CHICAGO — Elderly persons shown a video depiction of advanced Alzheimer's are less likely to opt for life-prolonging care, compared with those who listen to a verbal description.
A multicenter, prospective trial randomized 200 community-dwelling adults aged at least 65 years (mean 75 years) to one of two interventions and then compared their preferences for advanced care if they were in a state of dementia. In all, 106 participants listened to a standardized verbal description of stage 7 Alzheimer's, which is the final stage of the disease when individuals lose the ability to speak or respond to their environment, and ultimately their ability to control movement. The other 94 participants listened to the verbal description and viewed a 2-minute video of a real patient with features of stage 7 Alzheimer's and her family. (The video can be viewed online at www.ACPdecisions.com
Among those hearing only the verbal description, 68% preferred comfort care, 17% chose limited care, 13% wanted care that would prolong their life, and 2% were uncertain.
Among those receiving both the verbal narrative and the video, 87% preferred comfort care, 8% chose limited care, 4% desired life-prolonging care, and 1% were undecided, Dr. Angelo E. Volandes said at the annual meeting of the American Geriatrics Society.
“Most patients don't have experience with advanced disease,” he said. “Video may promote preferences for comfort care by providing more realistic expectations of dementia.”
Preferences also appear more stable when made with the assistance of a video. After 6 weeks, 27 (29%) of 94 participants interviewed in the verbal group changed their preferences, compared with only 5 (6%) of 84 participants in the video group. The difference between groups was statistically significant, said Dr. Volandes, an internist with Massachusetts General Hospital and Harvard University, both in Boston. Comfort care was significantly more likely to be selected as the new preference (86%) in the verbal group, whereas the percentage choosing this option remained constant in the video group.
“The use of innovative videos in end-of-life decision making and advance care planning discussions is relatively new,” Dr. Volandes said in an interview. “Further work and studies are needed to examine the implementation of these videos in clinical practice before they can become the standard of care.”
Dr. Volandes acknowledged that the study did not use real patients with a dementia diagnosis, and did not include Hispanics or Asians.
The convenience sample, selected from two primary care and two geriatric clinics, was 58% female, 29.5% African American, and had a score of 7 or higher on the Short Portable Mental Status Questionnaire. Overall, 68% of the verbal group and 73% in the video group had a ninth-grade or higher level of health literacy on the Rapid Estimate of Adult Literacy in Medicine test.
One audience member remarked that advance care directives are the most important thing he does as a geriatrician, and another acknowledged the struggle that often arises over goals of care with family members and health care power of attorney documents. The use of video in advance care planning has been evaluated in surrogate decision makers with similar results, Dr. Volandes said.
Dr. Volandes, who received a new investigator award for his work by the American Geriatrics Society, disclosed no conflicts of interest for himself or his associates.
The study was sponsored by the Alzheimer's Association, John A. Hartford Foundation, and the Foundation for Informed Medical Decision Making.