Failure to engage hospitalized elderly patients and their families in advance care planning

JAMA Intern Med. 2013 May 13;173(9):778-87. doi: 10.1001/jamainternmed.2013.180.


Importance: Advance care planning can improve patient-centered care and potentially reduce intensification of care at the end of life.

Objectives: To inquire about patients' advance care planning activities before hospitalization and preferences for care from the perspectives of patients and family members, as well as to measure real-time concordance between expressed preferences for care and documentation of those preferences in the medical record.

Design: Prospective study.

Setting: Twelve acute care hospitals in Canada.

Participants: Elderly patients who were at high risk of dying in the next 6 months and their family members.

Main outcome measures: Responses to an in-person administered questionnaire and concordance of expressed preferences and orders of care documented in the medical record.

Results: Of 513 patients and 366 family members approached, 278 patients (54.2%) and 225 family members (61.5%) consented to participate. The mean ages of patients and family members were 80.0 and 60.8 years, respectively. Before hospitalization, most patients (76.3%) had thought about end-of-life (EOL) care, and only 11.9% preferred life-prolonging care; 47.9% of patients had completed an advance care plan, and 73.3% had formally named a surrogate decision maker for health care. Of patients who had discussed their wishes, only 30.3% had done so with the family physician and 55.3% with any member of the health care team. Agreement between patients' expressed preferences for EOL care and documentation in the medical record was 30.2%. Family members' perspectives were similar to those of patients.

Conclusions and relevance: Many elderly patients at high risk of dying and their family members have expressed preferences for medical treatments at the EOL. However, communication with health care professionals and documentation of these preferences remains inadequate. Efforts to reduce this significant medical error of omission are warranted.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Advance Care Planning* / trends
  • Advance Directives*
  • Aged
  • Aged, 80 and over
  • Canada
  • Family*
  • Female
  • Humans
  • Inpatients*
  • Male
  • Medical Records / standards
  • Middle Aged
  • Patient Preference* / statistics & numerical data
  • Patient-Centered Care* / trends
  • Prospective Studies
  • Quality of Life
  • Surveys and Questionnaires
  • Terminal Care* / methods
  • Terminal Care* / trends