Sidebar: North Carolina's Process for Developing Our COVID-19 Vaccine Plan.

Abstract

### Background There are no national standards about the timing of initiating ACP discussions. It is suggested that ACP may be initiated following the diagnosis of a life-limiting condition, with a change in treatment focus, or following multiple hospital admissions. It was unknown how many patients dying at a specialist cancer centre had been involved in ACP prior to death, and at what stage in their illness this was commenced. ### Methods This was a baseline retrospective audit. The population sampled was all inpatient adult deaths over a two-month period in 2019 in a specialist cancer centre. Medical records and Co-ordinate My Care records (Electronic urgent care plan) were reviewed from six months prior to patient death for evidence and timing of ACP discussions. We anticipated that 70% of patients sampled would have ACP prior to death. ### Results There were 36 inpatient adult deaths. 89% of these patients had non-curative disease. 63% patients were involved in a DNAR discussion. Of these patients, 22% had a DNAR discussion prior to their final admission versus 78% who had a DNAR discussion during their final admission. 44% patients had a discussion about preferred place of care (PPC) and/or death (PPD). Of these patients, only 31% had these discussions prior to final admission compared to 69% who had these discussions during their final admission. ### Conclusions The most common form of ACP was a DNAR discussion, followed by PPC/PPD. The vast majority of ACP discussions occurred in the final inpatient admission as opposed to during outpatient clinics or previous hospital admissions. There is concern that by the time these conversations were being initiated, patients' options about future care and wishes were already restricted and had less chance of being achieved. This baseline audit will inform an education programme to encourage earlier and broader ACP discussions.