An Inpatient Advance Care Planning Intervention for Older Patients with Hematologic Malignancies: A Single-Arm Pilot Study
Authors: Locastro Marissa , Wang Ying , Mortaz-Hedjri Soroush , Frumusa Danielle , Natale Tracy , Cohen Jessica , Yates Nicole , Podlucky Jenna , Yu Tristan , Carroll Thomas , Liesveld Jane L. , Baumgart Megan , Sabtka Sandra , Hettler Dwight , Kaplan Nicole , Mendler Jason H. , Loh Kah Poh 
Published: December 2024

Introduction: Patients with hematologic malignancies (HM) receive more intense end-of-life (EOL) care compared to patients with solid tumors and are more likely to die in the hospital. Advance care planning (ACP), which may include goals-of-care discussions and/or completion of advance directives [i.e., health care proxy (HCP) form, Medical Order for Life Sustaining Treatment (MOLST)], is a process that allows patients to share their preferences for EOL care. Serious illness conversations may facilitate ACP and goal-concordant care. The aim of this study was to assess feasibility and preliminary efficacy of a Serious Illness Care Program (SICP) delivered by advanced practitioners and hematology/oncology fellows for hospitalized older patients with HM.
Methods: We conducted a single-arm pilot study of patients aged ≥60 years with HM and their caregivers. The inpatient SICP includes pre-visit materials, a 20-30-minute SICP visit with a clinician, and post-visit materials. Pre-visit materials included a geriatric assessment (measures of physical, nutritional, psychological, and cognitive functions) and the patient preparation pamphlet. Post-visit materials included a family guide and electronic medical record (EMR) template. Clinicians underwent a virtual 2-3-hour training on the Serious Illness Care Guide, which they used to elicit patient values during the SICP visit.
Primary outcomes were feasibility and preliminary efficacy. Feasibility was assessed using retention rate (i.e., % of consented patients who completed the visit; &gt;70% was considered feasible). Preliminary efficacy was assessed using completion of advance directives [MOLST form, HCP form]. Secondary outcomes were patient acceptability and ACP engagement (range 1-5; higher is better). Hypothesis testing was performed at α=0.10 (two-tailed) due to the pilot nature of the study. Participant feedback was gathered via semi-structured interviews and coded in MAXQDA by two investigators.
Results: We included 38 patients (mean age=68; SD 4.4) and 21 caregivers (mean age=59; SD 14.0). The majority of participants were White (patients: 97%; caregivers 100%), non-Hispanic (patients: 90%; caregivers: 95%). Approximately half of patients were female (53%). The most common HM was acute myeloid leukemia (61%), followed by multiple myeloma/plasma cell leukemias (13%), lymphoma (11%), myelodysplastic syndrome (8%), and acute lymphoblastic leukemia (8%). The majority of patients (58%) were &lt;6 months from their diagnosis at time of SICP visit. We trained 22 clinicians to deliver the inpatient SICP: 15 advanced practitioners; 7 hematology/oncology fellows. The average number of visits per clinician was 1.6 (SD 1.3) and the average time per visit was 15.5 minutes (SD 7.7).

PRIMARY OUTCOMES
We found the inpatient SICP to be feasible (retention rate: 94.7%; 36/38). The number of HCP forms completed increased from 20 to 24 within 4 months of SICP visits. The number of MOLST forms completed increased from 7 to 15 within 4 months and to 17 within 7 months of SICP visits. All inpatient SICP visits (100%; 36/36) were documented using the EMR template.

SECONDARY OUTCOMES
The inpatient SICP was acceptable. Of the patients who completed the acceptability survey, most patients received the exact amount of information they wanted from the visit (22/30; 73.3%), felt the visit took place at the right time (22/31; 71.0%), and found the visit to be very or extremely worthwhile (20/30; 66.6%). From baseline to post-intervention, ACP engagement scores numerically increased [mean +0.2 (SD 0.8); p=0.13].
In semi-structured interviews, 19 patients stated they would recommend a SICP visit to others. Three themes emerged 1) SICP visits prepare patients for the future by providing more medical information and social/emotional support, 2) After SICP visits, patients began discussing parts of their care that they hadn't addressed before, such as preferences for life-sustaining treatments, and 3) SICP visits are most impactful for patients who are willing and interested in sharing their values and care preferences with their healthcare team.
Conclusion: We found the SICP to feasible among hospitalized older patients with HMs and completion of advance directives increased after visits. Inpatient SICP visits may facilitate discussion about EOL care preferences, allowing for better preparation for the future.