Advance Care Planning Research Articles

Reimagining and rebranding advance care planning.

Advance care planning (ACP) has traditionally aimed at ensuring that patients' end-of-life (EOL) wishes are understood and respected. However, recent literature raises concerns about its effectiveness, with many trials indicating that ACP does not significantly improve goal-concordant care, enhance quality of life or reduce healthcare costs. This is because patients' future decisions are influenced by their transient preferences due to projection bias. To remain relevant, ACP requires a radical shift in perspective, implementation and branding. First, ACP's mission must be redefined with a focus on: Educate, Share and Prepare. This perspective emphasises ongoing conversations about patient health and illness, sharing of patients' current values and goals of care and preparation for the future, rather than making definitive future decisions. Second, ACP should be integrated into routine care, normalising these discussions. Simplifying ACP processes and shifting incentives to support shared responsibility among stakeholders can enhance integration. Last, rebranding ACP as 'Advance Care Preparation' can clarify its purpose, distinguishing it from EOL planning and increasing its uptake. This rebranding ensures that ACP meets the evolving needs of patients and their families, ultimately enhancing the quality of care and patient satisfaction. These changes in perspective, implementation and branding can transform ACP into a valuable tool for delivering compassionate, patient-centred healthcare, making it relevant to all individuals.

Improving advance care planning outcomes through social work and provider collaboration.

55 Background: For many patients living with a life-limiting illness, the ability to have authority in their end-of-life (EOL) decision making is a foundational aspect in achieving a peaceful passing. Literature shows, however, that a low percentage of adults in the United States have completed advance directive documents or had discussions indicating their wishes for EOL care. With their unique communication and advocacy skills, licensed masters-prepared social workers (MSWs) are primed to play an active and effective role in Advance Care Planning (ACP) discussions with patients. The purpose of this study aimed to explore the extent to which MSWs in an oncology setting are harnessing these skills. Methods: An online survey was dispersed to social workers working in outpatient oncology clinics in The US Oncology Network. The survey reviewed the level of education, licensure status, involvement and comfort with ACP discussions, and factors that would aid increased engagement of these conversations. Results: 41 out of 75 social workers completed the survey. 95% of respondents were masters prepared (MSW) and licensed at the masters (27%) or clinical (73%) level. Of these MSWs, 95% are having ACP conversations with their patients and loved ones, and 87% are initiating these discussions independently. Although 64% report that they are getting referrals from physicians in their practice, almost half (49%) indicated they would like more support from physicians around ACP conversations with patients. Per respondent comments, a need was expressed for providers to help initiate and normalize ACP discussions. It was also indicated that MSWs do not believe providers fully understand MSWs ability to engage in these discussions. Interestingly, only 10% of MSWs are billing for ACP discussions, yet 46% indicated they would be interested in doing so. Conclusions: Our results indicate there is a gap between the work MSWs are doing in the ACP space and how providers are utilizing the MSW’s clinical expertise in this area. The use of MSWs in a cancer care setting can enhance patient self-determination and documentation of wishes for EOL, as well as support multidisciplinary care of the patient. Additional benefits could include improvement of ACP quality measures, increased revenue, and provider satisfaction in knowing these sensitive conversations are being addressed by a trusted member of the healthcare team.

Advance Care Planning of Patients Undergoing High-Risk Surgery: A Concept Analysis

The aim of this research was to clarify the concept of advance care planning (ACP) for patients undergoing high-risk surgery. The Walker & Avant’s approach to concept analysis was used. ACP for the patient who received a high-risk surgery was defined as follows: patients who are aware of the risks of surgery are initiated voluntarily with the need to participate in anticipatory decision-making. To do this, patients define their life-prolonging treatment, provided that appropriate treatment is guaranteed, and prepare for end-of-life care decisions through discussions involving healthcare providers and surrogate decision-makers. It is a continuous, patient-centered decision that allows the patient’s treatment goals to transition over time. The goal of the ACP is to focus on quality of life and care rather than determining end-of-life care. The development of this concept contributes to an assessment of the value of ACP support, which can lead to improved approaches to help patients recover in a short period.

Extensivist: improving the delivery of enhanced health in older people’s care homes

BackgroundOlder people living in care homes are often frail and clinically complex. The Enhanced Health in Care Homes (EHCH) framework supports organisational and clinical strategies to deliver good care, promoting...

Improving completion rate of advance care planning at a tertiary rheumatological centre in Singapore: a quality improvement project

Advanced care planning (ACP) is a series of ongoing voluntary discussions between patients, families and healthcare professionals to plan for their future healthcare needs. Despite patients with rheumatic diseases having...

AI-enabled ACP on inpatient oncology: Feasibility, acceptability and impact on workflow.

403 Background: Advance care planning (ACP) can help patients understand and share their long-term health goals and values, and in turn facilitate the delivery of medical care consistent with those goals and values. However, in a survey of Californians about attitudes towards death and dying, while almost 80% of respondents indicated that they would like to talk to their doctor about end-of-life care, only 7% had ever had a doctor bring up the subject. To address this problem, the Stanford inpatient oncology service implemented an AI-enabled workflow to facilitate timely identification of patients for ACP conversations before discharge. While the workflow implementation has thus far been successful, less is known of the human factors from patients and providers that influence the feasibility and acceptability of this workflow. Methods: To gather perspectives on the AI-enabled tool, we used qualitative research methods to conduct semi-structured interviews with 15 patients and 15 providers. Patients were over the age of 18 and had been recently admitted to the Stanford Inpatient Oncology Service. Providers were over the age of 18 and worked within the Stanford Inpatient Oncology Service in one of four roles: attending oncologist, advanced practice provider, clinical dietician, occupational therapist. Interviews were conducted virtually via Zoom, recorded and transcribed for subsequent thematic analysis. Once transcribed, interviews were qualitatively coded using an inductive approach. Results: Patients and providers affirm the positive potential for AI implementation in healthcare settings, but emphasize the necessity of maintaining human-centered models of care which prioritize strong interpersonal relationships. Providers observe relatively minimal impacts of the AI-enabled tool on existing advance care planning workflows/practices, but express optimism surrounding the implementation of AI tools in inpatient oncology more generally. Patients exhibit similar levels of optimism and a general openness toward AI applications in healthcare settings, but highlight the need for transparency and informed consent throughout the processes of AI development and implementation. Conclusions: This study provides novel insights on the impacts of AI-enabled workflows in inpatient oncology care, as well as patient and provider perspectives concerning the implementation of AI technology in healthcare more broadly. As AI is increasingly developed with clinical care applications in mind, these insights provide valuable foundations for successful implementation.

Impact of a mortality prediction tool on end-of-life (EOL) quality measures.

404 Background: Determining treatment options for patients with cancer can be difficult for providers, especially when it comes to deciding the appropriate time to stop therapy. Many factors come into play when making important treatment and quality of life decisions including cancer responsiveness to treatment, patient preferences, labs, and diagnostic studies. Providers use their experience, instinct, and patient input in making these decisions, and can still have a difficult time knowing the best option for the patient. To support providers in identifying patients at high risk for poor outcomes, we developed a 90-day mortality risk machine-learning model (MRM) for patients with metastatic cancer. The tool was designed to facilitate earlier advance care planning (ACP) discussions and prognostic awareness leading to alignment of treatment with patient goals and values. The US Oncology Network (The Network) implemented the MRM beginning in early 2021 through late 2022. We assessed the impact of the MRM using performance on 5 EOL Quality Measures included in Medicare’s Merit-based Incentive Payment System (MIPS) Program. Methods: MRM predictions were made every two weeks and provided to practices through a secure web-based dashboard. Practices customized their use of the MRM based on their unique workflow. MRM utilization was collected July – December 2023 and determined how frequently practices accessed the dashboard. Practices were separated into two groups based on MRM utilization: High Utilizers (HU) used the tool more than once a week and Low Utilizers (LU) did not use the tool or used it less than or equal to once a week. EOL MIPS measure performance was collected and evaluated from the 2023 calendar year. For each of the EOL MIPS measures, we compared the average score between the two practice groups. A 2-sample unequal variance t-test with 1-tailed distribution was used to determine if there was a significant difference between the two practice groups for each EOL MIPS measure. Results: A total of 25 practices had available EOL MIPS scores. Five practices were classified as a HU group and 20 were in the LU group. EOL MIPS measure scores were higher among HU. All results trended towards improvement with a statistically significant difference observed for PIMSH 1 and MIPS 457 for HU compared to LU. The table shows the average MIPS scores across the two practice groups. Conclusions: Practices with the highest reported utilization of the MRM also reported improved MIPS EOL quality scores for the 2023 calendar year. While each practice implemented MRM independently, those using the tool more than once per week had improved performance in their MIPS EOL quality scores. EOL MIPS Measure HU LU Delta P MIPS 047 ACP 80.7 59.8 20.9 0.066 PIMSH 1 ACP Stage 4 disease 67.7 40.2 27.5 0.002 MIPS 453 Chemo Last 14 days (inv) 10.7 11.7 -1.0 0.279 MIPS 457 Hospice <3 days (inv) 11.7 14.8 -3.1 0.038 PIMSH 9 Supportive RX last 14 days (inv) 5.3 6.6 -1.3 0.119

A comparative analysis of supportive care service needs in patients with pancreas versus other gastrointestinal cancers.

272 Background: Pancreatic ductal adenocarcinoma (PDAC) is the third leading cause of cancer death and presents with advanced incurable disease approximately 75% of the time, contributing to the lowest survival rate and worst multidimensional quality of life (QOL) compared to other adult solid tumors. Standardized screening for early integration of interdisciplinary care (IDC) services, advance care planning, and utilization of electronic patient-reported outcomes (ePROs) for improved QOL and symptom management are recommended, yet the literature is lacking in rigorously-conducted PDAC needs assessments, an important prerequisite to care model design. Methods: Between September 12, 2023 and May 7, 2024, 525 patients with gastrointestinal (GI) malignancies were sent a Supportive Care Questionnaire (SCQ), an ePRO survey assessing multi-dimensional IDC needs prior to first visit at an NCI-designated comprehensive cancer center in the Pacific Northwest. The SCQ includes validated surveys and a total of 12 domains chosen by the IDC service responsible for management of the given need(s), who also set trigger thresholds for referral to the IDC service. Rates of positive screens for each service were compared by cancer type (PDAC, Colorectal [CRC], gastroesophageal [GE]). Results: 340 (65%) SCQs were completed (57% via MyChart, 43% in person) similarly across disease groups; with an average of 10 mins to complete. Respondents were 49% female/59% male (Race: White (76.5%), Asian (10%), Black/African-American (4.5%), Other/Unknown (9%)/Ethnicity Non-Hispanic (90%, Hispanic 7.6%), Other/Declined/Unknown 2.4%), with primary language spoken being English (92%), Spanish (3.5%), simplified Chinese (1.5%) and Other (2.5%). Table 1 shows – by GI cancer type –the total number of responses and the proportion of patients who screened positive for one or more IDC services. Conclusions: Patients with PDAC had the greatest need for IDC services with most frequent positive screens indicating need for nutrition, social work, palliative care and patient navigation services when surveyed in our institution-wide program of SC screening for all new GI cancer patients. Results will inform further development of IDC services in PDAC and other GI cancers, including via staff prediction modeling. The SCQ is also being considered for SC screening and management across the Canopy Cancer Collective, a nationwide learning health network of pancreas cancer programs. PDAC CRC GE Surveyed 187 237 101 Completed 122 (65%) 153 (65%) 65 (64%) Positive Screen 68 (56%) 70 (46%) 26 (40%)

Effect of an oncology care management program on ED visits in a rural Medicaid population.

175 Background: Optum’s Cancer Support Program (CSP) provides care management to members with cancer diagnoses facing healthcare barriers. CSP nurses educate members on symptom management, palliative care and advance care planning, address psychosocial needs and close gaps in care. Improving health equity and outcomes is a program priority. In 2023, Optum analyzed outpatient claims for 24,221 Medicaid members with cancer and found that rural members visit emergency departments (ED) 31% more than urban members. As part of a CSP quality and outcomes assessment, we aimed to understand CSP’s impact on ED utilization within a high-risk rural Medicaid population. Methods: Beginning 1/1/23, Medicaid members in rural zip codes with an active cancer diagnosis were stratified as high- or low-risk based on diagnosis and clinical factors. High-risk members were invited to participate in CSP and receive individualized telephonic care management. 2023 outpatient medical claims were evaluated, and rural ED visit rates were compared for high-risk CSP participants and non-participants for approximately 4 months (average CSP engagement) after CSP enrollment or identification (non-participants). Population demographics were tested via a Mood's median test; ED visits per thousand members per year (PTMPY)—engaged, non-engaged, and difference in means—was tested via a 10,000-iteration bootstrap. Results: The study population included 421 members stratified as high-risk. Of those, 38% (161) enrolled in CSP. Reasons for non-enrollment included inability to reach the member (61%) and member refused (39%). There were no statistically significant differences between the groups’ demographic composition (all variables had p ≥ 0.05). Under a 10,000-iteration bootstrap, there were 2,696 ED visits PTMPY, 80% CI [2,258, 3,150] in the participant group and 3,427 ED visits PTMPY, 80% CI [2,904, 3,974] in the non-participant group. The difference in means between the groups was 730 ED visits PTMPY, 80% CI [52, 1,421]. Conclusions: Rural Medicaid members enrolled in CSP experienced lower ED visit rates, suggesting that care management may be effective at reducing ED utilization within rural populations that lack access to wraparound oncology services. Limitations of this study include small sample size and potential enrollment bias. Further analysis is underway to increase the study sample size and identify other factors that may be impacted by care management, thereby improving healthcare equity.

End-of-Life and Hospice Care in Neurologic Diseases.

The care of a patient with neurologic disease at end-of-life requires expertise in addressing advance care planning, hospice, symptom management, and caregiver support. Neurologists caring for patients with advanced neurologic disease often identify changes in disease trajectory, functional status, or goals of care that prompt discussions of advance care planning and hospice. Patients nearing end-of-life may develop symptoms such as dyspnea, secretions, delirium, pain, and seizures. Neurologists may be the primary clinicians managing these symptoms, particularly in the hospitalized patient, though they may also lend their expertise to non-neurologists about expected disease trajectories and symptoms in advanced neurologic disease. This article aims to help neurologists guide patients and caregivers through the end-of-life process by focusing on general knowledge that can be applied across diseases as well as specific considerations in severe stroke and traumatic brain injury, amyotrophic lateral sclerosis, Parkinson's disease, and dementia.

Influence of an AYA cancer program on cancer care delivery.

4 Background: Adolescent and young adults (AYAs, aged 13-39) with cancer face barriers to care and stagnant survival outcomes. The University of North Carolina (UNC) at Chapel Hill's AYA Cancer Program, established in 2015, aims to address these challenges. The program operates through both consultations and targeted outreach based on patient risk-stratification, offering services such as fertility counseling, enhanced access to clinical trial enrollment, a dedicated sarcoma palliative care collaborative, survivorship clinic, and psychosocial support. AYA program providers work with patients to create tailored care plans that meet AYAs' psychosocial and medical needs. To better understand the reach and impact of this novel care delivery approach, we performed a retrospective cohort study over the 8-year period of program development. Methods: Using linked electronic health record (EHR) and State Cancer Registry data, we performed a retrospective cohort study of AYA patients at UNC from 2014-2022, comparing sociodemographic and clinical criteria between those with and without AYA Cancer Program contact. Our analysis included outcomes of care utilization, complications, and supportive care measures. Using SMR propensity weighting with multivariable log binomial modeling, we evaluated associations between outcomes and AYA program contact. Factors such as age at diagnosis, race, sex, insurance status, cancer site, metastatic disease, and receipt of systemic therapy were considered in the weighting scheme. Results: Of 4,016 AYAs receiving cancer care at UNC, 670 had contact with our program. Program-engaged patients were younger at diagnosis, more likely to be Black, and had higher rates of metastatic disease or hematologic malignancies. In weighted model analyses, program patients were more likely to receive guideline recommended care, including enrollment in a clinical trial, receipt of fertility counseling and palliative care, and documented advanced care planning. Over time, our program's reach expanded from 6% to more than 25% of the total AYA population. Conclusions: Our findings indicate that AYAs contacted by our program through a consult-based, targeted outreach model represent a distinct population with higher clinical needs. Despite this complexity, they were more likely to receive guideline-recommended care, including clinical trial enrollment, fertility counseling, and palliative care. Care delivery outcomes by program contact. No Program Contact (n= 3346) Program Contact (n=670) Clinical Trial Enrollment 882 (26.4%) 301 (44.9%) 1.31 (1.14, 1.49) Fertility Counseling 77 (2.3%) 119 (17.8%) 2.09 (1.56, 2.80) Palliative Care 102 (3.0%) 125 (18.7%) 3.46 (2.44, 4.91) Advanced Care Planning 176 (5.3%) 91 (13.6%) 1.55 (1.14, 2.11)

Neurologists' Attitudes and Perceptions on Palliative Care: A Qualitative Study.

Despite significant advances in the treatment of neurologic disorders, many conditions require complex care planning and advanced care planning. Neurologists are in a unique position because they are integral in providing patient centered care, understanding neurologic disease and illness trajectory, and how disease can affect patients' sense of self and values. Currently, little is known about neurologists' perceptions and challenges in care planning and palliative care for their patients. Neurologists from one Canadian academic institution participated in a 30-minute semistructured interview from November 2022 to April 2023. Interviews were conducted until saturation was reached and confirmed. Interviews occurred online through a secure platform or in-person and were recorded. Data were analyzed using a constant comparative method using constructivist grounded theory. Member checking was conducted post interview. Ten neurologists participated across a broad spectrum of neurology experience and subspecialties. We developed a detailed theory of understanding neurologists' attitudes and perceptions of palliative care. When neurologists delay or fail to initiate care planning discussions or palliative care, it results from a complex interplay between patient, physician, and resource accessibility factors. Certain contextual factors, such as a first visit or follow-up, inpatient vs outpatient setting, clinic culture, and the type of clinic practice, are factors that can influence these conversations. As a result, physicians may fail to use available resources, or they may involve other care providers or refer to subspecialty neurologic clinics. However, this delay can still lead to patient and provider harm. Opportunities to improve care exist with continuing education opportunities for trainees and staff, collaboration with palliative care specialists, and health systems support, such as increasing public awareness to address misconceptions about palliative care and resource availability. Our findings identify that failure or delay to initiate care planning and palliative care by neurologists results from a complex interplay between local culture, experience, context, practice type, and patient factors. Opportunities to improve care include increasing educational opportunities, building integrated and collaborative practices, and dedicated health systems support.

Advance care planning's promotion is crucial post-COVID-19 pandemic

Advance care planning's promotion is crucial post-COVID-19 pandemic

450P A review of the symptom control clinic, advance care planning and mortality in myotonic dystrophy 1 in a UK neuromuscular centre

450P A review of the symptom control clinic, advance care planning and mortality in myotonic dystrophy 1 in a UK neuromuscular centre

Assessing outcomes for patients receiving chemotherapy in the intensive care unit.

190 Background: Despite the low in-hospital mortality rate (9%) for Intensive Care Unit (ICU) stays in the US, outcomes for patients with cancer undergoing chemotherapy in the ICU remains unclear. We aimed to assess survival in patients with cancer (liquid, solid tumor and allogeneic stem cell transplant (alloSCT) receiving chemotherapy at our institution and identify patient characteristics for enhanced chemotherapy stewardship. Methods: We analyzed pharmacy data for patients with confirmed malignancies who received chemotherapy while admitted to the ICU at our institution from 1/1/21 to 12/31/23, excluding non-cancer patients and those on home oral regimens. Primary endpoints included 14-day, 30-day, and 90-day survival. Secondary analyses examined survival differences by age, ECOG performance status, and treatment history. Survival differences among patient subtypes were evaluated using Z-tests. Results: We identified 74 unique patients who received chemotherapy for cancer. 54 had liquid tumors, 5 were post-alloSCT, and 15 had solid tumors. The 90-day survival rate was 47% overall: 46% for the liquid tumor group, 80% for the alloSCT group, and 40% for the solid tumor group. When further stratified by tumor type, higher 90-day survival was variable; see Table 1 for details). In patients with lung cancer, 90-day survival was worse for non-small cell lung cancer without tumor mutations (0%, n=2) than those with targetable mutations (50%, n=4) or small cell lung cancer (33%, n=3). An ECOG performance status of 3-4 showed poorer 90-day survival in liquid tumors (23%) compared to ECOG 1-2 (74%; 95% CI 0.26 , 0.76). Solid tumors showed no significant ECOG differences (50%, 40%). Treatment-naive status showed higher 90-day survival in liquid tumors (59%) compared to treatment-resistant tumors (18%; 95% CI 0.17, 0.65), but not in solid tumors (50%, 20%). Conclusions: Our findings suggest generally unfavorable 90-day outcomes for ICU chemotherapy patients, especially those aged over 75, with multiple therapy lines, or ECOG status 3-4. Survival rates varied significantly across tumor types. We are currently broadening our study to include all solid tumor cancer patients. While this is a limited sample, this underscores the need for careful chemotherapy stewardship and advanced care planning in ICU settings. 90-day survival of solid and liquid tumor patients receiving chemotherapy in the ICU by select cancer diagnoses. Cancer Diagnosis n 90-Day Survival (%) AML 20 45 DLBCL 16 33 APML 6 83 Multiple myeloma 5 60 Other liquid tumors 1 11 45 Lung cancer 9 44 Germ cell tumor 2 100 Hormone-sensitive breast cancer 1 100 Other solid tumors 2 3 0 1 T-cell lymphoma, ALL, CNS lymphoma, Castleman, MPN, and plasmablastic lymphoma. Note, patients with allogenic stem cell transplants not included. 2 Carcinoma of unknown primary, colon adenocarcinoma, multiple solid tumors.

Early palliative care and its impact on end of life care.

The impacts of early palliative care for patients with advanced cancer are well described. This has led to endorsement of early palliative care, alongside cancer treatment, by leading cancer organisations. The aim of this review is to consider how best to adopt and integrate the learning from studies of early palliative care into an effective, sustainable service that is offered as part of routine cancer care. 'Timely', 'targeted' and 'precision' approaches have been proposed to ensure that limited palliative care resources are available to those who are most likely to benefit. Triage and referral based on individual patients' needs has been shown to be both efficient and effective. Standardised referral criteria and the use of tools to assess complexity may support equitable service development. A specialist multidisciplinary approach is a common factor underpinning successful integration between palliative care and oncology but does not negate the importance patient-centred considerations such as advance care planning, which can be facilitated by non-specialist teams. The challenge is no longer whether early palliative care should be provided, but how. Evidence-based strategies about how best to implement early palliative care are needed to inform appropriate resourcing, funding, and delivery.

Early palliative care involvement in gastrointestinal malignancies: A community cancer center perspective.

198 Background: Early involvement of palliative care (PC) specialists enhances quality of life for patients with advanced gastrointestinal (GI) cancer. Methods: This retrospective study evaluated patients with newly diagnosed stage III and IV GI cancer seen at a large community cancer center between 10/1/22 and 9/30/23. We compared patients seen by a PC provider in clinic at least once to those without an outpatient PC visit within the one-year study period. Results: 283 patients with stage III/IV colorectal (42%), gastroesophageal (23%), pancreatic (16%), hepatobiliary (12%), and other GI cancers (8%) received care within the study period (Table). Of these, 49 (17%) had at least one PC clinic visit, and 234 (83%) had no PC visits. Patients with pancreatic (35% vs 12%) and hepatobiliary cancer (20% vs 10%) were over-represented in the group receiving PC vs those without PC, while patients with colorectal cancer were under-represented (20% vs 47%). Greater percentages of patients in the group receiving PC completed advanced care planning (ACP) documents (63% vs 24%) and died during the study period (65% vs 15%). Conclusions: A minority of patients with GI malignancies at a large community cancer center are seen by an outpatient PC provider during the first year after diagnosis. These patients are more likely to have tumor types associated with worse prognosis, to complete ACPs, and to die within one year. Broader delivery of early PC will require expanded services in community cancer centers and continued development of tools for identifying patients most likely to benefit. The distribution of gastrointestinal cancer between outpatient palliative care visit and no outpatient palliative care visit. Primary cancer PC No PC Total Colorectal 10 (20% | 8%) 110 (47% | 92%) 120 (42% | 100%) Gastroesophageal 10 (20% | 16%) 54 (23% | 84%) 64 (23% | 100%) Pancreatic 17 (35% | 39%) 27 (12% | 61%) 44 (16% | 100%) Hepatobiliary 10 (20% | 30%) 23 (10% | 70%) 33 (12% | 100%) Other GI 2 (4% | 9%) 20 (9% | 91%) 22 (8% | 100%) Total 49 (100% | 17%) 234 (100% | 83%) 283 (100% | 100%) PC: Palliative care.

Acknowledgement and use of advance care directives and goals of care by emergency department staff: a mixed method post intervention study

Abstract Introduction Advance Care Planning (ACP) refers to a process that includes Advance Care Directives (ACD) and Goals of Care (GOC), a practice widely used for over three decades. Following the findings of an audit and a cross-sectional study in 2019 and 2021 respectively, we implemented several educational and other interventional strategies aimed at enhancing staff awareness and emphasizing the importance of recognizing and documenting of ACD/GOC. The aim of this study was to evaluate the acknowledgement and use of ACD and GOC by Emergency Department (ED) staff following these interventions. Method We used a mixed methods approach, incorporating both observational and cross-sectional designs with reflexive thematic analysis. Data extraction for the observational study took place between 1st April and 30th June 2023 focusing on a target population of randomly sampled adults aged ≥ 65 years. Demographics and other ACD and GOC related patients’ clinical data were collected. Data collection for the cross-sectional study occurred between 19th July and 13th September 2023 targeting all ED staff. Information gathered included demographics, awareness about ACD and GOC, including storage location and implementation, as well as knowledge of Medical Treatment decision Makers (MTDM), a jurisdictional term identifying a person legally appointed to make healthcare decisions on behalf of someone who lacks decision-making capacity and other Victorian State legislative requirements were collected. Results In the observational period, 22,335 patients attended the ED and 19% (n = 6546) qualified for inclusion from which a sample of 308 patients were randomly extracted. We found ACD documents were noted in the medical records of 6.5% of the sample, fewer than 8% identified in our previous study. There was no correlation between ACD record availability and age (p = 0.054; CI ranging from − 0.065 to 7.768). The response rate for the cross-sectional survey was 12% (n = 340) in contrast to earlier study with 28% (n = 476) respondents. Staff knowledge and familiarity with ACD was 25% and GOC 45%. Conclusion After implementing interventions in staff education and ACP awareness, we found that ACD documentation did not improve. However, GOC documentation increased in the context of heightened institutional awareness and integration into the Electronic Medical Records (EMR).

‘ALERT’, a machine learning predictive model to identify six-month mortality in patients with advanced cancer: Perception of the utility and acceptability among patients.

189 Background: Machine learning (ML) models can predict mortality and guide end-of-life (EOL) care for patients with advanced solid cancers. Early advanced care planning (ACP) leads to more goal-concordant care, yet many patients, especially from minoritized groups, do not engage in serious illness conversations (SIC). Reasons for delay include inability of oncologists to identify patients at high short-term mortality risk, and uncertainties about prognosis. While ML may improve prognosis accuracy, research on its use and impact on racial biases affecting SIC is limited. This study aims to evaluate the acceptability of deploying a ML model to predict 6-month mortality among patients with advanced solid cancers. Methods: In order to inform the implementation of ‘ALERT,’ a predictive mortality model into a clinical alert system, we conducted one-on-one semi-structured interviews with patients with advanced solid cancer receiving care at a single institution (N=26). Interviews were recorded, transcribed verbatim, coded, and themes were reviewed by a team of interdisciplinary investigators. Results: Benefits and challenges to guide the future implementation of ALERT were identified. Patient-perceived benefits were: 1) EOL Planning: preparing family members (e.g., financial, emotional); 2) Emotional Freedom: knowledge would give freedom to live out life more carefree due to limited time left; 3) Medical Autonomy: the treatment could be worse than the actual disease, if at any point it was not helping, knowing allows individuals to make the decision to stop. Challenges identified were: 1) Loss of Control: “when you don’t know [the outcome], you just keep moving, you just keep pushing”- knowing can result in a loss of control patients may desire for their course of treatment 2) Emotional Impact: knowledge of mortality could lead to grief among patients and families leading to distress around acceptability; 3) Faith: mortality prediction can be seen “playing God,” many patients believed when their time comes, it will happen and a ML tool cannot accurately predict when that time will be. Conclusions: Patients expressed equal balance of acceptability and resistance of ALERT for themselves and their families. This resulted in the difference of preferences regarding whether or not the knowledge this tool could provide would be helpful. This could lead to clinicians taking a patient-centered approach where the delivery of results using ALERT can be based on patient preference. The findings underscore the complexity of implementing ALERT, balancing significant benefits with notable challenges. These insights will guide the refinement of ALERT, ensuring it supports patient care while ensuring ALERT’s benefits are maximized and challenges are overcome.

Adopting prospective antimicrobial stewardship (AMS) practice in high-risk immunosuppressed groups: an urgent call to action in the era of antimicrobial resistance (AMR).

Life-saving immunosuppressive treatments including intensive chemotherapy and bone marrow transplantation expose patients to a considerable risk of death from infection globally. With evolving AMR and transmission, this could spell disaster for patients across the world and society at large. Antimicrobial stewardship (AMS) and prompt appropriate management of potentially fatal, emergent infections are essential. It is now apparent that antibacterial prophylaxis in patients with haematological cancer may not provide survival benefit while simultaneously increasing risks for AMR carriage. With evolving AMR and increasing immunosuppressed populations across the world, we must institute robust AMS practices. Significant resources are used to combat the impact of AMR on immunosuppressed patients. For lower-middle income countries (LMICs) these resources may not be available and as such the impact caused by AMR is greater. By considering the patient journey holistically we consider risk of infection presented to patients temporally and geographically. A short-term and easy to implement approach of multi-disciplinary team (MDT)-style advance care planning for infection is advocated. Antimicrobials, when used appropriately, enable healthcare procedures to occur and exist. Indeed, the very future of clinical medicine will rely on this yet to be realized value of enablement. Proactive effort and change must occur across all sectors with holism; hence our impetus for convening a joint industry and clinical working group. With at-risk immunosuppressed groups being a sentinel for change, awareness and implementation of patient-centric actions for infection are essential and our recommendations serve as an urgent call to action.