Original Studies
Can Goal-Based Advance Planning Guide Medical Care in the Nursing Home?

https://doi.org/10.1016/S1525-8610(05)70542-9Get rights and content

Objective

To determine whether a goal-based system of advance planning, which allows patients to choose among five “pathways of care” (longevous, ameliorative/comprehensive, ameliorative/basic, palliative/comfort, or palliative/hospice), enables physicians to select treatment options in specified clinical situations.

Design

A pencil and paper test was administered in which clinicians were presented five common clinical scenarios and were asked which of four possible treatment options they would recommend, given a predetermined “pathway of care.”

Setting

A 725-bed teaching nursing home and affiliated continuing care retirement community.

Measurements

The proportion of correct answers was measured for each clinician, for each clinical scenario, and for each pathway.

Results

Of the test answers, 78% coincided with the reference answers. The greatest rate of correct answers was found for the ameliorative/comprehensive pathway and the palliative/hospice pathway.

Conclusion

Establishing pathways of care by asking nursing home residents to prioritize their goals of care may help clinicians narrow the range of appropriate options when facing an acute medical problem.

Section snippets

Methods

The pathways approach was described to the staff of a 725-bed teaching nursing home and its affiliated continuing care retirement community. The clinicians were given a one-page document summarizing, for each pathway, the underlying goals and the types of treatment consistent with that approach (Table 1). A scenario-based pencil and paper test was then administered in a proctored setting to measure the usefulness of the pathways system in guiding medical decision making in the nursing home.

Results

Of the 21 tests distributed, 17 tests (81%) were completed. Two tests had to be discarded because the subjects did not fill out the answer sheet correctly: the respondents were asked which of four possible treatments they would recommend given a particular pathway but two respondents instead indicated which pathway corresponded to one of the treatment options listed. Overall, 78% of the answers were correct based on the reference answers, with individual scores ranging from 60% to 100%. When

Discussion

Previous studies have indicated that neither very general advance directives7 nor designation of a single overriding goal8 can reliably be used to infer preferences for specific treatments. We hypothesized that knowledge of a patient's chosen “pathway of care” based on the prioritization of three distinct goals of care would enable clinicians to recommend treatment options in the setting of acute illness. Our results suggest that although the pathway system does not lead to the determination of

Acknowledgments

The authors wish to thank Dan Kiely, MS, of the Research and Training Institute of the Hebrew Rehabilitation Center for Aged, for assistance with the statistical analysis.

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Cited by (7)

  • Development and testing of a decision aid on goals of care for advanced dementia

    2014, Journal of the American Medical Directors Association
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    GOC discussions are a fundamental component of shared decision-making.28,36 Gillick showed that NH residents or families of residents with dementia were willing to prioritize goals, and that clinicians were able to match possible treatments to a patient's ranking of the goals of care.30,37 The intervention piloted in this study facilitates the conditions for choosing and communicating a goal of care in NH care for persons with dementia.

  • Health care professionals' perceptions and use of the medical orders for scope of treatment (MOST) form in North Carolina nursing homes

    2012, Journal of the American Medical Directors Association
    Citation Excerpt :

    Future research is needed to determine if additional options for the scope of treatment or separate choices for hospitalization might provide greater differentiation of patient preferences and consistency in clinical interpretation. Other advance care planning paradigms have used up to 5 options for the scope of treatments.22 POLST-paradigm forms in other states offer a hospitalization option within Limited Additional Interventions or a separate section on the form to specify a patient’s desire for future hospitalizations.23,24

  • Re-engineering shared decision-making

    2015, Journal of Medical Ethics
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Supported in part by the Hartford American Federation for Aging Research (AFAR) Geriatrics Scholars Program

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