1. Barriers to the Completion of Advance Directives An Integrative Review of the Literature Anna Malia Connor Ticknor MENP for Non-Nurse (MS), College of Sciences and Health, DePaul University
Background
Advanced directives (ADs) are legal documents that allows an individual to document their specific wishes for medical care should they become unable to speak for themselves.
The use of ADs has implications directing the course of end-of-life care affecting both the cost and direction of care.
Advance directives can clarify confusion and provide guidance.
Their implementation is not clearly defined within the healthcare system.
Surveys indicate these documents have limited use within the United States for reasons that are not easily isolated.
Purpose
This literature review sought to
Synthesize existing research on AD utilization
Identify barriers to the use of ADs
Identify the nursing implications of these barriers.
Research Question
What are the barriers to the use of advanced directives?
What implications do advanced directives have for nursing?
Methods
Data was collected from CINAHL Complete, PubMed, PsychInfo using search terms “advance directive”, “barrier”, and/or “completion” between 2006 and Additional ancestry searching and citation-index searching was performed to add depth in reviewing seminal works.
Results: The review of literature revealed recurring themes of patient and provider reluctance, readiness, attitudes, time constraints, knowledge deficit, lack of opportunity, and lack of comfort with the subject of ADs all contributed to limited completion of ADs.
CINAHL
PubMed
PsycInfo
Number of studies found using keywords
210
297
174
Number of studies meeting inclusion criteria 67 15 18
Number of studies after removing duplicates 58 12 11
Number of studies after using exclusion criteria 13 8 3
Results
Barriers to the completion of ADs are multifaceted and include:
Deficient patient knowledge
Limited medical literacy among patient’s
Providers’ technical and cultural competence in discussing and documenting end-of-life wishes
Physicians dissonance between their personal beliefs and their influence on completing and documenting patients
Nurses may feel unclear about their role in the process of discussing and appropriately documenting patient’s wishes.
Conversations are often left for end-of-life though repeated conversations are shown to increase comfort with advanced directives and their completion.
A lack of comfort discussing advanced directives, unclear facility policy to delegate completion, and limited time with patients and families also prevent use of advanced directives.
Given the complexity of factors affecting the completion of advanced directives, their use may be profoundly affected by factors particular to a given patient and/or provider.
Conclusions
The findings suggest that barriers to ADs are complex and multifaceted. Limited research on overcoming these barriers exists. In the future, targeted interventions to individual barriers should be addressed to determine what interventions can increase the completion of ADs.
Nursing Implication
As health care providers who are often the most presence at the bedside, nurses have the opportunity to encourage the use of and educate patients about advanced directives.
Framework
In Merle Mishel’s Uncertainty in Illness theory, she asserted that uncertainty occurs when a lack of sufficient information prevents a person from categorizing an event. Prolonged instability can be interpreted as danger leading to intrusive thoughts, avoidance, and severe emotional distress (Alligood, M. R. & Marriner-Tomey, A., 2010, p ). Advanced directive planning and implementation provide the opportunity for clarity, continued assessment, and orientation to a patient’s goals when providing end-of-life care.