Factors that influence the ability to fulfill patient wishes: The health care agent's perspective

Objectives. Health care agency is a helpful mechanism for ensuring a patient's health care wishes are fulfilled when the patient can no longer express his wishes himself. However, health care agency is not a perfect system for ensuring health care wish fulfillment. Sometimes an agent, although having good intentions, is not able to carry out patient wishes. This study sought to identify the factors that agents perceive as influencing the ability to fulfill patient health care wishes.Methods. Health care agents' perceptions of the factors that influence health care agency effectiveness were explored through a qualitative inductive research study of data collected from individual in-depth interviews with agents from six sites. These sites represented three different types of care settings in New York City (nursing homes, hospices and medical intensive care units). All interviewees were identified through patient files and, in some cases, with the aid of site staff. Agents were selected based on their having acted as agents for patients who had died at the site between 3 and 12 months prior to the selection date.Results. Through analysis of the data collected from the 41 agent sample, four major influential themes emerged that agents perceived as influencing the ability to fulfill patient care wishes. These themes include: (1) the need for communication---both patient-agent and agent-medical staff (2) agent need for information (both on patient prognosis/treatment options as well as on the role of the health care agent) (3) agent personal agreement with patient health care wishes (or sharing the same philosophy toward medical intervention) and (4) the presence of social networks for agents (both supportive as well as conflicted). Data was also analyzed by type of setting.Conclusions. Hypotheses generated about factors expected to increase agent ability to fulfill patient wishes include: quality communication between patients and agents and agents and medical staff agent access to medical information upon which to base patient care decisions and information about the role/responsibilities of a health care agent (via friends, the internet, books, media) agent personal agreement with patient's philosophy toward end of life care and the presence of emotionally supportive social networks.