Advance care planning video helps heart failure patients make informed decisions

Adults with advanced heart failure who watched a video encouraging them to have advance care planning with their physicians were more likely to focus on comfort and less likely to choose cardiopulmonary resuscitation (CPR) and intubation, according to a recent randomized study.

Lead researcher Areej El-Jawahri, MD, of Massachusetts General Hospital in Boston, and colleagues published their results online June 29 in Circulation.

“In this case, a picture is worth a thousand words,” El-Jawahri said in a news release “After watching the video, patients have a much better sense of what procedures and therapies align with their own preferences and values.”

The researchers enrolled 246 participants from June 28, 2012, to Feb. 7, 2015, at seven teaching hospitals in the U.S. The participants were at least 64 years old and had advanced heart failure.

They were then randomized in a 1:1 ratio to a video-assisted intervention group or a control group. After listening to a physician or nurse describe the three goals of care, participants in the video-assisted group watched a six-minute video on an iPad that outlined the three goals of care: life-prolonging care, limited medical care and comfort care. The participants were also provided with a checklist on advance care planning, which the researchers defined as “a process of shared decision making that informs and engages patients to ensure that the care delivered is concordant with their informed wishes.”

The researchers obtained the participants’ goal-of-care preferences, CPR/intubation preferences and knowledge before randomization at baseline and after they watched the video. Meanwhile, participants in the control group did not watch the video or receive the advance care planning checklist.

The mean age of participants was 81 years old, while 85 percent were white and 61 percent were male. In addition, 91 percent had New York Heart Association class III heart failure and 28 percent had an implantable cardioverter-defibrillator.

At baseline, the groups had similar goals-of-care preferences. However, after the intervention, more participants preferred comfort care in the intervention group compared with the control group.

In the intervention group, 22 percent preferred life-prolonging care, 25 percent preferred limited medical care, 51 percent preferred comfort care and 2 percent were uncertain. In the control group, 41 percent preferred life-prolonging care, 22 percent preferred limited medical care, 30 percent preferred comfort care and 7 percent were uncertain.

The groups had similar rates of participants wanting to forgo CPR and intubation at baseline, as well. However, after the intervention, 68 percent of participants in the intervention group and 35 percent of participants in the control group preferred to forgo CPR. In addition, 76 percent and 48 percent of participants, respectively, preferred to forgo intubation.

In addition, 79 percent of participants in the intervention arm said they were “very comfortable” watching the video, 20 percent said they were “somewhat comfortable” and 1 percent said they were “not comfortable.” Further, 82 percent said they would “definitely recommend” the video, 14 percent said they would “probably recommend” the video and 3 percent said they would “not recommend” the video.

The researchers cited a few limitations of the study, including that the data collectors were not blinded to the randomization. The trial also included mostly white participants, so the results may not be generalizable to other groups. The researchers acknowledged, as well, that “visual media can be manipulated to favor a particular decision,” although they said they vetted the video with different sources and received mostly positive reviews.

“This trial is an important step forward because heart disease is the leading cause of death worldwide and because [advance care planning] has been slow to come to this clinical arena,” the researchers wrote. “Patients’ underestimation of poor prognosis, clinicians’ lack of communication training, and clinicians’ uncertainty about the trajectory of heart failure partly ac- count for the lack of [advance care planning] conversations. However, patients and families deserve to learn their options for goals of care and to be able to make decisions and communicate them to someone who can help them meet those goals. Our approach using video decision support tools offers a scalable solution to enhance these conversations and [advance care planning] more broadly.”