Understanding attitudes and preferences towards advance care planning in older adults: Insights from a cross-sectional study in primary care

Increasing medical possibilities, ageing of the population and the growing number of people with chronic illness appears to make advance care planning (ACP) inevitable. However, to what extent and how primary care providers (PCPs) provide ACP in daily practice is largely unknown. To provide an overview of the actual practice of ACP in primary care. We searched MEDLINE, EMBASE, CINAHL, PsycINFO and the Cochrane Library for empirical studies that described the practice of ACP with patients in primary health care. Studies focussing on non-adult patients, and hospital or nursing home settings were excluded. Ten articles met the inclusion criteria. The content of the ACP varied from discussing to refrain from cardiopulmonary resuscitation to existential issues. The prevalence ranged from 21% of PCPs having ACP discussions with the general elderly population to 69% having ACP discussions with terminal patients and 81% with patients with mild to moderate Alzheimer's disease. ACP was more common among cancer patients than among patients with non-cancer patients. Whether health care professionals or patients initiated ACP varied greatly. Advance directives and the Gold Standard Framework were perceived as helpful to guide ACP. ACP does not seem to have a systematic place in the care for all community-dwelling older people. Rather, it is used for specific groups, like patients with terminal disease, cancer and Alzheimer's Disease. Whether ACP might have beneficial effects for a broader primary care population, in terms of future care planning, is yet to be investigated.

Recent controversy has called into question the meaning and clinical utility of Advance Care Planning (ACP), however data have consistently shown potential benefit to patients and their surrogate decision makers. We present the concept of surgery-specific advance care planning and a structured, scalable approach to integrating it into clinical practice.

Ethical Considerations About Clinician Reimbursement for Advance Care Planning

Barriers and Facilitators of Advance Care Planning for Older Adults with Sickle Cell Disease

Achieving advance care planning in diverse, underserved populations

Group visits for advance care planning (ACP) may help patients document preferences for decision makers and future care. We assessed the impact of a primary care-based ACP group visit (ACP-GV) intervention on older adults' ACP documentation and why patients participated. Older adults (>65 years) in primary care participated in a 2-session ACP-GV intervention that promotes group dynamics, peer-based learning, and goal setting. Charts were reviewed at baseline, 3 months, and 12 months for documentation of decision makers and ACP forms. We described patients' reasons for participating through analysis of transcripts. 118 patients (mean age 76 years; 62% female and 82% white) participated in 16 ACP-GV cohorts. From baseline to 3-month follow-up, documentation of decision maker preferences increased from 39% to 81%, and was 89% at 12-month follow-up. Patients with completed ACP forms increased from 20% to 57% at 3 months, and was 67% at 12 months. Reasons for participating included recognizing the importance of ACP, curiosity, participation recommended by primary care provider, desire to talk with family/friends, and desire to complete advance directives. This ACP-GV intervention increased ACP documentation among patients with diverse reasons for participating. This is a patient-centered approach to ACP in primary care.

e18549 Background: Black women are more likely to be diagnosed with more aggressive subtypes of breast cancer, at more advanced stages, and have worse outcomes than white women. Rates of advanced care planning (ACP) discussions are lower among black patients with advanced cancer, and they are less likely to receive care concordant with their wishes at end of life. Community health workers (CHW) play a versatile role in bridging social barriers to care and offer a unique mechanism to improve ACP discussions in this population. The aim of our study was to use a mixed methods approach to examine current practices and strategies to facilitate integration of CHW in ACP with black women with breast cancer. Methods: Participants completed a 22-item questionnaire to assess prior training in ACP and experience serving cancer patients. Focus groups were conducted with CHW (N = 5) and providers (i.e., oncologists, radiation oncologists, and palliative medicine physicians; N = 6) to discuss knowledge of ACP, barriers to ACP discussions, strategies to integrate CHW into ACP, and components of an effective ACP training curriculum for CHW. Focus groups were transcribed and two independent coders analyzed the data using the Framework method to extract themes and components of an ACP training curriculum for CHW. Results: Approximately 60% of CHW reported having received prior training in ACP. All providers reported primarily serving Black patients, and 66% self-reported low rates of ACP documentation (10-25%) among their patients. In the focus groups, CHW and providers described elements of effective ACP discussions as patient value-focused, multidisciplinary, timely, and empowering. Common barriers to ACP discussions identified by CHW included inexperience with ACP, unclear responsibility to initiate the discussion, and patient factors such as reluctance and complex social dynamics; providers identified issues of mistrust, historic injustice and power dynamics with their patients. Both CHW and providers viewed the role of CHW in ACP as a longitudinal process to empower, educate and reinforce patients’ values via a non-judgmental member of the community. For both groups, an ideal training curriculum teaches about key oncologic concepts, assesses patient readiness, and increases familiarity with ACP documentation. Conclusions: CHW serve a vital role in bridging care gaps for vulnerable patients and provide an opportunity to improve rates of ACP discussions in Black women with breast cancer. A training curriculum designed to help CHW assess a patient’s understanding of ACP and reinforce a longitudinal conversation is feasible, straightforward and can be incorporated into CHW workflow. One such training curriculum could expose CHW to different ACP documents, provide simulated patient encounters, and educate CHW on verbal and non-verbal cues from providers that may signal an ACP discussion is needed.

Advance care planning (ACP) discussions are often procrastinated due to both physician and patient factors. However, ACP should be started earlier, to provide more time for reviewing one's values and discussing them with loved ones and medical professionals. This study examined the effectiveness of ACP discussions with health care providers held among older adults with chronic diseases. This was a non-randomized controlled trial among chronically ill people aged 65 years and older. A 6-month follow-up was conducted in the intervention group, in which participants had ACP discussions with trained nurses (n=115), and the control group, in which participants did not discuss ACP (n=115). Questionnaires were administered at baseline and at 6 months, to examine knowledge, ACP readiness and self-efficacy, and comprehensive quality of life (QoL). A total of 200 participants were included in the analysis. The mean age of participants was 69.6 years. There was only a small change in knowledge scores before and after the intervention, with no significant difference between the two groups. ACP engagement was significantly higher in the intervention group than in the control group at 6 months (P=0.016). Comprehensive QoL was significantly higher in the intervention group than in the control group (P<0.001). After adjusting for confounders using multiple regression analysis, there was still an association between those higher scores and the intervention (P=0.01, P=0.044). This study showed that older adults with chronic diseases can have better communication with their families and health care providers and a higher QoL if they engage in ACP discussions with trained nurses at an early stage.

2 Background: Documenting patients’ advance care planning (ACP) wishes is essential to providing value aligned care, as is having this documentation readily accessible. Early ACP is increasingly being recognized as integral to oncologic care, however, little is known about current documentation practices. In this cross-sectional study, we describe ACP documentation practices and accessibility of documented ACP discussions in the electronic health record (EHR). Methods: Participants were recruited from outpatient clinics at the San Francisco VA, were ≥60 years old, with ≥2 chronic/serious conditions and ≥2 primary care visits in the past year. ACP documentation was abstracted from the EHR in 2013-2015 and included any prior legal forms/orders and ACP discussions documented within the prior five years. Frequency and type of ACP documentation was calculated using percentages and means. For discussions, author discipline and location of documentation was determined. Discussions were deemed “accessible” if documented in a designated ACP posting location or “not easily accessible” if recorded as free text in progress notes. Results: The mean age of 414 participants was 71 years (SD ± 8), 9% were women, 43% were non-white, and 51% had documented ACP including 149 (36%) with ACP forms and 138 (33%) with ACP discussions. Seventy-five (54%) discussions were documented by social workers and 49 (36%) by primary care providers. However, 76 (55%) discussions were not easily accessible. For 27 (18%) participants with advance directives, subsequent discussions documented a change in treatment preferences. Nineteen (70%) discussions reporting a change in wishes were not easily accessible. Conclusions: Half of chronically ill, older patients had documented ACP wishes, including a third with documented ACP discussions. Most discussions were documented by social workers and were not easily accessible, although discussions often represented changes from prior advance directives. Clinician education and EHR changes to ensure documented discussions are accessible are important patient-safety and quality improvement targets to ensure patients’ wishes are honored.

Objective The aim of the present study was to develop, implement and explore the effects of a program in advance care planning (ACP) within a tertiary hospital general medicine service. Methods Before-after exploratory mixed-methods analysis was conducted of an ACP program comprising seven components designed to overcome well-documented barriers to ACP in clinical practice. The results of pre-ACP program audits performed in June 2014 were compared with those of post-ACP audits performed over 5 months from July to November 2014. The main outcome measure was the number of advance care plans completed in patients considered eligible for ACP based on a life expectancy of 12 months or less as assessed by two prognostication instruments. Questionnaire surveys ascertained staff perceptions of ACP and the usefulness of training and resources in ACP. Results Pre-ACP program analysis of 166 consecutive patients deemed eligible for ACP revealed that only 1% had a documented advance care plan. Following ACP implementation, 115 of 215 (53%) potentially eligible patients were considered able to participate in ACP discussions and were approached to do so before discharge, of whom 89 (77.4%) completed an advance care plan, whereas 26 (23.6%) declined. This equated to an overall completion rate for all potentially eligible patients of 41% compared to 1% pre-ACP (P<0.001). Major barriers to ACP perceived by at least 30% of questionnaire respondents included the reluctance of patients and family to discuss ACP, insufficient time to initiate or complete ACP, patient and/or family factors that rendered ACP impractical, inadequate communication skills around end-of-life issues, confusion about who was primarily responsible for conducting ACP and difficulty using ACP documentation forms. Enabling factors included dedicated ACP workshops, facilitator and resource packages for staff, and ACP brochures for patients and family. Conclusion A multifaceted ACP program in a general medicine service led to completion of an advance care plan in more than three of four patients considered eligible for, and who participated in, ACP. However, although program components were tailored to overcome known barriers to ACP, staff indicated ongoing difficulties, with less than half of ACP-eligible patients completing advance care plans. What is known about this topic? Advance care planning is increasingly recognised as an important part of hospital care for older patients with advanced chronic disease. However, research indicates that ACP discussions are rare in hospital settings because of various barriers that are not adequately addressed in the design of ACP programs. What does this paper add? The present exploratory study of the development, implementation and evaluation of an ACP program in a tertiary hospital general medicine service shows that program components designed to overcome specific barriers to ACP discussions was associated with a >75% completion rate of advance care plans among ACP-eligible patients who participated in ACP discussions. Dedicated staff training and resources in ACP, employment of an ACP facilitator and ready access to ACP documentation forms were important enabling strategies. What are the implications for practitioners? Hospital units caring for significant numbers of older patients with limited life expectancy can implement ACP programs that help normalise ACP discussions within routine clinical care.

e24067 Background: Advance Care Planning (ACP) ensures that patients receive care that is in line with their values and preferences. ACP is best done in the outpatient setting. Despite recognizing the importance of ACP, the rates of ACP completion continue to be low. We conducted a retrospective study to determine the rates of ACP in a resident run primary care clinic in Hartford, Connecticut, which serves the underserved community. We looked at patient characteristics to find correlation with ACP completion. We also aimed to determine the reasons which could decrease the completion of ACP. Methods: This was a retrospective chart review. Patients who met any of the inclusion criteria [i) Age&gt;65 ii) End stage renal disease on dialysis iii) Metastatic/Recurrent cancer iv) End stage heart failure v) COPD Gold stage D] and were seen in the primary care clinic from September 1, 2019 to December 31, 2019 were selected. Their charts were reviewed to see if ACP was documented during primary care visits over the past two years. The demographics of the patients were noted. Subsequently, a survey was distributed to residents to determine the possible causes of low rates of ACP discussion. Results: The characteristics of the 373 patients included in the study are shown in Table 1. Only 14 (3.8%) of the 373 had documentation of ACP during their primary care visits. The characteristics of the 14 patients in whom ACP was done are as follows: Sex- Female 9/14 (64%); Ethnicity- Hispanic 10/14 (71%), African American 4/14 (29%); Religious Affiliation- Christian 13/14 (93%), None 1/14 (7%); Married/Partner 2/14 (14%). Patient demographics including sex (p 0.6), religious beliefs (p 0.8), and marital status (p 0.6) did not show any correlation with the likelihood of ACP completion. Of the 31 residents who answered the survey, the most commonly listed barriers to ACP completion were the following: lack of time to conduct these discussions (94%), forgetting to conduct ACP discussions (48%), and lack of training (19%). All the residents believed that ACP discussion was beneficial to patients and medical providers. Conclusions: The rates of ACP planning in our clinic are much lower than the national average. African American and Hispanics, who make up the majority of our clinic population, traditionally have had low rates of ACP completion. This is an important issue that needs to be addressed. Advance care planning training should be also be strengthened during residency. [Table: see text]

This study aimed to explore the factors affecting the behavioral intentions of older adults toward advance care planning (ACP). A questionnaire survey was conducted at 2 medical wards and a senior activity center in northern Taiwan. Four hundred one participants were older adults aged over 65 years, comprising hospitalized patients, their caregivers, and members of a senior activity center. The regression model revealed that participant type (patient, caregiver, or community resident); financial support; discussion of ACP with family; and knowledge, attitudes, and subjective norms accounted for 46.3% of the variance in behavioral intentions. The behavioral intention of caregivers was higher than that of patients. The behavioral intention of participants who were financially dependent on the family was lower than that of pensioners. Regarding discussing ACP with family, older adults in the contemplation and preparation stages score higher on behavioral intention than those in the precontemplation stage. This study supports the theory of reasoned action. Older adults' ACP knowledge and attitudes need to be enhanced through education. Caregivers' behavioral intentions tend to perform ACP. Sharing their caring experiences may be a strategy for promoting ACP. Older adults' financial status affects their behavioral intentions. Therefore, financial planning should be performed early and should incorporate ACP.

Few older adults discuss their end-of-life care wishes with their physician, and even fewer minorities do this. We explored physicians' experience with advance care planning (ACP) including the barriers/facilitating factors encountered when initiating/conducting ACP discussions with South Asians (SA), one of Canada's largest minorities. Eleven primary care physicians (PC) and 11 hospitalists with ≥ 15 per cent SA patients ≥ 55 years of age were interviewed: 10 in 2020, 12 in 2021. Thematic analysis of transcripts indicated that cultural and communication barriers, physician's specialization, SA older adults' lack of ACP awareness, and decision-making deference to family and physicians were barriers to ACP discussions. Although the COVID-19 pandemic impacted physicians' practices, contrary to our hypothesis most reported no change in frequency of ACP discussions. Although ACP discussions were viewed as best conducted by PC physicians, only 55 per cent had ACP training and only 64 per cent had used ACP tools. Training in ACP facilitation, concerning ACP tool usage, and training in patient-physician communication are recommended.

BackgroundTo improve the quality of advance care planning (ACP) in primary care, it is important to understand the frequency of and topics involved in the ACP discussion between patients and their family physicians (FPs).MethodsA secondary analysis of a previous multicenter cross-sectional observational study was performed. The primary outcome of this analysis was the frequency of and topics involved in the ACP discussion between outpatients and FPs. In March 2017, 22 family physicians at 17 clinics scheduled a day to assess outpatients and enrolled patients older than 65 years who were recognized by FPs as having regular visits. We defined three ACP discussion topics: 1) future decline in activities of daily living (ADL), 2) future inability to eat, and 3) surrogate decision makers. FPs assessed whether they had ever discussed any ACP topics with each patient and their family members, and if they had documented the results of these discussions in medical records before patients were enrolled in the present study. We defined patients as being at risk of deteriorating and dying if they had at least 2 positive general indicators or at least 1 positive disease-specific indicator in the Japanese version of the Supportive and Palliative Care Indicators Tool.ResultsIn total, 382 patients with a mean age of 77.4 ± 7.9 years were enrolled, and 63.1% were female. Seventy-nine patients (20.7%) had discussed at least one ACP topic with their FPs. However, only 23 patients (6.0%) had discussed an ACP topic with family members and their FPs, with the results being documented in their medical records. The topic of future ADL decline was discussed and documented more often than the other two topics. Patients at risk of deteriorating and dying discussed ACP topics significantly more often than those not at risk of deteriorating and dying (39.4% vs. 16.8%, p < 0.001).ConclusionFPs may discuss ACP with some of their patients, but may not often document the results of this discussion in medical records. FPs need to be encouraged to discuss ACP with patients and family members and describe the decisions reached in medical records.

<h3>Context:</h3> Advance care planning (ACP) in primary care has become increasingly important during the COVID-19 pandemic. The pandemic has introduced a surge in the risk of morbidity and mortality of previously at-risk patients, creating pressure on the healthcare system and instigating an urgent need to improve ACP communication in primary care within the community. An increase in the advocacy of ACP along with a growing public interest may facilitate more patient engagement in ACP discussions with their healthcare provider. <h3>Objective:</h3> To assess knowledge, attitudes, and practices (KAP) of family physicians relating to ACP before the COVID-19 pandemic and after a city-wide ACP campaign. The perception and use of telemedicine to conduct ACP discussions was also assessed. <h3>Study Design:</h3> Quasi-experimental quality improvement study with a cross-sectional online survey administered from March to May 2020. <h3>Setting:</h3> Community based in Hamilton, Ontario (Canada). <h3>Population Studied:</h3> Family physicians working in Hamilton, as part of the Hamilton Family Medicine (HFAM) network which consists of approximately 350 physicians. 48 of 350 family physicians (14%) responded. <h3>Outcome Measures:</h3> Mean ratings on questions of KAP relating to ACP for three months preceding and following the onset of the pandemic, use of telemedicine for ACP discussions, and the perceived impact of web-based ACP resources. <h3>Results:</h3> On average, physicians felt ACP was beneficial to patients, both pre- and post-onset of COVID-19 pandemic. There was a significant increase in use of telemedicine to discuss ACP during the pandemic (mean 1.9 [a little] to 2.9 [somewhat] p&lt;0.001). Most respondents (89%) rated the experience of telemedicine-based ACP as positive. However, most (80%) perceived in-person ACP conversations as better than virtual conversations. Most respondents (80%) reported the city-wide ACP initiative increased their frequency of ACP discussions, but the number of discussions reported pre- and post-onset of pandemic was marginally higher (mean 2.9 to 3.1). <h3>Conclusions:</h3> There was no significant change in family physicians’ reported KAP regarding ACP during the COVID-19 pandemic as compared to prior. The use of telemedicine to conduct ACP conversations increased but in-person discussions were favoured. A city-wide initiative to promote ACP, including web-based resources, demonstrated some benefit.