Improving advanced directive completion rates on an inpatient oncology unit using internal medicine resident participation: A quality improvement study.

Abstract

e18636 Background: A written advanced directive (AD) allows patients to indicate their preferences for medical care should they ever lose the ability to make their wishes known. This may take the form of a living will or designation of a healthcare surrogate. AD completion rates remain poor on inpatient oncology units, with only 20-40% of patients having an AD. This is despite the fact nearly all cancer patients (95%) believe discussing ADs is an important issue. It has recently been shown that nearly 87% of cancer patients would support a policy in which admitting physicians offered to have a conversation regarding ADs. The goal of our project was to increase the percentage of patients with documented ADs on our inpatient oncology unit from 30% to 50% using the participation of internal medicine residents. Our secondary objective was to initially assess resident knowledge, confidence and skills with AD discussions. Methods: We carried out a prospective QI project in which we first calculated the percentage of consecutive patients on our inpatient oncology unit with documented ADs. After providing educational materials and delivering AD forms to the resident workroom to increase accessibility, we again calculated the percentage of consecutive patients with documented ADs. We also initially surveyed residents about their knowledge, comfort levels, and barriers to having AD discussions with patients. Results: Pre-intervention, 15 out of 50 (30%) consecutive patients on our inpatient oncology unit had documented ADs. Post-intervention, 13 of 27 (48%) consecutive patients in our oncology unit had documented ADs. Most residents felt their knowledge of ADs was average (46.88%, n = 15) or good (28.13%. n = 9). When asked about comfort in filling out ADs with patients, most responded as average (28.13%, n = 9) or poor (28.13%, n = 9). The main barrier to completing ADs was lack of time (25%, n = 20) followed by lack of knowledge (25%, n = 8) and not feeling the responsibility (12.5%, n = 4). Most residents were interested (65.53%, n = 21) or maybe interested (28.13%, n = 9) in further teaching on ADs. Conclusions: Our study showed that AD completion rates on an inpatient oncology unit can be improved using the participation of internal medicine residents. This was done through a standardized approach of housestaff offering to discuss ADs on admission after they had received short small group teaching sessions on AD discussions. Furthermore, we identified that most internal medicine residents had average or poor comfort in initiating advanced care discussions, but were interested in obtaining further knowledge to help discuss ADs with patients.