4 INFECCIÓN DE SITIO QUIRÚRGICO (ISQ).

I can remember a discussion with my parents about 15 years ago. They had recently met with an attorney and done some financial and estate planning. My Dad handed me a 9 by 12 inch envelope and told me it was a copy of their will, and that I needed to put it somewhere safe. My parents then wanted to talk a little bit about the will and about their advance directives. As the discussion got into some of the details regarding their wishes at end of life I can remember clearly saying, “OK, OK, let’s stop talking about this. I don’t want to talk about this.”That was well before I started pursuing a doctorate in public health or had much interest in advance directives and end-of-life planning. My literature review and research both clearly indicate that people do not like talking about death or dying, especially the death of a loved one or their own mortality. My own experience, as mentioned above, confirms this as well. I found it interesting that several of the key informants mentioned advance care planning being an uncomfortable topic for healthcare providers to raise with patients. In one of the articles identified in my second literature review, Felicia Cohn, Director of Bioethics for Kaiser Permanente, stated, “We need to reframe the advance care planning discussion as a matter of choice and empowerment rather than death and dying.” Reframing the advance care planning discussion will help with the most important of the six themes from the key informant interviews, advance care planning being an uncomfortable topic of discussion.

When you combine the lack of comfort that many healthcare providers have raising the subject with the time constraints placed on providers and add the need to educate both the general public and healthcare professionals, it is easy to see that there is work to be done in this

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area. Medicare providing reimbursement to healthcare professionals for advance care planning discussions is a step in the right direction.

As Table 1 showed, between the mid-1970s and mid-1990s all 50 states passed some form of advance directive or living will legislation. Over the past 50 years the culture of healthcare professionals in the U.S. has evolved from one that leans toward trying everything possible to preserve life toward one accepting of death as inevitable and trying to maximize the quality of life during the final days, weeks, or months of life. Palliative care as a board certified specialty for physicians is less than 15 years old, becoming a defined medical specialty in 2006. Palliative care is a specialty that focuses on the comforts and desires of the patient. End-of-life care is one of the areas in which palliative care is most commonly used. As a patient and his or her loved ones make decisions to limit life sustaining treatments, making sure the patient is comfortable and not experiencing any unnecessary pain or distress is important for most patients and families.

Educating patients and their loved ones on advance care planning and end-of-life

decisions can be complex and time consuming. In cases in which important end-of-life decisions should be discussed and have not yet been discussed it is important to first be sure the patient and loved ones understand the diagnosis and likely disease progression. This piece alone can be difficult. As applicable once that piece is accomplished the treatment options available to the patient should be covered along with the positive and negative aspects of each treatment option. If a patient does not have an advance directive, after the patient and loved ones understand the diagnosis and treatment options, advance directives and end-of-life planning should be

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A few key informants suggested that the simplification of some of the forms and different types of advance care planning forms would help. They expressed frustration that there are so many different types of advance directives, and several key informants shared that they prefer using the MOST form. The MOST form is a medical order that is signed by both the patient and clinician and becomes effective as soon as it is signed. MOST forms are not technically

considered advance directives because the MOST is effective immediately after it is signed and advance directives are not effective until the patient is no longer able to make his or her own decisions. MOST forms used in North Carolina clearly state that MOST is part of advance care planning, which also may include a living will and healthcare power of attorney. While a DNR form is only signed by a physician and only addresses cardiopulmonary resuscitation, a MOST form addresses cardiopulmonary resuscitation, medical interventions, such as intubation or mechanical ventilation, as well as the use of antibiotics and IV fluids. MOST forms and DNR forms are different but both forms have the same goal of honoring a person’s wishes for the care he or she receives at the end of life.

Interestingly, I did not hear anything about facilitators of getting an advance directive completed. This was in spite of the fact that I asked the following questions:

 How do you address the barriers to completing an advance directive?

 If you could change one thing to make it easier to get an advance directive completed what would you change and why?

 Are you trying any new approaches or considering trying any new approaches to getting an advance directive completed?

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The only answers I got that resembled facilitators were about education, simplification, and a two-step approach involving two separate meetings to complete an advance directive. In hindsight it would have been interesting to delve into potential facilitators a little more.

Exploring facilitators is something that could be explored in another research study that builds upon this research.

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