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each individual; yet the guidelines have not been widely used in Japan, and mutual communication between family members while still in a healthy stage is vital to determine preference. It has been recommended that advance care planning be considered during a comprehensive geriatric assessment.6 To respect the best interest of individuals with dementia, advance care planning should be started early on. Taizo Wada MD, PhD Center for Southeast Asian Studies Kyoto Japan Tanaka Home Visit Clinic Kyoto Japan Hissei Imai MD Eriko Fukutomi MPH Wen-Ling Chen MPH Department of Field Medicine School of Public Health Kyoto University Kyoto Japan Kiyohito Okumiya MD, PhD Yasuko Ishimoto PhD Yumi Kimura PhD, MPH Ryota Sakamoto MD, PhD Michiko Fujisawa MD, PhD Center for Southeast Asian Studies Kyoto University Kyoto Japan Kozo Matsubayashi MD, PhD Center for Southeast Asian Studies School of Public Health Kyoto University Kyoto Japan Department of Field Medicine School of Public Health Kyoto University Kyoto Japan

ACKNOWLEDGMENTS The authors wish to thank all participants in Tosa who participated in the survey. We are deeply indebted to Ms. Toshiko Nagao (Illustrator), Drs. Masayuki Ishine (Yasugi Clinic), Naomune Yamamoto (Aino Hospital), and Kuniaki Otsuka (Chronomics and Gerontology, Tokyo Women’s Medical University) for their invaluable contributions to the study. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Taizo Wada receives research support from a Grant-inAid for Scientific Research (C) from the JSPS (24590607). Author Contributions: Wada: study concept, data analysis, writing the manuscript. Imai, Okumiya, Fukutomi, Ishimoto, Kimura, Chen, Sakamoto, Fujisawa, Matsubayashi: data collection. Sponsor’s Role: None.

REFERENCES 1. Okamura H, Ishii S, Ishii T et al. Prevalence of dementia in Japan: A systematic review. Dement Geriatr Cogn 2013;36:111–118. 2. Ikejima C, Hisanaga A, Meguro K et al. Multicentre population-based dementia prevalence survey in Japan: A preliminary report. Psychogeriatrics 2012;12:120–123. 3. Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. Cochrane Database Syst Rev 2009:CD007209. 4. Guidelines for decision-making process in elderly care focusing on indications of artificial hydration and nutrition. Japan Geriatrics Society 2012

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[on-line]. [Article in Japanese] Available at http://www.jpn-geriat-soc.or. jp/proposal/pdf/jgs_ahn_gl_2012.pdf Accessed April 22, 2014. 5. Mullick A, Martin J, Sallnow L. An introduction to advance care planning in practice. BMJ 2013;347:6064. 6. Lakhani M. Consider advanced care planning in functional assessment of older people. BMJ 2011;343:5944.

PROMOTING ADVANCE CARE PLANNING DOCUMENTATION FOR VETERANS THROUGH AN INNOVATIVE ELECTRONIC MEDICAL RECORD TEMPLATE To the Editor: Advance care planning (ACP) is increasingly recognized as an essential component of medical care.1–3 ACP discussions should be documented in an easily accessible location for all members of the healthcare team to review so that they can guide treatment decisions. Despite the fundamental importance of ACP, most medical institutions lack effective documentation tools.4 Electronic medical record (EMR) reminders have been demonstrated to increase advance directive documentation,5 but no studies have examined EMR-based ACP discussion documentation templates.6 The goal of the current study was to examine the quality of ACP documentation after the implementation of a new Veterans Affairs (VA) EMR ACP template.

METHODS This study was conducted at the James J. Peters VA Medical Center in Bronx, New York, a tertiary care facility with 311 authorized hospital beds and 120 nursing home beds. Study approval was obtained from the VA institutional review board. A new template for ACP discussion documentation was implemented in the EMR in February 2009 as a part of larger quality improvement project to promote ACP documentation. This consisted of three parts: assessment of the individual’s decision-making capacity; the individual’s desired surrogate decision-maker; and a narrative summary of the individual’s preferences regarding personal goals, values, and wishes for future medical treatment in the event of worsening health status. For individuals without decision-making capacity, the third part reflected discussions with the healthcare agent or surrogate decision-maker. Once completed, the ACP discussion note became easily accessible in the fixed, highlighted “Postings” section of the EMR face sheet (Figure 1). When ACP discussions occurred more than once for a given individual, the newest signed note automatically appeared above the previous under “Postings.” The last 100 consecutive notes were reviewed. If an individual lacked decisional capacity, the reason for incapacity was reviewed. Note content was reviewed for description about goals and values, desired place of death, and care preferences. Care preferences were divided into three categories regarding desired limitations on medical interventions (no limitation, some limitation, and comfort care only). Notes lacking documentation of healthcare preferences were also reviewed for reasons of omission.

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Figure 1. Advance care planning (ACP) discussion documentation template. The tab on the right upper corner can be reached anytime the medical record of the patient is open. When it is clicked, the list of ACP discussion notes pops up.

RESULTS The last 100 consecutive notes (April–August 2011) represented conversations with 93 individuals (mean age 75.1, 99% male, 91% community dwelling). The most common diagnoses were active cancer, dementia, chronic obstructive pulmonary disease, and congestive heart failure; most individuals had at least one comorbidity. Geriatricians or palliative medicine physicians wrote 73 of the notes. Twenty-one notes documented a lack of decisional capacity, most commonly because of dementia. Of the remaining 79 notes documenting the presence of decisional capacity, 55 (70%) reported no previously completed advance directives. Of those lacking advance directives, 48 (87%) documented a desired surrogate decision-maker. Of the 100 reviewed notes, 52 had text reflecting goals and values, and 18 mentioned a desired place of death. Eighty notes contained documentation of care preferences. Ten percent documented a preference for all care possible, and 90% described some desired limitation of medical treatment (78% preferred some limitation and 12% preferred comfort care only). Of the 20 notes without documentation of care preferences, 70% contained a reason for the lack of care preferences (indecisive, 30%; unwilling to discuss, 25%; other, 15%).

DISCUSSION The authors believe that this small study is among the first to illustrate the great potential for making ACP documentation standardized and easily accessible in an EMR. This study had several findings. First, by documenting discussions with surrogates, the template enabled ACP documentation even in individuals without decision-making capacity, who would be unable to complete advance directives. Second, the vast majority of notes contained

important information regarding desired surrogate decision-makers and care preferences. Most ACP discussions reflected the desire for some limitation of medical interventions currently or in the event of worsening health. This study had a number of limitations. Only a small number of notes were retrospectively reviewed. Because this was conducted in a single facility with mostly men, generalizability is uncertain. This study did not address the accuracy of the documentation or provide data on outcomes, such as the degree to which the individual’s expressed wishes were adhered to. This study illustrates that interventions to make EMRbased ACP documentation easily accessible are feasible in the VA system and are important to promoting provider awareness of individual and family care preferences. Good, accessible documentation is critical to honoring individuals’ wishes. This information is fundamental to providing high-quality person-centered care and should be available in all EMRs. Shunichi Nakagawa, MD Adult Palliative Care Service, Department of Medicine, Columbia University Medical Center, New York, New York Elizabeth M. Clark, MD Division of Geriatrics, Montefiore Medical Center, Bronx, New York Elizabeth L. Cobbs, MD Division of Geriatrics and Palliative Medicine, Department of Medicine, George Washington University, Washington, District of Columbia Geriatrics, Extended Care and Palliative Care, Veterans Affairs Medical Center, Washington, District of Columbia Elayne Livote, PhD Optuminsight, QualityMetric, Inc., Lincoln, Rhode Island

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Kanwal S. Awan, MD Geriatrics, Extended Care and Palliative Care, Veterans Affairs Medical Center, Washington, District of Columbia Geriatric Medicine and Gerontology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland Karen A. Blackstone, MD Division of Geriatrics and Palliative Medicine, Department of Medicine, George Washington University, Washington, District of Columbia Geriatrics, Extended Care and Palliative Care, Veterans Affairs Medical Center, Washington, District of Columbia Elizabeth C. Lindenberger, MD Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York Geriatric Research, Education and Clinical Center, James J Peters VA Medical Center, Bronx, New York

ACKNOWLEDGMENTS Dr. Nakagawa was a geriatrics fellow in Icahn School of Medicine at Mount Sinai, and this research was conducted at the James J. Peters VA Medical Center, Bronx, New York. The authors would like to acknowledge the support of the Geriatric Research, Education and Clinical Center. The authors would also like to thank the healthcare providers, the veterans, and their families for their participation. Dr. Nakagawa has presented this work at the Presidential Poster Session of the 2012 American Geriatrics Society Annual Meeting. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that they have no financial or any other kind of personal conflicts with this paper. Author Contributions: Study concept and design: Nakagawa, Clark, Cobbs, Blackstone, Lindenberger. Acquisition of subjects and data: Nakagawa, Awan. Analysis and interpretation of data: Nakagawa, Clark, Livote, Lindenberger. Preparation of manuscript: Nakagawa, Clark, Cobbs, Livote, Lindenberger. Sponsor’s Role: There is no sponsor for this paper.

REFERENCES 1. Steinhauser KE, Christakis NA, Clipp EC et al. Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA 2000;284:2476–2482. 2. Detering KM, Hancock AD, Reade MC et al. The impact of advance care planning on end of life care in elderly patients: Randomised controlled trial. BMJ 2010;340:c1345. 3. Zhang B, Wright AA, Huskamp HA et al. Health care costs in the last week of life associations with end-of-life conversations. Arch Intern Med 2009;169:480–488. 4. Yung VY, Walling AM, Min L et al. Documentation of advance care planning for community-dwelling elders. J Palliat Med 2010;13:861–867. 5. Lindner SA, Ben Davoren J, Vollmer A et al. An electronic medical record intervention increased nursing home advance directive orders and documentation. J Am Geriatr Soc 2007;55:1001–1006. 6. Bose-Brill S, Pressler TR. Commentary: Opportunities for innovation and improvement in advance care planning using a tethered patient portal in the electronic health record. J Prim Care Community Health 2012;3: 285–288.

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CASE REPORTS PREVALENCE AND CLINICAL FEATURES OF ACUTE INTERMITTENT PORPHYRIA: A RETROSPECTIVE ANALYSIS To the Editor: Acute intermittent porphyria (AIC) is a rare inherited entity characterized by abdominal pain and a wide range of nonspecific symptoms that can be exacerbated through a multitude of environmental factors.1 Public attention has been given to the acute porphyrias because they may have affected the character of King George III and the creative genius of Vincent van Gogh.2 The porphyrias are eight genetically distinct metabolic disorders, mainly inherited, in which there are defects in normal porphyrin and heme synthesis. Traditionally, the porphyrias have been classified as hepatic or erythropoietic, although some have overlapping features.3 The cardinal clinical features are cutaneous (due to the skin-damaging effects of excess deposited porphyrins) or neurovisceral attacks of pain, sometimes with weakness, delirium, and seizures. Of the acute hepatic porphyrias, the most frequent is autosomal-dominant AIC—a metabolic disorder of heme synthesis due to a deficiency in the porphobilinogen deaminase enzyme; it affects women more than men and has a low penetrance, which is one reason why different clinical manifestations appear at different ages; moreover, because the wide range of nonspecific symptoms may occur with more-common conditions, individuals with AIP may not be readily diagnosed.3 There is an ethnic predisposition in Northern European countries known as Swedish porphyria.1 The purpose of this study was to document the prevalence and clinical features of AIC in a department of internal medicine. Between January 2006 and December 2013, 7,895 hospitalized individuals on a medical ward were retrospectively evaluated; four (0.05%) with AIC were identified (three female, one male, aged 85, 75, 90, and 81); the remaining individual with other types of porphyria are not included in this analysis. All individuals were hospitalized for recurrent acute abdominal pain, vomiting, weakness, and confusion. Patient 2 also had orthostatic hypotension and bradycardia. Factors precipitating the acute attack were severe weight loss due to stomach cancer in Patient 3, urinary tract sepsis in Patients 1 and 2, and alcohol abuse in Patient 4. Physical examination found no abnormalities in any of these individuals except for moderate quadriparesis in Patient 3 and abnormal behavior with hallucinations. Cerebral magnetic resonance imaging, abdominal computed tomography, gastroscopy, and colonoscopy were all normal. Electromyography showed acute motor neuropathy in Patient 3, and cerebrospinal fluid test revealed slightly high protein levels in all four. Patient 3 had low serum sodium level (124 mmol/L). When a urinary catheter was placed, dark urine (Figure 1) was drained; urinalysis showed no hematuria or pyuria.4 A diagnosis of AIP was confirmed in all four individuals because of high urinary excretion of porphobilinogen. They were treated with hematin and adequate calorie intake, and symptoms

Promoting advance care planning documentation for veterans through an innovative electronic medical record template.

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