Respecting Choices® and advance directives in a diverse community.

BACKGROUND: Respecting Choices® is a program designed and verified to improve advance care planning, yet it has not been tested in racially/ethnically diverse communities. Research has shown racial/ethnic minorities are less likely to have advance directives (ADs). OBJECTIVE: To determine whether Respecting Choices® would improve AD prevalence and utilization in a racially and ethnically diverse community. METHODS: The study design was that of a retrospective chart review. Subjects were all decedents from 2005 to 2010 (n=732) in a 300-bed Midwestern metropolitan hospital. Prevalence was assessed by the presence of an AD in the chart. Utilization was measured by the consistency of wishes expressed in an AD and treatment received ("No CPR," "No Feeding Tube," "No Antibiotics," "No Ventilator," "Comfort Care," and "Terminal Extubation"). Average treatment effect using regression analysis and matching on covariates was used for analysis of Respecting Choices® on AD prevalence. Proportional difference tests were used to compare consistency of wishes by race/ethnicity before and after Respecting Choices®. RESULTS: The prevalence of ADs increased significantly for racial and ethnic minorities after the implementation of Respecting Choices®: from 25.8% to 38.4% (p=0.011). The increase in AD prevalence for whites following Respecting Choices® was only marginal (46.7% to 47.3%; p=0.648), and the overall prevalence of ADs did not significantly change (35.9% to 42.9%; p=0.069). Consistency was high (74% to 96%) for all orders, and there were no significant differences following implementation of Respecting Choices® or between whites and racial and ethnic minorities. CONCLUSIONS: The prevalence of ADs increased after Respecting Choices® was initiated in a racially and ethnically diverse community.

Catholic identity and charity care in the era of health reform.

Catholic healthcare institutions live amidst tension between three intersecting primary values, namely, a commitment of service to the poor and vulnerable, promoting the common good for all, and financially sustainability. Within this tension, the question sometimes arises as to whether it is ever justifiable, i.e., consistent with Catholic identity, to place limits on charity care. In this article we will argue that the health reform measures of the Affordable Care Act do not eliminate this tension but actually increase the urgency of addressing it. Moreover, we will conclude that the question of limiting charity care in a manner that is consistent with the obligations of Catholic identity around serving the poor and vulnerable, promoting the common good, and remaining financially sustainable is not a question of if, but of how such limits are established. Such limits, however, cannot be established in light of one overriding moral consideration or principle, but must be established in light of a multitude of principles guiding us to a holistic understanding of the interrelatedness of the moral dimensions of Catholic identity.