Two Out of Three U.S. Adults Have Not Completed an Advance Directive

Advance directives are the primary tool for individuals to communicate their wishes if they become incapacitated and are unable to make their own health care decisions, particularly near the end of life. Despite this, 63 percent of American adults have not completed one, reports the most comprehensive study to date on the subject from researchers at the Perelman School of Medicine at the University of Pennsylvania this week in the July issue of Health Affairs.

A systematic review of studies from 2011-2016 led by Katherine CourtrightMD, MS, an instructor of Medicine in the division of Pulmonary, Allergy, and Critical Care and the Palliative and Advanced Illness Research (PAIR) Center at Penn, found that among more than 795,000 Americans who were part of 150 different studies, 63 percent had not completed any advance directive. Only 29.3 percent had completed a living will that contained specific end-of-life care wishes, and 33.4 percent had designated a healthcare power of attorney.

Completion of advance directives was nominally higher among patients with chronic illnesses (38.2 percent) than among healthy adults (32.7 percent), and was much higher among patients age 65 and older (45.6 percent) compared with younger adults (31.6 percent). One of the primary means to ensure medical teams treat patients according to their end-of-life care preferences is through an advance directive – a legal record signed by a competent individual that guides care decisions when a patient’s poor health prevents them from making the decisions on their own.

“Most experts agree that some form of written directives are a key component of advance care planning, and yet rates of completion are low and do not appear to be increasing,” Courtright said. “We need to address common barriers to completing these important documents on a national level, particularly among chronically ill patients who are at higher risk for critical illness and death.”

The authors note that detractors of advance directives cite the inability of living wills to capture all of the situations one might face near the end of life, whereas proponents of living wills note that many patients wish to protect their loved ones from having to make such burdensome end-of-life care decisions.

The research team makes a few recommendations to address these low rates. First, content and format of advance directives must better represent the issues discussed in advance care planning conversations – such as patient values and goals, along with care preferences. Second, legal barriers to executing an advance directive should be simplified. Finally, efforts to increase advance directive completion should focus on populations at high risk for poor end-of-life care outcomes.

“The treatments most Americans would choose near the end of their lives are often different from the treatments they receive,” Courtright said. Unfortunately, this disconnect can lead to unnecessary and prolonged suffering. Advance directives remain the primary tool for people to communicate their end-of-life care wishes and appoint surrogate decision makers, but improvements to the documents and completion process are clearly needed.

Interested in Medical Social Work: Interview with Sally Dagerhardt

Are you curious about what medical social workers do? Read this interview with Sally Howell Dagerhardt, MSW, LCSW, a clinical social worker for a primary care setting. She has worked for the past six years in various departments and capacities of medical social work, including Geriatrics, Gero-Psychiatric Nursing Home Unit, and Primary Care. Prior to her medical social work positions, she was a working in residential and community mental health.

How did you decide to go into medical social work?

Medical-social-workI was drawn to social work by the diversity of opportunities. After two years of being in rural mental health, I was feeling a bit burned out and I began to apply for opportunities within the medical field for a change of scenery. It would be dishonest to say that the pay increase wasn’t a big motivator as well. I firmly believe in the “clinical” (aka therapeutic) aspect of my social work practice as a medical social worker. I provide intervention during times of stress and crisis, and I assist patients in making changes to maintain their wellness. I also provide a more holistic, social work perspective to my medically trained co-workers – doctors, nurses, etc.

In your opinion, what are the best aspects of your job?

While there are problems and pitfalls with every employer, I try to actively focus on the best aspects of my job, and honestly, there are a number of them. First and foremost, I get to work directly with people and provide them with needed assistance. My employer values my position, as do my co-workers. I perform a variety of social work interventions throughout the day, and I enjoy the fact that each of my days is different. I think being a part of a medical team also helps with self-care, as I do not feel solely responsible for my patients’ care. I can take leave and know that my patients will be cared for, and we can collaborate as a team to ensure good care on a daily basis. I cannot leave out that another great aspect of my job is the pay and benefits, which also enable me to be more focused on my job, and are often unavailable in other social work positions.

What are the most challenging aspects of your job?

Two challenging aspects immediately come to mind. In each of my social work positions, including this one, navigating inadequate systems is always a challenge. Whether it’s your employer or an entity in the larger community upon whom you rely for assistance, there’s nothing more challenging or frustrating for me than inadequate resources or institutional barriers to care for someone who is working hard to make change. My second biggest challenge as a social worker will always be self-care and avoiding burnout, cynicism, etc.

What would you change about your job, if you could?

While I feel that my employer does an amazing job at valuing social work and the importance of what I can bring to the table, I still think that there are ways that my clinical skills could be better utilized. As a medical social worker in an outpatient primary care clinic, my job tasks are diverse, but at times I still feel compartmentalized. I think that this is a result of the way my employer is organized: primary care, mental health, specialty care, etc. and at times, it limits my ability to assist the “whole person” by directing me to refer patients to other services lines or departments for assistance, when my social work license would theoretically allow me to assist.

How long do you see yourself in this field?

Working for a large medical institution offers me a diversity of positions and moves that I can make within this organization. As a result, I plan to stay within the medical social work field indefinitely, secondary to the ability to work within different departments, thus avoiding burnout, and have an adequate retirement.

What advice would you give to someone considering medical social work as a career?

I think that there are a number of great opportunities within the medical field for social workers. I think as social workers we need to consider the diversity of our skills and the myriad of settings to which they can be applied. So many of us graduate from social work school with limited ideas as to the kind of work we would like to do. Opening your mind to the range of opportunities that exist for a licensed clinical social worker may improve your job satisfaction. There are so many environments where people in need can benefit from great social work intervention. It’s possible that you will improve your own job satisfaction and day to day life in the process.

Practical Palliative Care Resources for Patients and Family Caregivers

Caritas House headquarters of Harris HospisCare (Photo credit: Wikipedia)

Does your practice’s website include local or national resources that complement the professional medical services they provide?  One way to add value to the services and increase the efficiency of medical office visits is to provide palliative care resources that your patients and their caregivers can use to inform care decisions.

Many people are starting to hear the term palliative care in the media from care managers and from people they know.  Yet, national research indicates that most people are unfamiliar with the term or confuse it with only one type of palliative care – hospice. Unlike hospice, palliative care is available to anyone, regardless of his/her illness or condition or life expectancy.  Palliative care can be offered in conjunction with curative or life-extending care and is available in all care settings.

The California State University Institute for Palliative Care defines palliative care as care that improves quality of life for patients and families facing serious or chronic illness — whatever the diagnosis or prognosis. It prevents and relieves suffering by addressing pain as well as the physical, emotional, psychosocial and spiritual problems associated with serious and chronic conditions.

Palliative care complements the care that your patients receive from you and acute care providers and can help with care transitions and prevent costly ER visits or (re)hospitalizations, by holistically addressing pain and symptoms while supporting family caregivers. Simply adding some or all of these resources can help to educate your patients about palliative care and communicate your support for this emerging aspect of healthcare.

Palliative Care Resources:

  • CSU Institute for Palliative Care –
  • Get Palliative Care –
  • Center to Advance Palliative Care –
  • Caring Connections – 
  • WebMD –
  • Department of Veterans Affairs –
  • Mayo Clinic –
  • National Cancer Institute –
  • Next Step in Care –

The CSU Institute for Palliative Care at California State University San Marcos

Why Pharmacists Are at the Centre of Future Healthcare

In today’s changing medical world, the pharmacist is becoming more important. In many ways, pharmacists are becoming more like mini-doctors, depending on their education and training. Some pharmacists in the United States and UK can even offer some medical advice and prescribe limited medications. This flexible license is vital to the ever-changing and expanding medical world.

Is becoming a pharmacist a viable career? With today’s medical costs rising, becoming a pharmacist is one way to help people without the high costs of 12 years of medical school. Most pharmacists also make a decent salary, making the investment worth it.

Take a look at how the role of the pharmacist is changing below:

Market Concentration

PharmacistOver the next 10-20 years, general practitioners will fade away. What used to be prescribed by practitioners will now be able to be prescribed by pharmacists. Hospitals and doctors will stick to consolidated offerings and specialized treatments. A few organizations may even buy out smaller doctor’s offices.

Self reliance

The economic downturn has made many people less likely to visit an actual doctor. This means that many people will turn to their pharmacist long before they ever step into a doctor’s office. Patients are looking for prevention and self-care methods, rather than treatments like they wanted before. This will enabled pharmacists to become involved with lifestyle management.

Medication Therapy Management (MTM)

Medication Therapy Management is a new role for pharmacists. This is an important role that will only become more important as the decade progresses. MTM is designed to help patients receive the best treatment options for their unique needs, and the pharmacist can take on that role with ease.


Could medications be used based on the genetic makeup of a person? In modern medicine, the practice is not widely used, but in the future, it is likely that many medications will be offered based on genetics. Pharmacists will be able to help provide the flexibility necessary to identify which medications belong with each unique set of genetics. Pharmacists have a chance to lead along with scientists to discover the true benefits of genetic-based medications.

Primary Care

One new role for the pharmacist is the role of primary care. With the new ability to dispense certain medicines and provide an advice-based role, many pharmacists are uniquely qualified to act as primary care providers for many low-risk patients of any age.

Pharmacists as Doctors

In the past, the pharmacy was simply for dispensing medication. However, today, the pharmacy is more of a community health center, offering health screenings, immunizations, and more. This hybrid between pharmacy and doctor’s office is something that is only beginning to emerge, but has the chance to become a community-based medical center that provides for all patient needs.


Prevention is something that the medical industry hasn’t really focused on before now. However, with patients living longer and healthier lives, prevention becomes more important. Nutraceuticals, are foods and food products that provide medical and health benefits on more of a preventative role. This is something that a pharmacist can provide to patients- perhaps even uniting with fitness centers for a total health approach.

The role and future of pharmacists is changing. Rather than simply being pill pushers, the profession is changing and taking a more active role in the prevention and curing of medical illnesses. The pharmacist of today is able to interact directly with patients, offer medical advice, and help a patient take an active, preventative role in his or her health.

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