Kirchhoff KT, Hammes BJ, Kehl KA, Briggs LA, Brown RL: Effect of a disease-specific planning intervention on surrogate understanding of patient goals for future medical treatment. J Am Geriatr Soc 2010;58:1233–1240.
Summary and main findings
At the end of life, surrogates make health care decisions for most patients, yet surrogate-patient concordance about treatment preferences is often poor. This randomized controlled trial examined the ability of a structured patient-centered interview to improve surrogates' knowledge of seriously ill patients' end-of-life treatment preferences. Surrogates and patients with heart failure and end-stage renal disease were enrolled from outpatient community and academic clinics and dialysis centers in two cities in Wisconsin, and randomized to receive either usual care or the interview intervention. Usual care patient-surrogate pairs received routine advance care planning per routine practice at the site, including assessing whether the patient had an advance directive and, if they had not, offering to assist in completion. One study site offered a structured interview that did not routinely include the surrogate. The interview intervention was 60–90 minutes, included the patient and surrogate, and was conducted by a trained facilitator. It began with determining patients' understanding of their condition and its likely course, hopes and fears, what gave their life meaning, and how past medical and end-of-life experiences influenced their treatment preferences. The interviewer explained the importance of surrogate understanding of patient preferences, then presented disease-specific scenarios and elicited the patient's preferences for each. The interview concluded by highlighting the importance of the discussion for future decisions that the surrogate might need to make. The study outcome was patient-surrogate concordance about treatment preferences in four scenarios: a low probability of survival, severe functional impairment, severe cognitive impairment, and cardiopulmonary arrest. For each, options were to provide or not provide life-prolonging treatment.
Of the 313 patient-surrogate pairs who completed the study, about half in each arm had heart failure and half renal failure. The mean patient age was 71, most were white, and one third had greater than a high school education. Half of the surrogates were the patient's partner. The kappa score for surrogate-patient concordance in the four scenarios ranged from 0.26–0.28 in the usual care group and 0.61–0.74 in the intervention, indicating closer surrogate understanding of patient preferences in the intervention group for all four scenarios.
Strengths and limitations
Study strengths include use of a high-quality randomized controlled design, and the application of the intervention to patients with advanced illness and their surrogates. A limitation is the low enrollment rate (48%); reasons for patient/surrogate refusal are not stated. Future research should test whether the intervention changes the end-of-life decisions that surrogates make for patients. Generalizability of the results may be limited by the fact that all of the participants were from Wisconsin, and 74% lived in a city with high levels of community advance care planning education. The intervention should be tested in other life-limiting illnesses.
Clinical bottom line
Structured, facilitated patient-surrogate conversations are associated with improved surrogate understanding of patient wishes.
El-Jawahri A, Podgurski LM, Eichler AF, Plotkin SR, Temel JS, Mitchell SL, Chang Y, Barry MJ, Volandes AE: Use of video to facilitate end-of-life discussions with patients with cancer: A randomized controlled trial. J Clin Oncol 2010;28:305–310
Summary and main findings
In advanced cancer patients, receipt of life-sustaining therapies at the end of life (EOL) is associated with poor patient and family outcomes, yet providers struggle with how to effectively explain treatments such as mechanical ventilation and cardiopulmonary resuscitation (CPR). This randomized controlled trial tested the effect of a video presenting EOL care options on EOL treatment preferences in patients with malignant glioma at an academic medical center. Eligible patients could communicate in English and provide informed consent. They were approached in the outpatient setting by their primary oncologist. Enrolled patients were randomized to receive either a verbal narrative alone, or the verbal narrative supplemented by a video depicting the same information. Three care options were presented: 1) Life-prolonging care, which aims to prolong life at any cost and includes all potentially indicated treatments, such as CPR, mechanical ventilation, and ICU care; 2) Basic medical care, which aims to maintain physical and mental function, includes hospitalization, intravenous fluids, and antibiotics, but excludes CPR, mechanical ventilation, and ICU care; and 3) Comfort care, which aims to maximize comfort and alleviate suffering, includes treatments to relieve symptoms, hospitalization only for symptom control, and excludes CPR, mechanical ventilation, and ICU care. The supplemental video was six minutes in length and consisted of a narrator presenting the information from the verbal narrative, along with visual images of each care option. Study outcomes were the patient's preferred care option if their cancer became very advanced, their CPR preference, their knowledge of CPR and the care options, and, for patients randomized to view the video, its perceived usefulness and acceptability.
Of the 50 enrolled patients, most were white, educated, had completed an advance directive, and rated their current health as excellent or good. Compared to patients who received the verbal narrative alone, patients who viewed the video were significantly more likely to prefer comfort care if their cancer became very advanced, 22% versus 91%, p<0.001, and to prefer not to receive CPR, 59% versus 91%, p=0.02. Patients who viewed the video had higher knowledge of CPR and the care options, were comfortable watching the video, and would recommend it to others.
Strengths and limitations
Study strengths include high enrollment rate (78%), and the realistic portrayal of EOL care options without obvious bias toward one or the other. The study included patients who were willing to discuss these topics, as evidenced by their high rate of advance directive completion. As the authors note, the repetition of the information in patients who viewed the video may have contributed to the higher knowledge of CPR and the care options, but is unlikely to explain the difference in preferences between the two groups. Generalizability is limited by the small sample size of white, well-educated glioma patients from a single academic medical center, though the authors report similar results in a community dwelling sample of elder adults.3
It is important to note that these videos are not meant to replace but to supplement provider-patient discussions.
Clinical bottom line
Viewing a video depicting EOL care options increased patients' preference for comfort care, and decreased their desire to receive CPR and other life-prolonging therapies.