Advance directives are statements recorded by a competent individual containing information on health-related values and choices. They seek to extend the individuals' autonomy in anticipation of events that would subsequently compromise their ability to express themselves. Advance directives are likely to be particularly relevant to care home residents, who are may have prior experience of serious illness. We undertook a postal questionnaire survey of all managers of care homes in Leicestershire to determine their attitudes towards advance directives (Table 1), as care home managers would have a key role in facilitating advance directives for care home residents.
Table 1 Replies from a survey of Leicestershire care home managers on end-of-life care.
Seven homes were no longer operational and two homes declined to participate. Of the remaining homes, 243/391 (62%) returned the questionnaire. Overall, 67% of the homes cared for older clients and 41% catered for people with physical disabilities. Of those homes with a policy on advance directives or resuscitation, 16/95 (17%) discussed end-of-life care routinely with their clients; 22 (23%) when their clients became unwell; 37 (39%) when prompted by other healthcare professionals; and 24 (22%) discussed end-of-life care if requested by the client. Further information on end-of-life care was requested by 171/243 homes.
This is the first UK study examining the attitudes of care home staff towards end-of-life care for their clients. Awareness of advance directives was relatively low (28%) compared to awareness of DNR orders (72%), but higher in nursing homes compared to residential homes in both cases. The timing of end-of-life discussions suggested by this survey suggests a more reactive rather than a proactive approach. Weaknesses of the study include that we were unable to verify that responses reflect actual practice and whether the responders were indeed representative of the larger population of care home managers.
The North American experience of advance directives suggests that they can improve client care and reduce costs, when used systematically and in the context of a broader end-of-life managed care programme.1,2 The circumstances in the UK are coming together to facilitate the introduction of advance directives. The mental capacity bill provides the legislative framework and case management will provide the opportunity. What is not known, are the barriers that exist within the medical profession and the health service more generally, that will inhibit greater use of advance directives.
Acknowledgments
The authors are grateful to Dr John Gladman, Reader in Medicine for Older People, University of Nottingham for his constructive comments
Notes
Funding body
Funded by a British Geriatrics Society Specialist Registrar start up grant awarded to Dr Conroy
- © British Journal of General Practice, 2005.
