Treatment preference discussion in oncology outpatient clinic.

Abstract

106 Background: Often end of life discussions are either not held in a timely manner or remain poorly communicated when outpatients are transferred to hospital care. This leads to unwarranted and costly interventions. Methods: In an academic oncology clinic we developed an electronic medical record (EMR) template that listed important information for management decisions, including life expectancy, goals of management and specific patient treatment preferences (ventilator support, tube feedings, transfusions, do-not-resuscitate (DNR) wishes, etc.). The completed note was placed in an easily retrievable location in patients’ electronic charts. Clinic charts were reviewed one week ahead of visits to identify patients who were within the last year of life and a pop up reminder for the treating physician was placed in the EMR. The physicians who admitted our patients to the hospital were educated on utilization of the template notice. We compared the percentage of patients with advanced directives or treatment preference notes before the intervention with the percentage 1½ years after the intervention was begun. We utilized a cross-sectional, self-administered survey to compare in-patient physician responses before and after implementation of the intervention to evaluate the in-hospital utility of the intervention. Results: Easily accessible treatment preference or advanced directive discussions with patients in their last year of life increased from 32% to 55% (p =0.004) with the intervention. Results of the survey also showed improved understanding of patient’s wishes for DNR status (26.9% vs 52.6%, p = 0.08) among admitting physicians. Conclusions: The development of an easily utilized EMR template to record the treatment preferences of patients near the end of life, with an EMR accountability instrument, improved both documentation of discussion and physician understanding of patient treatment preferences when patients were transferred from outpatient to inpatient care. We hypothesize that this intervention will lead to a decline in costly and unwanted interventions for patients near the end of life, and plan to test this hypothesis with further outcomes measures.