Evaluation of Advance Directives Video Education for Patients

Abstract

Background:

Patients and families can make informed decisions at the end-of-life if they have had discussions regarding their wishes, but this is not regularly done due to poor understanding of advance directives (AD).

Objective:

The objective was to evaluate the effectiveness of an AD video to educate patients in both the inpatient and outpatient settings.

Methods:

A prospective, nonrandomized, pre/post-survey design study of 45 patients was conducted. Patients in clinics (n=37) and hospital (n=8) were asked to complete surveys measuring baseline understanding, completion, and discussions of AD prior to viewing the video. Patients viewed the video and completed similar surveys for feedback on the effectiveness of the video education.

Results:

Patients felt the video was informative and helpful and stated more of an urgency to complete AD with increased perceived understanding of the forms. Prior to the educational video, 66.7% of patients stated they had discussed AD with their loved ones, while only 29% stated they had discussed these with their provider. Only 44.4% of participants had completed AD forms, and the majority (70.3%) wanted more information. Participants stated that viewing the video increased their desire to complete AD (78.6%), felt they had enough information to have these discussions and complete the forms (97.6%), and rated the video very highly (mean rank of 8.8 of 10).

Conclusions:

AD video education is helpful to patients, improving perceived understanding of AD and increasing patients' intent to discuss and complete AD with family and providers.

Introduction

Advance directives (AD) include a health care directive (living will) and a durable power of attorney for health care (DPOA-HC). In some states, the health care directive (HD) is used only in the event patients are considered terminal and cannot speak for themselves, where life-sustaining treatment would only prolong the dying process.¹ AD are designed to protect the autonomy of the patient, with the idea that people will likely receive the care they want if they document their wishes in advance of losing decision-making capacity.^2,3 Many providers and patients alike feel that advance care planning is important, and should start early, prior to any life-threatening illness.^4–7 Patients see these directives as a way to prepare for future health care and death, avoid prolonging death, relieve burdens on family, and communicate their wishes.⁸

It is important to remember that it is the advance care planning discussion itself that is of most importance.^4–9 There is evidence that written advance directives alone, without discussion, are limited in their effectiveness.^10–13 Having the written documents alone does not ensure accurate decision-making about end-of-life and resuscitation decisions because wording is vague and specific to terminal conditions and futility.^14–16 Since it is almost impossible to predict an individual's exact end-of-life scenario, there is limited value to even the most detailed written directive.^14–17 Discussing wishes first and then documenting them with AD is most ideal.

Unfortunately, patients are not typically having these discussions with their providers and are not completing AD.^18–25 Barriers to having end-of-life care discussions include confusion about end-of-life issues and about advance directives,^22,26 not involving a physician when completing their living wills,^24,25 having a poor understanding of cardiopulmonary resuscitation (CPR) and life-sustaining therapies,²⁵ and having a fear of death and dying.^26,27 Although previous studies have used various educational methods, including videos, to address end-of-life care goals and choices,^28–34 none have used video education focused specifically on AD. The objective of our study was to evaluate the effectiveness of an educational AD video, to determine whether it increases patient understanding regarding discussions of future health care wishes and AD documents.

Methods

Participants

Participants were solicited from MultiCare Health System (MHS) outpatient clinics (n=37) and one hospital (n=8). The outpatient clinics included internal medicine and family medicine clinics. The hospital participants were recruited from the Critical Care Center (CCC) at one of our hospitals. All patients were over the age of 18 and English speaking.

Intervention

A 12-minute video was created, designed to encourage discussions about future health care wishes between a patient and patient's family and provider. It explains specific aspects of legal AD documents, current Washington state policy, and the benefits and limitations of the documents.¹ The content was written by this study's author and was further developed and edited with input from a multidisciplinary team consisting of MHS senior level clinical and administrative leadership, medical directors, hospice and palliative medicine providers, social work supervisors and their teams, nursing supervisors and directors, system nurse educators, chaplain director, and our Institutional Review Board. The video was created in partnership with the MHS Institute for Learning and Development.

Procedure

For a period of 4 months, providers and medical staff (nurses and social workers) were asked to offer patients the option of viewing the video during their clinic visit or returning at a convenient time to view the video. In the hospital, nurses and social workers offered patients the option to watch the video. The video was accessible on the television in each hospital room. Patients who agreed to watch the video completed a consent for the study, a prevideo survey, and a postvideo survey. The study was approved by the MHS Institutional Review Board.

Measures

Prevideo survey questions were developed to assess baseline AD information (Table 1). Surveys asked whether patients had discussed their wishes with family and/or providers, if they had completed AD forms, whether they felt they understood and were familiar with the forms, and if they wanted more information. Survey questions were either in a yes/no or written comment format.

Table 1.

Survey Questions Prior to Educational Video

Question	Possible responses
1. Have you discussed your health care wishes with family/loved ones in case you ever get seriously ill or injured and cannot communicate your wishes?	Yes/No
2. Have you discussed these wishes with your doctor?	Yes/No
3. Are you familiar with health care directives (living wills) and/or DPOA forms?	Yes/Somewhat/No
4. Have you completed a health care directive (living will) and/or DPOA DPOA form?	Yes/No
5. Do you feel that you understand the purpose of the living will and or DPOA forms?	Yes/Somewhat/No
6. Would you like more information about health care directives and DPOA?	Yes/No

DPOA, durable power of attorney for health care.

Postvideo survey questions were solicited to measure any changes or plans that may have occurred as a result of viewing the educational video. Patients were also asked to rate and comment on the video (Table 2). Initial surveys given did not ask participants to rate the video, therefore, our results only include rankings from 24 of 45 participants. Questions were designed to ascertain whether the education changed participant perception of AD and their desire to complete AD.

Table 2.

Survey Questions after Viewing Educational Video

Question	Possible responses
1. Has this education changed anything about your future health care wishes or about discussing your wishes with your family/loved ones and your doctor?	Yes/No
2. Do you plan to complete the health care directive (living will) and DPOA forms because of the education given in the video?	Yes/No/Undecided
3. Do you feel that you have enough information to start the process of discussing your wishes and completing the forms?	Yes/No
4. How helpful was the video to you?	Rank 1–10^a

Video Ranking: 1=not helpful, 10=extremely helpful.

DOPA, durable power of attorney for health care.

Statistical analysis

One-way analysis of variance (ANOVA) was used to evaluate associations between survey items and age. Tests were two-tailed and significance was assessed at α=0.05. Exploratory analysis of the relationships of survey items with gender and group did not yield statistically and/or clinically significant results and are not reported here. SPSS version 20.0 was used to perform all analyses (SPSS, Chicago, IL).

Results

Study participants

A total of 45 patients from outpatient clinics (n=37) and one hospital (n=8) participated in viewing the video and completed surveys. The mean age was 59.3 (standard deviation [SD]=15.8), with an age range of 21–84. Subjects came from both outpatient and inpatient settings, including 82.2% (n=37) from internal medicine and family medicine clinics, and 17.8% (n=8) from the hospital. Five participants did not report gender; of those who did, the majority were female (72.5%).

Prevideo surveys

Most participants had discussed their future health care wishes with family and loved ones (66.7%), but few had discussed wishes with their provider (28.9%). The majority had not completed a HD or DPOA-HC (55.6%), and, though most participants stated they were familiar with AD (52.3%) and understood them (77.8%), the majority (70.3%) wanted more information (Table 3). Participants reported lack of understanding and lack of urgency as the primary reasons for not having had discussions about AD (Table 4).

Table 3.

Survey Responses Prior to Educational Video

Question	Yes	Somewhat	No
1. Have you discussed your health care wishes with family/loved ones in case you ever get seriously ill or injured and cannot communicate your wishes?	66.7% n=30	—	33.3% n=15
2. Have you discussed these wishes with your doctor?	28.9% n=13	—	71.1% n=32
3. Are you familiar with health care directives (living wills) and/or DPOA forms?	52.3% n=23	34.1% n=15	13.6% n=6
4. Have you completed a health care directive (living will) and/or DPOA form?	44.4% n=20	—	55.6% n=25
5. Do you feel that you understand the purpose of the living will and DPOA forms?	77.8% n=35	15.6% n=7	6.7% n=3
6. Would you like more information about health care directives and DPOA?	70.3% n=26	—	29.7% n=11

DOPA, durable power of attorney for health care.

Table 4.

Reasons Given for Why a Participant has not Discussed Advance Directives

Category	Sample responses
Lack of understanding	“I don't know what I would do.”
	“It never came up.”
	“I didn't feel a need.”
Lack of urgency	“I kept putting it off.”
	“Haven't given it much thought.”
	“Haven't had the opportunity.”

Postvideo surveys

After viewing the video, the majority of participants planned to complete an AD (78.6%) and felt the video gave them enough information to start discussing their wishes and completing AD forms (97.6%) (Table 5). The average score among the 24 participants who were asked to rank the video was 8.8 out of 10 (Table 6). Participant comments showed a change in perspective, describing increased understanding of AD and the perception that this would assist in discussion of these issues with family and providers and completion of AD forms (Table 7).

Table 5.

Survey responses after Educational Video

Question	Yes	No	Undecided
1. Has this education changed anything about your future health care wishes or about discussing your wishes with your family/loved ones and your doctor?	58.1%n=23	41.9%n=18	—
2. Do you plan to complete the health care directive (living will) and DPOA forms because of the education given in the video?	78.6%n=33	19%n=8	2.4%n=1
3. Do you feel that you have enough information to start the process of discussing your wishes and completing the forms?	97.6%n=40	2.4%n=1	—
4. How helpful was the video to you?	Mean rank of 8.83 (of a possible 10)

DOPA, durable power of attorney for health care.

Table 6.

Ranking of Educational Video

Rank	Percent
5	4.2% (n=1)
7	16.7% (n=4)
8	20.8% (n=5)
9	4.2% (n=1)
10	54.2% (n=13)

Ranking: 1=not helpful, 10=extremely helpful.

Mean ranking: 8.83, standard deviation (SD)=1.47.

Table 7.

Participant Comments after Viewing Video

Category	Sample Responses
Increased urgency	“Will fill out forms now.”
	“Plan to have family discussion soon.”
	“Discuss with children they need to fill out info too.”
	“I will check out legal paperwork again this week.”
Change of perspective	“That it is ok to discuss this.”
	“Need to take things more seriously.”
	“Need to make a plan.”
	“Made it real for me.”
	“More intention to talk to kids.”
More understanding	“I'm understanding the need.”
	“Gave info I didn't know.
	“Didn't know living will was only for dire situations.”
	“I realize this is important to do so my family is aware of my wishes.”
General comments	“I want my family to watch this.”
	“I hope doctor will discuss with younger patients also.”
	“Straight to the point, relaxed discussion of difficult subject.”
	“Very thorough and understandable.”
	“This is really good, great info. The video is excellent.”

Discussion

AD video education emphasizing the importance of discussions and AD forms was shown to be helpful for both hospitalized patients and clinic patients. It was created to be informative and brief. Our results demonstrated that the video improved patient understanding of the purpose and limitations of AD forms, increased patients' intent for further discussions, and increased intent to complete AD forms.

Study limitations include the inability to track the number of patients who declined to view the video, limited demographic data, and not testing patients' factual knowledge regarding AD. Likert scale survey questions with the same questions on both pre and post surveys for a larger number of patients would be helpful for future research.

Conclusion

This study demonstrates that an educational video specifically about AD and discussions can help increase patients' awareness of the importance of having these discussions with their family and providers. Future studies are needed to explore optimizing methods to bring this video education to the greatest number of patients.

Footnotes

Acknowledgments

The author thanks the MHS staff and providers who helped with this project.

Author Disclosure Statement

No competing financial interests exist.

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