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Nudging residents to document advance directives

Picture of this frog has no bearing on the post. I'm not saying residents are frogs in disguise.  Seriously.  It's just a cool picture, isn't it?  Credit Wikimedia Commons
So on the one hand, it seems wierd that residents ask patients about code status when they are admitted to the hospital.  Some patients don't expect it.  I remember a healthy 20 something year old guy admitted for an inflammatory bowel syndome flare saying, "Why are you asking me this?  Am I going to die?"

On the other hand, hospital admission to a medicine service is one of the few times critical advance care planning conversations occur.  This represents a major opportunity to communicate with patients about their goals, values, and preferences for end-of-life care.  Unfortunately, even when these conversations take place, the medical residents sometimes do not document this information in the medical record or discharge summary in a place where it is clearly accessible for future clinicians.

In that context, Josh Lakin and colleagues at UCSF created a remarkable incentive program for residents to document advance directives in the chart.  The study was just published in JAMA Internal Medicine.  They set a goal of increasing documentation of the following for hospiatlized patients: 1) wishes for care 2) identification of health care proxy. 

The intervention consisted of
  1. A discharge summary template with these fields
  2. A financial incentive ($400 for each resident if the entire program achieved a 75% documenationa rate)
  3. Feedback about each resident and admitting team was doing emailed out to all the teams biweekly
The results:
  • Rates of documentation improved from 22% to more than 90% at the end of the year
  • In a comparison group of a hospitalist-only service (no residents) who had the template but no financial incentive or feedback mechanism, rates stayed constantly low throughout the year.
I love this idea.  It uses behavioral economics to nudge people to do what they should be doing anyway.  Can you imagine the peer pressure with the "public reporting" among the admitting medical teams, "Oh no! Our team is falling behind! We don't want to be the ones who jeaporidize the whole program being paid for not meeting the 75% target!  Let's document!"

by: Alex Smith


Anonymous said…
Hi, can anyone here please shed some light on why a MSG that is looking to hire a Geriatrician expects the doctor to see 25 patients a day? Are they living in the real world? This sounds like a mill that is only focused on the $$$$$$$$. How can a Geriatrician do justice much less have any kind of quality of life when expected to process 25 Geriatric Patients a day?

Thank you,

Carol Cross said…
Does this explain WHY DNR Code Status is so widespread in the charts of old Medicare/Medicaid patients in California.

I'm sure that it is rare indeed when an elderly patient requests CPR after talking with residents who explain how risky and futile CPR is (generally) for the elderly.

Unfortunately, the elderly don't understand that NO CPR translates to Do Not Resuscitate Code Status and that DNR status is often inappropriately used to limit life-saving treatments that the Hospitals KNOW will not be reimbursed by Medicare and the private insurers.

The problem of DNR Code Status is long standing and there have been many studies, most of which indicate that the mortality rate among patients with DNR in their hospital chart is always higher ---even when adjusted for known variables.

Somehow, paying $500 to residents to influence the elderly to shorten their lives seems immoral to me.

John Newman said…
These resident financial incentives seem to work. I've been curious, though, if they cause real cultural change or if there's a crowding-out effect where this year's incentive displaces last year's in the residents' workflow. For example, PCP notification was another highly successful incentive a couple of years ago. These days, are residents still notifying 90% of PCPs or are rates falling to pre-incentive levels? Ideas for the next study...
Alex Smith said…
Interesting John - I was wondering the same thing. How effective is the intervention after the intervention period? Is there a lasting effect due to culture change, or do we need "kickers" in the residents contracts for each of these outcomes.
I love your term, “behavioral economics to nudge people,” even though it takes 36 characters including spaces instead of 5 (for “bribe”), although I initially considered it a euphemism. What changed my mind about this value-laden word? The psychological herd effect; not to be the one who “jeopardizes the whole program being paid for not meeting the 75% target!” The psychological perception overcomes the economic one, since $400 is a small percentage of what residents now earn in a year. But this consideration makes one skeptical regarding on changing behavior after the intervention period. What might work? Testimonials from patients who say, “I am so glad my doctor asked me….”

Stan Terman
Alex Smith said…
Hi Stan, appreciate your comment, especially the word count joke! Behavioral economics builds on some terrific work by Kahneman and Tversky, for which they were awarded the nobel prize. The hope is that once norms around documentation are changed, people will have a hard time going against the grain and NOT documenting them. So the financial incentive may not be necessary long term.

Patient feedback would also be helpful, and satisfaction (the major measure used by hospitals) just isn't enough. It's the wrong question. The right question, as you imply, is about preparation. Later, when things get rough, are they glad their doctor asked them some difficult questions and documented their preferences.
Sarah Bird said…
Interesting way to solve an issue that is prevalent in healthcare. I work in Hospice and am well aware of the unique challenges of discussing sensitive issues. It's not unheard of for hospitals here to discharge patients to Hospice with no information about Advanced Directives. My company recently published an article describing what we have to do in situations where there are no AD and the patient is unable to communicate on their own, Making Healthcare Decisions in Arizona (use of a surrogate).

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