Making your PC a patient educator
Computer reminders get physicians talking
Helping physicians remember to discuss advance directives with elderly patients is probably the most effective method for increasing awareness of end-of-life care planning. But ethicists can't possibly be available around-the-clock in all parts of the facility to remind them.
One solution showing promise is to use computer software. Physicians in an outpatient general medicine practice affiliated with a public hospital got almost half - 45% - of patients to complete an advance directive after seeing a computer- generated reminder at the bottom of the standard patient encounter form. Those results come from a study involving 147 primary care physicians and 1,009 patients ages 50 and older with a serious disease and ages 75 and older.1
Two forms used
The yearlong study compared discussions with and without the use of the reminder on two forms of advance directives: using life-sustaining procedures and assigning a proxy for health care decisions, says Greg Gramelspacher, MD, one of the co-authors. Gramelspacher also serves on the program in medical ethics at Indiana University School of Medicine and is affiliated with Wishard Memorial Hospital in Indianapolis.
"Physicians who did not receive reminders discussed advance directives with 4% of the patients studied, compared with 24% for physicians who received both types of reminders [for assigning a proxy and for life-sustaining procedures]," adds Gramelspacher.
Using computer-generated messages to remind physicians to discuss advance directives seemed like a natural progression for the researchers. "We had previously shown that computer reminders increase physician compliance with practice guidelines,2-4 so with this study, we tested the hypothesis that reminding the primary care physician to discuss advance directives would stimulate further discussion with patients and establish more advance directives," he says.
Discussing end-of-life options in the clinic set ting might lead to the completion of more advance directives, he adds. "Hospitalized patients are often acutely ill, and they lose the ability to make decisions. It might be more appropriate to discuss completing such documents before a patient is hospitalized."
Standardized forms created
Before the study began, the study team created two forms for instruction directives and proxy directives. The forms became the official advance directive documents for the hospital and its outpatient services. The instruction directive allowed patients to indicate whether they wanted life- sustaining treatment in the event of terminal illness or mental incapacity. Eight types of care were identified:
· cardiopulmonary resuscitation;
· mechanical ventilation;
· surgery;
· invasive procedures;
· nutrition and hydration;
· transfusion of blood or blood products;
· antibiotics;
· noninvasive diagnostic tests.
"Physicians had to sign the completed instruction directive to indicate that they were aware of the contents. The proxy directive indicated both a primary and secondary representative," explains Gramelspacher.
Physicians received copies of the forms for their desks, and forms were placed in a central location in the staff room. "Forms and business reply envelopes were provided for patients who wanted to complete the forms at home," he says. Completed forms were entered into the hospital's medical records system, which enabled them to be viewed on all computer terminals in the inpatient and outpatient settings.
"The computer-generated reminder we used appeared at the bottom of the patient encounter form. The form is reviewed by the physician immediately before visiting the patient, which keeps the discussion fresh in the provider's mind," Gramelspacher says.
The reminder was followed by a choice list for the physician to complete:
· discussed today;
· next visit;
· not applicable;
· patient too ill;
· patient refuses to discuss;
· I disagree with advance directives.
"This study helped break an impasse that prevents more advance directives to be completed by patients," he says. "Many physicians believe that it's up to the patient to initiate end-of-life planning decisions, while patients look to their physicians for guidance in these areas. Our reminders helped motivate physicians to take the first step."
References
1. Dexter P, Wolinsky F, Gramelspacher G, et al. Effectiveness of computer-generated reminders for increasing discussions about advance directives and completion of advance directive forms. Ann Intern Med 1998; 128: 102-110.
2. McDonald C, Hui S, Smith D, et al. Reminders to physicians from an introspective computer medical record. Ann Intern Med 1984; 100:130-138.
3. Tierney W, Hui S, McDonald C. Delayed feedback of physician performance vs. immediate reminders to perform preventive care. Med Care 1986; 24:659-666.
4. Tierney W, Miller M, Hui S, et al. Practice randomization and clinical research. Med Care 1991; 29:JS57-64.
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