GN Management

Promotion of Advance
Care Planning in the
Nonhospitalized Elderly
Nagia S. Ali, RN, PhD

Abstract: Factors that influence the execution or lack of execution of
advance directives in 162 nonhospitalized older adults were examined. Significant results were found, and implications for geriatric
nurses are presented.
(Geriatr Nurs 1999;20:260-2)

D

espite the enactment of the Patient SelfDetermination Act in 1991, few
Americans have completed advance directives (ADs).1-5 Barriers to completing
ADs could be related to factors in the
general public or health care providers. Some individuals who had not signed ADs said they expected physicians to discuss that issue with them, expressed cautions
and impediments to their use, and perceived themselves
as having good health and quality of life.6-8 Although
most physicians indicated that they favor implementing
ADs, they do not initiate discussions about end-of-life
decisions. Physicians’ perceived barriers to such discussions were their discomfort with talking about death and
dying, time constraints, lack of administrative support,
legal uncertainties, and lack of proper knowledge.7-10
In an effort to pursue this problem further, the following questions were addressed in a study of 162 nonhospitalized individuals who were 60 or older:
• What are older adults’ current actions regarding
ADs?
• What are older adults’ perceived reasons for not
executing ADs?

260

• What factors contribute to older adults completing ADs?
• What are older adults’ preferences for life-sustaining treatments?
• Do significant differences exist between people
with ADs and those without in their life-sustaining treatment preferences?
Data were collected from participants using a
structured written questionnaire designed for the study.
The developed instrument was submitted to three experts in the area of gerontology and geriatric nursing.
Test-retest reliability was 0.85.

RESULTS
Table 1 shows the demographic characteristics and
the number of respondents in each variable. Participants
who were 70 and older signed more ADs than those who
were 60 to 69 (P < 0.001). Likewise, participants whose
annual household income was $40,000 or higher signed
more ADs than those whose income was less than
$40,000 (P < 0.001). The proportion of participants who
had read about ADs had signed more forms than those
who had not (P < 0.001).

Geriatric Nursing Volume 20, Number 5

Table 1. Demographic Characteristics
of the Sample
Variables

Frequency

Gender (n = 162)
Women
Men
Race (n = 148)
White
Black
Age (n = 162)
60 to 64
65 to 69
70 and older
Education (n = 139)
Less than 12 years
12 years
More than 12 years
Gross household income (n = 154)
$20,000 to $29,999
$30,000 to $39,999
$40,000 to $49,999
$50,000 to $59,999
$60,000 or more

Percentage

Table 2. Actions, Barriers, and Reasons
Regarding Advance Directive Execution
Actions (n = 160)

Frequency Percentage

Executed LW and HCP
105
57

64.8
35.2

139
9

93.9
6.1

50
46
66

30.9
28.4
40.7

41
57
41

29.5
41.0
29.5

21

13.1

Execute only LW

34

21.3

Execute only HCP
No ADs

4

2.5

101

63.1

21.7
38.3
32.1
7.2
9.7

Table 2 shows participants’ perceived barriers and
reasons for executing or failing to execute ADs. The
most frequent reason cited for not executing ADs was
the physician’s failure to discuss the issue; a desire to
participate in his or her own end-of-life decisions was
the most frequently cited reason for creating ADs.
Most participants chose the statement “The doctor
can decide what is best for me” as their first preference
for life-sustaining treatments, as outlined in Table 3.
Chi-square analysis showed that “comfort care” was significantly chosen (P < 0.001) by more participants with
ADs than by those without. However, the preferences of
“The doctor can decide what is best for me” and “All
possible means of care” were significantly chosen (P <
0.001) by more participants without ADs than those
with them.

DISCUSSION AND IMPLICATIONS
FOR GERIATRIC NURSES
Advance care planning must be executed with the
help of health care providers. The study finding that few
people execute ADs because of a physician’s failure to
initiate a discussion about end-of-life decisions implies a
strong need to improve physicians’ skills in counseling
their patients about these documents. Patients expect
guidance and advice from their physicians, including explanations related to the procedures they would or
would not desire should they be critically or terminally
ill. Physicians can play an important role in initiating
these discussions and explaining the terms used and life-

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64.4

Need information

67

56.8

Hadn’t discussed ADs with anyone

55

46.6

Unsure of the best time to execute ADs

46

39.0

Unsure I get quality care with ADs

37

31.4

Unsure they will follow my LW

36

30.5

ADS are only relevant to old
people with poor health

31

26.3

Not interested—family members decide

28

23.7

Need time to think about ADs

25

21.2

Language in the document is vague

24

20.3

Unsure of the need for two forms

21

17.8

My religion forbids ADs

35
59
34
11
15

Perceived Barriers to Executing ADs (n = 118)
Failure of physician to initiate
discussion on end-of-life issues
76

15

12.7

The forms are not available

11

9.3

Perceived Reasons for Executing Advance Directives (n = 50)
Want to participate in end-of-life
decisions

48

96

Discussed ADs with my family

41

82

Ease my mind and prevent the burden
on my family

37

74

Poor prognosis

31

62

Do not want to prolong life

29

58

Live alone

21

42

Cancer/multiple health problems

20

40

9

18

Many hospital admissions
Legend
ADs= Advance directives
LW= Living will
HCP= Health care proxy

Table 3. Preferences for Life-Sustaining Treatments
(n = 162)
Preferences

Number

Percentage

The doctor can decide what
is best for me*

92

56.8

Comfort care*

83

51.2

All possible means of care*

59

36.4

Just receive basic medical care

51

31.5

*Significant difference at the P < 0.001 between individuals with
advance directives and those without

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Table 4. Strategies to Promote
Execution of Advance Directives
in Nonhospitalized Older Adults
Geriatric Nurses’ Roles with Physicians
Conduct teaching workshops about ADS
Assess their perceived barriers to discussing end-of-life decisions
with their patients before and after the workshops
Address their uncomfortable feelings about death and dying (ask
them individually or in groups)
Use the preworkshop assessment data to provide needed
information
Teach them how to initiate a discussion about ADS
Provide them with written materials about ADS
Encourage them to initiate the discussion when their patients
are well
Emphasize their responsibility to explain to their patients lifesustaining treatments, the chances of survival, the probability of
recovery, and how to select or refuse a treatment

illness. A special office visit devoted to discussing ADs
might be an option. Geriatric nurses can educate physicians through hospital conferences, seminars, or structured workshops that focus on reducing their perceived
barriers and improving their skills in initiating the discussion and recognizing their patients’ wishes.
The study participants’ desire for information
about ADs, as well as the fact that more than half of
them chose “The doctor can decide what is best for me,”
underscores a crucial need to educate and empower
older adults to be active participants in their own endof-life decisions.11-14 Table 4 features some strategies
that geriatric nurses can use to enable both physicians
and older adults to promote AD enactment.
Furthermore, geriatric nurses might form a committee whose goal is educating the public about ADs.
This committee and its goals can be promoted in local
newspapers, public meetings, and local radio and television programs. Retired geriatric nurses who are interested in re-engaging themselves with older adults might
take an active role in this public education.

Emphasize that they should respect their patients’ wishes
REFERENCES

Geriatric Nurses’ Roles with Older Adults
Approach older adults in settings other than medical facilities,
such as churches, senior citizen centers, volunteer organization
meetings, practitioners’ offices, or nutrition centers
Empower them to be active participants in their end-of-life
decisions
Address their perceived barriers
Explain the benefits of ADS, the forms used, the time to execute
the forms, the role of health care proxy, and what to do if they
change their minds about the forms after signing them
Use teaching supplements, such as videotapes, informational
booklets, and the AD forms
Encourage older adults to talk to family members and significant
others about advance care planning
Involve the health care proxy, if possible
Adequately prepare older adults to talk to their physicians
about ADS
Follow up contact between patients and physicians to examine
progress and redirect as needed
Encourage people who have signed AD forms to communicate
and give copies to the physician and the health care proxy
Empower people to inform their physicians that they want their
wishes recognized
Empower those who complete AD forms to inform others

1. Teno J, Lynn J, Connors A, Wenger N, Phillips R, Alzola C, et al. The illusion
of end-of-life resources savings with advanced directives. J Am Geriatr Soc
1997;45:513-8.
2. Teno J, Licks S, Lynn J, Wenger N, Connors A, Phillips R, et al. Do advanced
directives provide instructions that direct care? J Am Geriatr Soc
1997;45:508-12.
3. Hanson L, Rodgman E. The use of living wills at the end of life. Arch Intern
Med 1996;156:1018-22.
4. Heintz L. Efficacy of advanced directives in a general hospital. Hawaii Med J
1997;56:203-6.
5. Gross M. What do patients express as their preferences in advance directives?
Arch Intern Med 1998;158:363-5.
6. Elder N, Schneider F, Zweig S, Peters P, Ely J. Community attitudes and
knowledge about advance care directives. J Am Board Fam Pract
1992;5:565-72.
7. Terry M, Zweig S. Prevalence of advanced directives and do-not-resuscitate
orders in community nursing facilities. Arch Fam Med 1994;3:141-5.
8. Cugliari A, Miller T, Sobal J. Factors promoting completion of advanced directives in the hospital. Arch Intern Med 1995;155:1893-8.
9. Reilly B, Wagner M, Ross J, Magnussen R, Papa L, Ash J. Promoting completion of health care proxies following hospitalization. Arch Intern Med
1995;155:2202-6.
10. Hofmann J, Wenger N, Davis R, Teno J, Connors A, Desbiens N, et al. Patient
preferences for communication with physicians about end-of-life decisions.
Ann Intern Med 1997;127:1-11.
11. Johns J. Advance directives and opportunities for nurses. Image 1996;28:14953.
12. Mezey M, Bottrell, M, Ramsey G. Advance directive protocol: nurses helping to protect patient’s rights. Geriatr Nurs 1996;17:204-10.
13. Haynor P. Meeting the challenge of advance directives. Am J Nurs
1998;98:27-33.
14. Kirmse J. Aggressive implementation of advance directives. Crit Care Nurs
Q 1998;21:83-9.

NAGIA S. ALI, RN, PhD, is a professor of nursing at Ball State
University’s School of Nursing in Muncie, Ind.
Copyright 1999 by Mosby, Inc.
0197-4572/99/$8.00 + 0

34/1/102756

sustaining treatments to enable their patients to make
informed choices in selecting or refusing a treatment.
Discussing end-of-life issues should occur when the
individual is well, not hospitalized for a life-threatening

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Geriatric Nursing Volume 20, Number 5