The majority of people visiting preoperative testing clinics before an elective surgery do not have an advance directive (AD) in case of surgical complications. This can lead to situations where patients' families are forced to make tough decisions about their loved one's care.
A study from researchers at the Regenstrief Institute, Indiana University Health and Indiana University School of Medicine found that only 30% of the patients in the study reported having some form of AD documenting their wishes regarding emergency medical care. However, only 16% had one on file in their electronic medical record (EMR) where a clinician could access it at the time of surgery. When there is no record of care preferences, families must decide what kind of emergency care their loved one receives.
An advance directive is a legal document stating the patient's wishes for care if he or she is incapacitated. These preferences can include whether or not the person wants to receive CPR or intubation or who is in charge of making care decisions on their behalf. If there is no AD, doctors turn to a priority list of people, reaching out to them, in order of priority, to make the decision.
The lead author of the study, Shilpee Sinha, M.D., is the service line lead for the Adult Academic Health Center for Palliative Care at IU Health in Indianapolis. She sees patients every day who are at an increased risk of surgical complications. "When a crisis does occur," Dr. Sinha said, "family members tend to project their own emotions into what they think is best for the patient, but their choices may not be what the patient actually wants."
Dr. Sinha and her colleagues looked at EMRs of 400 patients who underwent preoperative evaluation. They found only 16% of those people had some form of AD on file.
Dr. Sinha performed this research as part of The Advanced Scholars Program for Internists in Research and Education (ASPIRE). ASPIRE is a one-year program through the Division of General Internal Medicine and Geriatrics at IU School of Medicine and the Regenstrief Institute that provides physicians in clinical practice with a chance to hone their skills in research.
One of my goals for doing this study is to drive clinical change. The discussion of advance care planning is not part of the established routine. I think we've achieved buy-in on the idea of having these conversations. Now we need actual logistical application."
Shilpee Sinha, M.D, Service Line Lead, Adult Academic Health Center for Palliative Care, IU Health
Regenstrief researcher Alexia Torke, M.D., M.S., was Dr. Sinha's mentor through the ASPIRE program, and senior author of this paper. She has conducted extensive research in surrogate decision making.
"When an AD is not available in cases of emergency, it creates a complex situation for the care providers and surrogate decision makers. Emotions are often high, and family members may have difficulty navigating those emotions to make the best decision for their loved ones," said Dr. Torke. "Work like Dr. Sinha's is very important. These findings suggest there is a significant opportunity for improvement in advanced care planning in the clinical setting."
"Advance Care Planning in A Preoperative Clinic: A Retrospective Chart Review" was published in the Journal of General Internal Medicine. The study was funded through the ASPIRE program. Dr. Torke was supported by a Midcareer Investigator Award in Patient-Oriented Research (K24 AG053794) from the National Institute on Aging.
Sinha, S. et al. (2019) Advance Care Planning in A Preoperative Clinic: A Retrospective Chart Review. Journal of General Internal Medicine. doi.org/10.1007/s11606-018-4744-8