The quality of advance care planning at a comprehensive cancer center.
Authors: Goyco Vera Daniel , Lopez Elyse R , Milligan Kevin , Haro-Silerio Jaime , Patel Nikhil Anil , Bilal Mohammad , Ajene George , Grant Megan , Simmons Kristen , Walton Natalie , Rubio David 
Published: June 2023

e18700

Background: Advanced care planning (ACP) is the comprehensive process of clarifying, communicating, and implementing patient preferences, personal values, and goals as they pertain to medical care and quality of life, and is especially important for patients with cancer. Early communication regarding ACP can improve patient satisfaction and limit unwanted hospital visits and treatments. One study of 200 cancer patients showed that only 24% reported having conversations with any provider regarding end-of-life care despite 82.5% wanting to do so. The lack of ACP documentation is particularly concerning in patients with malignancies due to their high risk of sudden deterioration, especially during hospitalization. Therefore, there is an unmet need to complete ACP documentation which can be addressed during hospital admissions. Methods: We created a comprehensive process map for the current ACP note documentation process to determine areas for improvement in our inpatient hospital medicine resident team, where we take care of patients with GI, lung, endocrine, breast, and head/neck malignancies. We analyzed hospital admissions 4 weeks before and 4 weeks after our intervention to determine the rates of ACP note documentation, as well as ACP note documenter provider specialty. Our intervention consisted of (1) providing education during team orientation with individualized slides emphasizing on the importance of ACP documentation and how to write such note, (2) displaying instructional flyers in the communal workroom, and (3) implementing a new electronic medical record admission template with a forcing function. We established the percent of ACP note documentation as our primary outcome measure which was modeled via run chart. Results: Of the sixty-four patients admitted to our hospital team during the 1 month prior to our intervention, 24 (38%) had an ACP note documented within the first 72 hours of admission and 5 of the 24 patients had two ACP notes written by different providers. In total there were 13 notes completed by hospitalists, 7 by oncologists, 5 by ER physicians, 2 by supportive care providers and 1 by a medicine resident. One month after our intervention, 38 of the 44 (86%) patients admitted had an ACP note documented within 72 hours of admission and only one patient had 2 notes from different providers. In this cohort, there were 28 notes completed by residents, 3 by hospitalists, 3 by oncologists, 3 by supportive care providers and 2 by ER physicians. At 3 months post-intervention, 22 patients (34%) of the pre-intervention cohort were deceased, 14 (64%) of whom had ACP documentation. Conclusions: Cancer patients are at an increased risk of deterioration during their clinical course. Quality improvement interventions to promote ACP documentation during hospital admissions leads to care better aligned with patients' wishes and fulfills an unmet need in addressing goals of care.