84 Background: For seriously ill patients to plan for the end of life, they need to discuss with their clinicians their prognosis, values, and goals, yet such conversations often begin very late in the course of illness. To promote early advance care planning (ACP) in oncology, facilitators and barriers to these conversations need to be identified. Objectives: 1. To determine the effectiveness of “triggers” that remind oncologists to complete ACP discussions with outpatients whom they expect might die within a year. 2. To prospectively evaluate clinician-identified barriers to these conversations. Methods: A cluster-randomized controlled trial. The intervention includes: clinician identification of patients at high risk of death within a year; 2½ hour training program on the use of the Serious Illness Conversation Guide; an email trigger/reminder, immediately before an outpatient visit, for the oncologist to conduct an ACP discussion using the Conversation Guide; clinician reports of why they deferred such conversations. Results: Eighty-eight enrolled oncology clinicians (MDs, NPs, PAs) screened 15,576 patients and identified 1,743 for whom they would not be surprised about death within a year. To date, 332 patients have consented to enrollment; 104 patients and 40 clinicians entered the intervention arm; 124 subsequent visits were triggered, resulting in 62 completed conversations. 79% of the conversations occurred after 1 trigger; 92% by the second trigger. Of the 62 triggered visits that did not result in an immediate conversation, clinicians identified the following reasons: 26% not enough time; 20% clinician attitudes about the impact and timing of such conversations (i.e., they take away hope, patient not sick enough); 46% immediate patient issues making conversation inappropriate (i.e., patient acutely ill, anxious, depressed, or not ready); and 8% “other.” Conclusions: An email trigger in the outpatient oncology clinic is highly effective in promoting ACP conversations for trained clinicians. The majority of clinician-identified barriers to such discussions reflect beliefs about the impact and timing of the discussion and concerns about the patient’s immediate condition; time constraints only account for about a quarter of delays. Clinical trial information: NCT01786811.
Protocol for a Cluster Randomized Trial Comparing Team-Based to Clinician-Focused Implementation of Advance Care Planning in Primary Care
