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A Three-Step Letter Advance Directive Procedure to Facilitate Patient-Proxy Alignment in Advance Care Planning
Muthuraman Alagappan1, Michael T Richardson2, Matthew K Schoen2
1Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
Journal of Palliative Medicine
|September 25, 2018
Summary
Advance care planning (ACP) between hematopoietic stem cell transplant (HSCT) patients and proxies showed 72.9% concordance. A structured Letter Advance Directive (LAD) process helped resolve disagreements, favoring patient wishes.
Area of Science:
- Hematology
- Oncology
- Palliative Care
Background:
- Advance care planning (ACP) is crucial for hematopoietic stem cell transplant (HSCT) patients.
- Little is known about patient-proxy alignment regarding end-of-life preferences in HSCT.
Purpose of the Study:
- To assess patient-proxy concordance in advance care planning for HSCT.
- To evaluate a structured three-step Letter Advance Directive (LAD) process for surfacing and resolving disagreements.
Main Methods:
- Eighty HSCT patient-proxy dyads participated.
- Patients and proxies completed LADs separately, then discussed and reached consensus.
- Data analyzed for concordance and discordance on treatment preferences.
Main Results:
- Mean patient-proxy concordance was 72.9% across 12 ACP questions.
- Significant discordance noted for ventilator support, dialysis, hospice, and resuscitation preferences.
- Discussion resolved most discordances, generally favoring the patient's initial wishes.
Conclusions:
- A structured ACP process, like the LAD, effectively identifies patient-proxy differences.
- The LAD facilitates discussion and consensus-building on specific treatment choices.
- This approach helps reconcile disagreements, prioritizing patient autonomy in HSCT care.
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