Feasibility of a physician-extender approach to increase advance care planning uptake.

Abstract

8 Background: Advanced care planning (ACP) for people with life-limiting cancer has been associated with improved patient quality of life and care more consistent with patient wishes. Nevertheless, even though approximately 70% of patients with a life-limiting illness will require the substituted judgment of a proxy, fewer than 25% of patients have documented goals of care. This poor uptake has been attributed to limits in physician time and ACP training. The current study evaluated the feasibility of utilizing a physician-extender trained in ACP best practices to overcome these barriers and improve ACP uptake. Methods: Patients who met criteria for a life-limiting cancer diagnosis were identified by support staff in Medical Oncology offices and the Emergency Department (ED) in a large North East community health care system. Pending physician approval, a Licensed Clinical Social Worker (LCSW) with training and experience in ACP was available to provide support and assistance to patients, which included but was not limited to ACP. The LCSW initially met patients in clinic and subsequently in whatever way was most convenient for the patient (at future appointments, by phone, inpatient, or at the patient’s home). The program was approved by the Medical Oncology section and the Emergency Department. Results: ACP uptake, calculated as the percentage of eligible patients who participated in the program, was 14.6% in the Medical Oncology practices (60/140) and 44.6% (41/92) in the ED. The difference in uptake between the two sites was significant, χ2(1, N = 502) = 41.88, p < .01, and was primarily the result of Medical Oncologists determining that ACP was not appropriate for a subset of eligible patients. Conclusions: The results of this feasibility evaluation suggest that limits in time and ACP training are not the primary barriers to ACP uptake in oncology. Instead, the type of physician and setting proved to be important correlates of uptake. We consider the implications of these findings and identify next steps to better understand the factors that influence physician participation in ACP.