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Helping Patients Make Final Care Decisions

Meeting with a chaplain helps patients complete advance directives

By Charles Jolie

Planning for the end of your life is understandably difficult, let alone communicating your wishes. While public opinion research shows that 90 percent of Americans agree it is important to have end-of-life discussions with their loved ones, only about a third of adults in the U.S. have completed written advance directives that spell out wishes for care or designate the person they’d like to carry them out.

Making these preparations can be especially urgent when people are in the hospital, but their physicians often are not able to lead them. However a study led by the spiritual care director at Rush Oak Park Hospital found that 80 percent of participating patients completed an advance directive after visiting with a chaplain during previously scheduled outpatient physician appointments.

“This study shows not just how important advance care planning really is, but also that chaplains can make these conversations both feasible and acceptable to patients,” says Aoife Lee, DMin BCC, Rush Oak Park Hospital's spiritual director, who led the study. She and her colleagues in the research shared the results of their project in a research letter published in JAMA Internal Medicine on Jan. 16.  

Patients often don’t discuss end-of-life wishes with families

For the study, Lee partnered with Catherine McGinness, MD, a family medicine physician with Rush Oak Park Physicians Group. Lee identified patients of McGinness that met certain criteria — age 70 years or older, able to make advance care decisions but without an advance directive in their electronic medical record — and scheduled time for consultations at McGinness’ practice.

When McGinness finished her appointments with these patients, she invited them to speak with Lee. All of them did. “Among many things, the study determined that conducting these type of serious conversations with patients in physicians' offices as opposed to a hospital setting are feasible and acceptable to patients,” Lee says.

Lee undertook the project as part of a fellowship in palliative care training funded by the Coleman Foundation, a Chicago-based grant making charity. “After 17-plus years working with patients and families in different intensive care units at Rush University Medical Center and Rush Oak Park Hospital, I have often had to help a loved one with difficulty end-of-life decisions,” she says.

“Many times the patient and family have not talked about ‘what if something happens’ or ‘when my loved-one’s life is coming to its natural end how much aggressive medical intervention would he or she want?’" 

Less than half an hour with chaplain can start conversations with families

Advance directives provide patients with the peace of mind in knowing they have things in order to help loved ones if difficult health care decisions have to be made. They can also reduce the guilt and depression family members might experience when making decisions that hadn’t been determined in an advance directive.

Lee observed that patients are often happy to clarify and document their wishes, particularly around naming a power of attorney for health care. The chaplain-facilitated conversations, averaging less than 30 minutes in the study, provide a document that they can share with loved ones and start a conversation about their wishes. In addition, the directive is incorporated into the patient’s electronic medical record. 

Physicians have been receptive to incorporating chaplains in this planning, since they know these discussions require a different kind of expertise. “Chaplains can provide a vital service that we often aren’t able to offer,” says McGinness, who co-authored the letter in JAMA Internal Medicine. The researchers also included Sean O'Mahony, MB. BCh, BAO, a palliative care physician, and George Fitchett, DMin, Phd, a chaplain, both at Rush University Medical Center; and Stacie Levine, MD at University of Chicago Medicine.

Fitchett, director of research in Rush’s Department of Religion Health and Human Values, says that the findings of this study will be tested more widely: “We are eager to test this initiative in a larger study and to further investigate the contribution professional chaplains can make to ensuring that care at the end of life is guided by patients’ deeply-held beliefs.”

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