Dataset Information

An advance care planning long-term care initiative in response to COVID-19.

ABSTRACT:

Objective

Describe a systematic approach to address advance care planning (ACP) during a COVID-19 outbreak and its impact on the incidence of new do-not-hospitalize (DNH) directives among long-term care (LTC) residents.

Design

Prospective quality improvement initiative.

Setting

Two long-term chronic care campuses within a large academic healthcare organization.

Participants

LTC residents with activated healthcare proxies who lacked DNH directives based on documentation in the electronic medical record (EMR) as of April 13, 2020.

Intervention

Using a structured discussion guide, trained healthcare staff from various disciplines contacted the residents' proxies to conduct COVID-19 focused ACP discussions. Residents without DNH directives with COVID-19 were prioritized. Preferences ascertained in the discussion were communicated to the residents' primary care teams and directives were updated in the EMR accordingly.

Measurements

Residents who acquired a new DNH directive during the study initiative were determined using the EMR. Subsequent changes in DNH orders, hospitalizations, and deaths were ascertained by retrospective chart review from the date of new DNH through August 5, 2020.

Results

At baseline, 315/581 (54%) of LTC residents did not have a DNH directive. Their mean age was 87 (±9) years and 70% were female. Following ACP discussions, 124/315 (39%) of residents acquired a new DNH directive. Among residents with new DNH directives, 65/124 (52%) were diagnosed with COVID-19 from April 2, 2020 to May 21, 2020. During follow-up, only 6/124 (4.8%) residents had their DNH order reversed, 2/124 (1.6%) residents were hospitalized with illnesses unrelated to COVID-19, and 29/124 (23%) died.

Conclusions

There was substantial opportunity to increase the proportion of LTC residents with DNH orders during the COVID-19 pandemic through a systematic ACP initiative which utilized real-time EMR data. New directives to avoid hospitalizations were sustained among the majority of residents beyond the peak of the pandemic.

SUBMITTER: Berning MJ

PROVIDER: S-EPMC8013602 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundIn the Netherlands, it is customary to discuss directives regarding resuscitation, intubation, and ICU-admission with patients and/or their relatives upon hospital-admission. The outcome of this discussion is documented in a code status. Ideally, these advance care planning (ACP)-related decisions are made by a patient (and/or their relatives) and a professional together in a shared decision-making (SDM) process, to improve patient satisfaction and prevent undesired care. Given the bad outcomes in older COVID-19 patients, it is particularly important to discuss the code status upon admission. This study aims to describe the practice of SDM regarding code status during the COVID-pandemic. Specific aims were to find out to what extend patients took part in this decision-making process and whether all key elements of SDM for a shared decision were documented in medical reports.MethodsIn this retrospective cohort study, we included COVID-19 patients aged 70 years and older, admitted to two large teaching hospitals in the Netherlands, during the first months of the COVID-19 pandemic in 2020. Data about code status and the decision-making process were extracted from electronic healthcare records.ResultsCode status was documented for 274 of 275 included patients. Patient participation in the decision-making process was described in 48%. In 19% all key elements of shared decision-making have been described. Key elements of SDM were defined as the presence of a completed code status form, the presence of clinical notes showing that both patient's wishes and values and the opinion of the healthcare professional about the predicted outcome was taken into consideration and clinical notes of a patient-healthcare professional interaction during the admission.ConclusionOur results show that a proper SDM process regarding code status is possible, even in hectic times like the COVID-19-pandemic. However, shared decision-making was not common practice in older patients with COVID-19 regarding code status (an ACP-related decision) in the early phase of the COVID-19 pandemic. Only in 19% of the patients, all key elements of SDM regarding code status were described.