Goals of care documentation in advanced cancer.

Abstract

58 Background: Documenting goals of care (GOC) is integral to patient centered care, decision making and quality performance. Studies show patients value conversations about GOC after receiving a terminal diagnosis. Positive effects have been demonstrated for survival, quality of life, disease management and healthcare savings. The ASCO QOPI recommends documentation within 3 visits from diagnosis of metastatic cancer. For hospital inpatients, GOC are more often integrated into care planning, as admissions frequently reflect changes in illness trajectory, yet documentation remains poor. This Quality Improvement (QI) initiative aims to increase GOC documentation for ambulatory patients and referral rates to Palliative Medicine. Methods: A retrospective cohort receiving palliative chemotherapy for metastatic lung, pancreas, colorectal and breast cancers during 2010-2015 were identified from pharmacy records at a Canadian Regional Cancer Centre. Inclusion criteria required a minimum of 4 clinic visits post treatment. Clinical notes of Oncologists and Palliative Medicine Physicians were reviewed for GOC documentation and referrals to Palliative Medicine. Baseline data determined improvement target rates. A clinical practice QI initiative applied passive and active phases, beginning May 2016. Passive phase included the development of a guideline, documentation template and referral process. The active phase is the implementation process (ongoing). Results: A cohort included 456 patients with metastatic cancer, 63% lung cancer. Oncologists documented GOC in 6% (26/456) and referred 47% to Palliative Medicine. GOC rate was 48% post-referral. Improvement target rates were set at 40% and for referrals 70% by March 2017. Analysis during the passive phase showed Oncologists’ GOC documentations increased to 15%. Analysis of the active phase is ongoing and preliminary results will be presented. Conclusions: Low rates of GOC documentation and referrals to Palliative Medicine persist. The passive phase of engaging physicians in the QI development positively influenced GOC documentation. This QI initiative will inform the sustainability of GOC documentation, Palliative Medicine referrals and standardization of institutional guidelines.