Caring Wisely: A Model for Improving Advanced Care Planning for Cancer Patients

Abstract

Advanced Care Planning (ACP) is an important process to provide care that is consistent with patients’ desire. However, conversation about patients’ preference and ACP is often not included in the care of cancer patients receiving radiation. Historically, fewer than 10% of patients receiving care in the Department of Radiation Medicine at our institution have documents indicating their ACP such as advanced directives (AD), while 43% of interviewed cancer patients reported having an existing AD. Between February 2016 and November 2017 we aimed to implement a process that would enhance ACP for patients receiving radiation and increase the percentage of AD in the electronic medical record (EMR). We conducted a root cause analysis and identified cultural and system barriers. The most significant factor among systems barriers was that no standard work process existed for screening or collecting AD. Using the Plan-Do-Study-Act (PDSA) method, we developed and implemented a standard work process for nurses to ask patients about ACP, and provide ACP education material and a tool kit for completing an AD at the time of initial patient consultation. From February 2016 through November 2017 the Department of Radiation Medicine at our institution recorded the 1) number of AD collected and scanned into the EMR, and 2) the percent of EMRs with an AD or POLST at the time of their visit. Using chart for analysis and monitoring changes in real-time, we compared our pre-intervention AD compliance rate with our post-intervention rate at each PDSA cycle. Prior to implementation, 100% of staff completed training to use ACP standard work. Execution of ACP screening following the standard work was confirmed by independent observation of their patient encounter. Two hundred eighty-four patients were seen in our clinic for initial consultation after implementation of the first PDSA. Three months post- PDSA #1 we achieved 40% AD compliance rate (115 of 284 patients having an AD on file). Post-PDSA #2 (May 2016) we achieved a 57% (1,003 of 1,774 patients) AD compliance rate. Our overall post-intervention AD compliance rate through November 2017 was 54% (1,118 of 2,058 patients). This model highlights a feasible approach to improve advanced care planning in the department of radiation medicine that is sustainable and encourages end-of-life discussions as a routine part of the oncology workflow.