A letter to your care providers: implementation and analysis of a letter-based advance care planning initiative for gynecologic oncology patients

Abstract

<h3>Objectives:</h3> To determine the impact of a prospective, student-led, letter-based advance care planning (ACP) intervention on rates of ACP conversations and documentation among gynecologic oncology (GO) inpatients. <h3>Methods:</h3> Retrospective analysis of patients admitted to the GO service at a single academic institution in 2019 showed that compliance with recommendations for ACP documentation was suboptimal. We initiated a quality improvement initiative from January through September 2020 to improve our compliance. Patients admitted to the GO service were given ACP packets with a letter-based advance directive (AD) worksheet modeled after the Stanford Letter Project. In January and February 2020, patients who were interested in learning more about ACP were visited by medical students trained to lead ACP conversations. From March through September 2020, students were unavailable to facilitate in-person ACP conversations due to COVID-19 restrictions. Pre and post-intervention ACP documentation of patients admitted to the GO service were analyzed. Descriptive statistics were calculated, and associations between sociodemographic characteristics and ACP documentation were analyzed using logistic regression. <h3>Results:</h3> Since implementation of the letter-based ACP intervention, 98 patients were admitted to the GO service. The majority of those admitted had cancer (n=60, 61%). Only 16 patients (16%) had an AD on admission, and 65 patients (66%) reported never having an ACP conversation. Of 82 patients without ADs, 71 (87%) received an ACP packet. Of those receiving packets, 8 (11%) requested more information about ACP and 6 (8%) participated in an ACP conversation with a student. At 9-month follow-up among patients receiving a packet, 9 patients added an AD to their EMR (13%), and 2 updated their AD (3%). After the intervention, AD completion in our population went from 16% to 26%. Among those receiving ACP packets, increasing age was associated with increased post-admission AD completion (OR 1.1, p=0.01). <h3>Conclusions:</h3> Completion of AD among patients continues to be low. Barriers to AD completion include patient and provider reluctance surrounding discussing these issues and difficulty with uploading these documents into the EMR. Letter-based ADs offer a unique method for introducing ACP earlier in cancer care and may lead to increased conversations about patient values and goals of care. More work is needed to improve occurrence and documentation of ACP conversations.