MARKED IMPROVEMENT IN RECOGNITION AND COMPLETION OF HEALTH-CARE PROXIES - A RANDOMIZED CONTROLLED TRIAL OF COUNSELING BY HOSPITAL PATIENT REPRESENTATIVES

Background: Advance directives provide a means for patients to retain influence on their medical care should decisional capacity be lost. Se veral studies have now demonstrated that advance directives that are c ompleted in the ambulatory care setting are rarely available and recog nized when patients are admitted to the acute care hospital. Objective : To evaluate a generalizable model for improving recognition of previ ously completed advance directives and for promoting appointment of he alth care proxies in hospitalized patients. Methods: Hospitalized elde rly patients were randomly assigned to receive the intervention or usu al care (n=190). intervention patients with capacity were counseled by hospital patient representatives about advance directives and encoura ged to complete health care proxies. Patients with existing proxies ha d this information noted in their charts. For patients without capacit y, counselors reviewed their charts for proxy documentation and if abs ent, contacted patients' next of kin and private physicians to determi ne proxy status. Usual care patients were not contacted by patient rep resentatives. Results: Forty-eight percent of intervention patients co mpleted a new proxy or had a previously completed proxy identified com pared with 6% of controls (P<.001). For patients with capacity, 22% of intervention patients had a previously appointed proxy agent identifi ed compared with 6% of controls (P<.001). Thirty-six percent of interv ention patients appointed a proxy decision maker compared with 0% of c ontrols (P<.02). For patients without capacity, 31% of intervention pa tients had previously appointed proxies identified compared with 6% of controls (P<.001). Conclusions: Counseling by hospital patient repres entatives is an effective and generalizable means of improving recogni tion and execution of advance directives in the acute care hospital.