End of Life Care
Interventions to promote the use of advance directives: An overview of systematic reviews

https://doi.org/10.1016/j.pec.2009.09.027Get rights and content

Abstract

Objective

To identify, appraise and synthesise the results of systematic reviews of the literature (SRLs) that examines the effectiveness of interventions to increase advance directive (AD) completion rate.

Methods

Narrative review of the literature—an overview of SRLs focused on interventions to improve patients’ AD completion rate.

Results

Seven SRLs were located. A wide range of interventions was identified in order to determine their influence on the AD completion rate.

Conclusion

The most effective method of increasing the use of ADs is the combination of informative material and repeated conversations over clinical visits. The use of passive informative material in isolation does not significantly increase AD completion rates. However, when interactive informative interventions are employed, the AD completion rate increases and the majority of the studies identify multiple sessions as the most effective method for direct interaction between patients and health care professionals.

Practice implications

The progressive ageing of the population and the provision of quality care during the process of ageing and dying, have given rise to the Governments’ interest in developing moral autonomy and regulating tools as ADs. In order to put legislation into practice it is necessary to set up successful interventions to expand ADs use.

Introduction

Advance directives (ADs) or living wills are written documents used by patients to express their wishes or preferences in relation to medical treatment, and are to be applied in the event that the patient becomes incapable of making his or her own decisions. Such documents also afford the possibility of appointing a proxy (surrogate, substitute or healthcare agent) who will make decisions on behalf of the patient in accordance with the patient's wishes.

ADs were first introduced in the U.S.A. in the late 1960s and were quickly integrated into American legislation [1]. California was the first State to produce legislation in this area in 1976, a process that was gradually repeated in all remaining States. In December 1991 an extremely important federal law, the “Patient Self Determination Act” (PSDA), came into effect. This law obligates all healthcare companies charged with providing and managing services within federal healthcare programs (Medicare and Medicaid) to systematically offer all users the possibility of filling in a living will [2].

As a result of developments in North America, healthcare directives have gradually been introduced in other countries, a process that began in those countries where North American culture has a greater influence: Canada [3], Australia [4] and New Zealand [5]. Japan [6], [7] and Singapore [8] have also been influenced by these developments, but China has encountered greater difficulties with regards to these documents [9]. However, adherence to this trend has proven slower in Europe [10], probably due to the idiosyncratic development of bioethics on this continent [11]. Nevertheless, in recent years, many European countries have started to draw up laws in relation to the use of ADs. Spain is perhaps one of the most advanced European countries in terms of the legal regulation of ADs, given that the 17 Autonomous Regions into which the country is divided boast their own legislation and centralised AD registration system [12].

Despite the fact that we are dealing with a relatively new subject, the amount of research and publications focusing on ADs is already staggering. A simple search in PubMed employing the terms “advance directives”, “living wills” or “advance care planning” currently produces more than 5000 bibliographical references. Many of these references relate to theoretical studies; however, a large number actually refer to empirical studies with a wide range of objectives and different methodologies. Attention should be drawn to the lack of empirical studies that attempt to address the question of whether or not ADs actually produce improvements in the decision-making process and the quality of health care at the end of life. Indeed, many authors have suggested that ADs do not give rise to any improvements; however, their affirmations are not grounded on a solid empirical base [13], [14]. It appears that responding directly to this highly complex topic in an empirical manner proves difficult and responses are conditioned by subjective evaluations to a large degree. In any event, the large number of empirical studies focusing on other aspects of the use of ADs has given rise to the need to synthesise the results of the aforementioned research in a systematic manner. The systematic reviews focusing on this area that have been carried out up to this point in time take in a range of different aspects, such as the possible impact of treatment cost [15], the emotional impact occasioned by completing an AD [16] and the situation with regards to caring for elderly patients [17]. Attention has also been paid to the accuracy of surrogates’ predictions with regards to patient treatment preferences and the efficacy of commonly proposed methods to improve surrogate accuracy [18]. Thus, in general, research has focused on other aspects entailed in the process of filling in an AD, from the outset accepting the hypothesis that such documents are useful tools that produce improvements in health care.

Amongst these aspects, most attention has been focused on the identification of the best educational and informative strategies to increase the use of ADs.

Therefore, the authors of this paper considered the need to carry out a new systematic review of the literature employing Cochrane methodology. During the initial phases of the development of this protocol, various Systematic Reviews of the Literature (SRLs) were located. This demonstrated the need to carry out a search and detailed evaluation of these SRLs with the aim of determining whether or not a new SRL proved necessary. This paper is the result of this process. In view of the limitations identified in the SRLs listed at the end of the paper, we finally decided to perform a new Cochrane SRL that is in the process of being implemented [19].

Therefore, the objective of this narrative review is to identify, appraise and summarizes the results of SRLs that examines the effectiveness of interventions designed to increase the completion rates of ADs. Thus, clinics and those responsible for managing health care will be able to consider these findings when considering the possibility of drawing up protocols, programs or training activities focused on increasing the use of ADs amongst citizens.

Section snippets

Type of study

Narrative review of systematic reviews of the literature.

Design

A narrative review provides a general overview of the research literature within a specific area. The present study consists of a narrative review of SRLs designed to analyse studies employing various types of interventions in order to improve patient AD completion rate.

Inclusion criteria

SRLs wherein at least one of the objectives was to review the effectiveness of interventions to promote the use of ADs.

Search strategy

The search strategy employed to locate SRLs is

Results

A total of 236 references were retrieved via the search strategy. One more study was located by grey literature search. Evaluating the summaries of these references enabled us to exclude the majority, as they failed to address the topic under study or were not SRLs. We located 10 SRLs focusing on ADs. From those 10 SRLs, five addressed questions relating to ADs but did not met the inclusion criteria for the current study [15], [16], [17], [18], [20]. Five papers met the inclusion criteria and

Discussion

Seven SRLs were identified, six of which have been published within the last four years. Despite the methodological differences of each review, in terms of the design of the included studies, study quality, the inclusion or omission of meta-analysis and the nature of the interventions that were evaluated, the authors reached very similar conclusions.

Attention should be drawn to the fact that the current study is not a SRL. In contrast to SRLs, a narrative review does not systematically appraise

Conflict of interest

None declared.

Acknowledgements

We would like to express our gratitude to Miguel Barranco and Ricardo Ocaña for their support regarding epidemiological issues. And Gavin McCune for the language assistance.

Financial source: Cochrane Review: “Interventions for promoting the use of advance directives for end-of-life decisions in adults” (FILE PI06/90113).

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