The ABCs of ACPs: perspectives from gynecologic oncology clinicians on an advance care planning initiative

Abstract

Objectives: There are many advance care planning (ACP) initiatives for patients, however little is known on the clinician experience around these initiatives. Clinician experience can affect provider adoption of the initiative and willingness to utilize and engage in advance care planning. Our goal was to evaluate the attitudes and experience of Gynecologic Oncology clinicians utilizing an electronic health record (EHR) ACP notification in clinical practice to identify barriers and facilitators to use. Methods: Starting in 2017, an academic medical center Gynecologic Oncology division implemented a quality improvement project to increase ACP conversations and EHR documentation. Patients with high risk of death within 1 year, defined as a diagnosis of platinum-resistant ovarian cancer, recurrent endometrial cancer, or metastatic/recurrent cervical or vulvar cancer were identified in the outpatient setting by clinic staff and ACP discussion recommended. A template was provided to facilitate documentation in the medical record. Providers were notified by email and/or paper if a patient met ACP criteria. In 2019, an inpatient ACP project combined similar diagnostic criteria along with an unplanned hospital admission to identify patients appropriate for ACP. An EHR alert notified clinicians upon chart opening if inclusion criteria were met. At the completion of the quality improvement project, clinicians were surveyed on their experiences with these two interventions. Results: Nine out of 12 (75%) clinicians responded to the survey. Respondents were physicians (n=7, 78%) and advanced practice providers (n=2, 22%) with a median of 4 (IQR 2 -14) years in practice. Most participants agreed the notification in either setting improved delivery of patient care (88%) and was valuable to the care provided (88%). The notification was not burdensome in the daily work (88%) nor was it difficult to navigate (75%). A majority of respondents would continue to use the notifications (88%) and recommend the notification to other specialties (88%). While most (63%) felt that the notification was accurate in its identification of eligible patients, noticeable gaps include patients with new or undocumented serious illnesses or who had received care outside of the health system. Conclusions: Implementation of a system to identify patients at highest risk of death to facilitate advanced care planning discussions is not only feasible, but also viewed positively by the clinicians involved. Further work to better refine eligibility criteria as well as EHR integration is needed to optimize the delivery of goal concordant patient care.