
REVIEW OF EVIDENCE - ACP AS A TRIPLE AIM SOLUTION
For the adoption of ACP to increase, whether through a physician-led model
or alternative models, the benefits must be clear and aligned with the overall
strategic direction of industry players and the trends in healthcare reform. It is
only by aligning incentives for patients, providers and payers alike that true
change can occur. The IHI triple aim framework provides the underpinning for
much of the market and regulatory reform efforts in healthcare today,
including how how payers, providers and even patients are incentivized.
Therefore, ACP needs to be seen as a triple aim solution if it is to move from
being the exception to the rule in how healthcare is delivered in the US. We
now turn to reviewing the evidence of reduced cost, improved patient
expereince and improved popualtion health being acheived through ACP.
There is Strong Evidence that Advance Care Planning is
a Powerful Triple Aim Solution
Reduce the Per Capita
Cost of Healthcare
Improve the Patient
Experience of Care
9
Improving the Health
of Populations
Review of Evidence
9
Triple Aim Goal 1
Reducing the Per Capita Cost of Healthcare
Review of Evidence
10
REDUCING THE PER CAPITA COST OF HEALTHCARE
Various studies have found evidence of significantly reduced spending in the
final weeks and years of life. The reduction is over 35% in the final week of life
and the final two years of life. Roughly half of medical claims in the US are paid
by the Center for Medicare and Medicaid Services (CMS), and approximately
25% of CMS costs are for treatments in the last year of life.
This spending has
12 13
never been shown to improve outcomes.
A cost reduction by over 35% for this segment of the population, which
accounts for such an inordinate share of total spending, would have a dramatic
impact on achieving the triple aim goal of reducing per capita cost.
ACP reduces spending in the last week to two years of life.
STUDY A14
A health care system in La Cross, WI, named Gundersen Health made ACP
mandatory for patients over 55 years old and has promoted ACP in the
surrounding community for over two decades. As a result, ACP adoption is far
higher than anywhere else in the US, with 96% of patients with severe and
terminal illness having an Advance Directive compared to the national average
15
of 24%.
Medicare Spending
Region
Last 2 Years of Life
National Average
$70,685
La Crosse, WI
$45,611
Review of Evidence
11
STUDY A (continued)
Thus, La Crosse is widely studied as a test market for the impact of ACP. The
Dartmouth Atlas of Healthcare divided the nation into Hospital Referral Regions
(HRR). In 2012, the La Crosse HRR spends 35.5% or $25,075 less per patient
($45,611 vs. $70,686) when compared to Medicare’s national average spending
in the last two years of life. La Crosse effectively has the the lowest Medicare
spending in the country (second only to sparsely-popualted Minot, ND).
$25,075 or 35.5% Reduction
in Medicare Costs Per Patient
in the Last 2 Years of Life
Some of the drivers of this decrease is spending found by the study include
signficant reductions in hospital usage and ICU utilization. Inpatient hospital
days in the last two years of life was 6.7 days lower than the national average.
1
Week Less Inpatient
Time Per Patient
During Last 2 Years
of Life
Further, the percentage of decedents that spent seven or more days in the
ICU during the last six months of life in La Crosse was 2.7% compared the
18
national average of 15.2%.
Review of Evidence
12
STUDY B16
Advanced cancer patients who had end-of-life discussions with their physician had
a mean reduction of 37.5% or $1,041, in 2008 US dollars, in health care costs in the
last week of life compared with those who did not have EoL discussions.
Interestingly, a direct inverse relationship existed between costs and quality of
death, with higher costs driving down the quality of death.
37.5% Reduction in
Healthcare Costs Per Patient
in the Last Week of life.
STUDY C17
A study published in 2016 of American adults with an advanced cancer
diagnosis showed that a palliative care consultation and advance care
planning within two days of hospital admission reduced patient cost by 22%
(approximately $2,321) for patients with lower comorbidity scores and 32%
(approximately $3,515) for patients with highest comorbidity scores. Earlier
consultation and severity of comorbidities correlated with larger cost savings.
22% Reduction
Total Direct
With Palliative Care
33% Reduction
Without Palliative Care
Healthcare
Costs
Patients with
comorbidity
score of 2-3
Review of Evidence
Patients with
comorbidity score of
4 or more
13
Triple Aim Goal 2
Improving the Patient Experience of Care
Review of Evidence
14
IMPROVING THE PATIENT EXPERIENCE OF CARE
There is strong evidence that ACP improves the experience of care for both
the patient and their family members or caregivers. Relevant research cites:
improved satisfaction scores for both patients and caregivers, lower rates of
decisional conflict at EOL for patients and surrogates, care that is more
aligned with the patient’s wishes, reduced hospital time, fewer deaths in
hospitals, and more utilization of and longer time spent in hospice.
ACP improves satisfaction scores for both patients
and caregivers.
STUDY A19
In a study of inpatient cancer or end-stage medical illness patients and their
family members, only 18% of patients and 31% of family members recalled a
prognosis conversation with their physician. Patients who had a prognosis
discussion had higher satisfaction with overall care and were also more
satisfied with communication and decision-making aspects of care. They were
also more willing to discuss CPR than those who did not have a prognosis
discussion, which is an integral aspect of ACP. Patients who were in
accordance with family members on whether they were nearing EOL also had
increased satisfaction in all 3 areas. Family satisfaction with overall care was
also higher if they participated in EOL discussions.
Review of Evidence
15
STUDY A (continued)
Only
18% & 31%
of Patients
of Family Members
Had Discussions About
Prognosis With A Physician
ACP Lowers rates of conflict at end of life for patients
and surrogates.
STUDY B20
A study published in the Annals of the American Thoracic Society found that 48%
of surrogate decision makers of patients with acute respiratory distress syndrome
experienced moderate or high levels of decisional conflict. Surrogates who
engaged in ACP conversations had significantly less decisional conflict than those
who did not with a mean score 3.3 points lower on the Decisional Conflict Scale.
48% of Surrogate Decision Makers
Experienced Moderate or High Levels
of Decisional Conflict
Review of Evidence
16
STUDY C21
A study published in the Journal of the American Geriatrics Society investigated
the effect of providing education regarding the risks, benefits and life sustaining
treatment alternatives for hypothetical medical decisions for 78 residents of
community-based living facilities. The study found that education (a core part of
the ACP process) resulted in reduced levels of decisional conflict for adults.
ACP fosters empowerment so patients receive care that is
aligned with their wishes.
STUDY D22
A study published in the New England Journal of Medicine found that 70.3% of
adults over 60 years old with advanced illness did not have decision-making
capacity and needed a surrogate decision maker. Among the subjects in the study
who had advance directives, the vast majority stated a preference for limited or
comfort care. The study also found that 83.2% of those who requested Limited
Care (some limits to care in certain situations) and 97.1% of those who requested
Comfort Care (living pain free while forgoing extensive measure to prolong life)
received actual care consistent with their preferences.
Subjects with advance directives, a key component of ACP, were less likely to
receive highly aggressive care than those without, which shows that the default
care delivered without documented patient preferences is aggressive care, or All
Care Possible, in order to prolong life under any circumstances. Subjects with a
durable power of attorney also had a lower chance of receiving highly aggressive
care and a lower chance of dying in a hospital.
Review of Evidence
17
STUDY D
3746
Decedents
1536
Required Decision Making
999
Had Decision Made
by Surrogate
67
Had Living Will Only
2128
Did Not Required
Decision Making
410
Made Own Decision
82
Had Unknown
Decision Making Status
127
Had Unknown
Decision Making Status
378
Had Living Will and Had
Appointed Durable Power of
Attorney for Healthcare Only
215
Had Appointed Durable
Power of Attorney for
Health Care Only
1
Had Unknown
Advance-Directive
Status
338
Did Not Have Living Will
and Had Appointed Durable
Power of Attorney for Healthcare Only
With Advance Care Plan in Place…
82% of People Received Their
Preference of Limited Care
Review of Evidence
97.1% of People Received Their
Preference of Comfort Care
18
Triple Aim Goal 3
Improving the Health of Populations
Review of Evidence
19
IMPROVING THE HEALTH OF POPULATIONS
There is strong evidence that ACP improves the health of populations from
the standpoint of improving quality of life (QoL) and longevity for patients,
and improved mental and physical health for caregivers.
ACP reduces deaths in hospitals and increases
hospice enrollment.
STUDY A23
92%
Of Patients
w/ ACP
Prefered
Comfort
Care
Bischoff et al. studied end-of-life care for 4,394 decedents with a
mean age 82.6 years old. Of the total, 66% engaged in ACP and
were categorized into three groups by preference for EOL care:
All Care Possible, Some Limits, and Comfort Care. 92% of all
patients preferred Comfort Care. ACP improved quality of care at
EOL by reducing in-hospital deaths, increasing hospice
enrollment, reducing hospice admittance within 3 or fewer days
of death when benefits are significantly reduced. There was also
evidence of reduced emergency room and ICU utilization.
Reduction in
Hospital Deaths
Increase in
Hospice Utilization
Review of Evidence
Advance
Care
Planning
Reduction of
Hospice Admittance
20
ACP improves quality of life and extends length of life.
STUDY B24
A study published in the New England Journal of Medicine determined that
of 151 metastatic non-small-cell lung cancer patients, those who received
palliative care, of which ACP is a core component, had significantly higher
quality of life (QoL) and fewer symptoms of depression (16% vs. 38%).
Patients With Mood Symptoms (%)
Standard Care
Early Palliative Care
50
40
30
20
13
0
HADS-D
HADS-A
PHQ-9
Quality of Life Indicators
Palliative care patients also had 25% longer median survival times (11.6
months vs. 8.9 months) despite fewer patients receiving aggressive care
(33% vs. 54%).
25%
Review of Evidence
Longer Life for
Patients w/ ACP
21
STUDY C25
Garrido and Prigerson found that more than 50% of caregivers reported
distress (i.e. regret, anxiety, and depression) about the patient’s EOL care 6
months following the death of a loved one. In the 245 bereaved family
members, the study found that the three best predictors of lower caregiver
distress were better patient quality of death scores, reduced caregiver distress
before the death of the patient, and documentation of the patients’ wishes
(more specifically the completion of a do-not-resuscitate order).
Better Patient
Quality of Life
Better Caregiver
Distress Before Death
Lower
Caregiver
Distress
Documentation
Of Patient’s Wishes
ACP reduces distressing symptoms of depression and
psychological distress for patients and caregivers.
Review of Evidence
22
STUDY D26
Wright et al. found in their 342-cancer-patient study, that patients who die in a
hospital or ICU have worse QoL compared to those who die at home. Further,
the bereaved caregivers of patients who died in the hospital had a
heightened risk for developing posttraumatic stress disorder and prolonged
grief disorder. Interventions aimed at decreasing terminal hospitalization,
such as ACP, may enhance QoL for patients and decrease the risk of
developing psychological disorders for bereaved caregivers.
Bereaved Caregivers of Patients Who Died in the Hospital
had Heightened Risk of PTSD & Prolonged Grief.
Review of Evidence
23
THE ANATOMY OF PROPER ACP
The best healthcare outcomes for patients, families, providers, and payers start with
all the stakeholders being informed and empowered, discussing options, and
assuring that treatment preferences are widely known. Advance Care Planning is a
significant part of the solution to assure those with serious, chronic illnesses achieve
outcomes that fits their goals and honors their preferences. The studies referenced
in this document share a similar structure around the intervention. To move towards
desired results, it’s useful to understand that structure.
INFORM
ACP starts with assuring that people understand their illness. The
healthcare professional (HCP) providing this acts as a facilitator or
guide in throughout the process. The HCP is not there to impose
their opinions on the patient and family but instead elicit baseline
knowledge, educate, and promote a robust dialogue.
Patients gain perspective on their current situation, future options and
complications, and the impact of their condition on how they might feel and
function. Studies continue to demonstrate two significant trends around serious
conditions. One is that people have little understanding of their medical condition.
Few patients and families understand what an illness is currently doing to the body,
which bodily functions or organs are compromised, which ones will become
compromised in the future, and what the natural history of the illness looks like. The
second unfortunate trend is that those same patients have little understanding of
the what the illness does beyond the body – how it might limit their activities and
work or the impact on personal finances. Informed consent springs from
understanding burdens and benefits. This level of understanding is the result of a
dialogue where questions are answered, insights take shape, concerns are
addressed. ACP begins with education. This step concludes with a request to the
patient to spend time reflecting on what they’ve learned.
Conclusion
24
REFLECT AND DISCUSS
The reflection time is when the patient can talk with confidants,
pray, spend time in a pensive state, or employ whichever method
they choose to process information. Once this is accomplished more
sessions are held. These subsequent sessions bring out influencers
of care such as values, goals, spirituality, family dynamics, and financial situation.
They integrate these things with what they understand about their medical
condition. It is here that the patient’s loved ones learn about patient treatment
preferences for future care. Common situations and scenarios are explored that are
relevant to the specific person for their specific situation. This is a highly
personalized process. Family members and other stakeholders in the patient’s life
have an opportunity to express hopes and concerns. Often times different levels of
conflict or disagreement will be revealed. The facilitator’s role is to unravel these
situations and assure the patient’s voice has an advocate while assuring that all
parties feel heard and valued. This is not an easy task. Opinions often differ, feelings
are strong, and the stakes are high. Once care preferences have been expressed
and there is agreement to honor the patient’s choices, the discussions can conclude.
However, it is important to note that this may not be a “one and done” piece of the
process. It is not uncommon for several sessions to be held for these goals to be
realized.
DOCUMENT AND DISSEMINATE
Typically, patient preferences are documented in state-sanctioned
forms such as the Directive to Physician, Medical Power of Attorney,
Out of Hospital Do Not Resuscitate, or the Physician Order for Life
Sustaining Treatment (POLST). In an ideal state additional
documentation is done specific to the particular patient and their
highly unique set of circumstances. The documents are signed, witnessed, and/or
notarized depending on the state statutes. Once the paperwork is finalized then the
documents are distributed to the extend the patient allows. The recipients may
include the patient, the chosen healthcare agent, other loved ones, the primary care
provider, any specialists involved in their care, the hospital system utilized, and, if
applicable, the facility in which they reside. Documents should be accessible
electronically within the electronic medical record or in other technologic
depositories to assure they can be retrieved and reviewed anytime, anywhere.
Conclusion
25
NEXT STEPS
Healthcare is moving swiftly from fee-for-service to value based services. In parallel,
regulatory forces exert a stronger presence and consumer scrutiny is driving
transparency and information sharing. These movements all make it imperative for
payers, hospitals, and providers to assure that patients’ wishes are explored,
understood, documented, and followed. There are four suggested steps that should
be well-defined processes and, where appropriate, automated.
1) Identify – Providers, hospitals, and payers need to understand who needs ACP
and when its most appropriate. The earlier someone engages in ACP the better
the outcomes for all involved.
2) Engage – Patients and family members consistently need more information,
with multiple repetitions, regarding the specific serious medical condition(s)
they are facing. Making decisions consistent with their goals will leave patients
feeling valued and important.
3) Document – While completing advance directive forms and physician orders for
end-of-life care is a good place to start, the documentation needs to be much
more upstream. The record should not state only what a patient wants when
they are actively dying but along the entire trajectory of the illness.
4) Disseminate - The patient and all the stakeholders in their care – family and
friends, primary care and specialty providers, hospitals, and facilities – all need
easy access to the documents so that they are actionable at the point of care.
No healthcare system in the world has a perfect approach to ACP. In fact, most have
little to no operations dedicated to this crucial service. As ACP is one of the few
offerings in healthcare that truly benefits the patients and families, providers,
hospitals, and payers it is past time to see this become more widely championed
and available.
Iris Plans can help you in all, or any, of the steps. We provide ACP for patients and
families facing serious medical conditions anytime, anywhere. Our cost-saving,
convenient process, via videoconferencing and on-line tools, makes a significant
impact on utilization, communication, and satisfaction on the patients that are the
most complex.
Conclusion
26
Iris Plans provides Advance Care Planning via telehealth
to people facing serious medical conditions across the US
We partner with health insurers and healthcare providers
in our mission to make this win-win solution available to all
Contact:
Phil Ovitt
[email protected]
www.irisplans.com
(800) 845-2018
Conclusion
27
REFERENCES
¹
²
³
US Congressional budget office.
Centers for Medicare and Medicaid Services, Office of the Actuary.
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4
World Health Organization. The World Health Report 2000 – Health systems: Improving performance.
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Davis K, et al. Mirror, Mirror on the Wall: How the U.S. Healthcare System Compares Internationally, 2014
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6
DiJulio B, Firth J, and Brodie M. Kaiser Health Tracking Poll: September 2015. Kaiser Family Foundation. Sep
2015.
7
Anderson W, et al. Code status discussions between attending hospitalist physicians and medical patients at
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8
Heyland, DK, et al. Failure to engage hospitalized elderly patients and their families in Advance Care
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9
Dying in America: Improving quality and honoring individual preferences near the end of life. Institute of
Medicine. Washington, DC, 2015.
10
Conversation Stopper: What's Preventing Physicians from Talking with Patients About End-of- Life and
Advance Care Planning? California Health Care Foundation. Apr 2016.
11
Christakis N and Lamont E. Extent and determinants of error in doctors’ prognoses in terminally ill patients:
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12
Riley GF and Lubitz JD. Long-term trends in medicare payments in the last year of life. Health Serv Res.
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13
Hogan C, et al. Medicare beneficiaries’ costs of care in the last year of life. Health Aff. 2001;20(4):188-195.
14
The Dartmouth Atlas of Healthcare. (2012): Online. Internet 10 Jun 2016.
Available: http://www.dartmouthatlas.org.
15
Hames BJ, Rooney BL, and Gudrum JD. A comparative, retrospective, observational study of the
prevalence, availability, and specificity of advance care plans in a county that implemented an advance care
planning microsystem. J Am Geriatr Soc. 2010;58:1249-1255
16
Zhang B, et al. Health care costs in the last week of life: Associations with end of life conversations. Arch
Intern Med. 2009;169(5):480-488. The study examined health care costs of 603 advanced cancer patients in
the last week of life. 188 Patients reported having end-of- life conversations with their physician, and were
compared against a group of 145 control patients.
References
28
REFERENCES (continued)
17 May
P. et al. Palliative care team’s cost-saving effect is larger for cancer patients with higher numbers of
comorbidities. Health Aff. 2016;35:144-153. The study included 906 adult patients with advanced cancer and
comorbidities, excluding dementia or patients that had previously received palliative care. Data was from the
period of 2007 to 2011. Patients were from 6 hospitals—2 tertiary care academic medical centers, 1 specialty
cancer center, and 3 community teaching hospitals. 192 patients received palliative care within 2 days of
admission. For patients with a comorbidity score of 0-1, the estimated reduction in cost was not significant.
However, for patients with a score of 2-3, the estimated reduction in cost was 22% (approximately $2321).
Furthermore, for patients with a score of 4 or higher, the reduction was 32% (approximately $3515).
18
The Dartmouth Atlas of Healthcare. (2012): Online. Internet 10 Jun 2016. Available: http://
www.dartmouthatlas.org.
19
Heyland DK, et al. Discussing prognosis with patients and their families near the end of life: impact on
satisfaction with end-of-life care. Open Med. 2009;3(2):e101-110. A total of 440 inpatients with advanced
cancer or end-stage medical disease and 160 family members participated in the study. The survey included
a 5-domain questionnaire and supplementary questions on satisfaction with specific aspects of EOL and their
overall satisfaction with EOL.
20
Chiarchiaro J, et al. Prior advance care planning is associated with less decisional conflict in surrogates. Ann
of the Am Thorac Soc. 2015;12(10):1528-1533. The study was a secondary data analysis of a multicenter
prospective cohort study completed at five U.S. academic medical centers, which included 471 surrogates of
257 critically ill patients with acute respiratory distress syndrome to examine if prior advance care planning is
associated with less decisional conflict.
21
Allen RS, et al. End-of- life decision-making, decisional conflict, and enhanced information: Race effects. J
Am Geriatr Soc. 2008;56(10)1904–1909.
22
Silveira MJ, Kim SYH, and Langa KM. Advance directives and outcomes of surrogate decision-making
before death. N Engl J Med. 2010; 362:1211-1218. The study looked at the prevalence of the need for a
surrogate decision maker and concordance of treatment plan with Advance Directives for patients having
them. Of the 3,746 subjects studied, 42.5% required decision-making. Of this subset, 70.3% did not have
decision-making capacity and 67.6% of this group had advance directives, the vast majority of which
requested limited or comfort care.
23
Bischoff KE, et al. Advance care planning and the quality of end-of- life care in older adults. J Am Geriatr
Soc. 2013; 61(2)209-214.
24
Temmel JS, et al. Early palliative care for patients with metastatic non-small- cell lung cancer. N Engl J Med.
2010;363(8):733-742. In the study, mood symptoms were measured using the Hospital Anxiety and
Depression Scale (HADS) and the Patient Health Questionnaire 9 (PHQ-9). Health-related quality of life was
measured by the use of the Functional Assessment of Cancer Therapy-Lung (FACT-L) scale and the lungcancer subscale (LCS) was used specifically for lung cancer.
25
Garrido MM and Prigerson HG. The end-of- life experience: modifiable predictors of caregivers’
bereavement adjustment. Cancer. 2014;120(6):918-25.
26
Wright AA, et al. Place of death: correlations with quality of life of patients with cancer and predictors of
bereaved caregiver’s mental health. J Clin Oncol. 28(29):4457-4464.
27
Institute of Medicine 2012.
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