Bridging Disciplinary Boundaries (January 11 - 14, 2007)

Advance directives, which include the living will and health care proxy (HCP), are legally recognized directions on health care. An advance directive, executed when a person is mentally competent, becomes active when his or her mental capacity to make decisions about health care is lost. In the interests of self-determination at the end of life, advance directives are promoted by NASW. This study, employing a quasi-experimental design, included 94 orthopedic, surgical patients at a New York teaching hospital and comprised three groups: i) an experimental group (n=21) who received an educational interview on HCPs conducted by a qualified social worker; ii) a comparison group (n=36) from whom the interview was withheld, but who received federally mandated written information on HCPs in the manner common to all patients, and iii) patients (n=37) who reported already having executed a HCP and were therefore ineligible for the educational interview. Using logistic regression, the major finding was that a face-to-face educational interview on HCPs provided by a social worker led to a statistically significantly higher rate of signing HCPs in the experimental group compared to that of a comparison group (Fisher's Exact Test: p = 0.0013; 43% in the experimental group signed a HCP, compared to 6% in the comparison group). The social worker used an interview guide developed by Meier (1996) and the interviews took approximately 15 minutes. In addition, to deepen the understanding of patients' motivation and inclination to sign, or not to sign, a HCP, grounded theory was employed to analyze patients' responses to a set of questions that included: reasons for signing/not signing; from whom patients learned about advance directives. Major findings related to signing a HCP were that patients valued having representation and did not want extraordinary measures at the end of life, and although difficult to define, felt that HCPs were inherently “good”. Reasons for not signing included: surgery not being considered life threatening; ignorance about HCPs (despite receipt of federally mandated information); disinclination to think about them. There appeared to be a higher likelihood that HCPs were fully completed and therefore be legally valid if patients first learned about HCPs from a lawyer. Implications for social work practice are that a short informational interview about HCPs provided, for many patients, a sufficient prompt to sign a HCP. Patients voiced the importance of having representation, in the event of decisional incapacity, at the end of life and perhaps educators on advance directives should make this of central importance. Despite widespread education on advance directives, several patients were unfamiliar with them; so, it appears that further educational efforts are called for. Reference Meier, D. E., Gold, G., Mertz, K., Taylor, B., Cammer-Paris, B. E., Seckler, A., & Mulvihill, M. (1996). Enhancement of proxy appointment of older persons: Physician counseling in the ambulatory setting. Journal of the American Geriatrics Society, 44(1), 37-43.