Advance Directives and Advance Care Planning

Advance Directives and
Advance Care Planning
for Healthcare Clinicians
Ensuring Patient Voices Are Heard

CE Provider
Information
VITAS®
Healthcare programs in California/Connecticut/
Delaware/Illinois/Northern/Virginia/Ohio/Pennsylvania/
Washington DC/ Wisconsin are provided CE credit for their
Social Workers through VITAS Healthcare Corporation,
provider #1222, is approved as a provider for social work
continuing education by the Association of Social Work
Boards (ASWB) www.aswb.org, through the Approved
Continuing Education (ACE) program. VITAS® Healthcare
maintains responsibility for the program. ASWB Approval
Period: (06/06/18 - 06/06/21). Social Workers participating
in these courses will receive 1 clinical continuing education
clock hour. {Counselors/MFT/IMFT are not eligible in Ohio}

CE Provider
Information
VITAS®
Healthcare, #1222, is approved to offer social work
continuing education by the Association of Social Work
Boards (ASWB) Approved Continuing Education (ACE)
program. Organizations, not individual courses, are approved
as ACE providers. State and provincial regulatory boards
have the final authority to determine whether an individual
course may be accepted for continuing education credit.
VITAS®
Healthcare maintains responsibility for this course.
ACE provider approval period: 06/06/2018 – 06/06/2021.
Social workers completing this course receive 1.0 continuing
education credits. VITAS®
Healthcare Corporation of
California, 310 Commerce, Suite 200, Irvine, CA 92602.
Provider approved by the California Board of Registered
Nursing, Provider Number 10517, expiring 01/31/2021.
Exceptions to the above are as follows: AL: No NHAs, DE:
No NHAs, DC: No NHAs, GA: No NHAs, KS: No NHAs, NJ:
No NHAs, OH: No NHAs, PA: No NHAs, TX: No NHAs, VA:
No NHAs, WI: No NHAs and Nurses are not required – RT
only receive CE Credit in Illinois

Goal
To educate healthcare clinicians about
advance directives and advance care
planning, as well as serve as a support
resource for those individuals.

ACP Basics
Per the National Hospice and Palliative
Care Organization (NHPCO), “Advance
care planning is making decisions about
the healthcare you would want to receive
if you’re facing a medical crisis. These are
your decisions to make, regardless of
what you choose for your care, and the
decisions are based on your personal
values, preferences, and discussions with
your loved ones.”
Advance Care Planning. Retrieved from https://www.nhpco.org/patients-and-caregivers/advance-care-planning/

• “Many people nearing the end of life
(EOL) are not physically or cognitively
able to make their own care decisions.”
• Of people who indicate their EOL care
preferences, most choose care focused
on alleviating pain and suffering.
Institute of Medicine (IOM). (2014). Dying in America: Improving Quality and Honoring Individual
Preferences Near the End of Life. Summary. Washington, DC: The National Academies Press.
Detering, K., et. al. (2018, May) Advance care planning and advance directives. Retrieved from:
https://www.uptodate.com/contents/advance-care-planning-and-advance-directives
ACP Basics
(cont.)

ACP Basics
(cont.)
Sudore, R.L., et al. (2017) Advance care planning for adults: A consensus definition from a
multidisciplinary Delphi panel. Journal of Pain and Symptom Management, 53(5):821.
• Frequent and ongoing clinician-patient
conversations about EOL care values,
goals, and preferences are necessary to
avoid unwanted treatment.
• Clinicians bear the responsibility to
help the patient explore treatment
options and to help them formulate their
preferences based upon a risk-benefit
analysis and their own values whenever
circumstances allow.

ACP Basics
(cont.)
• ACP supports people at any age or stage
of health in understanding and sharing their
personal values, goals, and preferences
regarding future medical care.
• Discussion goals and timing vary, based on
whether the person is healthy, has mild to
moderate chronic illness, or has an
advanced life-limiting illness.

ACP Basics
(cont.)
• ACP requires communication between
patients, their loved ones, and their
healthcare team, and is best done with
consideration of the patient’s relationships
and culture, which will then drive specific
medical treatment decisions that can be
recorded in an advance directive (AD).
• The primary objective of ACP is to ensure
that patients receive care aligned with their
goals and values.

Improved
Outcomes
with ACP
Teno, J.M. (2007). Association between advance directives and quality of end-of-life care:
A national study. Journal of the American Geriatric Society, 55(2):189.
Silvester, W., et al. (2016). Advance care planning in Australia: what does the law say?
Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/26567895
Molloy, D.W., et al. (2000). Systematic implementation of an advance directive program
in nursing homes: A randomized controlled trial. JAMA, 283(11):1437.
• Studies show ACP conversations improve
multiple outcomes:
– Fewer hospital admissions and intensive
treatments at end of life
– Increased enrollment in hospice care
– Higher likelihood of the person dying in
the setting of their choice
– Increased satisfaction

Few
Individuals
Have Had
an ACP
Discussion
With Their
Physician
Kaiser Family Foundation/The Economist. (2016, March 30-May 16). Four-Country Survey of Aging and End-Of-Life Medical Care.
Eggerston, L. (2013). Doctors, patients urged to discuss advanced care plans. CMAJ, 185(13): E617–E618.
• Only 11% report having a conversation
about end-of-life care with their health
care providers.
• Only 22% of those ages 65 and older
have had a conversation with their
healthcare provider.
• Most healthcare professionals want to
talk to patients about EOL care, and yet,
the majority of clinicians:
– Are uncomfortable
– Are unprepared
– Do not engage

Patients
Desire ACP
Discussions

End-of-Life
Discussions
Align Care
With Patient's
Wishes and
Values
Wright, et al. (2008). Associations between end-of-life discussions, patient mental health,
medical care near death, and caregiver bereavement adjustment. JAMA, 300(14):1665-1673.
McGill Psychological Subscale* Total Yes (+ACP) No (-ACP) P value
adjusted least square means (SE) Sample
“Depressed” 7.4 (2.9) 7.3 (0.2) 7.4 (0.2) 0.79
“Nervous or worried” 6.9 (3.2) 6.5 (0.3) 7.0 (0.3) 0.19
“Sad” 7.2 (3.0) 7.3 (0.2) 7.2 (0.2) 0.79
Acceptance, preferences Total Yes No AOR (95% CI)
and planning, N (%) Sample
Accepts illness is terminal 125 (37.7) 65 (52.9) 60 (28.7) 2.19 (1.40-3.43)*
Against death in ICU 118 (35.5) 60 (48.8) 58 (27.8) 2.13 (1.35-3.37)*
Completed DNR order 134 (41.1) 75 (63.0) 59 (28.5) 3.12 (1.98-4.90)*
Completed living will, durable 181 (55.2) 86 (71.7) 95 (46.1) 1.96 (1.25-3.07)**
power of attorney, or health
care proxy
*Subscales of the McGill Quality-of-Life Questionnaire (scale 0-10) where 0 is undesirable and 10 is desirable.
N = 322 *P value < 0.001 **P value = 0.003

End-of-Life
Discussions
Align Care
With Patient's
Wishes and
Values (cont.)
End-of-Life Discussions:
– 2x as likely to accept advanced diagnosis
– 2x as likely to be opposed to death in ICU
– 3x as likely to complete DNR
– Almost 2x as likely to complete a power
of attorney
– Give control back to patients and offer hope.
– Are not associated with physiological
distress compared to those who do not have
end of life discussions.
Wright, et al. (2008). Associations between end-of-life discussions, patient mental health,
medical care near death, and caregiver bereavement adjustment. JAMA, 300(14):1665-1673.

History of
Advance
Directives
• The advance directive is a product of the
patient and consumer rights movements
of the 1960s and 1970s, when the U.S.
Supreme Court established that patients
have a constitutional right to refuse
life-sustaining treatment – the right
of refusal.
• Over time, the Court decided that
withdrawal of care was tantamount to
refusal and extended these rights to
patients without decisional capacity
through their health care surrogates.

History of
Advance
Directives:
Patient
Self-
Determination
Act
Omnibus Budget Reconciliation Act of 1990. (1990). Public Law No. 101-508, §4206 & 4751.
• In 1990, Congress passed the Patient Self-
Determination Act (PSDA) incentivizing hospitals,
nursing facilities, hospices, and health maintenance
organizations to implement programs that provide all
adult patients, at the time of admission or enrollment,
with information about their rights under state laws
regarding healthcare decision-making.
• As part of the PSDA, institutions must inform
patients of the right to:
– Participate in and direct their own
healthcare decisions
– Refuse medical or surgical treatment
– Prepare an advance directive
– Review information on the institutional policies
governing these rights

Legal Case:
Karen Ann
Quinlan
First “right-to-die” case in U.S. legal history
April 14, 1975
• 21 year-old Quinlan stopped breathing and lapsed
into a coma
5 months later – September 12, 1975
• Was diagnosed as being in a persistent
vegetative state
• Parents requested to be disconnected from ventilator
• Doctors and county prosecutor refused to disconnect
from machines and parents took case to court
10 years later – June 11, 1985
• Weaned from respirator she survived nearly
10 more years
• Died of pulmonary failure in a nursing home

Legal Case:
Nancy Cruzan
Congress passed the Patient Self-Determination
Act (1990) in response to Cruzan’s case
January 11, 1983
• At 25 years old, Cruzan was in a car accident in
Missouri and was thrown from the car
• Paramedics resuscitated her
• A feeding tube was inserted after 3 weeks
in a coma
Almost 5 years later – October 23, 1987
• Cruzan’s parents requested that they be allowed to
remove feeding tube

Almost 6 years later – 1988
• July 27 – Cruzan’s parents were
authorized to request the withholding of food
and water
• November 16 – Missouri State Supreme Court
overturned the decision.
• Appealed the U.S. Supreme Court
8 years later – December 26, 1990
• County court ruling allowed Cruzan’s parents to
remove the feeding tube.
• Cruzan died 11 days later – 8 years after
her car accident
Legal Case:
Nancy Cruzan
(cont.)

Legal Case:
Terri Schiavo
The case of Terri Schiavo became subject of
intense public debate and activism
• February 25, 1990
• 26-year-old Terri collapsed at home and was
rushed to the hospital
• Four months later, Michael Schiavo, Terri’s husband,
was appointed her plenary guardian
• 8 years later – May 1998
• Michael Schiavo filed a petition to
withdraw life support
• Terri’s parents opposed, and court appointed a new
guardian ad litem (third party during custody disputes)

Legal Case:
Terri Schiavo
(cont.)
10-15 years later – 2000-2005
• 2000 - Given lack of living will, a trial was held to
determine what Terri’s wishes would have been.
• 2001 - Terri’s parents filed a motion filing new
evidence of Terri’s wishes and claiming new medical
treatment available.
• 2003 - Feeding tube was removed for second time.
A week later Florida legislature passed “Terri’s Law,
ordering feeding tube to be reinserted.
• 2004 - Florida Supreme Court overturned the law as
unconstitutional.
• 2005 - March 18 - Terri’s feeding tube was removed
for the third and final time.
• 2005 - March 31 - Terri died.

Advance
Directives
Defined
Advance directives are legal documents that
allow patients to formally state their choices
regarding what actions should be taken or
not taken regarding their health in case they
are no longer able to make decisions for
themselves because of lack of capacity
(lack of ability to make informed medical
decisions).

Only 1/3 of
Americans
Have an
Advanced
Directive
Yadav, K.N., et al. (2017). One in three U.S. adults completes any type of advance
directive for end-of-life care. Health Affairs, 36(7):1244-1251.
A 2017 study looked at data from more
than 795,000 Americans:
– Only 29% percent had completed a
living will that contained specific
end-of-life care wishes
– Only 33% percent had designated a
health care power of attorney

Do Advance
Directives
Work?
Silveira, M.J., et al. (2010). Advance directives and outcomes of surrogate decision making before death.
New England Journal of Medicine, 362:1211-1218.
* Percentages are weighted and were derived with the use of sampling weighs from the Health and Retirement Study.
DPAHC denotes durable power of attorney for health care.
Table 3. Key Outcomes According to Advance-Directive Status among 999 Subjects.*
Outcome Living Will No Living Will
(N=44) (N=552)
% of subjects
Adjusted Odds
Ratio (95% CI)
DPAHC No DPAH
(N=589) (N=407)
% of subjects
Adjusted Odds
Ratio (95% CI)
Death in a hospital 38.8 50.4 0.71 (0.47–1.07) 38.2 55.8 0.72 (0.55–0.93)
All care possible 8.1 27.7 0.33 (0.19–0.56) 13.4 27.0 0.54 (0.34–0.86)
Limited care 80.6 66.0 1.79 (1.28–2.50) 75.4 68.1 1.18 (0.75–1.85)
Comfort care 96.8 91.3 2.59 (1.06–6.31) 95.9 90.6 2.01 (0.89–4.52)

Importance
of Completing
Advance
Directives
Thomson Reuters. National survey of healthcare consumer: End-of-life care. Retrieved from:
http://www.factsforhealthcare.com/pressroom/NPR_report_EndofLifeCare0710.pdf
Yadav, K.N., et al. (2017). Approximately one in three U.S. adults completes any type of
advance directive for end-of-life care. Health Affairs, 36(7):1244-1251.
• Approximately 85% of adults believe that
completing an advance directive is the right
thing to do.
• 38% of patients with chronic illnesses had
completed advance directives vs. 33%
for healthy adults.
• We think it’s important, but we don’t do it.

Education
About EOL
Topics and
ACP Is
Needed
Fulmer, T., et al. (2018). Physicians' views on ACP and end-of-life conversations. Journal of the American Geriatrics Society. 1-5.
Figure 1. Responses to question: In your
own opinion, how important is it that
healthcare providers have advance care
planning conversations with patients?
Figure 2. Percentage of respondents who
support the new Medicare benefit paying
for advance care planning conversations.
Somewhat
important,
10% Not too/not
at all
important,
1%
Extremely
important,
51%
Very
important,
38%
Somewhat
oppose, 3%
Strongly
oppose, 1%
Supports,
95%Strongly
support, 66%
Somewhat
support ,
29%

Types of
Advance
Directives
• Vary depending on state law and individual
preferences within the state’s legal
requirements
• Most common types of advance directives:
– Living Will
– Durable Power of Attorney for
Healthcare/Medical Power of Attorney

Living Wills
• Specifies future healthcare decisions when
a patient becomes unable to express their
wishes or make informed decisions about
their healthcare
• Must also have an advanced illness or be
permanently unconscious
• Describes the type of medical treatment the
person would want or would not want
• Identifies a legal representative (sometimes
called a “surrogate” or “medical proxy”)
and provides general guidance about
what treatment an individual would or
would not want.

Living Wills
(cont.)
• Can range from general to specific wishes
• A legal document, not a medical order
• A competent person may revoke a living will
• Can be changed or revoked at any time if
the patient is able to communicate and is
legally competent
• Because it is not a medical order, it is
not used to treat a patient in an
emergency situation.

Durable
Power of
Attorney for
Healthcare
Peeler, T. (2019, October 10). Types of advance medical directives. LegalMatch. Retrieved from:
https://www.legalmatch.com/law-library/article/types-of-advance-medical-directives.html
• Legal document in which a patient names a
person to be their proxy (agent) to make all
healthcare decisions if they become unable
to do so (lacks capacity)
• Usually part of an Advance Directive, but may
be separate, as can be broader than only
healthcare decisions.
• The document may also be called a medical
(or healthcare) power of attorney (MPOA),
medical proxy, or healthcare agent.
• Almost all states require proxy designation to
be in writing.
• Proxy can be whomever the patient chooses.
• Proxy should be someone the patient trusts.
• Advisable to name a back-up

Durable
Power of
Attorney for
Healthcare
(cont.)
Peeler, T. (2019, October 10). Types of advance medical directives. LegalMatch. Retrieved from:
https://www.legalmatch.com/law-library/article/types-of-advance-medical-directives.html
• Proxy can speak with caregivers and make
decisions based on directions given earlier.
• If the patient’s wishes are unknown, the
proxy will decide based on what he/she
thinks the patient would want .
• If the agent does not know the patient’s
wishes, the agent must make the decision
according to the agent’s assessment of the
patient’s best interests.
• Proxy cannot be a physician or nurse
providing professional care to the patient
unless a close relative.

POLST/MOL
ST Forms
American College of Physicians. (2015). Advanced care planning implementation for practices. ACPOnline. Retrieved from:
https://www.acponline.org/system/files/documents/running_practice/payment_coding/medicare/advance_care_planning_toolkit.pdf
• The Physician/Medical Orders for Life-
Sustaining Treatment POLST/MOLST
summarizes the patient’s wishes in the form
of medical orders that specify the specific
medical treatments a patient wants during
a medical emergency.
• These are not advance directives, because
they contain actionable medical orders that
are effective immediately based on a
patient's current medical condition.

POLST/MOL
ST Forms
vs. Advance
Directives
• POLST/MOLST would be used with a
Living Will/Advance Directive to guide
clinicians if the patient is unable to make
their own decision.
• POLST/MOLST forms are intended for
individuals with a serious illness or near
the end-of-life.
• They do not name a surrogate or
medical proxy.

Important
Factors to
Consider
• Choosing not to have certain life-sustaining
or aggressive medical treatment is different
from refusing all medical care
• Patients may revoke a living will at
any time.
• No general agreement exists for recognizing
living wills from other states.
• A living will is much more limited than a
healthcare power of attorney.

• Advance directives become legally valid
as soon as they are signed in front of the
required witnesses.
• They do not go into effect unless the patient
is unable to make his/her own decisions.
• Use approved, state-specific documents.
• Changes to an advance directive should
be recorded and given to appropriate
healthcare clinicians and proxy.
• Re-evaluate yearly and as needed,
recording any changes.
Please
Remember…

Do Not
Resuscitate
(DNR)
Orders
• Resuscitation is an attempt by medical staff
to restart the patient’s heart and breathing.
• This may include chest compressions,
shock, and breathing machines (ventilators).
• A Do Not Resuscitate (DNR) order means
that if the patient stops breathing or their
heart stops beating, a natural death will
be allowed to happen.
• This applies in the hospital/acute care
setting.
• Some states and hospitals require a
new DNR order each time the patient
is admitted.

Out-of-
Hospital
(OOH) DNR
• An out-of-hospital DNR (OOH DNR)
is used when a person does not want
to be resuscitated if they are outside of
a hospital.
• Without a physician-signed OOH
DNR order or MOLST/POLST,
emergency crews must perform CPR.
• OOH DNR (like POLST/MOLST) stays
with the patient.
• OOH DNR forms and rules are
state-specific.

Completing
Advance
Directives Five Wishes includes a living will and a healthcare
surrogate (proxy) designation.
Five Wishes meets the legal requirements for
an advance directive in 42 states and the District
of Columbia.
For more information visit: Aging with Dignity,
www.AgingWithDignity.org, 888.594.7437

Five
Wishes
Wish 1: The Person I Want to Make Care
Decisions for Me When I Can't
Wish 2: The Kind of Medical Treatment
I Want or Don't Want
Wish 3: How Comfortable I Want to Be
Wish 4: How I Want People to Treat Me
Wish 5: What I Want My Loved Ones
to Know

What to
Do With
Advance
Directives
• Provide a copy to the proxy, backup,
clinicians, attorney, and other
trusted people.
• Keep original safe but easily accessible.
• Recommend to keep a card in their purse
or wallet that states that they have an
advance directive and where it is located.

Advance
Directives
and Hospice
• Patients are not required to have advance
directives or an OOH DNR in order to
receive hospice care.
• Hospice staff will discuss the importance
of advance directives in preserving
patient choice.
• Hospice offers training on advance
directives.

Starting the
Conversation
• Take the initiative
• Take responsibility
• Take a closer look at dying
• Listen more than you talk
• Find out what is important to the patient
• Learn the patient's underlying values and goals
• Tie the discussion to relatable experiences
• Include discussion about faith
• Allow yourself to not know all the answers
• Allow the patient and family to not know all the
answers
• Allow for silence and time to think

Taking the
Initiative
Abdelmalek, C., Goyal, S., Narula, A., Paulino, R., & Thomas-Hemak, L. (2013).
Advance directives: Give teeth to end-of-life choices. Aging Well, 6(1), 24-27.
• ACP is a recurring conversation
about the patient’s goals, values, and
treatment preferences
• Include DPOA in the ACP conversations
• Accommodate diverse belief systems
• Conduct ACP when the patient is
mentally and emotionally healthy
whenever possible

SPIKES
Buckman, R., and Kason, Y. (1992). How to break bad news: A guide for health care professionals.
Baltimore: The Johns Hopkins University Press
• S = Setting. Choose a private setting where you can
sit with the patient and a family member
or confidant. Plan ahead. Know the patient and situation.
• P = Perception. Ask the patient what they have been
told/understand before sharing information with them.
• I = Invitation. Ask permission to share your knowledge of the
situation – how much do they want to know about their disease,
tests, treatments, prognosis, etc. Give permission for them to
stop or pause the conversation if needed.
• K = Knowledge. Share information clearly and compassionately.
Avoid jargon. Share information, then stop talking. Listen.
• E = Emotion/Empathy. Convey empathy with body language
and words. Allow for emotion, and offer support statements
(“I’m sorry we are having this conversation,” “it’s okay to be
upset.” Don’t say “I understand what you’re going through.”
• S = Summary. Summarize the conversation. Plan for next
visit/conversation.

Something
to Consider
It is difficult to have an
end-of-life discussion through
an ET tube.
—Mark Reid, MD
@medicalaxioms

Physician Reimbursement for
Advanced Care Planning
Effective January 2016

ACP Services
Reimbursement
CPT Code 99497
• Advance care planning including the
explanation and discussion of advance
directives such as standard forms
(with completion of such forms, when
performed) by the physician or other
qualified healthcare professional
• First 30 minutes of the day, face-to-face
with the patient, family member(s)
and/or surrogate
CPT Code 99498
• Each additional 30 minutes (list separately
in addition to code for primary procedure)
• May have multiple in a day

Closing
Thought
I have an advance directive, not
because I have a serious illness,
but because I have a family.
—Ira Byock, MD

References
• Abdelmalek, C., Goyal, S., Narula, A., Paulino, R., & Thomas-Hemak,
L. (2013). Advance directives: Give teeth to end-of-life choices.
Aging Well, 6(1), 24-27.
• Advance Care Planning. Retrieved from:
https://www.nhpco.org/patients-and-caregivers/advance-care-planning/
• American College of Physicians. (2015). Advanced care planning
implementation for practices. ACPOnline. Retrieved from:
https://www.acponline.org/system/files/documents/running_
practice/payment_coding/medicare/advance_care_planning_
toolkit.pdf
• Buckman, R., and Kason, Y. (1992). How to break bad news:
A guide for health care professionals. Baltimore: The Johns
Hopkins University Press.
• Detering, K., et. al. (2018, May) Advance care planning and
advance directives. Retrieved from:
https://www.uptodate.com/contents/advance-care-planning-and-
advance-directives
• Eggerston, L. (2013). Doctors, patients urged to discuss advanced
care plans. CMAJ, 185(13): E617–E618.

References
• Fulmer, T., et al. (2018). Physicians' views on ACP and end-of-life
conversations. Journal of the American Geriatric Society. 1-5
• Institute of Medicine (IOM). (2014). Dying in America: Improving Quality
and Honoring Individual Preferences Near the End of Life. Summary.
Washington, DC: The National Academies Press.
• Kaiser Family Foundation/The Economist. (2016, March 30-May 16).
Four-Country Survey of Aging and End-of-Life Medical Care.
• Molloy, D.W., et al. (2000). Systematic implementation of an advance
directive program in nursing homes: A randomized controlled trial.
JAMA, 283(11):1437.
• Omnibus Budget Reconciliation Act of 1990. (1990). Public Law No.
101-508, §4206 & 4751.
• Peeler, T. (2019, October 10). Types of advance medical directives.
LegalMatch. Retrieved from: https://www.legalmatch.com/law-
library/article/types-of-advance-medical-directives.html
• Silveira, M.J., et al. (2010). Advance directives and outcomes of
surrogate decision making before death. New England Journal of
Medicine, 362:1211-1218.

References
• Silvester, W., et al. (2016). Advance care planning in Australia: what
does the law say? Retrieved from:
https://www.ncbi.nlm.nih.gov/pubmed/26567895
• Sudore, R.L., et al. (2017) Advance care planning for adults: A
consensus definition from a multidisciplinary Delphi panel. Journal of
Pain and Symptom Management, 53(5):821.
• Teno, J.M. (2007). Association between advance directives and quality
of end-of-life care: A national study. Journal of the American Geriatric
Society, 55(2):189.
• Thomson Reuters. National survey of healthcare consumer: End-of-life
care. Retrieved from:
http://www.factsforhealthcare.com/pressroom/NPR_report_EndofLifeCar
e0710.pdf
• Wright, et al. (2008). Associations between end-of-life discussions,
patient mental health, medical care near death, and caregiver
bereavement adjustment. JAMA, 300(14):1665-1673.
• Yadav, K.N., et al. (2017). one in three U.S. adults completes any type
of advance directive for end-of-life care. Health Affairs, 36(7):1244-1251.

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