A diagnostic accuracy study for predicting who should have an Advance Health Directive (AHD)

Validation of CARING Criteria

Grant ID: EMSS-2008-005-RICHARDSON-VALIDATION

Project Summary

This study sought to validate a modified CARING tool (termed PREDICT) using a population of patients presenting to the Emergency Department.

Advanced health directives are legal documents that outline patients’ desires for end-of- life care. For individual’s nearing the end of their lives, advanced health directives are an important part of their treatment plan. This is because they tell health care providers about the patient’s wishes regarding treatment near the time of death. However, very few patients hold these documents. This study looks to see whether we can easily identify individuals who are nearing the end of their lives, and therefore, should have an advanced health directive. The research is an initial step in increasing the number of individuals who hold advanced health directives.

In identifying those people who are nearing the end of their lives, we will utilise a clinical tool called the CARING criteria. This tool was designed in the United States and uses demographic and clinical information to identify patients who are likely to die within twelve months. In its original setting, the CARING criteria was highly accurate. However, no research has examined whether this tool is valid in the Australian Emergency Department setting. Therefore, we will assess the tool by looking at the medical charts of 1000 patients presenting to the Emergency Department. We will use the information in these charts to determine which patients meet the CARING criteria, and therefore, likely to have a limited life expectancy. After 12 months, we will conduct a search of the state death registries to determine whether individuals have deceased. We will then determine how accurate the CARING criterion is for predicting mortality.

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Outcomes

The sample comprised 976 patients with a median (interquartile range) age of 71 years (62–81 years) and a 1-year mortality of 23.4%. In total, 50% had ≥1 PREDICT criteria with a 1-year mortality of 40.4%. Receiver operator characteristic analysis gave an area under the curve of 0.86 (95% confidence interval: 0.83–0.89). Using a cut-off of 13 points, PREDICT had a 95.3% (95% confidence interval: 93.6–96.6) specificity and 53.9% (95% confidence interval: 47.5–60.3) sensitivity for predicting 1-year mortality. PREDICT was simpler than the CARING criteria and identified 158 patients per 1000 admitted who could benefit from advance care planning.

PREDICT was successfully applied to the Australian healthcare system with findings similar to the original CARING study conducted in the United States. This tool could improve end-of-life care by identifying who should have advance care planning or an advance healthcare directive.

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Dissemination

Richardson, P., Greenslade, J., Shanmugathasan, S., Doucet, K., Widdicombe, N., Chu, K. and Brown, A., 2015. PREDICT: a diagnostic accuracy study of a tool for predicting mortality within one year: Who should have an advance healthcare directive?. Palliative medicine, 29(1), pp.31-37.

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