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Improving Preoperative Completion of Advanced Care Planning Documents in Patients With Expected Postoperative Intensive Care Unit Stay

Urman, Richard D. MD, MBA*; Gross, Caroline S. MD; Sadovnikoff, Nicholas MD, FCCM; Bader, Angela M. MD, MPH*

doi: 10.1213/XAA.0000000000000993

Directed discussion about advanced care planning in the preoperative setting is often lacking. We implemented an educational intervention pilot to increase the number of high-risk patients who have health care proxy and advanced directives documents completed. We developed a novel short video describing the advanced care planning process and the intensive care setting, encouraging patients to have conversations about advanced care planning. Survey results showed that majority of patients felt the intervention increased their knowledge about advanced care planning (65%–70%) and that the video raised some topics worth discussing with family and health care providers. This intervention is scalable and could improve documentation and quality of care.

From the *Department of Anesthesiology, Perioperative Medicine and Pain Medicine, Brigham Health, Boston, Massachusetts

Division of Critical Care Medicine, Department of Anesthesiology, Perioperative Medicine and Pain Medicine, Brigham Health, Boston, Massachusetts.

Accepted for publication January 29, 2019.

Funding: Supported by Brigham Care Redesign Incubator and Startup Program (BCRISP) grant, Brigham and Women’s Hospital, Boston, Massachusetts.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations are provided in the HTML and PDF versions of this article on the journal’s website.

IRB: Approved by Partners Institutional Review Board.

Address correspondence to Richard D. Urman, MD, MBA, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115. Address e-mail to

At our institution’s Preoperative Evaluation Clinic, we triage the higher-acuity patients to an in-person visit. Currently, all patients coming through our Preoperative Evaluation Clinic receive an advance directive booklet that explains the basics of health care proxy and living will documents and provides the forms to complete both. Because patients may lose the capacity to make decisions about their medical treatment during a hospital admission, the health care proxy document allows the patient to appoint someone else—their health care agent—to make decisions regarding ongoing medical therapy if he or she becomes incapacitated.1 However, patients rarely have a directed discussion about these documents or end-of-life care in the preoperative setting.2 Also, the importance of discussing preferences with the designated health care agent and having an advanced directive form on file has not been uniformly emphasized in the preoperative setting, and, even if these discussions did take place, the actual documentation is often lacking.3,4

Studies suggest that there are notable deficits in patients’ understanding about expected postoperative course. One survey-based study revealed that only about 54% of patients booked for a stay in the intensive care unit postoperatively had a health care proxy, and only 48% of patients who were scheduled for intensive care unit admission postoperatively were aware of scheduled intensive care unit admission.5 Another study which noted the difficulties in ensuring patient and surrogate concordance enrolled patients having high-risk surgery. These patients then held a structured conversation with their health care proxy and a palliative care–trained physician at the time of their preoperative evaluation to ensure that the proxy understood patient preferences and goals.6 This study suggested that there was a benefit to conducting such discussions to ensure concordance. A pilot study conducted previously at our institution noted that only 54% of decedents had an advance directive on the date of the procedure.7 These studies suggest the need for increased patient education regarding expected recovery course, advance care planning, and the importance of the health care agent, particularly in a patient population at a significant risk for losing decision-making capacity during a surgery.

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Our main objective was to develop a feasible and easily implementable intervention that would increase the number of high-risk patients who have advance directive documents completed and are more informed about their care.

Our secondary goal was to target patients whom we identified as having a scheduled intensive care unit admission postoperatively and provide them with patient-centered education in the form of a short, professionally made video, regarding the importance of having advanced care planning documents completed before surgery.

Patients are provided with the advance directive booklet when they check in at the Preoperative Evaluation Clinic front desk. Vital signs and weight are obtained first in a room with a medical assistant. During that period, the medical assistant provides patients with access to a 6-minute video on the computer desktop (Supplemental Digital Content 1, Video, The patient is then seen by the Preoperative Evaluation Clinic clinician (a nurse practitioner) as normal practice, and any additional questions about these documents are answered at that time. All nurse practitioners working in Preoperative Evaluation Clinic are trained to discuss these documents as part of their job orientation and standard Preoperative Evaluation Clinic protocols.

The video consisted of a series of short recordings by intensive care unit physicians and an elderly former patient, to give a real former patient’s perspective. The content of this novel video was developed by the intensive care unit–trained physicians and preoperative assessment experts. It was available in English language only for this pilot and contained content that was deemed appropriate for sixth-grade education level. The video also contained subtitles for those who are hearing impaired:

  1. The former patient started off by stating that his and the hospital’s goal is to make sure that patients and families are given the right information to make decisions about the extent of their care. He acknowledged that, like him, patients may feel nervous about their upcoming surgery and intensive care unit stay.
  2. The intensive care unit physicians provided an overview of the intensive care unit setting and how it differs from a regular inpatient ward in terms of monitoring, equipment, and advanced care that cannot be offered in other parts of the hospital. The video showed images of an actual intensive care unit room and described the types of care it provides.
  3. The physician experts in the video provided an explanation, using nontechnical terms, of what a health care proxy, health care agent, and living will are and why they are important. The former patient specifically stated that the effects of surgery, medications, and anesthesia may impair one’s ability to make decisions or communicate with his or her doctors. Additional information was provided about how to complete the documents as well as the importance of discussing care preferences and what is important to one’s quality of life with the designated health care agent and health care providers before hospitalization. The video described what happens if the patient is incapacitated and care decisions need to be made using those documents.
  4. The video emphasized that the patients can designate anyone they trust as their health care agent—a friend, family member, or a spouse. The document needs to be completely filled out and signed by 2 witnesses. The former patient also stated that, without a prior conversation with the health care agent, it would be difficult for someone to make sure they are making decisions that are consistent with one’s goals and wishes. The viewer was encouraged to make copies of the signed document, give a copy to the health care agent and primary care doctor, and bring a copy on the day of surgery so that it can be scanned into the medical record. Finally, the patient was encouraged to discuss the information with the Preoperative Evaluation Clinic staff.

During our study period, before showing the video, the medical assistant administered a short questionnaire to assess baseline knowledge of health care proxy and advanced care directive concepts, whether the patient felt that they were given enough information before their Preoperative Evaluation Clinic visit about a possible stay in the intensive care unit, and how much they knew about the intensive care unit setting (Supplemental Digital Content 2, Out of the 37 patients surveyed, 12 did not know they were going to the intensive care unit, 10 knew they were going but would like more information, 2 knew they were scheduled but did not want more information, and only 11 thought they had been well informed.

After watching the video and completing their Preoperative Evaluation Clinic visit, the patients completed a postvideo survey. All steps involved in this quality improvement project are outlined in Figure 1. We collected pilot data during a 6-week period.

Figure 1.

Figure 1.

Figure 2.

Figure 2.

The results of the postvideo survey showed that the majority of patients indicated that they either “agreed” or “strongly agreed” that the video increased their knowledge about health care proxy (26; 70%) and advanced care directive (24; 65%) and that they more likely to fill out the health care proxy (20; 54%) and advanced care directive (21; 57%) forms. The majority felt that they were better informed about their stay in the intensive care unit (25; 68%), found the video helpful (25; 68%), and many felt that the video raised some topics worth discussing with their loved ones (Figure 2). Free-text comments revealed that patients were interested in completing the documents before surgery, updating their existing documents, and/or asking more questions of their surgeon.

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The results suggest that our intervention may help increase the number of patients admitted to the intensive care unit who have health care proxy and advanced care planning documents, as well as improve concordance between patients and surrogates. Increasing the understanding of patient goals and values could potentially help decrease the length of intensive care unit stay by avoiding unnecessary or unwanted treatments not consistent with patient goals.3,8,9 These improvements could be achieved with minimal cost impact; as patients watched the video on the computer desktop in the medical assistant’s office, the only real cost was that of the videography.

Patients undergoing high-risk procedures may develop complications requiring use of unplanned, often burdensome life-sustaining interventions, but many have not previously expressed whether these would be consistent with their wishes. This can lead to patient and family dissatisfaction, moral distress for providers, and substantial resource utilization.10,11 We propose that completion of health care proxy and advanced care directive be considered an absolute preoperative requirement for high-risk patients. Educating clinicians about conducting these discussions and answering questions may also be necessary, as our recent systematic review indicated a substantial lack of structured education.12 A checklist for the provider conducting the preoperative visit should ensure that high-risk patients have been educated both about potential intensive care unit admission and the advanced care planning process (by viewing the video). Presumably, by answering any questions before the day of surgery, the rate of completed advanced care planning documents and discussions should approach 100%.

We believe that the process we developed is scalable and sustainable. The video and surveys can be administered via a mobile device to improve efficiency and data collection. In the future, we plan to gather data on outcomes such as presence of this documentation on the day of surgery, as well as the percent of patients who endorse having had a conversation with the designated health care agent as a result of the intervention. We also plan to expand this intervention to other high-risk patients and non–English speakers, accounting for possible cultural differences related to end-of-life discussions.

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Name: Richard D. Urman, MD, MBA.

Contribution: This author helped conduct the study and prepare the manuscript.

Name: Caroline S. Gross, MD.

Contribution: This author helped conduct the study and prepare the manuscript.

Name: Nicholas Sadovnikoff, MD.

Contribution: This author helped conduct the study and prepare the manuscript.

Name: Angela M. Bader, MD, MPH.

Contribution: This author helped conduct the study and prepare the manuscript.

This manuscript was handled by: Mark C. Phillips, MD.

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