A randomized controlled trial of a goals-of-care video for elderly patients admitted to skilled nursing facilities

Abstract

Objective: To determine the impact of a video on preferences for the primary goal of care.

Design, subjects, and intervention: Consecutive subjects 65 years of age or older (n=101) admitted to two skilled nursing facilities (SNFs) were randomized to a verbal narrative (control) or a video (intervention) describing goals-of-care options. Options included: life-prolonging (i.e., cardiopulmonary resuscitation), limited (i.e., hospitalization but no cardiopulmonary resuscitation), or comfort care (i.e., symptom relief).

Main measures: Primary outcome was patients' preferences for comfort versus other options. Concordance of preferences with documentation in the medical record was also examined.

Results: Fifty-one subjects were randomized to the verbal arm and 50 to the video arm. In the verbal arm, preferences were: comfort, n=29 (57%); limited, n=4 (8%); life-prolonging, n=17 (33%); and uncertain, n=1 (2%). In the video arm, preferences were: comfort, n=40 (80%); limited, n=4 (8%); and life-prolonging, n=6 (12%). Randomization to the video was associated with greater likelihood of opting for comfort (unadjusted rate ratio, 1.4; 95% confidence interval [CI], 1.1-1.9, p=0.02). Among subjects in the verbal arm who chose comfort, 29% had a do-not-resuscitate (DNR) order (κ statistic 0.18; 95% CI-0.02 to 0.37); 33% of subjects in the video arm choosing comfort had a DNR order (κ statistic 0.06; 95% CI-0.09 to 0.22).

Conclusion: Subjects admitted to SNFs who viewed a video were more likely than those exposed to a verbal narrative to opt for comfort. Concordance between a preference for comfort and a DNR order was low. These findings suggest a need to improve ascertainment of patients' preferences.

Trial registration: Clinicaltrials.gov Identifier: NCT01233973.

FIG. 1.

Flow diagram of study and subjects' flow.

FIG. 2.

Subjects' preferences for their goals of care.