Advance directive education sessions emphasizing the importance of discussions and AD forms were demonstrated to be helpful for outpatient dialysis patients and may help facilitate a patient’s desire to complete the AD. Responses from the post-educational survey indicate that the educational session influenced patient decision-making, and an overwhelming majority of
participants responded favorably to completing an AD because of the information provided. However, there was no change in the AD completion rate, which is likely due to a lack of
appropriate social worker follow-up due to external factors. Overall, the project reflects the need for education and increased patient awareness regarding ADs and supports the role of patient education in the process of advance care planning.
Implication for Practice
Despite the lack of improvement in the AD completion rate or code status change after the intervention, participants in the study found the education to be helpful and responded positively to completing ADs. The process of patient education may be a low-cost solution to raise patient awareness of advance directives, stimulate patient interest in completing advance directives, and establish a useful patient education tool for dialysis staff. Overall, the project results have several clinical and organizational implications.
Clinical Implications. First, this project provides evidence that patient education may be
an important step in the process of facilitating AD completion. The project led to an increased patient awareness of ADs among both patients and dialysis staff. Several participants requested to speak with their social worker after the educational intervention to complete ADs, and two requested copies of the dialysis organization’s AD forms to take home to review with their family. One participant called his son immediately after the intervention to consult about having a code status change. One dialysis staff member approached the project leader to obtain online resources for filling out an AD for herself. Given these promising signs observed by the project leader, the project leader suspects that the lack of an improved AD completion rate is likely due to lack of follow-up among the social workers or other external factors, such as the dialysis facility renovation that began one week after the intervention concluded.
Organizational Implications. Organizationally, this project supports integrating patient
education about ADs into current facility protocol to improve the AD completion rate at the dialysis facility. The dialysis facility that participated in the project has a low rate of AD completion, despite the current facility protocol to address AD completion by facility social workers as part of a mandatory annual review. Participants who were recruited to the study have
been on dialysis at the facility setting at least three years, and yet have not completed ADs, suggesting patient resistance to AD completion. From the results of this project, it is suggested that a patient education session may play a key role in encouraging patient compliance with completing ADs at the current facility, as patients who are “primed” with baseline knowledge regarding ADs may be more receptive to further steps in the process of advance care planning when the subject is approached by a member of the health care team. Further studies should be conducted to measure the AD completion rate at the dialysis facility after the education session during a period more conducive to follow-up.
Strengths. Project strengths include the representative nature of the dialysis patient
participant sample, which is thought to be very similar to other dialysis clinics in rural Virginia. Another strength is the feasibility of this intervention. The project design may be easily
replicated in a broader setting, given the cost-effectiveness of a strategy using accessible online resources as a guide to provide patient education on ADs.
Limitations. The major confounding factor of this project was the lack of social worker
follow-up. The dialysis facility began building renovations, which required a shut-down of parts of the facility. Current dialysis patients were temporarily moved to different dialysis facilities within the organization and the dialysis times of most of the current patients were changed to accommodate the renovations. This occurred right after the patient education sessions concluded. Seven patients went to different facilities and all the study participants’ dialysis times were changed. The renovations also created additional workload for the social workers, as they were displaced from their offices and there was chaos at the dialysis facility, since patient times were changed often to accommodate the progression of renovations.
The study limitations also include limitations of internal validity due to the small sample size and relative homogeneity of the sample ethnicity, as the participating patient population consisted primarily of African American patients. However, the sample size is representative of the dialysis clinics in the rural Virginian area. Convenience sampling may also include bias, as patients who agreed to participate in the study may be more likely to respond positively to the education. In addition, the project leader was also an employee at the dialysis facility, although the patients were informed during the consent that participation would not influence the quality of their care or their relationship with the project leader. Additional confounding variables include patient awareness and education on ADs from other sources. External validity effects include patients’ subjective perceptions of ADs, personal experience with end-of-life care discussions, and lack of social worker follow-up due to clinic renovations.
Sustainability
The sustainability of the practice change was addressed through email communication with the social workers and dialysis clinic manager. It is promising that the social workers intend to follow up with the participants to the study, although a more structured approach is necessary for long-term sustainability. It is worthy to note that the dialysis facility has begun implementing AD education into the orientation for patients new to dialysis, and a new research project on advance care planning will be launched at the facility in the coming months. However,
implementing a strategy to continue to re-address AD completion and raise awareness regarding AD and advance care planning is essential.
Feasibility. The material used in the education session was provided to the social
workers and clinic manager to utilize as a continued educational tool. Although individual patient educational sessions require a time commitment the social workers may not have, the
educational material can be shared by any qualified member of the dialysis health care team. For example, nurses, who spend the most time with the patients and are often the first to identify patients who would benefit from the education, are ideal candidates to provide the patient education.
Project Evaluation. The project was limited by the timing of the dialysis clinic’s
renovations, which created a huge barrier for the facility’s social workers. It is possible that a longer time to allow for social worker follow-up could have produced more favorable results. Closer collaboration with the social workers by the project leader, more consistent reminders, and closer follow-up by the project leader may have improved follow-up, although the current building renovations would still have been a barrier.
Dissemination Plan
The dissemination plan includes sharing the study results with key stakeholders. Results of the study will be summarized into a poster presentation and presented at the dialysis clinic staff meeting. An email summary of the results will also be emailed to key stakeholders. The project leader also hopes to present the information to all dialysis managers of multiple dialysis clinics at a monthly leadership meeting, thus reaching all the dialysis clinics within the
References
American Nurses Association (ANA). (2015). Code of ethics with interpretive statements. Silver Spring, Maryland: Nursesbooks.org. Retrieved from
https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics- for-nurses/coe-view-only/
Arozullah, A. M., Yarnold, P. R., Bennett, C. L., Soltysik, R. C., Wolf, M. S., Ferreira, R. M., . . . Davis, T. (2007). Development and validation of a short-form, rapid estimate of adult literacy in medicine. Medical Care, 45(11), 1026-1033.
doi:10.1097/MLR.0b013e3180616c1b
Bristowe, K., Shepherd, K., Bryan, L., Brown, H., Carey, I., Matthews, B., & ... Murtagh, F. M. (2014). The development and piloting of the REnal specific Advanced Communication Training (REACT) programme to improve Advance Care Planning for renal patients.
Palliative Medicine, 28(4), 360-366. doi:10.1177/0269216313510342
Buckwalter, K. C., Cullen, L., Hanrahan, K., Kleiber, C., McCarthy, A. M., Rakel, B., & ... Tucker, S. (2017). Iowa Model of Evidence-Based Practice: Revisions and Validation.
Worldviews on Evidence-Based Nursing, 14(3), 175-182. doi:10.1111/wvn.12223
Eneanya, N. D., Wenger, J. B., Waite, K., Crittenden, S., Hazar, D. B., Volandes, A., & ... Paasche-Orlow, M. K. (2016). Racial Disparities in End-of-Life Communication and Preferences among Chronic Kidney Disease Patients. American Journal of Nephrology,
44(1), 46-53. doi:10.1159/000447097
Eneanya, N. D., Olaniran, K., Xu, D., Waite, K., Crittenden, S., Hazar, D. B., . . . Paasche- Orlow, M. K. (2018). Health literacy mediates racial disparities in cardiopulmonary
resuscitation knowledge among chronic kidney disease patients. Journal of Health Care
for the Poor and Underserved, 29(3), 1069-1082. doi:10.1353/hpu.2018.0080
Gazarian, P. K., Cronin, J., Dalto, J. L., Baker, K. M., Friel, B. J., Bruce-Baiden, W., & Rodriguez, L. Y. (2018). A systematic evaluation of advance care planning patient educational resources. Geriatric Nursing (New York, N.Y.).
https://doi.org/10.1016/j.gerinurse.2018.09.011
Geldsetzer, P., & Fawzi, W. (2017). Quasi-experimental study designs series—paper 2:
Complementary approaches to advancing global health knowledge. Journal of Clinical
Epidemiology, 89, 12-16. doi:10.1016/j.jclinepi.2017.03.015
Haras, M. S., Astroth, K. S., Woith, W. L., & Kossman, S. P. (2015). Exploring Advance Care Planning from the Nephrology Nurse Perspective: A Literature Review. Nephrology
Nursing Journal, 42(1), 23–36. Retrieved from EBSCO.
Hickman, R. L., Lipson, A. R., Pinto, M. D., & Pignatiello, G. (2014). Multimedia decision support intervention: A promising approach to enhance the intention to complete an advance directive among hospitalized adults. Journal of the American Association of
Nurse Practitioners, 26(4), 187–193. https://doi-org.ezproxy.liberty.edu/10.1002/2327-
6924.12051
Hilgeman, M. M., Uphold, C. R., Collins, A. N., Davis, L. L., Olsen, D. P., Burgio, K. L., … Allen, R. S. (2018). Enabling Advance Directive Completion: Feasibility of a New Nurse-Supported Advance Care Planning Intervention. Journal of Gerontological
Nursing, 44(7), 31–42. https://doi-org.ezproxy.liberty.edu/10.3928/00989134-20180614-
Hinderer, K. A., & Mei Ching Lee. (2014). Assessing a Nurse-Led Advance Directive and Advance Care Planning Seminar. Applied Nursing Research, 27(1), 84–86. https://doi- org.ezproxy.liberty.edu/10.1016/j.apnr.2013.10.004
Holley, J. L., & Davison, S. N. (2015). Advance care planning for patients with advanced CKD: A need to move forward. Clinical Journal of the American Society of Nephrology, 10(3), 344-346. doi:10.2215/CJN.00290115
Houben, C. H. M., MSc, Spruit, M. A., PhD, Groenen, M. T. J., MSc, Wouters, Emiel F.M., PhD, MD, & Janssen, Daisy J.A., PhD, MD. (2014). Efficacy of advance care planning: A systematic review and meta-analysis. Journal of the American Medical Directors
Association, 15(7), 477-489. doi:10.1016/j.jamda.2014.01.008
Janssen DJ, Spruit MA, Schols JM, van der Sande FM, Frenken LA, & Wouters EF. (2013). Insight into advance care planning for patients on dialysis. Journal of Pain & Symptom
Management, 45(1), 104–113. https://doi.org/10.1016/j.jpainsymman.2012.01.010
Kurella Tamura, M., Montez-Rath, M. E., Hall, Y. N., Katz, R., & O’Hare, A. M. (2017). Advance Directives and End-of-Life Care among Nursing Home Residents Receiving Maintenance Dialysis. Clinical Journal of The American Society of Nephrology: CJASN,
12(3), 435–442. https://doi.org/10.2215/CJN.07510716
Lazenby, S., Edwards, A., Samuriwo, R., Riley, S., Murray, M. A., & Carson, S. A. (2017). End- of-life care decisions for haemodialysis patients - “We only tend to have that discussion with them when they start deteriorating.” Health Expectations, 20(2), 260–273.
Lim, C.E.D., Ng, R.W.C., Cheng, N.C.L, Cigolini, M., Kwok C., & Brennan, F. (2016). Advance care planning for haemodialysis patients. Cochrane Database of Systematic Reviews
2016, 7. DOI: 10.1002/14651858.CD010737.pub2.
Lind, D. A., Marchal, W. G. & Wathen, S. A. (2010). Statistical Techniques in Business & Economics. (14th ed.). New York, NY: McGraw-Hill Companies, Inc.
Luckett, T., Sellars, M., Tieman, J., Pollock, C. A., Silvester, W., Butow, P. N., . . . Clayton, J. M. (2014). Advance care planning for adults with CKD: A systematic integrative review.
American Journal of Kidney Diseases, 63(5), 761-770. doi:10.1053/j.ajkd.2013.12.007
Mandel, E. I., Bernacki, R. E., & Block, S. D. (2017). Serious illness conversations in ESRD.
Clinical Journal of the American Society of Nephrology, 12(5), 854-863.
doi:10.2215/CJN.05760516
Marshall, E. (n.d.). The statistics tutor’s quick guide to commonly used statistical tests. Retrieved fromhttps://learn.liberty.edu/bbcswebdav/courses/NURS839_B01_201840/tutorsquickgui detostatistics_1.pdf
Mateo, M. A. & Foreman, M. D. (2014). Research for advanced practice nurses: From evidence
to practice. (2nd ed.). New York, NY: Springer Publishing Company.
Melnyk, B.M. & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & Healthcare:
A guide to best practice. (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Miller, B. (2018). Nurses preparation for advanced directives: An integrative review. Journal of
Professional Nursing: Official Journal of the American Association of Colleges of Nursing, 34(5), 369-377. doi:10.1016/j.profnurs.2018.07.001
National Institute on Aging. (2018). Advance Care Planning: Tips from the National Institute on Aging. Retrieved from: https://order.nia.nih.gov/sites/default/files/2018-03/advance- planning-tip-sheet.pdf
O’Halloran, P., Noble, H., Norwood, K., Maxwell, P., Shields, J., Fogarty, D., … Brazil, K. (2018). Advance Care Planning with Patients Who Have End-Stage Kidney Disease: A Systematic Realist Review. Journal of Pain and Symptom Management, 56(5), 795– 807.e18. https://doi-org.ezproxy.liberty.edu/10.1016/j.jpainsymman.2018.07.008
O'Hare, A. M., Szarka, J., McFarland, L. V., Taylor, J. S., Sudore, R. L., Trivedi, R., . . . Vig, E. K. (2016). Provider perspectives on advance care planning for patients with kidney disease: Whose job is it anyway? Clinical Journal of the American Society of Nephrology
11(5), 855-866. doi:10.2215/CJN.11351015
Patient Self-Determination Act of 1990 (PSDA) of the Omnibus Budget Reconciliation Act of 1990 (1990). (Pub. L. No. 101-508, § 4206, 104 Stat. 1388-31)
Pfeiffer, E. (1975). A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. Journal of American Geriatrics Society. 23, 433-41. Sinclair, C., Auret, K. A., Evans, S. F., Williamson, F., Dormer, S., Wilkinson, A., … Brims, F.
(2017). Advance care planning uptake among patients with severe lung disease: a randomized patient preference trial of a nurse-led, facilitated advance care planning intervention. BMJ Open, 7(2), e013415. https://doi-
org.ezproxy.liberty.edu/10.1136/bmjopen-2016-013415
Smith, V., & Wise, K. (2017). Evaluating nurses’ action outcomes and exploring their perspectives of implementing the POS-S (Renal) assessment tool for haemodialysis patients. Renal Society of Australasia Journal, 13(1), 14–21. Retrieved from EBSCO.
Strupeit, S., Buß, A., & Dassen, T. (2013). Effectiveness of nurse-delivered patient education interventions on quality of life in outpatients: A systematic review. Applied Nursing
Research, 26(4), 232–238. https://doi-org.ezproxy.liberty.edu/10.1016/j.apnr.2013.08.004
Song, Mi-Kyung, RN, PhD, Ward, Sandra E., RN, PhD, Fine, J. P., ScD, Hanson, Laura C., MD, MPH, Lin, F., PhD, Hladik, G. A., MD, . . . Bridgman, Jessica C., RD, MPH. (2015). Advance care planning and end-of-life decision making in dialysis: A randomized controlled trial targeting patients and their surrogates. American Journal of Kidney
Diseases, 66(5), 813-822. doi:10.1053/j.ajkd.2015.05.018
Skår, Å., Juvet, L., Smedslund, G., Bahus, M. K., Pedersen, R., & Fure, B. (2014). End-of-Life Care - How to Find the Appropriate Level and Intensity of Medical Treatment of
Seriously Ill and Dying Patients. Retrieved from https://www.fhi.no/en/publ/2014/end-of- life-care-how-to-find-the-appropriate-level/
Titler, M. G., Kleiber, C., Steelman, V. J., Rakel, B. A., Budreau, G., Everett, L. Q., & ... Goode, C. J. (2001). The Iowa Model of Evidence-Based Practice to Promote Quality Care.
Critical Care Nursing Clinics Of North America, 13(4), 497-509.
Tong, A., Cheung, K. L., Nair, S. S., Kurella Tamura, M., Craig, J. C., & Winkelmayer, W. C. (2014). Thematic synthesis of qualitative studies on patient and caregiver perspectives on end-of-life care in CKD. American Journal of Kidney Diseases: The Official Journal of
The National Kidney Foundation, 63(6), 913–927.
https://doi.org/10.1053/j.ajkd.2013.11.017
Toraya, C. (2014). Evaluation of advance directives video education for patients. Journal of
United States Renal Data System. (2017). Annual data report 2017: Epidemiology of kidney
disease in the United States. Retrieved from https://usrds.org/2017/view/v2_01.aspx
University of Virginia Healthcare Systems. (2017). Mission. Retrieved from: https://uvahealth.com/about/mission
Waite, K. R., Federman, A. D., McCarthy, D. M., Sudore, R., Curtis, L. M., Baker, D. W., … Paasche-Orlow, M. K. (2013). Literacy and race as risk factors for low rates of advance directives in older adults. Journal of the American Geriatrics Society, 61(3), 403–406. https://doi-org.ezproxy.liberty.edu/10.1111/jgs.12134
Wasylynuk, B. A., & Davison, S. N. (2016). An overview of advance care planning for patients with advanced chronic kidney disease: The basics. CANNT Journal = Journal ACITN,
List of Tables
Table 1. Responses to Pre-Education Survey
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?
63.3% n = 19
___ 36.7%
n = 11
2. Have you discussed these wishes with your doctor?
30% n = 9
___ 70%
n = 21 3. Are you familiar with advance
directives (living wills)?
53.3% n = 16 26.7% n = 8 20% n = 6 4. Do you feel that you understand
the purpose of advance directives (living will)? 63.3% n = 19 26.7% n = 8 10% n = 3 5. Would you like more information
about advance directives?
66.7% n = 20
___ 33.3%
Table 2. Responses to Post-Education Survey
Question Yes No
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?
66.7% n = 20
33.3% n = 10
2. Do you plan to complete the advance directive (living will) forms because of the education provided?
73.3% n = 22
26.7% n = 8 3. Do you feel that you have enough information
to start the process of discussing your wishes and completing the forms?
86.7% n = 26
13.3% n = 4 4. How helpful was the education to you? Mean rank of 4.43 (from 1 – 5)
Table 3. Correlation between Survey Items and Patient Age
*significant result
Survey Questions Pearson’s Correlation Two-tailed
significance Pre-Education Survey Questions
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?
-0.101 0.647
2. Have you discussed these wishes with your
doctor? 0.362 0.09
3. Are you familiar with advance directives (living
wills)? -0.542 0.008
4. Do you feel that you understand the purpose of
advance directives (living will)? -0.408 0.053
5. Would you like more information about
advance directives? -0.066 0.766
Post-Education Survey Questions
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?
-0.426 0.043*
2. Do you plan to complete the advance directive (living will) forms because of the education provided?
-0.391 0.065
3. Do you feel that you have enough information to start the process of discussing your wishes and completing the forms?
-0.315 0.143
4. How helpful was the education to you?
Table 4. Correlation between Survey Items and Years on Dialysis at Current Facility
Survey Questions Pearson’s Correlation Two-tailed
significance Pre-Education Survey Questions
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?
-0.62 0.865
2. Have you discussed these wishes with your
doctor? -0.452 0.189
3. Are you familiar with advance directives (living
wills)? 0.627 0.052
4. Do you feel that you understand the purpose of
advance directives (living will)? 0.552 0.098
5. Would you like more information about
advance directives? -0.497 0.144
Post-Education Survey Questions
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?
0.058 0.874
2. Do you plan to complete the advance directive (living will) forms because of the education provided?
-0.158 0.663
3. Do you feel that you have enough information to start the process of discussing your wishes and completing the forms?
0.362 0.305
4. How helpful was the education to you?
Appendices Appendix A Evidence Table
Article Title, Author, etc. (Current APA Format)
Study
Purpose Sample Methods Study Results
Level of Eviden ce Study Limitati ons Would Use as Evidence to Support a Change? (Yes or No) Provide Rationale. Lim, C.E.D., Ng, R.W.C., Cheng, N.C.L, Cigolini, M., Kwok C., & Brennan, F. (2016). Advance care planning for haemodialysis patients. Cochrane Database of Systematic Reviews 2016, 7. DOI: 10.1002/14651858.CD010 737.pub2. To compare ACP intervention with no form of advance care planning and its effect on hospital admissions and quality end-of- life care Studies on people with ESRD undergoing hemodialysi s, did not include people with clinically diagnosed mental illness Systemic review of RCTs and quasi- RCTs Patients were highly satisfied with quality of communication and greater levels of comfort; ACP discussion did not destroy hope, cause unnecessary discomfort or anxiety for patients Level 1 Only two studies were included in the review due to poor study quality Yes; provides background information on ACP in dialysis and reflects need for more research Song, Mi-Kyung, RN, PhD, Ward, Sandra E., RN, PhD, Fine, J. P., ScD, Hanson, Laura C., MD, MPH, Lin, F., PhD,