Assessing Quality in Advance Care Planning Documentation: A Survey of Current Methods

2021 ◽  
pp. 104990912110603
Author(s):  
Callie M. Berkowitz ◽  
Jessica Ma ◽  
Jared Lowe ◽  
Rowena J. Dolor
Keyword(s):  
Health Care ◽  
Language Processing ◽  
Advance Care Planning ◽  
Improve Patient Care ◽  
Outcome Variable ◽  
Care Planning ◽  
Health Care Proxy ◽  
Code Status ◽  
Manual Search ◽  
Advance Care

Background High-quality advance care planning (ACP) documentation facilitates the communication of patients’ wishes as they progress in their disease course and travel between health care settings. No consensus exists regarding evaluation of documentation quality, and diverse strategies for assessing quality have been adopted in clinical ACP studies. Methodology We conducted a literature review in PubMed and via manual search to identify clinical studies that assessed ACP quality or completeness as an outcome measure over a 5-year period. Studies that treated ACP as a binary outcome variable (present or absent), studies that took place outside of the US, and studies in pediatric populations were excluded from review. Results We identified 11 studies for inclusion in our review. Across study methodologies, the following 8 quality domains were identified: discussion frequency, documentation accessibility, discussion timing, health care proxy, health goals or values, scope of treatment/code status, prognosis/illness understanding, and end of life (EOL) care planning. Each study assessed between 2 and 6 domains. Divergent methods for assessing quality domains were utilized, including manual qualitative analysis and natural language processing techniques. Conclusion Defining and measuring the quality of documentation is critical to developing ACP programs that improve patient care. Our review provides an adaptable framework centered around quality domains.

scholarly journals Advance care planning in Norwegian nursing homes – limited awareness of the residents’ preferences and values? A qualitative study

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Lisbeth Thoresen ◽  
Reidar Pedersen ◽  
Lillian Lillemoen ◽  
Elisabeth Gjerberg ◽  
Reidun Førde
Keyword(s):  
Health Care ◽  
Nursing Homes ◽  
Advance Care Planning ◽  
Health Care Professionals ◽  
Qualitative Content Analysis ◽  
Care Planning ◽  
Next Of Kin ◽  
Medical Issues ◽  
Interdisciplinary Approaches ◽  
Advance Care

Abstract Background 52% of all deaths in Norway occur in nursing homes. Still advance care planning (ACP) is scarce and heterogeneous. To improve the implementation and practice of ACP in nursing homes, knowledge about health care professionals’ views on ACP is vital. The objective of this study is to explore nurses and physicians’ aims and experiences with carrying out ACP in nursing homes. Methods Semi-structured group interviews were conducted with 20 health care professionals, recruited from nursing homes where ACP was performed regularly. Qualitative content analysis was used to analyse the data. Results The primary aim of the nursing home professionals when doing ACP in nursing homes were to build alliances with next of kin to avoid misunderstandings and future conflicts. Two main experiences with ACP were described: i) due to the sensitivity of ACP issues, it was important to balance directness with being sensitive, and ii) when the physicians raised questions concerning future medical treatment, the answers from residents as well as next of kin were often hesitant and unclear. Conclusion Our study add insights into how ACP is practiced in nursing homes and the professionals’ agenda. A focus on medical issues and achieving consensus with next of kin may result in lack of involvement of the residents and limited awareness of the residents’ needs. Interdisciplinary approaches, ACP-training and tailored guidelines may improve the implementation and practice of ACP.

scholarly journals Prevalence of Advance Care Planning Practices Among People with Chronic Diseases in Hospital and Community Settings: A Quasi-Experimental Design

2020 ◽  
Author(s):  
Sarah Yeun-Sim Jeong ◽  
Tomiko Barrett ◽  
Se Ok Ohr ◽  
Peter Cleasby ◽  
Ryan Davey
Keyword(s):  
Health Care ◽  
Chronic Diseases ◽  
Advance Care Planning ◽  
Healthcare Professionals ◽  
Community Setting ◽  
Care Planning ◽  
Community Settings ◽  
Future Health ◽  
Number Of Patients ◽  
Advance Care

Abstract Background: Advance Care Planning (ACP) enables healthcare professionals to embrace the important process where patients think about their values in life and goals for health care, and discuss their future health care preferences with family members for a time when they are not able to make health care decisions. Despite the promotion of ACP last two decades, and well-known benefits of ACP and a written Advance Care Directive (ACD), they are still underutilised in Australia and across the world. Previous studies have provided some insights, however, an uptake of ACP and prevalence of ACDs in community setting is rarely reported.Methods: The aim of this study was to determine the uptake of ACP and prevalence of ACDs among people with chronic diseases in hospital and community settings. A retrospective medical record audit of eligible patients looking for evidence of ACP was conducted in 16 research sites (eight intervention and eight control) in hospital and community care settings. Participants included those who were admitted to one of the research sites, and who were aged 18 years and over with at least one of nine nominated chronic diseases. The primary outcome measures included the number of patients with evidence of ACP through the following practices: completion of an ACD, appointment of an Enduring Guardian (EG), or completion of a resuscitation plan. Results: The overall prevalence of ACD was 2.8% (n=28) out of 1006 audited records, and only 10 of them were legally binding. The number of EGs legally appointed was 39 (3.9%) across the sites. A total of 151 (15.4%) resuscitation plans were found across the eight hospital sites. 95% (n=144) of the resuscitation plans advised ‘Not-for-resuscitation’. Conclusions: The uptake of ACP is very low. Current medical recording system reveals the challenges in ACP lie in the process of storage, access and execution of the ACDs. Given that having an ACD or EG in place is only useful if the treating physician knows how and where to access the information, it has implications for policy, information system, and healthcare professionals’ education. Trial registration: The study was retrospectively registered with the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001627246). The URL of the trial registry record http://www.anzctr.org.au/trial/MyTrial.aspx

Health-Care Provider Personal Religious Preferences and Their Perspectives on Advance Care Planning With Patients

2018 ◽  
Vol 35 (12) ◽  
pp. 1565-1571
Author(s):  
Marjorie Bowman ◽  
Sarah St. Cyr ◽  
Adrienne Stolf i
Keyword(s):  
Health Care ◽  
Health Care Providers ◽  
Advance Care Planning ◽  
Religious Affiliation ◽  
Living Will ◽  
Care Planning ◽  
Care Providers ◽  
Power Of Attorney ◽  
Religious Preference ◽  
Advance Care

Objective: To understand how health-care providers’ (HCPs) religious preferences influence their willingness to undertake advance care planning (ACP) with patients and their acceptance of other HCP’s involvement. Methods: Online anonymous survey distributed to HCPs in hospital, ambulatory offices, and hospice settings in Dayton, Ohio. We evaluated the associations of HCP religion with their personal ACP, willingness to facilitate ACP, and acceptance of other HCPs’ ACP participation. Results: 704 respondents: nurses (66.2%), physicians (18.8%), other HCPs (15.0%), white (88.9%), and primarily Catholic (23.3%) or Protestant (32.0%). “No religion” was marked by 13.9%. Respondents were favorable to ACP with patients. Religious respondents were more likely to have a living will ( P = .035) and health-care power of attorney ( P = .007) and more accepting of clergy as ACP decision coaches ( P = .030). HCP’s religion was not associated with willingness to facilitate ACP discussions. There were minor differences between Catholics and Protestants. Conclusions: Personal religious preference is associated with HCP’s own ACP but had little relationship with their willingness to facilitate ACP conversations with patients or acceptance of other professional types of HCPs involvement in ACP conversations. Regardless of religious affiliation, HCPs have interest in undertaking ACP and endorse other HCPs ACP involvement. As results of this study suggest that personal religious affiliation is not a barrier for HCPs engaging in ACP with patients, attempts to overcome barriers to increasing ACP should be directed to other factors.

scholarly journals Advance Care Planning: Understanding Clinical Routines and Experiences of Interprofessional Team Members in Diverse Health Care Settings

2016 ◽  
Vol 34 (10) ◽  
pp. 946-953 ◽  
Author(s):  
Kelly Arnett ◽  
Rebecca L. Sudore ◽  
David Nowels ◽  
Cindy X. Feng ◽  
Cari R. Levy ◽  
...  
Keyword(s):  
Health Care ◽  
Advance Care Planning ◽  
Health Care Team ◽  
Care Team ◽  
Clinical Settings ◽  
Care Planning ◽  
Educational Materials ◽  
Team Members ◽  
Interprofessional Team ◽  
Advance Care

Background: Interprofessional health care team members consider advance care planning (ACP) to be important, yet gaps remain in systematic clinical routines to support ACP. A clearer understanding of the interprofessional team members’ perspectives on ACP clinical routines in diverse settings is needed. Methods: One hundred eighteen health care team members from community-based clinics, long-term care facilities, academic clinics, federally qualified health centers, and hospitals participated in a 35-question, cross-sectional online survey to assess clinical routines, workflow processes, and policies relating to ACP. Results: Respondents were 53% physicians, 18% advanced practice nurses, 11% nurses, and 18% other interprofessional team members including administrators, chaplains, social workers, and others. Regarding clinical routines, respondents reported that several interprofessional team members play a role in facilitating ACP (ie, physician, social worker, nurse, others). Most (62%) settings did not have, or did not know of, policies related to ACP documentation. Only 14% of settings had a patient education program. Two-thirds of the respondents said that addressing ACP is a high priority and 85% felt that nonphysicians could have ACP conversations with appropriate training. The clinical resources needed to improve clinical routines included training for providers and staff, dedicated staff to facilitate ACP, and availability of patient/family educational materials. Conclusion: Although interprofessional health care team members consider ACP a priority and several team members may be involved, clinical settings lack systematic clinical routines to support ACP. Patient educational materials, interprofessional team training, and policies to support ACP clinical workflows that do not rely solely on physicians could improve ACP across diverse clinical settings.

scholarly journals Patient Perspectives on Advance Care Planning via a Patient Portal

2019 ◽  
Vol 36 (8) ◽  
pp. 682-687 ◽  
Author(s):  
Sarah R. Jordan ◽  
Adreanne Brungardt ◽  
Phoutdavone Phimphasone-Brady ◽  
Hillary D. Lum
Keyword(s):  
Health Care ◽  
Advance Care Planning ◽  
Clinical Care ◽  
Patient Perspectives ◽  
Medical Decision ◽  
Patient Portal ◽  
Care Planning ◽  
Power Of Attorney ◽  
Regional Health Care ◽  
Advance Care

Background:Patient portals can offer patients an opportunity to engage in the advance care planning (ACP) process outside of clinical visits.Objective:To describe patient perspectives on use of patient portal-based ACP tools.Design:Interviews with patients who used portal-based ACP tools. The tools included an electronic Medical Durable Power of Attorney (MDPOA) form to designate a medical decision maker, a patient-centered educational web page, online messaging, and patient access to completed advance directives stored in the electronic health record (EHR).Setting:Regional health-care system with a common EHR.Measurements:Semistructured interviews with purposefully sampled patients who used the ACP tools. Questions explored motivations for using the tools and perceptions about how the tools fit into ACP. Analysis followed a grounded hermeneutic editing approach.Results:From 46 patients (mean age: 49, 63% female), 4 key themes emerged: (1) individualized explorations of the ACP tools, (2) personal initiation and engagement with ACP tools through the portal, (3) value of connecting ACP portal tools to clinical care, and (4) practicality of the ACP tools. Patients described benefits of communicating with health-care team members who referred them to online ACP tools, as well as having the electronic MDPOA form connected to clinical care.Conclusions:Patients considered the portal-based ACP tools to be practical and feasible to use within the scope of their own ACP experiences. Further study is needed to understand whether portal-based ACP tools increase the quality and quantity of ACP conversations and documentation that is available to inform medical decision-making.

Outpatient palliative care at a tertiary cancer center: Perceptions, pathways, and pitfalls.

2012 ◽  
Vol 30 (34_suppl) ◽  
pp. 28-28
Author(s):  
Kavitha Ramchandran ◽  
Sandy Trieu ◽  
Stephanie Harman ◽  
Judy Passaglia ◽  
Janet Rodriguez ◽  
...  
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Advance Care Planning ◽  
End Of Life Care ◽  
Cancer Center ◽  
Care Planning ◽  
Life Care ◽  
Code Status ◽  
Wide Range ◽  
Advance Care

28 Background: To describe an outpatient palliative care program at a quaternary cancer center- Stanford Cancer Institute. Outpatient palliative care (PC) programs are still in their nascency. Best practices are still being developed and key performance metrics are being delineated. This is a description of Stanford Cancer Institute outpatient PC program. Methods: Observational study of the first six months of encounters to the outpatient PC program. Description of potential barriers to launch and growth, as well as description of resources required for continued success. Data evaluated included program volume, referral patterns, advance care planning, symptom assessment and team structure as collected by the clinical team. Results: Initial barriers to program initiation included lack of funding and infrastructure. Additional barriers included coordination between teams, flow of care (patients late for next appointments), and cultural perceptions of palliative care as equal to end of life care. There are 32 referring practitioners to the program. Over the first six months the outpatient PC program has seen growth with volume increasing from 10 consults per month to 26 consults per month for a total of 60 patients. At the time of initial consult, 11 of the 60 patients seen had an advance directive. Only 1 patient had a physician order for life sustaining treatment (POLST). Code status was documented in 21 of the 60 patients. Conclusions: Our program had multiple barriers to launch: perceptions that palliative care equaled end of life care, lack of infrastructure and funding, and difficulty with coordination between teams. With administrative support the program secured funding, developed infrastructure with the assistance of IT, Cancer Center administration, and Care Coordination. Consults now come from a wide range of providers. Based on preliminary data indicating a very low percentage of completion of these tasks by patients on initial consult there is need for outpatient palliative care for advance care planning. Future growth will include continued penetration of the cancer center, increasing volume of consults, and additional assessments of patient satisfaction, symptom improvement, and hospital utilization.

Advance-care planning quality improvement plan: A Cancer Care Ontario toolkit to support primary care teams to implement advance care plans in practice.

2014 ◽  
Vol 32 (31_suppl) ◽  
pp. 76-76
Author(s):  
Jeff Myers ◽  
Suzanne Strasberg ◽  
Kathi Carroll ◽  
Zabin Dhanji ◽  
Ingrid Harle ◽  
...  
Keyword(s):  
Primary Care ◽  
Health Care ◽  
Quality Improvement ◽  
Advance Care Planning ◽  
Cancer Care ◽  
Care Planning ◽  
Advance Care ◽  
Care Practices ◽  
Primary Care Practices ◽  
Eol Care

76 Background: In Ontario, the Ministry of Health and Long Term Care’s (MOHLTC) uses Quality Improvement Plans (QIPs) to drive system improvement aimed at providing high value, high quality care for all. To support the introduction of QIPs into the primary care sector, Cancer Care Ontario has developed an Advance Care Planning (ACP) toolkit for practices that include ACP as part of their annual QIP. ACP is an ongoing and dynamic process that involves a capable individual reflecting on their current values and beliefs for their health care, communicating their personal wishes for future health care and identifying an individual who will make decisions on their behalf in the event that they are unable to provide informed consent. The process is iterative and wishes may change over time with changes in health status. Methods: The ACP QIP was developed based on the Plan, Do, Study, Act cycle of continuous quality improvement. The ACP QIP provides primary care practices with detailed instructions on how to implement, monitor and report on an ACP Quality Improvement initiative. Importantly, the ACP QIP provides guidance and practical tools for developing objectives, establishing targets, and identifying measures and baselines for performance. CCO is actively promoting the ACP QIP in an effort to encourage uptake and broad adoption across Ontario. Results: There is now evidence that with ACP there is a greater likelihood EOL wishes will be both known and followed resulting in improved EOL care. ACP is also associated with decreased distress among the family members. Conclusions: Creating an ACP QIP supports primary care’s focus on advancing quality patient care. Importantly, implementing the ACP QIP into primary care practices has the potential to improve EOL care and secondarily reduce health care costs ultimately working towards achieving the triple aim of “better care, better health, and lower costs”.

Health disparities in advance care planning at a safety-net hospital.

2015 ◽  
Vol 33 (29_suppl) ◽  
pp. 125-125 ◽  
Author(s):  
Elizabeth Levin ◽  
Michael Ries ◽  
Jeffrey B Rubins ◽  
Andres Wiernik
Keyword(s):  
Health Care ◽  
Intensive Care Unit ◽  
Intensive Care ◽  
Advance Care Planning ◽  
Safety Net ◽  
Stage Iii ◽  
English Speakers ◽  
Care Planning ◽  
Advance Care ◽  
English Speaking

125 Background: Advance health care directives (AHCDs) are recommended by ASCO as a strategy to improve compliance with patient wishes at the end-of-life, thereby facilitating appropriate use of health care resources. We already know too few cancer patients complete AHCDs, but we know less about barriers to their completion. This study assessed the frequency with which AHCDs were completed in different ethnic groups and whether hospice enrollment varied by ethnicity. Methods: Retrospective analysis conducted at Hennepin County Medical Center in Minneapolis, MN with review of the cancer registry data from 2008 to 2013. Data were collected for deceased patients with stage III-IV cancer from the time of diagnosis through death. Demographics, AHCD, hospital deaths, enrollment in hospice, and individual patient data were analyzed using logistic regression, adjusting for both race and language as covariates. Results: From 2008 to 2013, there were 273 patients diagnosed with stage III-IV cancer and followed through death. Fourteen percent of patients were non-English speaking. Thirty-one percent were African American (AA), 4% were Hispanic, and 4% were Asian. Only 21% of patients completed an AHCD during their care, and none were Asian or Hispanic. English speakers were almost five times more likely than non-English speakers to have an AHCD (OR = 4.66, 95% CI = (1.06, 20.46), p = 0.04). Fifty-one percent of English-speaking patients enrolled in hospice compared to 39% of non-English-speaking patients (p = 0.08). Sixty percent of patients with an AHCD enrolled in hospice compared to 46% of those patients without an AHCD (p = 0.10). Forty-three percent of patients with an AHCD died in the hospital, 33% of whom died in an intensive care unit (ICU), versus 46% without an AHCD, 49% of whom died in an ICU. Of patients with advanced cancer, 46% died in the hospital and 21% died in the intensive care unit (ICU). Conclusions: Non-English-speaking patients are far less likely to have an AHCD than English speakers. Some ethnicities in our study had no patients with an AHCD. Since completing an AHCD may increase hospice enrollment and decrease ICU deaths, strategies to promote advance care planning are urgently needed, particularly with non-English speaking patients.

Advance care planning in Hispanic/Latino and non-Hispanic white patients with cancer.

2017 ◽  
Vol 35 (31_suppl) ◽  
pp. 10-10
Author(s):  
X Friedman ◽  
Veronica Cardenas ◽  
Sandahl Nelson ◽  
Paulette Gabbai-Saldate ◽  
Joseph Ma ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Cancer Patients ◽  
Advance Care Planning ◽  
Cancer Type ◽  
Matched Pairs ◽  
Care Planning ◽  
Surrogate Markers ◽  
Code Status ◽  
Advance Care ◽  
Hispanic Latinos

10 Background: Advance care planning (ACP) is a process whereby patients communicate their end-of-life treatment preferences. Despite a growing US Hispanic/Latino population, much remains unknown regarding ACP for Hispanic/Latinos. This study examined the association between ethnicity and ACP, including individual surrogate markers—code status documentation, advance directive (AD)/physician order for life-sustaining treatment (POLST) completion, and/or palliative care (PC) consultation—in deceased Hispanic/Latino vs white non-Hispanic (WNH) cancer patients. Methods: A retrospective analysis was performed in randomly-selected, matched pairs of deceased (2011-2016) Hispanic/Latino and WNH cancer patients at an NCI-designated cancer center. Pairs were matched based on sex, age (at diagnosis/death), and cancer type. Conditional logistic regression was used to assess ethnicity (Hispanic/Latino vs WNH) and the presence any ACP (yes/no). Secondary aims examined the association between ethnicity and the presence of individual ACP surrogate markers using separate logistic regression models. All analyses were completed using SAS 9.4. Results: 152 eligible matched pairs were analyzed with no significant differences in presence of any ACP, code status documentation, or PC consultation. Cancer patients with AD/POLST completion were 58% less likely to be Hispanic/Latino than WNH. Conclusions: Historically, ACP in cancer care is difficult to implement with 20-30% penetrance across all racial/ethnic groups. This study suggests even lower rates of AD/POLST completion in Hispanic/Latino patients consistent with prior studies. However, based on the small sample size, these results are not generalizable and requires further evaluation. This study affirms the need for continued efforts to improve AD/POLST completion in Hispanic/Latinos. [Table: see text]

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