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Author List:
Pasquale D (Stratton VAMC)
Engelhardt JB (Stratton VAMC)
Tobin D (Upstate NY VA Health care System)
Toseland RW (University at Albany)
Sacco J (Stratton VAMC)
Barelski L (Stratton VAMC)
Objectives:
Evaluate the impact of an end of life program delivered by a care coordinator and supported by an interdisciplinary team on, (1) improving quality of life (QOL) outcomes and care delivery for CHF patients, with ejection fractions of <=35 percent, or assessed as level III or IV on the NYS Heart Association Classification System, (2) addressing fears about dying, (3) increasing formulation and documentation of Advance Directives (ADs), and 4) evaluating provider consistency with patient preferences in ADs. Also, describe trends that may occur in measures of disease-specific QOL, survival, and health care use and cost.
Methods:
The study employed a randomized control group design. The program was compared with usual care (UC) on QOL measures (McGill QOL Scale, revised spirituality and Fear of Death scales), frequency of formulation and documentation of ADs, provider consistency with ADs
Results:
There were no significant differences between study arms in, (1) consistency of medical care with patient preferences, (2) QOL outcomes, or (3) survival. Improvement was reported for important CHF symptoms (e.g. fatigue) for participants in both study arms. Significant differences favoring treatment in AD development were found (74 percent vs. 36 percent).
Implications:
Unlike some previously reported studies, consistency of medical care delivery with patient preferences was extremely high (> 95 percent). Chart reviews indicated providers acknowledged ADs and patients were engaged in decision-making concerning acceptance of medical procedures. Twice as many treatment arm participants documented ADs. VA health costs for all participants and also for decedents will be presented. The improvement in CHF symptoms (e.g. dyspnea) focused participants on health improvement and survival concerns rather than the life closure issues that were assessed by the QOL measures and may suggest why no differences between groups in QOL measures were found.
Impacts:
Patients participated in advanced planning when offered the opportunity. Advance planning was well received and it greatly improved AD documentation rates, suggesting that patients can tolerate planning for undesired health outcomes. VA providers acknowledged patient care preferences and involved patients in planning for medical procedures. Active planning for end of life care as expressed by AD formulation did not impact survival.
