Advance medical directives (AMD) are statements made by individuals indicating the life-sustaining treatment that they would refuse in the future when they lost their mental capacity for medical decisions. While the proposal for the AMD legislation is ongoing locally in Hong Kong SAR, there are limited reviews on the clinical outcomes associated with it.
Objective
To provide a comprehensive review on clinical outcomes of signed AMD.
Methodology
Retrospective, multi-center study, which includes AMD signed within five cluster hospitals. Records of signed AMD from 1st JAN 2020 to 31st DEC 2022 were retrieved from a central registry. Clinical information of each patient was obtained from the electronic patient record.
Result
456 patients with documented AMD were included in the study. 91.6% of AMD were signed by palliative care (PC) team. Majority (74.6%) of the patients were accompanied by family members or friends when AMD were signed. The concordance rate between the AMD and the medical care received was 89.5%. No patient revoked their AMD. Cancer and non-cancer patients showed similar rates of AMD concordance, frequency of Accident & Emergency Department (AED) visits or acute ward admissions, duration of hospital stays in the 30 days before death, and prevalence of receiving invasive or intensive treatments.
Conclusion
Our study demonstrated that PC team currently plays a pivotal role in AMD completion, and AMD remains important in ensuring patients’ care preferences are executed across different medical conditions. With the upcoming AMD legislation in Hong Kong SAR, adequate promotion and education should be launched.
SilveiraMJKimSYLangaKM. Advance directives and outcomes of surrogate decision making before death. N Engl J Med. 2010;362(13):1211-1218. doi:10.1056/NEJMsa0907901.
3.
TenoJMGruneirASchwartzZNandaAWetleT. Association between advance directives and quality of end-of-life care: a national study. J Am Geriatr Soc. 2007;55(2):189-194. doi:10.1111/j.1532-5415.2007.01045.x.
4.
TyackeMHGuttormsonJLGarnier-VillarrealMSchroeterKPeltierW. Advance directives and intensity of care delivered to hospitalized older adults at the end-of-life. Heart Lung. 2020;49(2):123-131. doi:10.1016/j.hrtlng.2019.08.018.
5.
Dalmau-BuenoASaura-LazaroABusquetsJMBullich-MarínIGarcía-AltésA. Advance directives and real-world end-of-life clinical practice: a case-control study. BMJ Support Palliat Care. 2021;12:e337-e344. doi:10.1136/bmjspcare-2020-002851.
6.
HickmanRLJPintoMD. Advance directives lessen the decisional burden of surrogate decision-making for the chronically critically ill. J Clin Nurs. 2014;23(5-6):756-765. doi:10.1111/jocn.12427.
TseCY. Advantages of legislation for advance directives in Hong Kong and areas of concern for clinicians. Hong Kong Med J. 2021;27(4):309-311. doi:10.12809/hkmj208985.
10.
EscherMPerrierARudazSDayerPPernegerTV. Doctors' decisions when faced with contradictory patient advance directives and health care proxy opinion: a randomized vignette-based study. J Pain Symptom Manag. 2015;49(3):637-645. doi:10.1016/j.jpainsymman.2014.06.012.
11.
NicholasLHBynumJPIwashynaTJWeirDRLangaKM. Advance directives and nursing home stays associated with less aggressive end-of-life care for patients with severe dementia. Health Aff. 2014;33(4):667-674. doi:10.1377/hlthaff.2013.1258.
12.
AcheKHarroldJHarrisPDoughertyMCasarettD. Are advance directives associated with better hospice care?J Am Geriatr Soc. 2014;62(6):1091-1096. doi:10.1111/jgs.12851.
13.
HartogCSPeschelISchwarzkopfD, et al.Are written advance directives helpful to guide end-of-life therapy in the intensive care unit? A retrospective matched-cohort study. J Crit Care. 2014;29(1):128-133. doi:10.1016/j.jcrc.2013.08.024.
14.
HalpernNAPastoresSMChouJFChawlaSThalerHT. Advance directives in an oncologic intensive care unit: a contemporary analysis of their frequency, type, and impact. J Palliat Med. 2011;14(4):483-489. doi:10.1089/jpm.2010.0397.
15.
GoodmanMDTarnoffMSlotmanGJ. Effect of advance directives on the management of elderly critically ill patients. Crit Care Med. 1998;26(4):701-704. doi:10.1097/00003246-199804000-00018.
16.
HerrerosBBenitoMGellaPValentiESánchezBVelascoT. Why have advance directives failed in Spain?BMC Med Ethics. 2020;21(1):113. doi:10.1186/s12910-020-00557-4.
17.
WillkinsonA. Literature review on advance directives.” U.S Department of Health and Human Services Assistant Secretary for Planning and Education Office of Disability, Aging and Long-Term Care Policy, 2007. https://aspe.hhs.gov/reports/literature-review-advance-directives-0.
18.
RamsaroopSDReidMCAdelmanRD. Completing an advance directive in the primary care setting: what do we need for success?J Am Geriatr Soc. 2007;55(2):277-283. doi:10.1111/j.1532-5415.2007.01065.x.
19.
ChanHYNgJSChanKS, et al.Effects of a nurse-led post-discharge advance care planning programme for community-dwelling patients nearing the end of life and their family members: a randomised controlled trial. Int J Nurs Stud. 2018;87:26-33. doi:10.1016/j.ijnurstu.2018.07.008.
20.
LiaoJWuBNiPMaoJ. Advance directive preferences among terminally ill older patients and its facilitators and barriers in China: a scoping review. J Am Med Dir Assoc. 2019;20(11):1356-1361. doi:10.1016/j.jamda.2019.05.013.
21.
Tamayo-VelázquezMISimón-LordaPVillegas-PorteroR, et al.Interventions to promote the use of advance directives: an overview of systematic reviews. Patient Educ Counsel. 2010;80(1):10-20. doi:10.1016/j.pec.2009.09.027.
22.
DurbinCRFishAFBachmanJASmithKV. Systematic review of educational interventions for improving advance directive completion. J Nurs Scholarsh. 2010;42(3):234-241. doi:10.1111/j.1547-5069.2010.01357.x.
23.
LeeMOParkJParkEY, et al.The Korean-advance directive model and factors associated with its completion among patients with hematologic disorders. J Hospice Palliat Nurs. 2019;21(4):E10-E16. doi:10.1097/NJH.0000000000000522.
24.
DowlingTKennedySForanS. Implementing advance directives-An international literature review of important considerations for nurses. J Nurs Manag. 2020;28(6):1177-1190. doi:10.1111/jonm.13097.
25.
BanjaJSumlerM. Overriding advance directives: a 20-year legal and ethical overview. J Healthc Risk Manag. 2019;39(2):11-18. doi:10.1002/jhrm.21388.
26.
LeongSMTamKICheSLZhuMX. Prevalence and predictors of willingness to make advance directives among Macao Chinese. Int J Environ Res Publ Health. 2021;18(15):7942. doi:10.3390/ijerph18157942.
27.
HardinSBYusufalyYA. Difficult end-of-life treatment decisions: do other factors trump advance directives? [published correction appears in Arch Intern Med. 2004 Oct 25;164(19):2124]. Arch Intern Med. 2004;164(14):1531-1533. doi:10.1001/archinte.164.14.1531.
28.
DobbinsEH. End-of-life decisions: influence of advance directives on patient care. J Gerontol Nurs. 2007;33(10):50-56. doi:10.3928/00989134-20071001-08.
29.
LauKSTseDMTsan ChenTWLamPTLamWMChanKS. Comparing noncancer and cancer deaths in Hong Kong: a retrospective review. J Pain Symptom Manag. 2010;40(5):704-714. doi:10.1016/j.jpainsymman.2010.02.023.
30.
EnguidanosSAilshireJ. Timing of advance directive completion and relationship to care preferences. J Pain Symptom Manag. 2017;53(1):49-56. doi:10.1016/j.jpainsymman.2016.08.008.
31.
LutaXMaessenMEggerMStuckAEGoodmanDClough-GorrKM. Measuring intensity of end of life care: a systematic review. PLoS One. 2015;10(4):e0123764. doi:10.1371/journal.pone.0123764.
32.
GlassDPWangSEMinardiPMKanterMH. Concordance of end-of-life care with end-of-life wishes in an integrated health care system. JAMA Netw Open. 2021;4(4):e213053. doi:10.1001/jamanetworkopen.2021.3053.
33.
HaddadGLiTTurrinDOwensCRolstonD. A descriptive analysis of obstacles to fulfilling the end of life care goals among cardiac arrest patients. Resusc Plus. 2021;8:100160. doi:10.1016/j.resplu.2021.100160.
34.
WongJDuanePGIngrahamNE. A case series of patients who were do not resuscitate but underwent cardiopulmonary resuscitation. Resuscitation. 2020;146:145-146. doi:10.1016/j.resuscitation.2019.11.020.
35.
WongSYLoSHChanCHChuiHSSzeWKTungY. Is it feasible to discuss an advance directive with a Chinese patient with advanced malignancy? A prospective cohort study. Hong Kong Med J. 2012;18(3):178-185.
36.
ChengHWBShekPSKManCW, et al.Dealing with death taboo: discussion of do-not-resuscitate directives with Chinese patients with noncancer life-limiting illnesses. Am J Hosp Palliat Care. 2019;36(9):760-766. doi:10.1177/1049909119828116.
37.
O'SullivanRMailoKAngelesRAgarwalG. Advance directives: survey of primary care patients. Can Fam Physician. 2015;61(4):353-356.
38.
Toro FloresRSilva MatoAPiga RiveroAAlfonso GalánMT. [Knowledge and attitudes about advance directives on physicians and nurses]. Atención Primaria. 2013;45(8):404-408. doi:10.1016/j.aprim.2013.03.003.
39.
AlFayyadINAl-TannirMAAlEssaWAHeenaHMAbu-ShaheenAK. Physicians and nurses' knowledge and attitudes towards advance directives for cancer patients in Saudi Arabia. PLoS One. 2019;14(4):e0213938. doi:10.1371/journal.pone.0213938.
40.
TeeKHSeetLTTanWCChooHW. Advance directive: a study on the knowledge and attitudes among general practitioners in Singapore. Singapore Med J. 1997;38(4):145-148.
41.
Poveda-MoralSde la CasaPJSánchez-ValeroPPomares-QuintanaNVicente-GarcíaMFalcó-PeguerolesA. Association between knowledge and attitudes towards advance directives in emergency services. BMC Med Ethics. 2021;22(1):75. doi:10.1186/s12910-021-00646-y.
42.
DavidsonKWHacklerCCaradineDRMcCordRS. Physicians' attitudes on advance directives. JAMA. 1989;262(17):2415-2419.
43.
WissowLSBeloteAKramerWCompton-PhillipsAKritzlerRWeinerJP. Promoting advance directives among elderly primary care patients. J Gen Intern Med. 2004;19(9):944-951. doi:10.1111/j.1525-1497.2004.30117.x.
44.
ScholtenGBourguignonSDelanoteAVermeulenBVan BoxemGSchoenmakersB. Advance directive: does the GP know and address what the patient wants? Advance directive in primary care. BMC Med Ethics. 2018;19(1):58. doi:10.1186/s12910-018-0305-2.
45.
ChangHYTakemuraNChauPHLinCC. Prevalence and predictors of advance directive among terminally ill patients in Taiwan before enactment of Patient Right to Autonomy Act: a nationwide population-based study. BMC Palliat Care. 2022;21(1):178. doi:10.1186/s12904-022-01069-1.
46.
WangYHEnguidanosS. Comparing variations in advance directives timing among older adults with end-stage renal disease versus cancer. Am J Hosp Palliat Care. 2023;40(2):147-152. doi:10.1177/10499091221097676.
47.
BaharoonSAlzahraniMAlsafiELayqahLAl-JahdaliHAhmedA. Advance directive preferences of patients with chronic and terminal illness towards end of life decisions: a sample from Saudi Arabia. East Mediterr Health J. 2019;25(11):791-797. doi:10.26719/emhj.19.038.
48.
TingFHMokE. Advance directives and life-sustaining treatment: attitudes of Hong Kong Chinese elders with chronic disease. Hong Kong Med J. 2011;17(2):105-111.
KasdorfADustGHamacherS, et al.The last year of life for patients dying from cancer vs. non-cancer causes: a retrospective cross-sectional survey of bereaved relatives. Support Care Cancer. 2022;30(6):4971-4979. doi:10.1007/s00520-022-06908-8.
51.
LastrucciVD'ArienzoSColliniF, et al.Diagnosis-related differences in the quality of end-of-life care: a comparison between cancer and non-cancer patients. PLoS One. 2018;13(9):e0204458. doi:10.1371/journal.pone.0204458.
52.
TriplettDPLeBrettWGBryantAK, et al.Effect of palliative care on aggressiveness of end-of-life care among patients with advanced cancer. J Oncol Pract. 2017;13(9):e760-e769. doi:10.1200/JOP.2017.020883.
53.
ChanCWHWongMMHChoiKC, et al.Prevalence, perception, and predictors of advance directives among Hong Kong Chinese: a population-based survey. Int J Environ Res Publ Health. 2019;16(3):365. doi:10.3390/ijerph16030365.
54.
KofflerSMintzkerYShaiA. Association between palliative care and the rate of advanced care planning: a systematic review. Palliat Support Care. 2020;18(5):589-601. doi:10.1017/S1478951519001068.
