The VHA mission to serve the health care needs of America's veterans assumes a veteran-centered approach - one that evolves not only from the health team's assessment of needs, but especially one that begins with the veteran's assessment of his or her own needs. Preliminary data from the Alabama Veterans Rural Health Initiative study suggest that approximately 30% of rural Alabama veterans do not have an Advance Directive and want help completing one. Rural Alabama veterans live in counties with a higher percent of African American minorities, lower levels of education, and higher family poverty rates, than the average for the US population at large. Prior studies have demonstrated that disparities in Advance Directive completion rates may be related to race, level of income, and level of education. VHA research priorities include addressing the challenges of minority health care needs and the disparities that arise in healthcare delivery. Although many studies evidence the effectiveness of education and counseling in facilitating Advance Directive completion, data are lacking that demonstrate the efficacy of resource-conservative nursing interventions to enable Advance Directive completion by rural, southern minorities. This pilot lays the groundwork to address this evidence gap.
The objectives of the pilot study were to (1) test the feasibility of recruitment, randomization, and retention; (2) test the feasibility of a standardized Nurse-Supported Advance Care Planning Intervention; (3) evaluate the feasibility of the assessment process and data collection procedures; (4) evaluate the Veterans' satisfaction with the intervention and their Advance Directive decisions; and (5) evaluate preliminary effects of the Nurse-Supported Advance Care Planning Intervention.
A prospective, randomized, controlled pilot study. Fifty Alabama veterans who receive care at the Tuscaloosa VA Medical Center were randomized to either the Nurse-Supported Advance Care Planning Intervention or Care-as-Usual. The Nurse-Supported Advance Care Planning Intervention was a manualized education, support, and guidance session provided by a Registered Nurse that included information about risks, benefits, and alternatives of specific choices. The Care-as-Usual was a session with the social worker who explained what the Advance Directive is, and guided the Veteran regarding the process of completing the Advance Directive document, without providing information about risks, benefits, and alternatives of specific choices. Data related to recruitment, randomization, and retention; study completion by subjects; completeness of data collection; Veterans' satisfaction; and preliminary effects of the intervention were collected, analyzed, and evaluated.
Recruitment, randomization, and retention rates surpassed the predetermined acceptable outcomes (100%, 100%, and 94% respectively). Feasibility of the standardized Nurse-Supported Advance Care Planning Intervention was confirmed with 100% retention through the immediate follow-up assessment. Feasibility of the assessment process and data collection procedures was confirmed by a 99% data completion rate. Veterans' satisfaction with the intervention was confirmed by a mean CSQ-8 score for the Nurse-Supported Advance Care Planning Intervention group that was no less than the level of satisfaction for the Care-as-Usual group. All participants reported satisfaction with their new Advance Directive decisions. There was a significant difference in Advance Directive completion rates between groups (p < .0001) such that those assigned to the Nurse-Supported Advance Care Planning Intervention group were more likely to complete an Advance Directive than those assigned to the Care-as-Usual group (i.e., 94% compared to 29%, respectively). Forty-seven percent of those randomized to the Care-as-Usual group received the social worker session; fifty-three percent did not. Of those who received the social worker session, sixty-three percent completed an Advance Directive. The mean times for the Nurse-Supported Advance Care Planning Intervention session and the Care-as-Usual session were 45 and 29 minutes respectively. The mean costs for the Nurse-Supported Advance Care Planning Intervention session and the Care-as-Usual session were $27.59 and $11.23 respectively.
This study supports the VHA mission to provide Veteran-centered care. It lays the groundwork to address a health care disparity related to Advance Directive completion. The findings confirm the feasibility of the design and the readiness of Nurse-Supported Advance Care Planning Intervention for a full clinical trial. The results suggest the efficacy of the Nurse-Supported Advance Care Planning Intervention in its current form.
External Links for this Project
Grant Number: I01HX000560-01A1
None at this time.