Improving code status documentation as a marker of advanced care planning at an outpatient academic cancer center: A pilot project.

Abstract

38 Background: Advanced care planning can significantly impact the quality of end of life care. Readily accessible documentation of goals of care for patients (pts) known to have a high morbidity and mortality provides a concrete means for practitioners to discuss and guide advanced care planning. We previously reported a surprisingly small proportion of established pts in our oncology clinic with a documented code status (CS), and undertook a pilot project aimed at improving this rate. Methods: Query of the outpatient electronic medical record (EMR) at the Abramson Cancer Center for established pts revealed an average of 2% with a documented CS. Our pilot study focused on 8 providers in thoracic and gastrointestinal oncology. We established provider agreement on the importance of CS documentation, and analyzed the mechanisms in place for documentation. We educated providers on the method of documentation, raised visibility and importance of advanced directives, implemented a system of normalizing conversations for all new pts, reported weekly to providers on upcoming established pts without documentation and provided monthly report cards, indicating provider rates within the pilot group. Results: Prior to intervention, a median of 499-established pts per month were seen by our pilot group. A median of 50 pts (10%) had a documented CS with documentation rates by provider ranging from 0 – 91%. 5 of 8 providers had no established pts with a documented CS. After intervention, a median of 494-established pts per month were seen by the same group. A median of 197 pts (40%) (p < 0.05) had a documented CS with provider rates ranging from 26 – 94%. All providers had documented a CS on at least some of their established pts; improvements ranged from an increase of 0 to 26%, to an increase of 1 to 43%. Conclusions: Previously, at our institution, only a small minority of established patients with an oncologic diagnosis had documentation of CS in the readily available EMR. Our pilot study resulted in a statistically significant increase in the documentation rates for all providers over a 2-month period. We have yet to analyze the clinical significance of this, with attention to quality and cost of end of life care.