An advance care planning long-term care initiative in response to COVID-19.

Abstract

ObjectiveDescribe a systematic approach to address advance care planning (ACP) during a COVID‐19 outbreak and its impact on the incidence of new do‐not‐hospitalize (DNH) directives among long‐term care (LTC) residents.DesignProspective quality improvement initiative.SettingTwo long‐term chronic care campuses within a large academic healthcare organization.ParticipantsLTC residents with activated healthcare proxies who lacked DNH directives based on documentation in the electronic medical record (EMR) as of April 13, 2020.InterventionUsing a structured discussion guide, trained healthcare staff from various disciplines contacted the residents' proxies to conduct COVID‐19 focused ACP discussions. Residents without DNH directives with COVID‐19 were prioritized. Preferences ascertained in the discussion were communicated to the residents' primary care teams and directives were updated in the EMR accordingly.MeasurementsResidents who acquired a new DNH directive during the study initiative were determined using the EMR. Subsequent changes in DNH orders, hospitalizations, and deaths were ascertained by retrospective chart review from the date of new DNH through August 5, 2020.ResultsAt baseline, 315/581 (54%) of LTC residents did not have a DNH directive. Their mean age was 87 (±9) years and 70% were female. Following ACP discussions, 124/315 (39%) of residents acquired a new DNH directive. Among residents with new DNH directives, 65/124 (52%) were diagnosed with COVID‐19 from April 2, 2020 to May 21, 2020. During follow‐up, only 6/124 (4.8%) residents had their DNH order reversed, 2/124 (1.6%) residents were hospitalized with illnesses unrelated to COVID‐19, and 29/124 (23%) died.ConclusionsThere was substantial opportunity to increase the proportion of LTC residents with DNH orders during the COVID‐19 pandemic through a systematic ACP initiative which utilized real‐time EMR data. New directives to avoid hospitalizations were sustained among the majority of residents beyond the peak of the pandemic.