Advance Care Planning Communication Research Articles

Feasibility of a Serious Illness Communication Program for Pediatric Advance Care Planning

Pediatric advance care planning (ACP), which aims to ensure care is aligned with family goals and values, is associated with better end-of-life outcomes; however, ACP in pediatrics remains uncommon. To determine the feasibility and acceptability of the Pediatric Serious Illness Communication Program (PediSICP) and explore family-centered outcomes. This cohort study was a single-group pilot study of the PediSICP in adolescents and young adults (AYAs; age ≥13 y) with serious illness, parents of seriously ill children, and interprofessional clinicians from April 2021 to March 2023 in a quaternary care pediatric hospital. Duration of follow-up was 1 month. Data were analyzed from January 2022 to March 2023. The PediSICP includes clinician training preceding an ACP communication occasion supported by communication guides and a template for electronic medical record documentation. Outcomes of interest were parent, patient, and clinician experiences with and perceptions of the PediSICP. Feasibility was defined a priori as at least 70% clinician intervention completion rates. A total of 10 virtual trainings were conducted among 40 clinicians, including 27 physicians, 7 nurse practitioners, 5 nurses, and 1 respiratory therapist, and 30 trained clinicians (75%) conducted and documented 42 ACP conversations with 33 parents (median [IQR] age, 43 [35-51] years; 25 [76%] female) and 5 AYAs (median [IQR] age, 19 [17-19] years; 3 [60%] female) who completed the intervention. The median (IQR) conversation duration was 27 (10-45) minutes. Most clinicians (29 clinicians [97%]) agreed that they felt prepared for the conversation, and all clinicians recommended the PediSICP. Parents reported participation was worthwhile (27 parents [84%]), they felt listened to (31 parents [94%]), and would recommend the PediSICP (28 parents [85%]). Parents endorsed higher therapeutic alliance after the PediSICP intervention compared with before (The Human Connection scale mean [SD] score, 57.6 [6.4] vs 55.3 [7.8]; P = .03) and decreased anxiety immediately after the intervention (Generalized Anxiety Disorder-7-item mean [SD] score, 10.1 [7.3] vs 8.4 [6.9]; P = .003), which persisted at the 1-month follow-up (mean [SD] score, 7.7 [6.8]; P = .03). This pilot cohort study found that the PediSICP was feasible, acceptable, and highly valued by clinicians and parents of children with serious illness. These findings suggest that the PediSICP may empower interprofessional clinicians and improve ACP with families of children and AYAs who are seriously ill.

Pre-post-evaluation of a dementia-specific advance care planning toolkit for Japanese primary care clinicians.

The population of people living with dementia (PLwD) continues to grow in Japan where advance care planning (ACP) for PLwD is relatively new. Our aim was to evaluate the feasibility and cultural acceptability of a dementia-specific ACP communication skills toolkit for Japanese primary care clinicians. We delivered 13 training sessions in primary care clinics across central Japan and conducted a post-training survey to assess whether the toolkit increased confidence in dementia-specific ACP communication skills and the acceptability of the toolkit with the following four statements: (1) The language in the sessions was clear, (2) The sessions took an appropriate amount of time to complete, (3) The design of the sessions was an effective educational method, and (4) The sessions were culturally appropriate for communication with Japanese patients with dementia and their family members. We asked participants to respond using a 5-point Likert scale from strongly agree to strongly disagree. All participants were Japanese and included 80 physicians (mean age 39.8 years), 33 nurses (mean age 45.7 years), and 58 other participants (mean age 42.9 years), who were 30.0%, 87.9%, and 55.2% female, respectively. Most participants practiced in rural settings. In pre- post-comparisons, participant confidence increased in determining capacity, understanding dementia prognosis, goals of care, eliciting surrogates, recommending self-care practices to families, and leading family meetings (all p < 0.001). Most participants strongly agreed or agreed that the toolkit was an effective method (96.9%), took an appropriate amount of time (94.5%), contained clear language (89.8%), and was culturally appropriate (73.6%). Dementia-specific ACP communication skills toolkit can be delivered in Japan. Japanese primary care clinicians generally felt the dementia-specific ACP toolkit increased their confidence in ACP communication skills and was acceptable. The language, time, and design were well received, though further work is needed to improve the cultural appropriateness of the toolkit.

Developing an innovative national ACP-OSCE program in Taiwan: a mixed method study

ObjectivesTo evaluate the process and the comprehensiveness of advance care planning (ACP), we designed a national ACP-OSCE (Objective Structured Clinical Examination) program.MethodsThe program was designed as a 40-minute OSCE test. Participants were categorized as different ACP team members to illustrate realistic scenarios. Preceptors were asked to observe ACP professionals’ actions, responses, and communication skills during ACP with standardized patients (SP) through a one-way mirror. Participants’ communication skills, medical expertise, legal knowledge, empathetic response and problem-solving skills of ACP were also self-evaluated before and after OSCE. Thematic analysis was used for qualitative analysis.ResultsIn Nov 2019, a total of 18 ACP teams with 38 ACP professionals completed the ACP-OSCE program, including 15 physicians, 15 nurses, 5 social workers, and 3 psychologists. After the ACP-OSCE program, the average score of communication skills, medical expertise, legal knowledge, empathetic response, ACP problem-solving all increased. Nurses felt improved in medical expertise, legal knowledge, and problem-solving skills, psychologists and social workers felt improved in legal knowledge, while physicians felt no improved in all domain, statistically. Thematic analysis showed professional skills, doctoral-patient communication, benefit and difficulties of ACP were the topics which participants care about. Meanwhile, most participants agreed that ACP-OSCE program is an appropriate educational tool.ConclusionThis is the first national ACP-OSCE program in Asia. We believe that this ACP-OSCE program could be applied in other countries to improve the ACP process and quality.

Changes in care managers' positive attitudes toward dying patients compared to that of nurses by one-day online advance care planning communication training.

Culturally appropriate communication training programs for a wide range of professions that can be used during infection epidemics are crucial for advance care planning implementation. Starting in 2018, the Japanese Ministry of Health, Labour and Welfare made a major policy change, and doctors, nurses, and social workers, and care managers were identified in the guidelines as the professions that promote advance care planning. Motivated by the lack of online programs for Japanese care managers, we proposed a new one-day program. This study aimed to determine the changes in the positive attitude of care managers toward dying patients compared to that of nurses, which has been used in past literature as an outcome of advance care planning educational interventions, after administering the program in Japan. Before-after comparison study. Care managers were recruited through our website, ACP-Piece, http://plaza.umin.ac.jp/~acp-piece/piece.html. A questionnaire survey concerning positive attitudes toward dying patients was administered before and after the program on 28 August 2021. Sixty-six subjects participated in the training and 60 participants, including 14 care managers, consented to the study and completed the questionnaire surveys before and after the program. The Frommelt attitude toward care of the dying scores for care managers increased after the program (p-values, confidence intervals, and effect sizes: p < 0.001, -11.90 to -4.388, -1.252). After training, care managers had a significantly higher maximum score occurrence than nurses. Older care managers with advance care planning experience may have had a higher maximum score occurrence compared to younger, inexperienced participants. To our knowledge, this is the first to demonstrate the increased positive attitude scores toward dying patients after online communication training for Japanese care managers. The limitations of this study include the lack of evidence regarding reasons for score changes, long-term score changes, and effectiveness for patients and their families.

Consensus definition of advance care planning in dementia: A 33-country Delphi study.

Existing advance care planning (ACP) definitional frameworks apply to individuals with decision-making capacity. We aimed to conceptualize ACP for dementia in terms of its definition and issues that deserve particular attention. Delphi study with phases: (A) adaptation of a generic ACP framework by a task force of the European Association for Palliative Care (EAPC); (B) four online surveys by 107 experts from 33 countries, September 2021 to June 2022; (C) approval by the EAPC board. ACP in dementia was defined as a communication process adapted to the person's capacity, which includes, and is continued with, family if available. We identified pragmatic boundaries regarding participation and time (i.e., current or end-of-life care). Three interrelated issues that deserve particular attention were capacity, family, and engagement and communication. A communication and relationship-centered definitional framework of ACP in dementia evolved through international consensus supporting inclusiveness of persons with dementia and their family. This article offers a consensus definitional framework of advance care planning in dementia. The definition covers all stages of capacity and includes family caregivers. Particularly important are (1) capacity, (2) family, (3) engagement, and communication. Fluctuating capacity was visualized in relation to roles and engaging stakeholders.

Advance care plans for vulnerable and disadvantaged adults: systematic review and narrative synthesis

BackgroundEvidence suggests that there is a gap in advance care planning (ACP) completion between vulnerable and disadvantaged populations compared with the general population. This review seeks to identify tools, guidelines...

Quality and Satisfaction With Advance Care Planning Conversations Among English- and Spanish-Speaking Older Adults.

Background: Little is known about the patient-reported quality of and satisfaction with advance care planning (ACP) conversations with surrogates and clinicians among English- and Spanish-speaking older adults, or the potential disparities associated with ACP communication satisfaction. Objectives: To determine patients' perceived quality of and satisfaction with ACP surrogate/clinician conversations and associated patient characteristics. Design: Cross-sectional baseline data were used from two ACP trials, 2013-2017. Outcomes included self-reported ACP conversation quality ("general" vs. "detailed") and communication satisfaction (5-point Likert scale). Associations were determined by chi-squared and t-tests. Setting/Subjects: Subjects were primary care patients ≥55 years with chronic/serious illness in the United States. Results: Of 1398 patients, mean age was 65.6 years (±7.7), 46% women, 32% Spanish speaking, 34% had limited health literacy, and 589 (42%) reported conversations with surrogates and 216 (15%) with clinicians. Of these, less than half rated the conversations as detailed high quality (clinician: 43%; surrogate: 37%). Five-point communication satisfaction scores were higher with detailed versus general conversations (e.g., surrogates: 4.4 vs. 4.1, p = 0.001; clinicians: 4.4 vs. 4.2, p = 0.18) and more often reported by men versus women [(4.4 (0.8) vs. 4.0 (1.0), p = 0.003]; those with adequate versus limited health literacy [4.4 (0.8) vs. 4.0 (0.9), p = 0.002]; and English versus Spanish speakers [4.5 (0.7) vs. 3.5 (0.9), p < 0.001]. Conclusions: Among English- and Spanish-speaking older adults, ACP conversations were infrequent and most were general in quality. Higher quality detailed conversations resulted in greater communication satisfaction. Interventions are needed to improve conversation quality, particularly for Spanish-speaking patients and those with limited health literacy. Trial Registrations: ClinicalTrials.gov identifiers: "Improving Advance Care Planning by Preparing Diverse Seniors for Decision Making (PREPARE)" NCT01990235 and "Preparing Spanish-Speaking Older Adults for Advance Care Planning and Medical Decision Making (PREPARE)" NCT02072941.

Adapting the Voicing My CHOiCES Advance Care Planning Communication Guide for Australian Adolescents and Young Adults with Cancer: Appropriateness, Acceptability, and Considerations for Clinical Practice.

Background: Adolescents and young adults (AYAs) with life-threatening illnesses need support to discuss and voice their end-of-life choices. Voicing My CHOiCES (VMC) is a research-informed American advanced care planning guide designed to help facilitate these difficult discussions. This multi-perspective study aimed to evaluate its appropriateness, acceptability, and clinical considerations for Australian AYAs with cancer. Procedure: Forty-three participants including AYAs who were either undergoing or recently completed cancer treatment, their parents, and multidisciplinary health professionals assessed the acceptability of each VMC section quantitatively (appropriateness-yes/no, helpfulness and whether content caused stress-1 = not at all, to 5 = very) and qualitatively (sources of stress). AYAs also assessed the benefit and burden of completing several sections of the document, to inform clinical considerations. We conducted a mixed-methods analysis to obtain descriptive statistics and to identify prominent themes. Results: In terms of acceptability, almost all participants (96%) rated VMC as appropriate overall. Perceived helpfulness to their situation (to themselves/their child/their patients), to others, and stressfulness were rated, on average, as 4.1, 4.0, and 2.7/5, respectively. Stress was attributed to individual and personal factors, as well as interpersonal worries. All sections were considered more beneficial than burdensome, except for the Spiritual Thoughts section (Section 6). Conclusions: While VMC is an acceptable advance care planning guide for AYAs with cancer, changes to the guide were suggested for the Australian context. Health professionals implementing VMC will need to address and mitigate anticipated sources of stress identified here. Future research evaluating the impact of a new culturally adapted Australian VMC guide is an important next step. Finally, the clinical implications of the present study are suggested.

Effects of advance care planning training on advanced practice nurse students’ knowledge, confidence, and perception of end-of-life care: A mixed-method study

AimsThis study aimed to assess how an advance care planning training program affected advanced practice nursing students’ knowledge, confidence and perception of end-of-life care in South Korea. BackgroundEffective communication between healthcare providers, patients and their families is one of the most important components of quality end-of-life care. However, nurses in South Korea may feel uncomfortable helping patients and families with advance care planning because of the cultural taboo against talking about dying. DesignA mixed-method design was used with data obtained from self-administered questionnaires at the onset and end of the advance care planning training program and qualitative data from participant feedback after the program. MethodsData collected from 65 advanced practice nursing students who participated in advance care planning training programs in June-July 2020 and 2021, conducted as part of a graduate clinical practice course, were analyzed. Data were originally collected to examine students’ course outcomes. A training program was provided to advanced practice nursing students to improve their knowledge, confidence and perception in advance care planning conversations with their patients. The program comprised three sessions: online lectures, face-to-face simulations and discussions on advance care planning and ethical issues. Changes in advance care planning knowledge, confidence in supporting patients’ advance directives, perceived nursing roles in end-of-life treatment decisions and perception of a good death were examined before and after the training. ResultsThere were statistically significant increases in participants’ advance care planning knowledge, confidence in supporting patients’ advance directives and perception of the active role of nurses in patients’ end-of-life treatment decisions after the training. ConclusionsThe results indicate the effects of training programs on advanced practice nursing students’ knowledge, confidence and perception of advance care planning communication. They also provide evidence about what contents and methods can be helpful in developing end-of-life care training for advanced practice nursing students.

Is Simulation as an Investigative Method as Good as Reality?

Clinical simulation offers an alternative to naturalistic inquiry of phenomena in health care that are ethically and logistically difficult for researchers to access firsthand. However, whether it is a similar experience, and the extent simulation elicits data that is meaningful for the real-world phenomenon under investigation is unknown. To address this gap, we explored the experience of 18 paediatricians who were participants in our wider phenomenological simulation-based study of communication practices related to paediatric advance care planning. We identified that: (1) the simulation felt real despite differences to reality, and (2) the paediatricians’ consciousness of their involvement in research condensed the pace of the advance care planning communication process but did not change their overall approach. In summary, simulation as an investigative method can enrich the understanding of the phenomenon of interest. These findings should encourage researchers to consider simulation for future qualitative inquiry.

THE LANDSCAPE OF ALZHEIMER’S DISEASE AND RELATED DEMENTIAS CAREGIVER COMMUNICATION RESEARCH

Abstract Alzheimer’s Disease and Related Dementias (ADRD) affect one in nine adults aged 65 and over. Past research has demonstrated the need for services that improve quality of care for those with ADRD and their caregivers. Those with ADRD are at a greater risk for negative health outcomes. Therefore, it is crucial that those with ADRD receive care consistent with their preferences. However, more research is needed to shed light on effective tools available and patterns of advance care planning (ACP) when it comes to those with ADRD and their caregivers. This symposium highlights the landscape of ACP communication among those with ADRD and their caregivers. The session begins with a study that explored experiences of apathy and preferences for dyadic-communication via mobile health (mHealth) among adults with mild cognitive impairment and their care-partners. The second presentation demonstrates the feasibility and effectiveness of a palliative care education in assisted living program for nurses and administrators on increasing ACP discussions with family caregivers of residents with dementia. The third presentation investigates ACP among African Americans with ADRD and their caregivers and the critical role the community can play in facilitating communication. The final presentation explores how ACP differs by race, ethnicity and ADRD status using data from the 2018 Wave of the Health and Retirement Study. Future directions for implementation of these innovations for improving ACP communication among caregivers and persons with ADRD will be discussed.

Goals-of-care and serious illness conversations for patients with cancer with inpatient mortality.

184 Background: Goals-of-care (GOC) and serious illness conversations are an integral part of personalized cancer care, particularly toward the end of life (EOL). Eliciting patients (pts)’ preferences and values facilitates informed decision-making throughout the disease course and enables oncologists to provide patient-centered care. Many aspects of GOC discussions and advance care planning (ACP) are inadequately understood, particularly during transitions of care when pts are hospitalized. Methods: We administered surveys to inpatient and outpatient medical oncologists of pts who died while hospitalized from 5/1/2020 to 5/31/2021. Survey items included oncologists’ knowledge of inpatient death, anticipation of pt death within six months of admission, recollection of GOC discussions taking place, and perceived barriers to GOC discussions. To better characterize EOL planning for these pts, retrospective data was collected to identify documentation of GOC discussions, advance directives, and hospice consideration in pts’ electronic health records. Results: For 75 cancer pts who died while hospitalized, 158 surveys were electronically administered with 104 responses (response rate: 66%). Pts characteristics: median age 62 (range 25-89); 63% men; 79% white; median length of hospital stay 7 days (range 1-45). Primary cancer disease type varied: 26.7% gastrointestinal, 18.7% non-small cell lung, 14.7% hematologic, 10.7% sarcoma, 9.3% genitourinary, and 19.9% other cancers. Of 104 completed surveys, responses were received from 40 inpatient and 64 outpatient oncologists. 81 oncologists (77.9%) were aware of the pt’s death prior to survey communication, 68 (65.4%) anticipated the pt’s death within six months of admission, and 67 (64.4%) recalled having a GOC discussion prior to or during the terminal hospitalization. Only 21.3% of pts had documented GOC discussions prior to admission, 33.3% had advance directives, and 22.7% had prior documentation of hospice consideration. Oncologist-reported barriers to GOC discussions included unrealistic expectations from pts or family (25%) and inability for pts to participate due to their clinical condition (15%). Oncologists commented on lack of time, lack of communication between inpatient and outpatient teams, and discordance among multiple inpatient providers as additional barriers. Conclusions: Most oncologists recalled having GOC discussions and anticipated six-month mortality for cancer pts who died while hospitalized. However, documentation of ACP and serious illness communication remained sub-optimal. Ongoing analyses are examining potential associations between patient, provider, and patient-provider relationship factors and oncologists’ survey responses. Addressing barriers to serious illness conversations across different healthcare settings is crucial to providing high-quality EOL care for cancer pts.

Development of a Standardized Simulation: Advance Care Planning Conversations for Nurses.

Advance care planning conversations focus on articulating and documenting patients' healthcare goals. These conversations should occur early and iteratively but are often not completed. Clinicians, specifically registered nurses, lack the needed training in advance care planning to have effective conversations; hands-on teaching modalities are necessary to enhance these communication skills. The aim of this study was to increase knowledge and comfort in communication about advance care planning; therefore, a validated and standardized simulation was developed and tested among registered nurses. We examined the feasibility of an advance care planning simulation called Conversations Had at Trying Times to explore changes in knowledge, attitudes, and self-efficacy among registered nurses. The National League of Nursing Jeffries simulation theory and Bandura's self-efficacy theory framed the study, which consisted of two stages: (a) simulation development and (b) simulation testing. Construct and content validity guided simulation development; standardization was achieved through International Nursing Association for Clinical Simulation and Learning standards. Testing consisted of a pilot one-group pretest/posttest. Conversations Had at Trying Times, a researcher-designed high-fidelity validated simulation, enhanced nurses' communication skills. Thirty-six registered nurses completed the simulation; knowledge, attitudes, and self-efficacy increased pre- to posttest. Postsimulation evaluations confirmed the feasibility of the simulation. The greatest variation in results was among registered nurses with less than a year of experience. The study findings support the feasibility and effectiveness of the Conversations Had at Trying Times simulation in its development and outcome measurements of knowledge, attitudes, and self-efficacy in advance care planning. Simulation is an educational modality underutilized, and Conversations Had at Trying Times is one of the few validated simulations for nurses. Further analysis showed that years of experience was a significant factor. Younger, inexperienced nurses had positive outcomes, but not to the extent of other practicing nurses, which suggests that simulation tailoring is necessary for newer nurses or alternative education modalities need to be explored. In addition, more training in advance care planning communication is needed for newer nurses through nurse residency programs, staff development, and mentorship. Finally, advance care planning communication needs to be addressed in undergraduate education to better prepare new graduate nurses.

Interdisciplinary staff perceptions of advance care planning in long-term care homes: a qualitative study

BackgroundResidents living in long-term care homes (LTCH) have complex care needs, multiple chronic conditions, increasing frailty and cognitive impairment. A palliative approach that incorporates advance care planning (ACP) should be integrated with chronic disease management, yet it is not a norm in most LTCHs. Despite its growing need, there remains a lack of staff engagement in the ACP process.ObjectivesThe aim of this study was to explore the perceptions and experiences of interdisciplinary staff related to the practice of ACP in LTCHs.MethodsThis study is part of a larger Canadian project, iCAN ACP, that aims to increase uptake, and access to ACP for older Canadians living with frailty. An exploratory qualitative design using an interpretive descriptive approach was employed utilizing focus groups and semi-structured interviews with staff from four LTCHs in Ontario, Canada.FindingsThere were 98 participants, including nurses (n = 36), physicians (n = 4), personal support workers (n = 34), support staff (n = 23), and a public guardian (n = 1). Three common themes and nine subthemes were derived: a) ongoing nature of ACP; b) complexities around ACP conversations; and c) aspirations for ACP becoming a standard of care in LTCHs.DiscussionThe findings of this study provide important contributions to our understanding of the complexities surrounding ACP implementation as a standard of practice in LTCHs. One of the critical findings relates to a lack of ACP conversations prior to admission in the LTCHs, by which time many residents may have already lost cognitive abilities to engage in these discussions. The hierarchical nature of LTCH staffing also serves as a barrier to the interdisciplinary collaboration required for a successful implementation of ACP initiatives. Participants within our study expressed support for ACP communication and the need for open lines of formal and informal interdisciplinary communication. There is a need for revitalizing care in LTCHs through interdisciplinary care practices, clarification of role descriptions, optimized staffing, capacity building of each category of staff and commitment from the LTCH leadership for such care.ConclusionThe findings build on a growing body of research illustrating the need to improve staff engagement in ACP communication in LTCHs.

The Impact of a Curriculum to Teach Advance Care Planning Communication to Pediatric Interprofessional Clinicians Using a Serious Illness Conversation Guide

The Impact of a Curriculum to Teach Advance Care Planning Communication to Pediatric Interprofessional Clinicians Using a Serious Illness Conversation Guide

“It's not something that's really been brought up”: Opportunities and challenges for ongoing advance care planning discussions among individuals living with mechanical circulatory support

BackgroundPeople living with mechanical circulatory support (MCS) are at risk for catastrophic complications that require advance care planning (ACP) as part of the preimplantation work up. Palliative care consultants are a mandatory and essential component of the MCS team tasked to enhance conversations. However, in reality, there is often a serious deficiency of ACP communication after the initial implant counseling. A better understanding of opportunities and challenges in ACP can mobilize intensive care unit and step-down nurses to bridge this gap in crucial communication. ObjectivesTo identify and describe MCS individuals’ perceptions of opportunities and challenges for ongoing ACP communication. MethodsA constructivist grounded theory study was conducted with 24 MCS individuals from 2 medical centers in Southern California. Semi-structured interviews were audio recorded, transcribed, and reviewed for accuracy. The data were systematically analyzed through 3 rounds of coding. ResultsMCS clinicians, supportive others, and peers with MCS were identified as stakeholders in ongoing communication. Four categories of opportunities and challenges for ongoing ACP were synthesized from the narratives: identifying context and timing, sharing information, understanding of ACP, and assessing satisfaction. All participants reported a preference for MCS clinicians, including nurses, to initiate ACP conversations. ConclusionUnderstanding opportunities and challenges is key to facilitating ongoing ACP discussions among MCS patients. MCS-trained nurses are positioned to address the dearth of ongoing ACP by facilitating these sensitive discussions. The personal accounts of this sample serve to guide future research and structure training to prepare MCS clinicians for primary palliative care.

AD-LAST! An interdisciplinary clinical workshop to improve cultural and spiritual awareness in advance care planning skills.

Clinicians report training deficits in advance care planning (ACP), including limits to their understanding of cultural/spiritual influences on patient decision-making and skills in interdisciplinary teamwork. This study describes Advance Directives-Live Action Simulation Training (AD-LAST), an interdisciplinary experiential and didactic training program for discussing ACP and end-of-life (EOL) care. AD-LAST highlights cultural/spiritual variations in medical decision-making. Prospective educational cohort study with pre-post intervention survey. AD-LAST incorporated standard curricular tools for didactic and experiential training in ACP/EOL communication. Study conducted in an urban community teaching hospital in Queens, NY, one of the most diverse counties in the USA. Participants included physicians, house staff, nurses, therapists, and other disciplines. AD-LAST format was a one-day workshop. The morning focused on didactic teaching using widely available curricular tools. The afternoon involved experiential practice with standardized patient-actors. Pre-post intervention questionnaires assessed ACP operational knowledge and self-efficacy (i.e., self-confidence in skills) in ACP and EOL communication. Repeated measure ANOVAs evaluated changes from pretest to posttest in knowledge and self-efficacy. A total of 163 clinical staff participated in 21 AD-LAST training sessions between August 2015 and January 2019. Participants displayed a significant increase from pretest to posttest in total knowledge (p < 0.001), ACP procedural knowledge (p < 0.001), ACP communication/relationships knowledge (p < 0.001), and self-efficacy (p < 0.001). Knowledge and self-efficacy were not correlated and represented independent outcomes. Postprogram evaluations showed greater than 96% of participants were highly satisfied with AD-LAST, especially the opportunity to practice skills in real-time and receive feedback from members of other professional groups. AD-LAST, a multifaceted training program deployed in an interdisciplinary setting, is effective for increasing ACP knowledge and self-efficacy, including the capacity to address cultural/spiritual concerns. The use of standard tools facilitates dissemination. The use of case simulations reinforces learning.

Abstract P5-15-03: The effectiveness of an advance care appointment companion to increase completion of advance care planning among patients with metastatic breast cancer

Abstract Previous research has demonstrated that patients express a desire to discuss advance care planning (ACP). ACP has been associated with numerous positive outcomes including improved patient satisfaction, improved quality of life in terminal illness, and better psychological outcomes. Additionally, ACP has been related to peace of mind that wishes will be followed, less hospital re-admissions, and less use of extreme treatments close to death. Furthermore, it has been linked to increased use of hospice and palliative care and increased concordance between preferred care and the care delivered. However, despite the documented benefit of ACP, these conversations often do not occur due to discomfort with the topic or are communicated inadequately. Documentation rates of ACP in oncology patients have been as low as 10%, with rates of documentation increasing between 30-40% in intervention studies. Specific to women with metastatic breast cancer (MBC), one study found that 66% had written advance directives, but providers were only aware of these in 14% of the cases. Thus, the present study aimed to examine the effectiveness of an online Advance Care Appointment Companion (ACAC) decision-support tool to improve ACP communication between MBC patients and their oncologist and increase completion rates of ACP documents. Data were collected from 68 patients with MBC during their medical oncology appointments (Time 1) and three months later (Time 2) at the Koontz Center for Advanced Breast Cancer. At their Time 1 clinic visit, patients were introduced to and enrolled on the ACAC platform and then completed questions in the clinic or at home about completion status of a healthcare directive and durable power of attorney (DPOA) for healthcare, comfort in discussing ACP with their care team and loved ones, goals of care at end of life, and discussion topics about ACP for upcoming visits. A summary of these responses with a provider prompt script was securely sent to the oncologist prior to each subsequent appointment over the three-month study period. The oncologist used this summary and scripting to help navigate ACP conversations during each appointment. Descriptive statistics and McNemar’s test were conducted to examine changes in rates of ACP document completion and patient reported levels of comfort in discussing ACP. Majority of the sample was female (n=68, 100%), white (n=57, 84%), married (n=36, 53%), with a mean age of 64 years. At baseline, 41% of patients reported having a completed healthcare directive and 49% reported having a completed DPOA for healthcare, but only 12% had a healthcare directive and 24% had a DPOA in their electronic medical record (EMR). To-date, 35% (n=24) have a healthcare directive and 47% (n=32) have a notarized DPOA in their EMR; McNemar’s test showed a significant increase in the proportion of patients who completed ACP documents at Time 2 (p&amp;lt; .001). At baseline, 74% of patients reported feeling comfortable discussing ACP with their care team and 69% reported feeling comfortable discussing ACP with their loved ones. Of note, 35% reported that they were unsure if they would want artificial nutrition, 37% reported they were unsure if they would want dialysis, and 37% reported that they were unsure if they would want resuscitation in the event that their heart stops. On average, ACP conversations during medical appointments took 5 minutes to discuss. Preliminary results suggest that the ACAC is an effective tool to facilitate discussion about ACP, resulting in significantly increased completed ACP documents in patient’s medical records. Assessment of patient-reported outcomes on comfort with discussing ACP and goals of care at Time 2 is ongoing. Results also revealed the potential for this tool to help foster communication about the intricacies of ACP as a large portion of patients reported that they were unsure about decisions that need to be made about end of life care. Citation Format: Kadie M Harry, Cathy E Mitchell, Loic Nijiakin, Arabella Sykes, Timothy J Pluard. The effectiveness of an advance care appointment companion to increase completion of advance care planning among patients with metastatic breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P5-15-03.

Communication About Advance Directives and Advance Care Planning in an East Asian Cultural Context: A Systematic Review

In East Asian cultural contexts, advance directive (AD) and advance care planning (ACP) discussions are generally challenging given patients' unawareness of decision-making rights. Selected databases were searched for articles published from January 2000 to December 2020. 21 studies were included and appraised with Critical Appraisal Skills Programme Systematic Review Checklist. Five themes emerged. Future research should focus on developing a culturally appropriate AD and ACP communication framework.

“By the time she got sick it was just kind of too late”: A qualitative study on advanced care planning among bereaved lesbian, gay, and bisexual older women

Background: Lesbian, gay, and bisexual (LGB) older women have unmet communication needs around palliative and end-of-life care. Past research has found communication differences for LGB women patients. Consequently, older LGB women may experience healthcare communication barriers around advance care planning. Aim: To explore experiences of bereaved LGB older women to understand perspectives regarding advance care planning communication between clinicians, patients, and dyads. Design: Guided by queer gerontology as a theoretical framework, this qualitative descriptive study employed individual interviews with purposively recruited participants. Interviews were conducted in person using a semi structured protocol and analyzed using inductive thematic analysis. Setting/participants: Sixteen LGB women, age 60 years or older from across the United States who had lost a spouse/partner within the past 5 years. Results: Four main themes emerged from the transcripts, LGB older women: (1) experience unclear advance care planning communication and end-of-life care support from clinicians, (2) often avoid advance care planning discussions with spouse or partners, (3) lack of knowledge about palliative or end-of-life care, and (4) have more positive experiences when there is consistent communication with spouse or partner and clinicians during a spouse/partner’s illness and end-of-life. Discussion: While certain experiences and opinions may reflect those of non-LGB older adults, novel advance care planning barriers exist for LGB older women. Greater understanding among clinicians is needed regarding advance care planning conversations with LGB dyads. We recommend four improvements in training, recognition, acceptance, and dyad-based communication interventions.