An Effective Strategy to Increase Advance Care Planning

Abstract

Introduction Nearly one in five patients recently admitted to the hospital for heart failure (HF) will die within 30 days of discharge. Despite this poor prognosis, most do not recall discussing end of life preferences with a health care provider. Advance care planning (ACP) helps to ensure that patients receive care that aligns with their goals and wishes and helps engage them in shared decision making with providers in an ongoing and iterative process. The 2017 American College of Cardiology Pathway for Optimization of HF Treatment recommends the use of patient decision aids followed by personalized ACP conversations. Hypothesis Compared to a prior year, patients in an outpatient HF clinic who view an ACP video decision aid will be more likely to have documented follow up ACP conversations with nurse practitioner (NP) providers. Methods During a follow-up outpatient visit to the clinic after hospitalization patients were shown a 6-minute video introducing them ACP. The video described levels of medical care they may choose if they become very sick including life prolonging care, limited medical care, and comfort care. The video was shown by clinic staff, which included a community health worker, a nurse coordinator and an infusion nurse. Follow-up conversations were conducted by clinic NPs and documented in the EMR using standardized documentation. Data collection occurred over 10 weeks and data were compared to a comparable period in the preceding year. Results Nearly one third (n=62, 30%) of eligible patients were shown the ACP video and nearly two thirds (n=40, 65%) of those who saw the video had a follow up ACP conversation with a nurse practitioner. This was a 20-fold increase from two documented ACP conversations the preceding year. A chi-square test was used to test associations of the occurrence of ACP conversations at baseline and after the ACP video was added to visits. Using a nominal scale, patients seen after the video was added were significantly more likely to have an ACP conversation documented by the provider (x2 = 19.66, df = 1, p = Conclusions Use of a video decision aid was an effective way to increase the number of ACP conversations with patients who have advanced heart failure. Routine ACP conversations align clinical practice with ACC standards of care. The sustainability of this practice change hinges on access to appropriate patient video decision aids. The use of Medicare ACP billing codes may offset the cost of video access.