Advance Care Planning Conversations Research Articles

Advance Care Planning With Black Women with Breast Cancer: A Community Health Worker Model.

Despite the importance of advance care planning (ACP), a process that optimizes future medical treatment and end-of-life care, for at-risk populations, rates of patient-provider ACP conversations are extremely low among Black women with breast cancer. Community health workers (CHWs) are well-positioned to support patients in engaging in ACP conversations with their providers; yet research on integrating CHWs to promote ACP is scant. The current study examined multilevel facilitators and barriers to successful ACP conversations among Black women from the perspective of providers and CHWs who serve this community. Providers and CHWs were recruited from an academic medical center in a large urban city. Retrospective qualitative data on barriers and facilitators to ACP conversations, as well as CHWs' training needs, were collected from two focus groups (N = 5 providers, N = 5 CHWs) and one individual interview (N = 1 provider), and transcribed and coded for themes. All providers reported working primarily with Black patients, and identified stigma and time constraints as major barriers to ACP discussions; they also identified the structural barriers and injustices that their patients face during medical care. CHWs reported having a trusted relationship with their patients and flexibility in their care that would allow for ongoing ACP conversations, discussing their ability to serve as a bridge between the patient and provider. However, CHWs discussed that they lacked the tools and skills to have ACP conversations, largely because existing formal trainings in ACP are cost prohibitive. Competing priorities of the provider to discuss/treat the patient's disease and medical mistrust were major barriers to successful ACP conversations among Black women with breast cancer, leading to ACP completion occurring late in treatment. CHWs are uniquely qualified to overcome multilevel barriers to ACP and establish trusting relationships with patients in order to facilitate earlier and ongoing communication between patients and providers.

Advance Care Planning Conversations: Laying the Foundation for Goal-Concordant Care at End of Life.

The delivery of culturally congruent, person-centered, family-focused quality care requires an exploration of the values, beliefs, and preferences of those we serve [13]. Nuanced advance care planning conversations lay the foundation for shared decision making and promotes the delivery of goal-concordant care. This chapter will provide clinicians with guidance and resources to aid this process with a focus on contextualized communication with those with serious illness.

A model for community-led peer-facilitated advance care planning workshops for the public.

The core to successful advance care planning (ACP) facilitation is helping people determine their values, beliefs and wishes, and understand substitute decision-making. Recognizing the potential for community members to support public awareness and education we developed a model of ACP education, whereby peer facilitators associated with community organizations host workshops that educate and assist members of the public with ACP. Describe the development and evaluation of the model for community-led peer-facilitated ACP workshops for the public. Descriptive mixed methods. A training curriculum and program model were co-developed with two community organizations that had been successful in delivering ACP workshops independently in their communities. Herein we describe a mixed-methods evaluation of three cycles of implementation and improvement of the model. The model centers on three key concepts; the right content (based around three steps Think, Talk, Plan), the right facilitator, and the right approach. A suite of tools was designed to support the three groups involved in the delivery of the ACP workshops: the public participants, the peer facilitators, and the community-based organizations. The peer-facilitator training addresses the facilitator's learning needs of ACP content knowledge, facilitation skills, and understanding change behavior. Training evaluation data from 106 facilitators confirmed that the curriculum prepared them to facilitate the workshops. Qualitative data revealed that support from organizations with established reputations in their community is critical, with mentoring from more experienced facilitators beneficial. Our model demonstrates the potential of community-led, peer-facilitated ACP initiatives to enhance the capacity of community to upstream ACP conversations. Reaching a broader audience and creating a supportive, inclusive environment for individuals to comfortably learn about ACP can drive the much-needed culture shift to normalize ACP. Meaningful community engagement, empowerment, and partnerships are essential for the successful development and widespread impact of these initiatives.

ADVANCE CARE PLANNING MOTIVATED BY THE COVID-19 PANDEMIC

Abstract The COVID-19 pandemic has exposed older adults to complex healthcare situations, via personal experience or media stories about serious illness. Hearing about lengthy intubation, sedation, rapid decline, and distress at the end of life has the potential to prompt people to reevaluate their perspective on their own end-of-life care. This study explored advance care planning (ACP) among older adults and whether COVID-19 experiences altered their healthcare preferences and planning. One hundred and fifty-one respondents (M age = 71.2 yrs, range = 55–93) completed an online survey about ACP completion, ACP conversations, and life-prolonging interventions. Respondents were mainly female (78%), White (71%), and well educated (77% with at least a bachelor’s degree). A substantial proportion had not completed an advance directive (31%) or chosen a medical power of attorney (33%), and 78% of them intended to complete them in the next year or had initiated ACP. Among those who had completed ACP, a quarter intended to make changes, with 13% less open to life-prolonging medical treatments and 13% more open to them. Despite these intentions, a small proportion of people had ACP conversations since the start of the pandemic with their spouse/partner (37%), children (25%), siblings, (19%), friends (27%), primary care physician (16%), or other healthcare provider (12%). Results of this study suggest that now may be a critical moment to encourage older adults to have ACP conversations, in light of how their experience during the pandemic has motivated a reconsideration of treatment preferences.

THE RELATIONSHIP BETWEEN PHYSICIAN VISITS AND ADVANCE CARE PLANNING

Abstract Some studies have shown that advance care planning (ACP), discussions about future care given a serious illness, are associated with improved quality of death and better end-of-life care. Studies also have found that physicians play an important role in ACP. In fact, in 2016 CMS began reimbursing physicians for ACP discussions. However, little is known about the relationship between the number of physician visits and engaging in ACP . This study investigated the association between outpatient physician visits and ACP engagement. Only respondents over 65 were included in our study. We conducted logistic regressions using the 2016 Health and Retirement Study. We used ACP engagement (n=9838), advance directive (AD; eg, living will) completion (n=9746), and healthcare power of attorney (e.g., proxy) assignment (n=9724) as outcome variables. In addition to the frequency of physician visits, we controlled for basic demographics (age, gender, marital status, race, and socioeconomic status), number of chronic conditions, and self-rated health in our models. For each additional physician visit, the probability of having an ACP conversation, (p<.001), AD completion (p<.001), and healthcare proxy assignment (p<.001) increased by 1.6%,1.4%, and 1.9% respectively after controlling for covariates. Number of chronic conditions also was independently and positively associated with ACP-related activities. Additionally, greater perceived health was associated with higher odds of AD completion (OR= 1.08, p<.05) and healthcare proxy assignment (OR= 1.07, p<.05). This study found that frequent encounters with physicians are associated with higher rates of ACP engagement even after controlling for health conditions.

ADAPTING PRIMARY CARE WORKFLOWS TO PROMOTE ADVANCE CARE PLANNING WITH AN EMPHASIS ON A DEDICATED ACP FACILITATOR

Abstract The COVID-19 pandemic has sharpened attention regarding the need to proactively plan for a future medical crisis. Advance Care Planning (ACP) has emerged in the last 30 years as a potential way to improve individuals’ end-of-life care by ensuring that patients explore and communicate personal values, goals, and preferences regarding future medical care to surrogate decision makers and medical providers. Elevating ACP as a core function of direct patient care, the University of Southern Indiana’s (USI) Geriatric Workforce Enhancement Program (GWEP) embedded a multi-modal ACP initiative in a primary care clinic, anchored by the Medicare Annual Wellness Visit (AWV). Within this initiative, the role of a dedicated ACP Facilitator embedded in the practice is highlighted to promote and bill (Medicare CPT codes 99494, 99498) for ACP conversations. The addition of an ACP Facilitator (who is a licensed clinical social worker) as part of the primary care team complements the efforts of the providers to focus on What Matters most to patients. This is particularly important to patients with serious illness. This presentation will summarize the re-alignment efforts of the primary care clinic to prioritize ACP conversations for older adults, amounting to 10,000 visits per year.

ESTABLISHING A SPANISH FOCUSED ADVANCED CARE PLANNING EDUCATIONAL SESSION FOR LATINA BREAST CANCER SURVIVORS

Abstract In this exploratory, qualitative study, a focus group was conducted with Latina breast cancer survivors and patients to explore their feedback on how a culturally, sensitive educational session looks like, and whether a Spanish-speaking advanced care planning (ACP) educational session might be able to identify barriers for promoting awareness and discussion of ACP. First, the educational session informed participants on ACP, specifically an advanced directive (AD) and barriers that contribute to decreased rates in ACP among Latino populations. Second, a group interview was facilitated by the project lead using a semi structured interview guide. Eight Latina cancer survivors or patients participated in the educational session. Thematic analysis revealed four themes: 1) Familial Involvement 2) Need for Advanced Care Planning Education 3) Addressing Language and Cultural Barriers and 4) Culturally Sensitive and Informative Resources. A Spanish focused educational session may reduce current barriers that hinder ACP conversations, and may lead to increased rates of participants engaging in AD documentation.

Actual vs Documented Advance Care Planning in a Primary Care Clinic.

Advance care planning (ACP) is a complex and multifaceted entity that has significant impact on patient care. ACP takes many forms, may be underbilled, and can have significant ramifications on quality care metrics. We performed a retrospective chart review for patients over 70 years in age in our family medicine resident clinic to evaluate the ways in which ACP is charted and the gap between billed and nonbilled ACP. The first 50 patients over 70 years in age seen between August 25, 2020 and September 25, 2020 were selected for standardized chart review. Billing for ACP was defined as Current Procedural Terminology codes=-10 codes 99497 or 99498. Primary outcomes were the percentage of patients with ACP and incidence of ACP documents. Secondary outcome was the proportion of documented ACP conversations in office visits which had billing for ACP. Forty-eight patients over 70 years in age were identified with an average age of 80.9 years old. Forty-one of 48 patients (85.4%) had some form of ACP and 12 (25%) had formal ACP documents. Of 25 patients with documented ACP conversations in office visits, eleven patients (44%) had ACP which had been formally billed. The majority of our patients had some form of ACP ranging from inpatient discussions of code status to outpatient visits regarding end-of-life care. However, ACP was underbilled in our practice. Physicians are often evaluated based on quality care metrics such as billed ACP which may not accurately reflect the work physicians are doing.

Implementing advance care planning in Swedish healthcare settings – a qualitative study of professionals’ experiences

Background Advance care planning (ACP) is a process involving conversations about values and preferences regarding future care at the end-of-life. ACP has led to positive outcomes, both in relation to quality of life and with increased use of palliative care, less life-sustaining treatment and fewer hospital admissions. Sweden has yet to embrace the practice systematically, but scattered initiatives exist. Aim To study implementation of a routine for ACP in NH settings in Sweden by exploring healthcare professionals’ experiences of engaging in ACP following this implementation. Methods The study followed a qualitative inductive design with convenience and snowball sampling. Semi-structured group and individual interviews with registered healthcare professionals were analysed using qualitative content analysis. Findings Organisational support for sustainable ACP implementation was found to be essential. This included sufficient training, facilitation, collaboration and uniform work routines across providers and professionals. Engaging in ACP conversations following the implemented routine was found to be a process of preparing, being, talking, deciding and sharing. Conclusions Successful implementation of ACP in NHs requires a carefully planned implementation strategy. ACP in NHs tend to be medically focused at the expense of residents’ psychosocial care-planning needs. Widespread uptake of ACP in Sweden could be useful in the national effort to adopt more person-centred care in Swedish healthcare. KEY POINTS While advance care planning has been implemented in many other countries, Sweden lacks a national strategy on advance care planning and Swedish healthcare settings have yet to systematically implement this practice. • This study is the first to report on professionals’ experiences of engaging in sustainable advance care planning, following top-down implementation of the practice in one Swedish region. • Successful implementation of advance care planning in nursing homes requires a system-level approach, and shortcomings of the implementation process are highlighted.

Actual timing versus GPs’ perceptions of optimal timing of advance care planning: a mixed-methods health record-based study

BackgroundTimely initiation of advance care planning (ACP) in general practice is challenging, especially in patients with non-malignant conditions. Our aim was to investigate how perceived optimal timing of ACP initiation and its triggers relate to recorded actual timing in patients with cancer, organ failure, or multimorbidity.MethodsIn this mixed-methods study in the Netherlands, we analysed health records selected from a database with primary care routine data and with a recorded ACP conversation in the last two years before death of patients who died with cancer, organ failure, or multimorbidity. We compared actual timing of ACP initiation as recorded in health records of 51 patients with the perceived optimal timing as determined by 83 independent GPs who studied these records. Further, to identify and compare triggers for GPs to initiate ACP, we analysed the health record documentation around the moments of the recorded actual timing of ACP initiation and the perceived optimal timing of ACP initiation. We combined quantitative descriptive statistics with qualitative content analysis.ResultsThe recorded actual timing of ACP initiation was significantly closer to death than the perceived optimal timing in patients with cancer (median 88 vs. 111 days before death (p = 0.049)), organ failure (227 vs. 306 days before death (p = 0.02)) and multimorbidity (113 vs. 338 days before death (p = 0.006)). Triggers for recorded actual versus perceived optimal timing were similar across the three groups, the most frequent being ‘expressions of patients’ reflections or wishes’ (14% and 14% respectively) and ‘appropriate setting’ (10% and 13% respectively).ConclusionACP in general practice was initiated and recorded later in the illness trajectory than considered optimal, especially in patients with organ failure or multimorbidity. As triggers were similar for recorded actual and perceived optimal timing, we recommend that GPs initiate ACP shortly after a trigger is noticed the first time, rather than wait for additional or more evident triggers when the illness is in an advanced stage.

Courage in Care Planning: Advance Care Planning Readiness in the Context of COVID19 for Caregivers of Individuals Living with Dementia

AbstractBackgroundCaregivers of individuals living with dementia frequently make medical decisions and develop care plans for future needs of care recipients, often without a clear understanding of those needs. For many, the COVID19 pandemic has exacerbated these challenges. Educational tools are needed to guide caregivers about when and how to raise the topic of advance care planning (ACP).MethodAs part of a larger study about the utility of video decision aids for ACP in dementia, caregivers of individuals living with dementia completed online surveys and watched educational videos about COVID19 and ACP. One day, one week and one month following watching the videos, we assessed ACP‐related knowledge, thoughts, readiness, plans, conversations, and actions in quantitative (validated ACP Engagement Survey) and through qualitative open‐ended questions. Forty‐six caregivers participated. For this analysis, we examined the subset of participants who were not at the most engaged level on the ACP engagement survey. We coded and conducted a content analysis of the open‐ended qualitative questions at one month follow up.ResultFrom pre‐post intervention, about 1/3 of participants increased their scores about ACP knowledge, thoughts, plans, and readiness to be a substitute decision‐maker or to make decisions for their loved one if they became very sick (possibly due to Covid). In particular, on one question (how ready are you to discuss with your loved one’s doctor whether or not there are certain health situations that would make your loved one’s life not worth living?), 74% of participants increased their engagement score pre‐ to post‐intervention. In qualitative analyses, 57% reported they engaged in ACP conversations after the intervention.ConclusionImmediately after the ACP video intervention, a substantial proportion of caregivers of individuals with dementia increased ratings of knowledge, confidence, and readiness to participate in ACP plans, conversations, and actions for their loved one. One month after the intervention, more than half engaged in ACP conversations. In future research, we will examine participant’s characteristics (e.g., dementia stage of loved one) in relationship to ACP Engagement responses. We plan to evaluate whether exposure to ACP video educational tools increases caregiver confidence in planning for healthcare decisions.

Use of Machine Learning and Lay Care Coaches to Increase Advance Care Planning Conversations for Patients With Metastatic Cancer.

Patients with metastatic cancer benefit from advance care planning (ACP) conversations. We aimed to improve ACP using a computer model to select high-risk patients, with shorter predicted survival, for conversations with providers and lay care coaches. Outcomes included ACP documentation frequency and end-of-life quality measures. In this study of a quality improvement initiative, providers in four medical oncology clinics received Serious Illness Care Program training. Two clinics (thoracic/genitourinary) participated in an intervention, and two (cutaneous/sarcoma) served as controls. ACP conversations were documented in a centralized form in the electronic medical record. In the intervention, providers and care coaches received weekly e-mails highlighting upcoming clinic patients with < 2 year computer-predicted survival and no prior prognosis documentation. Care coaches contacted these patients for an ACP conversation (excluding prognosis). Providers were asked to discuss and document prognosis. In the four clinics, 4,968 clinic visits by 1,251 patients met inclusion criteria (metastatic cancer with no prognosis previously documented). In their first visit, 28% of patients were high-risk (< 2 year predicted survival). Preintervention, 3% of both intervention and control clinic patients had ACP documentation during a visit. By intervention end (February 2021), 35% of intervention clinic patients had ACP documentation compared with 3% of control clinic patients. Providers' prognosis documentation rate also increased in intervention clinics after the intervention (2%-27% in intervention clinics, P < .0001; 0%-1% in control clinics). End-of-life care intensity was similar in intervention versus control clinics, but patients with ≥ 1 provider ACP edit met fewer high-intensity care measures (P = .04). Combining a computer prognosis model with care coaches increased ACP documentation.

Patients' spiritual concerns and needs and how to address them during advance care planning conversations: Healthcare chaplains' perspectives.

Advance care planning (ACP) conversations require the consideration of deeply held personal values and beliefs and the discussion of uncertainty, fears, and hopes related to current and future personal healthcare. However, empirical data are limited on how such spiritual concerns and needs are supported during ACP. This study explored board-certified healthcare chaplains' perspectives of patients' spiritual needs and support in ACP conversations. An online survey of 563 board-certified chaplains was conducted from March to July 2020. The survey included 3 open-ended questions about patients' hopes and fears and about how the chaplains addressed them during ACP conversations. Written qualitative responses provided by 244 of the chaplains were examined with content analysis. The majority of the 244 chaplains were White (83.6%), female (59%), Protestant (63.1%), and designated to one or more special care units (89.8%). Major themes on patients' hopes and fears expressed during ACP were (1) spiritual, religious, and existential questions; (2) suffering, peace, and comfort; (3) focus on the present; (4) hopes and fears for family; and (5) doubt and distrust. Major themes on how chaplains addressed them were (1) active listening to explore and normalize fears, worries, and doubts; (2) conversations to integrate faith, values, and preferences into ACP; and (3) education, empowerment, and advocacy. ACP conversations require deep listening and engagement to address patients' spiritual needs and concerns - an essential dimension of engaging in whole-person care - and should be delivered with an interdisciplinary approach to fulfill the intended purpose of ACP.

Emotional cues and concerns of patients with a life limiting, chronic illness during advance care planning conversations in general practice

ObjectiveTo explore a) to what extent patients with serious illness express emotional cues and concerns during advance care planning (ACP) conversations with their general practitioner (GP), b) the content of cues/concerns and c) GPs’ responses to cues/concerns. MethodsCues/concerns and GPs’ responses in 20 conversations were coded using the Verona Codes (VR-CoDES and Verona Codes-P). A qualitative thematic analysis was used to identify overarching themes within the content of the cues/concerns. ResultsA total of 216 cues/concerns were identified (range: 1–28; mean: 13) in 85% of conversations; with 85% of these being cues/implicit expressions of emotions. In 72% of responses, the GP provided space for the patient to elaborate on cues/concerns. The most common theme cues/concerns were expressed about was “the consequences of illness on quality of life and burdening others”. ConclusionEmotions were mainly communicated implicitly as cues and the content varied greatly.The amount of cues/concerns expressed show that ACP can evoke many emotions. Practice implicationsGPs should be attentive to implicit expressions of emotions as these provide opportunities to engage patients in tailored ACP conversations. As patients expressed many cues/concerns, GPs are recommended to have recurrent conversations with patients and actively ask about diverse ACP topics.

Support from healthcare professionals in empowering family carers to discuss advance care planning: A population-based survey

Background: Family carers have a prominent role in end-of-life care for seriously ill persons. However, most of the advance care planning literature is focused on the role of healthcare professionals. Aims: To investigate (1) what proportion of family carers discussed advance care planning with their relative and associated socio-demographic and clinical characteristics (2) what proportion received support from healthcare professionals for these conversations, (3) what type of support they received and (4) to what extent the type of support received was considered sufficient. Design/participants: Population-based cross-sectional survey in Belgium of bereaved family carers of persons with a serious chronic illness (N = 3000) who died 2–6 months before the sample was drawn, identified through three sickness funds. The survey explored support from healthcare professionals for family carers during the last 3 months of the patient’s life. Results: Response rate was 55%. The proportion of family carers that engaged in an advance care planning conversation with their relative was 46.9%. Of these family carers, 78.1% received support from a healthcare professional, mostly by doing the advance care planning conversation together (53.8%). Of family carers receiving support from a healthcare professional, 57.4% deemed the support sufficient. Conclusion: Many family carers engage in advance care planning conversations with their dying relative. Healthcare professionals often support them by performing the advance care planning conversations together. More insight into how family carers can be supported to conduct these advance care planning conversations, both with and without involvement of healthcare professionals, is necessary.

Abstract 12778: Improving Advanced Care Planning for Hospitalized Patients With Heart Failure

Introduction: Advanced Care Planning (ACP) is an important and proven strategy to improve end-of-life communication and the quality of life of patients with heart failure and their relatives. However, the frequency of ACP conversations in practice remains low. UCI’s heart failure (HF) metrics show that in the months of April 2021 to October 2021 prior to intervention, an average of 13.24% of HF patients hospitalized at UCI had completed ACP at discharge, as measured by presence of POLST form or Advanced Directive (AD) in Epic. The goal of this quality improvement project was to determine whether the rate of ACP completion could be improved using electronic medical record (EMR) reminders to the healthcare team. Methods: For a 3-month period [January 2022-March 2022], our research team messaged providers designated as ‘First Call’ for each hospitalized patient with a primary diagnosis of HF and no existing ACP documentation in the Epic EMR. Messages were sent via Epic’s secure chat function, serving as a reminder to complete ACP documentation including a POLST form. Messages were sent on the day of admission with a second message sent after 2 weeks if the patient remained hospitalized and there was no change in ACP completion status. Percentage of ACP documentation completion was calculated during the 3-month study period. Results: Our results have demonstrated that the ACP completion was an average of 21.00% during the 3 months of the intervention. This is a 7.76% absolute increase in ACP completion compared to 3 months prior to our intervention (13.24%); a 58.61% relative increase. Conclusions: ACP among hospitalized HF patients remains low. Direct message reminders to providers serves as a beneficial means of improving ACP completion among this subset of patients.

Vulnerability and Resilience: Phenomenological Analysis of Cancer Patients Value Directives.

Personal values are individual conceptions of the desirable appraisals and actions that guide our attitudes and behaviour. Advance care planning (ACP) now emphasises the consideration of personal life goals and values expressed as a Values Directive (VD) to guide discussions concerning medical treatment. To investigate the diversity of values, experiences and adaptations expressed in cancer patients VDs. Contents of the VDs of ACPs of cancer patients who participated in a randomised control trial comparing a video intervention showing values communication between cancer patient-caregivers with usual care were analysed. Qualitative phenomenological content analysis was used to understand how participants made meaning of their lived experiences. Forty-two participants completed an ACP (37.2% response rate), with 97.6% of these completing a VD (57.1% female, mean age 72 years, 30.1% gastrointestinal cancer). Participants described diverse adjustments to frailty and adaptive coping with deteriorating functionality. Emotional and financial concerns were eased through experiencing benevolence and trust established through family and friendship bonds and reciprocation of care. Death anxiety and ambivalence were expressed concurrently with the experiential acceptance of dying. Secular and sacred rituals featured as an affirmation of their faith or beliefs. Cancer patients seek to make meaning of their experiences, concurrently posturing vulnerability and resilience, despite conflicting emotions and experiences. Given that the choices people make as they approach dying relate to their most deeply held values, ACP conversations should explore how patients draw from their values and life goals to optimise their adaptations to illness.

Social Isolation and Implementation of Advanced Care Planning Among Hospitalized Patients With Heart Failure.

Background The implementation of advance care planning (ACP) in heart failure management is insufficient. Social isolation (SI) could be a barrier to ACP initiation, albeit the relationship between SI and patients' preference for ACP or end-of-life care remains unknown. Methods and Results We conducted a questionnaire survey, including assessments of SI using the 6-item Lubben Social Network Scale as well as patients' perspectives on ACP and end-of-life care. Of the 160 patients approached by our multidisciplinary heart failure team during admission, 120 patients (75.0%) completed the survey (median age, 73.0 years; men, 74.2%). A Cox proportional hazard model was constructed to elucidate the short-term (180-day) prognostic impact of SI. Overall, 28.3% of participants were at high risk for SI (6-item Lubben Social Network Scale score <12). High-risk patients had more negative attitudes toward ACP than those without (61.8% versus 80.2%; P=0.035). The actual performance of ACP conversation in patients with and without high risk were 20.6% and 30.2%, respectively. Regarding preference in end-of-life care, "Saying what one wants to tell loved ones" (73.5% versus 90.6%; P=0.016) and "Spending enough time with family" (58.8% versus 77.9%; P=0.035) were less important in high-risk patients. High risk for SI was associated with higher 180-day risk-adjusted all-cause mortality (hazard ratio, 7.89 [95% CI, 1.53-40.75]). Conclusions In hospitalized patients with heart failure, high risk for SI was frequently observed. High-risk patients were associated with a negative attitude toward ACP, despite higher mortality. Further research is required to establish an ideal approach to provide ACP in socially vulnerable patients.

Primary Palliative Care in Huntington's Disease.

Palliative care practices, including communication about patient-centered goals of care and advance care planning (ACP), have the potential to enhance care throughout the course of Huntington's disease (HD) and related disorders. The goal of our project was to develop a pilot program that integrates primary palliative care practices with interdisciplinary care for HD. (1) To train HD team members to facilitate goals of care and ACP conversations at all stages of HD; (2) To create materials for care planning in HD focused on patient-centered goals of care and health-related quality of life; and (3) To modify clinic workflow to include goals of care and ACP discussions. We defined planning domains to expand care planning beyond end-of-life concerns. We created a patient and family guide to advance care planning in HD. We conducted VitalTalk communications training with the HD team. We modified the interdisciplinary clinic workflow to include ACP and developed an EMR template for documentation. After communication training, more team members felt well prepared to discuss serious news (12.5% to 50%) and manage difficult conversations (25% to 62.5%). The proportion of clinic visits including advance care planning discussions increased from 12.5% to 30.6% during the pilot phase. Provision of primary palliative care for HD in an interdisciplinary clinic is feasible. Integration of palliative care practices into HD specialty care requires additional training and modification of clinic operations.

Resident-Led Effort Improves Adoption of Advance Care Planning among Emergency General Surgery Patients

INTRODUCTION: Advanced Care Planning (ACP) is underused in surgery, especially among older adults undergoing high-risk operations. For patients who may permanently or temporarily lose their ability to communicate preferences, pre-operative ACP and identification of a surrogate decision-maker is often the only mechanism to guide medical decision-making. METHODS: A resident-led, collaborative (faculty, advanced practice providers [APP], medical student, and nurse) quality improvement project including education (grand rounds, case-based conferences, didactic sessions), performance measurement and financial incentives, conducted on the Emergency General Surgery (EGS) service aimed to increase use of a tailored surgical template in the ACP tab in the electronic health record (EHR). 566 patients in the baseline period (2020-2021) were compared to 423 patients in the project period (2021-2022). Residents were surveyed about barriers to adoption. RESULTS: ACP compliance increased by 8.1% (10.1% to 18.2%) with a greater increase noted in patients age 65+ (20.3% vs 34.3%). Residents and APPs completed ACP, usually by integrating into patient admission workflow (52.1% within the first 24 hours of admission). For major cases, ACP compliance rates increased by 19.7% (18.9% to 38.6%). Residents surveyed (n = 19), all of whom had an ACP conversation all recognized the importance of ACP, noted barriers, including competing clinical duties (50%), patient or family hesitancy (30%), and language barriers (15%), (Table 1). CONCLUSION: A resident-APP partnership was effective at increasing ACP adoption on an EGS service. Further study is needed to identify approaches to facilitate ACP conversations in EGS patients with limited English proficiency.Table 1