The effect of advance care planning on completion of advance directives and patient satisfaction in people with HIV / AIDS

The effects of advance care planning are poorly understood. The purpose of this study was to evaluate the effect of an advance care planning intervention on the completion of advance directives (ADs) and patient satisfaction. A volunteer sample of persons with HIV/AIDS received advance directive documents, watched an educational video and received individual counselling on completing an advance directive during three face-to-face interviews over approximately six months. The advance care planning intervention was associated with an increase in advance directive completion rates from 16.4% to 40.7% (p 5 0.001), but 23.1% of advance directives reported as completed were legally invalid. There was a trend towards decreased overall patient satisfaction with health care (p 5 0.07). Advance are planning increases the rate of AD completion but many `completed’ advance directives are legally invalid. Advance care planning did not improve patient satisfaction with health care. Advance care planning (ACP) is a `process of communication among patients, their health care providers, their families, and important others regarding the kind of care that will be considered appropriate when the patient cannot make decisions’ (Teno et al., 1994). ACP may contain written advance directives (ADs), which detail a person’ s wishes about life-sustaining treatments and/or who the person wants to make decisions (Emanuel et al., 1991). The ethical principle of autonomy, legal doctrine of informed consent and policies of professional organizations support the use of ADs (Singer et al., 1996). AD completion and patient satisfaction are two key measures of the effectiveness of ACP programmes. Previous studies have shown that ACP interventions are associated with modest increases in the rate of AD completion (Cohen-M ans® eld et al., 1991a; Cugliari et al., 1995; Dexter et al., 1998; Duf® eld et al., 1996; Hanson et al., 1997; Hare et al., 1991; High, 1993; Holley et al., 1993; Landry et al., 1997; Luptak et al., 1994; Markson et al., 1994; Meier et al., 1996a; Sachs et al., 1992; Silverman et al., 1995; Sulmasy et al., 1996). However, two recent studies suggest that 16 and 29% of ADs reported to be completed were legally invalid and hence might fail to in ̄ uence health care during incapacity the way the person had intended (Richter et al., 1995; Rubin et al., 1994). This ® nding requires con® rmation as it Address for correspondence: Dr Peter Singer, Sun Life Chair in Bioethics and Director, University Joint Centre for Bioethics, Professor of Medicine, University of Toronto, 88 College Street, Toronto, Ontario, Canada M5G TL4. Tel: 416 9979 2709; Fax: 416 078 1911. Email: peter.singer@utoronto.ca ISSN 0954-012 1 print/ISSN 1360-045 1 online/00/010097-1 2 Ó Taylor & Francis Ltd 98 V. W . K . HO ET AL. signals the need for ACP interventions to incorporate counselling, and the examination of completed AD documents to ensure their validity. Patient satisfaction with health care measures one dimension of the quality of health care (Ware et al., 1988). Previous studies showed that ACP interventions do not change patient satisfaction (Finucane et al., 1988; Schneiderman et al., 1992). However, neither study used a measure of patient satisfaction that was speci® c for the effects of ACP (Schneiderman et al., 1992). General measures of satisfaction may not be sensitive enough to detect changes in speci® c domains of satisfaction related to ACP interventions. This study used a satisfaction measure speci® cally designed to measure the aspects of satisfaction that might be in ̄ uenced by ACP. Positive changes in patient satisfaction would add to the argument for the use of ACP interventions. The purpose of this study was to evaluate in people with HIV/AIDS the effect of an ACP intervention on completion of ADs and patient satisfaction. The evaluation was conducted by measuring: (1) AD completion by self-report and an examination of AD documents to determine whether they were legally valid, and (2) patient satisfaction with health care, using a detailed questionnaire speci ® cally focused on the interpersonal aspects of care that may be in ̄ uenced by ACP.