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. Several studies have now demonstrated that advance directives that are completed in the ambulatory care setting are rarely available and recognized when patients are admitted to the acute care hospital. Objective: To evaluate a generalizable model for improving recognition of previously completed advance directives and for promoting appointment of health care proxies in hospitalized patients. Methods: Hospitalized elderly patients were randomly assigned to receive the intervention or usual care (n=190). intervention patients with capacity were counseled by hospital patient representatives about advance directives and encouraged to complete health care proxies. Patients with existing proxies had this information noted in their charts. For patients without capacity, counselors reviewed their charts for proxy documentation and if absent, contacted patients' next of kin and private physicians to determine proxy status. Usual care patients were not contacted by patient representatives. Results: Forty-eight percent of intervention patients completed a new proxy or had a previously completed proxy identified compared with 6% of controls (P<.001). For patients with capacity, 22% of intervention patients had a previously appointed proxy agent identified compared with 6% of controls (P<.001). Thirty-six percent of intervention patients appointed a proxy decision maker compared with 0% of controls (P<.02). For patients without capacity, 31% of intervention patients had previously appointed proxies identified compared with 6% of controls (P<.001). Conclusions: Counseling by hospital patient representatives is an effective and generalizable means of improving recognition and execution of advance directives in the acute care hospital.