In a recent iHealthBeat post, Steve Findlay talks about a provision in the new meaningful use rules for health information technology issued by DHSS. Findlay noted that nothing seems to have moved the needle on people completing advance directives. He expressed hope that this can now be rectified if hospitals embrace the optional (menu set) meaningful use objective that promotes recording the existence of an advance directive in a person's EHR. It's a start.
Hmm. Hasn't the requirement to ask each patient if they have an advance directive been part of the JCAHO standards for years? And how has that been working?
Here's my experience with this measure in real life:
Last fall I was suddenly admitted to a local hospital for testing and observation. While in the emergency room over several hours, I was asked by two separate members of my care team: Do you have an advance directive? When I later reached my hospital room, another clinician asked: Do you have an advance directive? Three times I was asked this one simple question'three times I said no. There was no explanation for the question provided by any of the team. In just one instance, I was offered sample information about advance directives. Although I indicated I would like to have it'no information was ever provided.
Nothing about this promoted anything but a bit of idle curiosity and pique on my part. Given all the other scary things that were going on during this intake evaluation, why did they keep asking me this specific question? And then why once answered, did they ask the same question over and over again? Would they have been satisfied if I had said yes, but it's at home? What if I had had the foresight in the midst of my crisis to bring a copy would it actually be included in my record? What if I had an outdated advance directive entered in the system would this question have been asked in the first place?
I was reminded of the box I mindlessly check off at my local pharmacy, indicating that I am declining individual counseling by the pharmacist about my prescription. Nothing in the process encourages me to seek information in this public setting; nothing suggests doing so might be worthwhile.
Neither recording the existence of advance directive in my hospital record nor documenting that that I waived consultation by a pharmacist really supports or facilitates my active participation. Rather, each one bluntly attempts to align an ideal (people should complete and share advance directives with health care providers; make it possible to get experts' advice at the point of Rx dispensing) with what appears to be a teachable moment.
After the first inquiry about my advance directive in the emergency room, with no discussion or assistance offered, this stopped being a meaningful opportunity. When filling in a box is the desired outcome, those in charge learn very quickly how to achieve that goal. All those good intentions and the multiple steps that it takes to actually influence people's behavior merely get in the way.