Standardized documentation of advanced care planning to facilitate goal-concordant care in a large gynecologic oncology practice.
Authors: Soliman Pamela T. , Taylor Jolyn Sharpe , Meyer Larissa Alejandra , Fleming Nicole D. , Tran Cao Hop Sanderson , Zhukovsky Donna S. , George Marina C. , Lu Karen H. 
Published: June 2022

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Background: Advanced care planning (ACP) involves sharing of knowledge related to prognosis, treatment options, and patient values/goals, among the patient, their caregivers, and the clinical care team. These goals of care (GOC) discussions are critical at different time points during the care of a cancer patient, but are not performed or documented consistently in most oncology practices. The American Society of Clinical Oncology recommends that documentation of advance directive discussions, a component of ACP, take place by the third office visit for patients with newly diagnosed invasive cancer. We implemented a quality improvement initiative to improve ACP discussion and documentation in our large gynecologic oncology practice. Methods: As part of an institution-wide effort called “Mind the Gap: bridging the gap between patients’ perception of their oncologic situation and the reality thereof”, we identified 3 critical timepoints for which a GOC discussion and ACP documentation was recommended in the outpatient setting. These time points included: (1) by the 3rd visit for new patients with an invasive cancer, (2) preoperative (within 30 days of surgery), and (3) at time of treatment/chemotherapy change. Providers were educated on the key components of ACP documentation including surrogate decision maker and goals of cancer treatment. Standard templates were used to document these discussions for easy identification in the electronic health record. Metrics for each faculty team were shared monthly with the entire department. The department goal was to reach a cumulative goal > 60% completion for all patients in each of the 3 clinical time points within 6 months. Results: The proposed plan and education on ACP standard documentation was presented to 22 gynecologic oncologists during a faculty retreat in 10/2020. Baseline data from 8/2020 was shared revealing that ACP documentation was completed in 24% of new patients, 1% of preoperative, and 19% at treatment change. At the 6-month assessment (5/2021), ACP documentation was completed in 83.6% of new patients, 79.8% of preoperative, and 63% of patients at the time of treatment change. At one year (10/2021), ACP documentation was completed on 88.6% of new patients, 70.3% of preoperative, and 59% of patients at the time of treatment change. There was variability among providers in documentation of ACP for new patients (range 50-100%), preoperative (range 0-100%) and treatment change (range 12.5-100%). Conclusions: Through a departmental initiative, we were able to successfully encourage more frequent goals of care discussions and their standardized documentation, which was maintained at 1 year. We are currently evaluating the impact of this program on end-of-life quality metrics including chemotherapy within 14 days, ICU stay within 30 days and multiple hospital admissions within 30 days of end of life.