The value of advance care planning (ACP) in cancer critical care.

Abstract

109 Background: Findings from previous research on the effect of advance directives (ADs) on patient outcomes have been mixed and are limited in the oncology population. A palliative care project in our Cancer Center’s ICU revealed patients with long length of stay (LOS) and ICU death without ADs in place. The Center’s Bone Marrow Transplant (BMT) program has implemented a protocol to obtain ADs pre-transplant. We sought to determine the presence and effect of ADs on end-of-life cost of care (COC) and LOS in critical care patients at our Center. Methods: We compared the 2013 COC and LOS of all ICU patients to the subset of patients for whom ICU care proved futile. The presence of ADs and DNR orders for expired ICU patients were matched to their respective COC and LOS. The COC of floor and ICU care were compared to determine potential cost savings from ICU avoidance. BMT-specific data was reviewed to establish the effect of early ADs on care and LOS. Results: Floor care proved to cost on average $2,000 less per day than ICU care. Thirty-eight percent of ICU patients had ADs. Only 41% of patients who expired in the ICU had an AD. If an AD was present, it was most likely to be a Living Will (LW) with DNR. The daily COC was highest for patients without ADs and lowest for those with LWs with DNR, despite a longer LOS in the LW/DNR group. In the BMT group, AD prevalence was 83% and resulted in earlier discussions about futility and shorter LOS. Conclusions: Obtaining timely ADs with DNR is likely to result in the lowest daily COC for critical patients. The greatest savings is likely to result from early ACP and ICU avoidance. Further study is needed to understand and overcome barriers to timely ACP implementation.