Death at Home Following a Targeted Advance-Care Planning Process at Home: The Kitchen Table Discussion

Authors


Address correspondence to Edward Ratner, MD, University of Minnesota Department of Family Practice, Mayo Mail Code 381, 420 Delaware Street SE, Minneapolis, MN 55414.

Abstract

OBJECTIVE: To determine whether home health agency patients' preferences to die at home can be honored following a structured, professionally facilitated advance-care planning (ACP) process provided in the home.

DESIGN: A case series of patients who were identified by their home health agency nurses as having a life-limiting illness and then referred for social service assessment, followed for at least 6 months, with median follow-up of 191 days.

SETTING: A large, urban, home health agency owned by a not-for-profit integrated healthcare system.

PARTICIPANTS: Eighty-four adult patients (median age 75, range 37–94) receiving home care services other than hospice.

INTERVENTION: Formally structured social work visits at patients' homes to discuss end-of-life issues, with communication of results to home health nurses and attending physicians. Social workers performed standard psychosocial assessments, obtained patient and family preferences regarding end-of-life care, and provided education about hospice services.

MEASUREMENTS: Acceptance of the ACP process, preferences for location of end-of-life care, location of care at the end of life, adequacy of timing of intervention as measured by length of life after ACP, and use of hospice services.

RESULTS: Eighty-three of 84 participants (99%) were willing to complete an ACP process in the home setting. Of the 54 patients expressing a clear preference for location of end-of-life care, 46 (82%) wanted this care to be at home. Thirty-nine (46%) of the participants died within 90 days of ACP; 58 (69%) died by the end of the study. Forty-three (75%) of these deaths occurred at home or in a hospice residence. Fifty-one (61%) patients used home, residential, or nursing home–based hospice services during the study.

CONCLUSION: In this series of seriously ill home health patients, most preferred to die at home and virtually all were willing to participate in a home-based ACP process. Facilitating ACP among such patients and their families was associated with end-of-life care at home. Use of hospice services was common following ACP in this population. J Am Geriatr Soc 49:778–781, 2001.

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