Implementing values-based advance care planning (ACP) in a community oncology network.

Abstract

105 Background: Oncologists often embrace the concept of having discussions with patients regarding end-of-life care. Still, challenges remain with initiating these discussions early in the metastatic setting so that the full ACP process can be satisfied. A framework and infrastructure are needed to systematically initiate and promote the ACP process at a time when metastatic disease is identified and patients are better able to make thoughtful decisions regarding their future care. Methodology is needed for documenting and updating the ACP process within the patient’s health record. Methods: During a 15 month period, 32 independent sites of service within a nationwide community oncology network implemented an electronic health record (EHR)-based program for initiating ACP conversations with patients having a metastatic cancer diagnosis. Patients were identified for program engagement based on clinical criteria populated within the EHR. Identified patients received a brief introduction to ACP by the physician or other clinician and were encouraged to meet with a trained ACP Counselor to engage the full process. ACP Counselors provided guidance to the patient to discover and share personal values and goals for care. Values for care were documented within the EHR. Counselors provided appropriate patient education regarding code status and state-specific advance directives. At end-of-life, practices included hospice and death details within the EHR. Results: For metastatic patients (n = 29,389), ACP counseling was provided for 1,034 individuals (4%). Code status was visible in 3648 health records (12%) and patient values were included for 376 patients (1%). 2,206 patients (8%) transitioned to hospice care during the 14-month period. EHR-based infrastructure allowed for ongoing ACP visibility by the healthcare team. Conclusions: Use of an EHR-based ACP process demonstrates promising outcomes for realizing meaningful delivery of ACP. Essential components are patient identification early in the metastatic trajectory, assessment of patient values for care, thorough patient education regarding code status and advance directive documents, and full visibility of the ACP process within the health record.