This paper examines the persistent gap in living will and advance directive completion among elderly and chronically ill patients. It identifies key barriers — including patient reluctance, staff overburdening, and inadequate institutional protocols — and proposes a targeted intervention led by a designated medical professional rather than nurses. The paper discusses appropriate settings for the intervention (hospitals, nursing homes, assisted living facilities, and home visits), evaluates it using both qualitative and quantitative methods, and outlines short- and long-term goals. Ultimately, the paper argues that proactive, structured conversations about end-of-life care documentation can benefit patients, families, and healthcare providers alike.
All too often, living wills are something "swept under the rug" by patients who need them and by those who could help patients set them up. When a patient goes to the hospital — either to be admitted or to use emergency services — he or she is often asked whether a living will is in place. Often, the answer is "no," and when asked whether he or she would like to create one, the answer is still "no." There is too much stress in a situation like that, and the person wants to be treated for his or her immediate problem rather than taught about other documentation.
Because of that reality, there must be a better way to reach elderly patients and those living with chronic conditions such as COPD. The proposed intervention would target these populations specifically. The intervention could take place at one of several locations. The hospital is the most logical choice for a discussion of living wills, but nursing homes, assisted living facilities, and doctors' offices are also appropriate venues. Another important setting is the home, especially when the services of a visiting nurse are already required.
While many people do not think about living wills, they are highly important documents for anyone who wants their wishes followed. The intervention may need to take place more than once, however, for people to fully understand the importance of this kind of document. Nurses or an appointed medical care professional would both be reasonable candidates to lead these conversations, but logically — and budgetary considerations aside — it would be better to designate a specific person for this role rather than asking nurses to handle it. Many nurses are already overburdened, and adding living will discussions to their workload would not benefit them or their patients.
A direct intervention is necessary because advance directives are not being completed upon admission to hospitals, doctors' offices, and other medical settings. This is especially true for elderly, chronically ill, and terminally ill patients. Findings from a focus group organized to address this issue confirmed that elderly patients, their families, and medical staff — including doctors, nurses, secretaries, case management clerks, admissions personnel, and ER triage nurses — do not routinely take the time to complete or discuss the importance of living wills. Hospitals and other medical care facilities must appoint someone other than the bedside nurse to speak with patients who do not have living wills during their stay.
The intervention could take place across a range of healthcare settings. Hospitals remain the most logical choice given patient volume and the frequency with which end-of-life questions arise during admissions. However, nursing homes and assisted living facilities serve populations that are equally — if not more — in need of advance directive guidance, as residents in those settings are often managing chronic or terminal conditions on an ongoing basis.
Doctors' offices offer another important touchpoint, particularly for patients who are seen regularly for chronic conditions such as COPD, heart failure, or diabetes. A routine appointment can provide a calm, low-pressure environment in which a designated professional can raise the subject without the urgency or anxiety associated with an emergency admission. Home visits by a visiting nurse represent yet another opportunity, as the home setting may make patients more comfortable discussing end-of-life preferences than a clinical environment would.
This intervention must be evaluated using both qualitative and quantitative methods in order to ensure it is working correctly. If there are problems with the initial intervention, there are opportunities to adjust it — but only if the reasons behind those problems can be discovered. A qualitative method well suited to this intervention is direct observation. The goal would be to determine how many people were "swayed" by the information they received about living wills. If a patient was properly informed, would that patient decide to create a living will? Would the results of that approach differ from the results of the current, largely absent intervention taking place in hospitals and other medical facilities? These are questions that cannot be answered without structured study, and qualitative methods alone do not necessarily provide enough data for an accurate assessment.
"Observation and statistical analysis to measure effectiveness"
"More completed documents and clearer end-of-life care plans"
A structured intervention could change that reality. By providing patients with clear information about living wills, offering follow-up opportunities to answer questions, and connecting them with the resources needed to create these documents, the intervention would help ensure that end-of-life care aligns with each patient's own values and desires. The benefits extend to families, nurses, and physicians alike, making this a meaningful and practical improvement to standard care practice.
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