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Use of a video tool to enhance advanced care planning in dementia.

Use of a video tool to enhance advanced care planning in dementia.

Critique date: Mon, 12/19/2011 - 2:48pm
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Institution: 
Mount Sinai School of Medicine
   
Article Citation
Citation: 
Volandes AE, Paasche-Orlow MK, Barry MJ, Gillick MR, Minaker KL, Chang Y, Cook EF, Abbo ED, El-Jawahri A, Mitchell SL. Video decision support tool for advance care planning in dementia: randomised controlled trial. BMJ 2009;338:b1964.
   
Clinical Bottom Lines

In this randomized trial, community-dwelling, cognitively intact seniors shown a 2 minute video depicting advanced dementia were much more likely to select comfort as their preferred goal of care than those subjects just given a verbal description of the disease. In addition, those shown the video demonstrated greater knowledge of advanced dementia. 

Video should be considered as a useful tool to enhance patient decision-making, particularly at the end-of-life and in those with possible health literacy barriers. To ensure that the type of care patients receive actually reflects their preferences and values, other communication and educational modalities beyond simple verbal descriptions should be strongly considered.

Disclaimer: 
This is a review of the validity of a single study; the ‘bottom lines’ do not reflect comparison with the rest of the literature on this subject.
   
Methods
Type of Study: 
Therapy / Prevention
Study Design: 
Randomized, controlled clinical trial
Follow-up Period: 
6 weeks
Setting: 
Community-based
Patient Population: 

Setting: 4 primary care clinics in Boston, affiliated with teaching hospitals; both urban and suburban

English-speaking patients, age > 65

Significant Exclusions: 

Moderate-severe cognitive impairment

Intervention/Exposure: 

The intervention group was shown a 2 minute video depicting a real patient with advanced dementia. The video shows her sitting with her daughters, unable to communicate, being pushed in a wheelchair and being fed pureed food. Both the intervention and control groups received a verbal narrative describing advanced dementia.

Outcome Measures: 

Preference for care (life-prolonging, limited, comfort or uncertain) if advanced dementia were to develop. The primary outcome was the proportion of participants choosing comfort care. Other variables measured included knowledge regarding advanced dementia and overall health literacy.

Participant Follow-up: 
100% for primary endpoint, 89% for the 6 week follow-up interview
   
Results
Results: 

64% of subjects in the verbal-only narrative of dementia selected comfort care versus 86% of those who were also showed the video. This represents an absolute difference of 22%. Only 4% of those patients shown the video selected life-prolonging care versus 14% of those only receiving a verbal description.

Those subjects randomized to the video group also demonstrated higher knowledge scores in regards to understanding dementia. 

In addition to watching the video, high health literacy and white race were also predictive of a participant selecting comfort care.

   
Methodological Issues…
Methodological Issues and Applicability to Older Adults: 

There is a potential limitation in terms of the study’s external validity given that only English-speaking patients were enrolled. 

End of life decision making is a politically sensitive topic because of lingering concerns that care will be restricted or rationed by a 3rd party like the government. This study focused on the best tool for eliciting the preferences of patients so that the care they receive at the end of life is actually consistent with their goals and values.

   
Other Information
Funding Source and Role: 
The primary author was supported by funding through the Foundation for Informed Medical Decision Making, the Alzheimer’s Association, and the Hartford Foundation.
Created By: 
Ashley Shreves, MD, Fellow, Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine

Disclaimer: This is a review of the validity of a single study; the ‘bottom lines’ do not reflect comparison with the rest of the literature on this subject.