Advance Care Planning Documentation Research Articles

A cross-sectional study on advance care planning documentation attitudes during national advance care planning week in a South-East Asian country

BackgroundThrough advocacy initiatives such as roadshows during “National ACP Week”, the Agency for Integrated Care (AIC) had increased advance care planning (ACP) engagement since 2011. Project Happy Apples (PHA), a community initiative project led by medical students from the National University of Singapore, also conducted a public exhibition to raise ACP awareness during this period. This study aimed to investigate and identify predictors of attitudes towards ACP documentation among ‘ACP Week’ respondents which may be used to formulate strategies to increase ACP documentation in Singapore.MethodsA cross-sectional study on ACP documentation attitudes of 262 respondents during local roadshows were conducted. Multiple logistic regression models were built to investigate the associations between demographic variables and attitudes toward ACP documentation.ResultsThe mean age was 43.5 years (SD = 17.4), 79 (30.15%) were males and 49 (18.7%) were healthcare professionals (HCP). 117 (44.66%) respondents had prior experience with serious illness and 116 (44.27%) had heard of ACP. Age was a significant predictor of readiness to sign official papers naming nominated healthcare spokesperson (NHS) (OR = 1.04, 95%CI: 1.02–1.07). Experience with serious illness was a significant predictor of readiness to discuss end-of-life (EOL) care with healthcare professionals (HCP) (OR = 3.65, 95%CI: 1.36–11.61). Being female was a significant predictor for readiness to speak to their nominated healthcare spokesperson about EOL care (OR = 7.33, 95%CI: 2.06–46.73). Subgroup analyses revealed that those aged 20–39 were less likely to speak to their healthcare professional about or sign official papers regarding EOL care. We also found that being a healthcare professional does not necessitate better or worse attitudes.ConclusionAdvocacy programs tailored to targeting respondents of different age groups and prior experience with serious illness may improve the efficacy of advocacy efforts.

The Association Between Timely Documentation of Advance Care Planning, Hospital Care Consumption and Place of Death: A Retrospective Cohort Study.

Objectives: (1) To describe ACPT implementation frequency in practice. (2) To assess associations of ACPT documentation with a) hospital care consumption, including systemic anti-tumor treatment in the last month(s) of life, and b) match between preferred and actual place of death, among oncology patients. Methods: A retrospective cohort study was performed. Data concerning ACPT documentation, hospital care consumption, and preferred and actual place of death were extracted from electronic patient records. Patients with completely documented ACPT (cACPT) and no ACPT were compared using multivariable logistic regression analyses. Results: ACPT was implemented in 64.5% (n = 793) of all deceased patients (n = 1230). In 17.6% (n = 216), preferred place of care or death was documented at least three months before death (cACPT). A cACPT was not associated with systemic anti-tumor treatment (Adjusted OR (AOR): 0.976; 95% CI: 0.642-1.483), but patients with cACPT had fewer diagnostic tests (AOR: 0.518; CI: 0.298-0.903) and less contacts with hospital disciplines (AOR: 0.545; CI: 0.338-0.877). In patients with cACPT, a match between preferred and actual place of death was found for 83% of the patients for whom the relevant information was available (n = 117/n = 141). In patients without ACPT, this information was mostly missing. Conclusion: Although the ACPT was implemented in two thirds of patients, timely documentation of preferred place of care or death is often missing. Yet, timely documentation of these preferences may promote out-hospital-death and save hospital care consumption.

Automated patient selection and care coaches to increase advance care planning for cancer patients.

Advance care planning/serious illness conversations can help clinicians understand patients' values and preferences. There are limited data on how to increase these conversations, and their effect on care patterns. We hypothesized that using a machine learning survival model to select patients for serious illness conversations, along with trained care coaches to conduct the conversations, would increase uptake in cancer patients at high risk of short-term mortality. We conducted a cluster-randomized stepped wedge study on the physician level. Oncologists entered the intervention condition in a random order over six months. Adult patients with metastatic cancer were included. Patients with <2 year computer-predicted survival and no prognosis documentation were classified as high-priority for serious illness conversations. In the intervention condition, providers received automated weekly emails highlighting high-priority patients and were asked to document prognosis for them. Care coaches reached out to these patients to conduct the remainder of the conversation. The primary endpoint was proportion of visits with prognosis documentation within 14 days. 6,372 visits in 1,825 patients were included in the primary analysis. The proportion of visits with prognosis documentation within 14 days was higher in the intervention condition than control condition: 2.9% vs 1.1% (adjusted odds ratio 4.3, p < .0001). The proportion of visits with advance care planning documentation was also higher in the intervention condition: 7.7% vs 1.8% (adjusted odds ratio 14.2, p < .0001). In high-priority visits, advance care planning documentation rate in intervention/control visits was 24.2% vs 4.0%. The intervention increased documented conversations, with contributions by both providers and care coaches.

End Of Life Care in Nursing Home Residents Supported Through a Nursing Home Specialist Liaison Service

Abstract Background Advance Care Planning (ACP) is a crucial aspect of ensuring that nursing home residents receive care aligned with their preferences and values, especially as they approach the end of life. Supportive end of life care planning involves discussion with the person and/or their support person, symptom management and multidisciplinary collaboration. Evidence shows that even where an ACP has been recorded there can be significant barriers to enabling end of life care in the nursing home. We examined the role of a nursing home specialist liaison team in supporting implementation of ACPs towards end of life. Methods Retrospective analysis of medical and nursing care records from deceased residents referred to the liaison service in 2023 across four nursing homes in the hospital catchment was examined. Data included recording and/or reviewing of ACP at time of liaison consultation, anticipatory medication prescribing, cause and location of death. Results 41 resident reviews conducted by Registered Advanced Nurse Practitioner and/or Consultant Geriatrician. 16 (39%) of residents had an ACP in place at the time of initial review. 18 (26%) residents had anticipatory medications prescribed prior to liaison service consultation. Following consultation ACP documentation in residents increased to n=40 (97%). A further 11 (26%) residents were charted anticipatory medications at time of review as they were actively dying. Five (12%) residents required referral to specialist palliative care services for complex symptom management. All 41 residents passed away in the nursing home. Cardiac related issue was documented in 63% of reviews as cause of death. Conclusion Documentation of ACPs was low in this cohort of nursing home residents towards end of life. Input from the nursing home liaison service supported resident’s end of life care through consultation, support with ACP and anticipatory medication prescribing.

Missed Opportunities for use of Advanced Care Planning and Palliative Care in Open Aortic Surgery

Major vascular surgery, including open aortic procedures, is associated with having a 30-day mortality rate greater than 6% and a perioperative complication rate greater than 50%. Published literature suggests that patients undergoing high-risk procedures benefit from having a care plan in place to not only maximize quality of life but also to ensure medical interventions align with care goals. Currently, there is a paucity of published data on the prevalence of goals of care conversations, advance care planning documentation, and palliative care evaluations in patients undergoing high-risk vascular operations. A retrospective chart review of all patients who underwent open aortic surgery at a tertiary care academic medical center from July 2014 to March 2023 was performed. Patient demographics, comorbidities, type and timing of advanced care planning (ACP), palliative care evaluations, and clinical outcomes during the periprocedural period were recorded. For patients who died during the study period, the use of palliative care prior to death were noted. Patients who received ACP or palliative care were compared with those who did not. The cohort consisted of 192 patients who underwent major open aortic surgery. The mean age was 63 years (SD 12.3) and the majority of patients were male (73.4%) and white (64.1%). Thirty-nine (20.6%) operations were classified as emergent. At the time of their operation, 16.7% (n=32) of patients had an ACP document on file. Of the 38 documents on file, most were durable power of attorney (DPOA) (86.8%) documents while a smaller percentage were physician orders for life-sustaining treatment (POLST) (13.2%). There were no patients with Do Not Resuscitate and/or Intubate (DNR/DNI), living will, or organ/tissue donation orders noted in their chart prior to surgery. One percent (n=2) of patients had a palliative evaluation prior to their operation. During the perioperative period, an additional 2 (1%) of patients had advanced care planning documentation and 7 (3.7%) of patients underwent palliative care evaluation. Fifteen percent of patients (n=28) died during the perioperative period and an additional 21 patients died by the end of the study period for a total mortality of 25.2% in the study population. Among patients that died during the perioperative period, 28.6% (n=8 out of 28) received palliative care. Overall, 28.6% of all study patients that died (n=14 out of 49) received a palliative care evaluation prior to or during their terminal hospitalization. Patients who had ACP documents or who received palliative care consultations prior to surgery were older (p=0.01), more likely to be on Medicare or Medicaid (p=0.004), and more likely to have a history of solid organ malignancy (p=0.03). The median interval between surgery and receiving palliative care was 20 (IQR 3-71) days. The median interval between palliative care and death was 5 (IQR 2-13) days. Patients who utilized ACP or PC were more likely to die at home (p=0.05). Despite a high mortality and morbidity rate, ACP documentation is poor for patients undergoing major open aortic surgery. Palliative care interventions tend to be performed closer to the end of life, suggesting a missed opportunity to define goals of care.

Abstract C005: Predictors of advance care planning documentation in female patients with breast cancer: A multilevel model analysis

Abstract Background: Advance care planning (ACP) is a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care. Likewise, ACP is associated with multiple benefits, such as lower rates of hospitalizations and reduced futile, aggressive cancer treatment at the end of life. However, ACP rates remain low in the U.S., especially for patients with advanced cancer. Despite being more likely to be diagnosed at advanced stages and hospitalized due to advanced cancer with poor prognosis, the Black and Hispanic/Latino populations continue to have meager rates of ACP. Research has shown that both individual-level and systems-level factors contribute to these racial disparities in ACP. Considering these disparities among vulnerable populations, interventions that increase ACP among minority patients with cancer are needed. Objective: To analyze using multilevel model analysis the predictors of ACP documentation in female patients with breast cancer over 5 years in the UChicago Health System. Methods: Using the Clinical Data Research Warehouse, this study included women diagnosed with breast cancer (N=7,814) from 2016 to 2021. Descriptive statistics were performed to characterize ACP, and potential differences in ACP rates among control variables were assessed using odds ratio (OR) estimations. Significantly correlated variables were included as covariates in the multivariate analyses through a logistic regression model. The multilevel random-effects (mixed-effects) model, using restricted maximum likelihood estimation, examined the pattern of ACP documentation; in the multilevel model, level 1 modeled the changes in individual ACP documentation, and level 2 included the between-subjects effects of the predictors of documentation. Results: 13.76% of women with breast cancer filled out at least one type of ACP documentation, 4.25% filled out the Power of Attorney, 5.75% filled out the Advance Directive, and 8.92% filled out the Code Status. Increasing age and being black/African-American seem to be related to an increased likelihood of completion of at least one type of ACP documentation. While increasing BMI and outpatient services seem to be related to a decrease in the likelihood of completing at least one type of ACP documentation. Conclusion: Understanding the factors related to ACP documentation will allow us to manage them and improve their completion. These results will help to inform the development of tools to increase the integration of ACP into care, especially those that are technology-based. Further work could include designing a predictive model to prioritize patients requiring ACP. Providing knowledge about ACP in nonclinical areas can lead to increased education about ACP and its benefits to families and communities. Citation Format: Andres Mauricio Garcia Sierra, Marcia Tan. Predictors of advance care planning documentation in female patients with breast cancer: A multilevel model analysis [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr C005.

Quality of Advance Care Planning in Long-Term Care and Transfers to Hospital at the End Of Life

ObjectivesOur primary objective was to determine if more comprehensive advance care planning (ACP) documentation was associated with fewer transfers to hospital in the last year of life. Our secondary objective was to determine the impact of ACP processes and practices on hospital transfers in the last year of life. DesignRetrospective cohort study. Setting and ParticipantsLong-term care (LTC) residents in Ontario, Canada, 65 years and older who died between January 1, 2017, and May 30, 2018, and resided in a participating LTC home. MethodsWe administered a survey to directors of care at LTC homes inquiring about ACP practices. Our exposure of interest was living in a home with comprehensive ACP documentation that includes information beyond preferences for cardiopulmonary resuscitation and hospital transfer. Our primary outcome was the number of transfers to hospital in the last year of life. We fit negative binomial regression models to determine the independent effect of comprehensive ACP and other indicators of ACP quality. ResultsA total of 157 LTC homes with 6637 decedent residents were included in our study; 2942 lived in homes with comprehensive ACP documentation and 3695 had non-comprehensive ACP documents. Comprehensive documentation was not associated with fewer hospital transfers in the final year of life [incidence rat ratio (IRR), 1.00; 95% CI, 0.91–1.09]. ACP documentation update frequency, availability of ACP documents in the electronic medical record, referring to ACP documents during a health crisis, inclusion of resident values in ACP documents, and involvement of a multidisciplinary team were all associated with fewer transfers to hospital during follow-up in the last year of life. Conclusions and ImplicationsACP documents that contain information beyond preferences for cardiopulmonary resuscitation and hospital transfer had no association with transfers to hospital, but high-quality ACP practices and processes were associated with fewer transfers.

Machine learning for targeted advance care planning in cancer patients: a quality improvement study

Context: Prognostication challenges contribute to delays in advance care planning (ACP) for patients with cancer near the end of life (EOL). Objectives: Examine a quality improvement mortality prediction algorithm intervention's impact on ACP documentation and EOL care. Methods: We implemented a validated mortality risk prediction machine learning model for solid malignancy patients admitted from the emergency department (ED) to a dedicated solid malignancy unit at Duke University Hospital. Clinicians received an email when a patient was identified as high-risk. We compared ACP documentation and EOL care outcomes before and after the notification intervention. We excluded patients with intensive care unit (ICU) admission in the first 24 hours. Comparisons involve chi-square/Fisher's exact tests and Wilcoxon rank sum tests; comparisons stratified by physician specialty employ Cochran-Mantel-Haenszel tests. Results: Pre-intervention and post-intervention cohorts comprised 88 and 77 patients, respectively. Most were White, non-Hispanic/Latino, and married. ACP conversations were documented for 2.3% of hospitalizations pre-intervention vs. 80.5% post-intervention (p<0.001), and if the attending physician notified was a palliative care specialist (4.1% vs. 84.6%) or oncologist (0% vs. 76.3%) (p<0.001). There were no differences between groups in length of stay (LOS), hospice referral, code status change, ICU admissions or LOS, 30-day readmissions, 30-day ED visits, and inpatient and 30-day deaths. Conclusion: Identifying patients with cancer and high mortality risk via machine learning elicited a substantial increase in documented ACP conversations but did not impact EOL care. Our intervention showed promise in changing clinician behavior. Further integration of this model in clinical practice is ongoing.

Action plans increase advance care planning documentation and engagement among English and Spanish-speaking older adults.

Advance care planning (ACP) has been reconceptualized as a health behavior. Action plans (APs), or patient-directed mini contracts, improve behavior change. However, no prior studies have assessed whether APs can increase ACP documentation and engagement. We included English and Spanish-speaking primary care patients from San Francisco, ≥55 years of age, with ≥2 serious or chronic illnesses. Participants were in the intervention arm of the PREPAREforYOURcare.org trial and asked at baseline to choose 1 of 5 actions (e.g., choose a surrogate). At 6 months, we assessed whether participants completed their AP and if completion was associated with demographics, electronic health record (EHR) ACP documentation, and five-point ACP Engagement Survey scores. We used t-tests, chi-squared, multivariate analysis adjusted for baseline ACP and clustering by physician, and qualitative thematic analysis to explore reasons for non-completion. The mean age of 586 participants was 65 ± 10 years; 44.0% women, 45.9% Spanish-speaking, 31.4% had limited health literacy, and 43% completed an AP at 6 months; surrogate-related (47.4%), tell others about medical wishes (33.7%), ask clinicians questions (13.7%), and decide what matters most in life (5.2%). Participants with limited versus adequate health literacy were less likely to complete an AP (25.4% vs 35.9%, p = 0.01). Completing an AP was associated with greater ACP EMR documentation 49.8% vs 35.6%, p < 0.001 (adjusted odds ratio: 2.06; 95% CI [1.43-2.97]) and engagement (adjusted five-point scores [3.69; 95% CI 3.57-3.81 vs 3.10; 95% CI: 2.98-3.21], p < 0.001). Themes for non-completion included not being ready and logistical issues (e.g., surrogate deceased). Among English and Spanish-speaking older adults, creating an ACP AP resulted in greater documentation and engagement. APs may help facilitate ACP behavior change as part of effective ACP interventions. Additional support may be needed for patients with limited health literacy and those facing logistical barriers.

2254 Improving the quality and breadth of advance care planning discussions on gerontology wards in an acute London trust

Abstract Introduction Advance care planning (ACP) offers people the opportunity to plan their future care whilst they have capacity to do so and is supported by national guidance. Decisions regarding future care are more likely to be individualised and holistic when patients and their significant others are involved. This QI project aimed to address this by increasing the frequency of ACP discussions being offered and recorded on gerontology wards in an acute London Trust. Method A multi-professional steering group was established to improve ACP using PDSA methodology. A new ACP toolkit, training programme and electronic flowsheet (within the hospital’s patient record system) were implemented. ACP documentation quality was audited on gerontology wards pre and post implementation (over one to four months respectively). Data was compared using Pearson’s Chi-squared test. Results ACP flowsheets were completed by junior and senior doctors, and clinical nurse specialists in frailty and palliative medicine. The initial audit found disparity between documented topics of ACP conversations, with cardiopulmonary resuscitation recommendations being most discussed. Post implementation, 24 ACP flowsheets were reviewed, showing that more ACP topics were documented where these conversations were had; preferred place of death increased from 24% to 60% (p 0.011); treatment escalation plan increased from 41% to 75% (p 0.014); preferred place of care increased from 59% to 71% (p 0.066). Topics not showing significant improvement in documentation (despite inclusion in the flowsheet) were spiritual needs, information needs and prognostic discussion, broader social needs and what was most important to the patient. Conclusion The implementation of an electronic ACP flowsheet improved documented ACP conversations in some topics, guiding healthcare professionals to deliver care that aligns with peoples’ wishes and preferences. Documented conversations became easier to access, review and audit. Work is still needed to promote ACP conversations being centralised around what matters most to patients.

Quality Improvement Study Using a Machine Learning Mortality Risk Prediction Model Notification System on Advance Care Planning in High-Risk Patients

Background: Advance care planning (ACP) is an important aspect of patient care that is underutilized. Machine learning (ML) models can help identify patients appropriate for ACP. The objective was to evaluate the impact of using provider notifications based on an ML model on the rate of ACP documentation and patient outcomes. Methods: This was a pre-post QI intervention study at a tertiary academic hospital. Adult patients admitted to general medicine teams identified to be at elevated risk of mortality using an ML model were included in the study. The intervention consisted of notifying a provider by email and page for a patient identified by the ML model. Results: A total of 479 encounters were analyzed of which 282 encounters occurred post-intervention. The covariate-adjusted proportion of higher-risk patients with documented ACP rose from 6.0% at baseline to 56.5% (Risk Ratio (RR)= 9.42, 95% CI: 4.90 - 18.11). Patients with ACP were more than twice as likely to have code status reduced when ACP was documented (29.0% vs. 10.8% RR=2.69, 95% CI: 1.64 – 4.27). Additionally, patients with ACP had twice the odds of hospice referral (22.2% vs. 12.6% Odds Ratio=2.16, 95% CI: 1.16 – 4.01). However, patients with ACP documented had a longer mean LOS (9.7 vs. 7.6 days, Event time ratio = 1.29, 95% CI: 1.10 - 1.53). Conclusion: Provider notifications using an ML model can lead to an increase in completion of ACP documentation by frontline clinicians in the inpatient setting.

Improving age-friendly advance care planning in primary care: Outcomes from a Pacific Northwest learning collaborative.

Advance care planning (ACP) is the process of having conversations with patients to ensure preferences are known and support patient healthcare goals. ACP and the Age-Friendly Health Systems (AFHS) Initiative's, "What Matters," are synergistic approaches to patient-centered conversations. Implementation and measurement of ACP in primary care (PC) are variables in quality and consistency. We examined whether participation in an ACP learning collaborative (LC) would improve knowledge and ability to conduct ACP discussions and increase the frequency of documented ACP in participating practices. The WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) region Practice and Research Network (WPRN) and the Northwest Geriatrics Workforce Enhancement Center collaboratively organized a 9-month virtual LC. It consisted of 4 synchronous, 1.5-h sessions, technical support, and a panel of ACP experts. A Wilcoxon rank sum test assessed differences in knowledge from a pre-post survey. Documentation of ACP in the EHR was collected after at least one plan-do-study-act cycle. We enrolled 17 participants from 6 PC practices (3 hospital-affiliated; 3 Federally Qualified Health Centers) from the WPRN. Two practices did not complete all LC activities. There was a trend toward increased ACP knowledge and skills overall especially in having discussions patients and families (pre-mean 2.9 [SD = 0.7]/post-mean 4.0[SD = 1.1], p < 0.05). 4/6 practices observed an increase in EHR documentation post-collaborative (median 16.3%, IQR 1.3%-36.9%). The LC increased PC providers knowledge and skills of ACP and AFHS's What Matters, reported ACP EHR documentation, and contributed to practice change.

Improving Goal-Concordant Care in Intensive Care Unit Admissions from the Emergency Department in a Comprehensive Cancer Center

ContextAs patients approach the end of life, discussion of their treatment goals is essential to avoid unnecessary suffering and deliver care in a manner consistent with their overall values. ObjectivesImplement a multipronged approach to improve the rates of advance care planning (ACP) documentation among providers admitting patients with cancer to the intensive care unit (ICU) from the emergency department (ED). MethodsWe developed multiple interventions including the development of a best-practice advisory to alert providers when patients had previous do-not-resuscitate orders; standardization of ACP documentation; early oncologist involvement in goals-of-care conversations with patients; a survey of ED providers to identify barriers to success; and positive reinforcement strategies aimed at improving the rates of ACP documentation in patients admitted from the ED to the ICU. ResultsPrior to our interventions, only 13% of patients admitted to the ICU from the ED had ACP notes. This percentage increased to 90% by the last month of our project. ConclusionThrough our multipronged approach, we significantly improved the rates of ACP documentation among providers admitting patients from the ED to the ICU.

Using machine learning for targeted advance care planning (ACP) conversations in patients with cancer: A quality improvement initiative.

1552 Background: Despite improvements, patients with advanced cancer often do not receive goal-concordant care at the end of life (EOL). Challenges with prognostication contribute to delays ACP conversations and result in more aggressive care, gaps in symptom management, and hospice underuse. Early identification of patients at high risk for mortality provides an avenue to implement targeted ACP conversations. Methods: We used a validated machine learning model that integrates demographics, lab values, vital signs, and medications to predict in-hospital, 30-day, and 6-month mortality risk for patients with a solid malignancy admitted from the emergency department (ED) to a dedicated solid malignancy oncology unit at Duke University Hospital. This unit includes one oncology and one palliative care attending physician, advance practice providers, and nurse coordinators. Providers received an email when a patient was identified as high risk for mortality. A pre-post study design compared ACP documentation and other EOL healthcare utilization before and after the notification intervention. The pre-intervention cohort included patients hospitalized from 1/7/2019 to 10/25/2019 and the post-intervention cohort from 9/19/2020 to 8/31/2021. We excluded patients admitted to the intensive care unit in the first 24 hours. We used chi-square or Fisher’s exact tests for categorical variables and Kruskal-Wallis tests for continuous variables; we stratified comparisons of categorical variables by physician division using Cochran-Mantel-Haenszel tests. Results: The pre-intervention cohort comprised 105 hospitalizations and 88 unique patients. Mean (SD) age was 64.9 (11.4); 60.0% (n=63) were White, 3.8% (4) Hispanic/Latino, and 65.7% (69) married. The post-intervention cohort comprised 84 hospitalizations and 77 patients. Mean (SD) age was 66.0 (12.2); 52.4% (44) were White, 2.4% (2) Hispanic/Latino, and 60.7% (51) married. Considering index hospitalizations, an ACP note was written for 2.3% (2) of hospitalizations pre-intervention vs. 80.5% (62) post-intervention (p &lt;0.0001). This relationship held even if the physician was in palliative care (4.1% [2] vs. 84.6% [33]) or oncology (0% [0] vs. 76.3% [29]) (p &lt;0.0001). Inpatient length of stay (LOS), hospice referral, code status change, ICU admission rate or LOS, 30-day readmissions, 30-day ED visits, and inpatient and 30-day deaths did not differ significantly between groups. Conclusions: Identification of hospitalized cancer patients with high mortality risk via machine learning led to a substantial increase in documented ACP conversations but did not impact EOL healthcare utilization. Further integration of the model in clinical practice is ongoing. Our intervention showed promise in changing clinician behavior, and additional work is needed to evaluate downstream impacts.

A Personalized and Interactive Web-Based Advance Care Planning Intervention for Older Adults (Koda Health): Pilot Feasibility Study.

Advance care planning (ACP) is a process that involves patients expressing their personal goals, values, and future medical care preferences. Digital applications may help facilitate this process, though their use in older adults has not been adequately studied. This pilot study aimed to evaluate the reach, adoption, and usability of Koda Health, a web-based patient-facing ACP platform, among older adults. Older adults (aged 50 years and older) who had an active Epic MyChart account at an academic health care system in North Carolina were recruited to participate. A total of 2850 electronic invitations were sent through MyChart accounts with an embedded hyperlink to the Koda platform. Participants who agreed to participate were asked to complete pre- and posttest surveys before and after navigating through the Koda Health platform. Primary outcomes were reach, adoption, and System Usability Scale (SUS) scores. Exploratory outcomes included ACP knowledge and readiness. A total of 161 participants enrolled in the study and created an account on the platform (age: mean 63, SD 9.3 years), with 80% (129/161) of these participants going on to complete all steps of the intervention, thereby generating an advance directive. Participants reported minimal difficulty in using the Koda platform, with an overall SUS score of 76.2. Additionally, knowledge of ACP (eg, mean increase from 3.2 to 4.2 on 5-point scale; P<.001) and readiness (eg, mean increase from 2.6 to 3.2 on readiness to discuss ACP with health care provider; P<.001) significantly increased from before to after the intervention. This study demonstrated that the Koda Health platform is feasible, had above-average usability, and improved ACP documentation of preferences in older adults. Our findings indicate that web-based health tools like Koda may help older individuals learn about and feel more comfortable with ACP while potentially facilitating greater engagement in care planning.

Systems for electronic documentation and sharing of advance care planning preferences: a scoping review

Digital approaches to support advance care planning (ACP) documentation and sharing are increasingly being used, with a lack of research to characterise their design, content, and use. This study aimed to characterise how digital approaches are being used to support ACP documentation and sharing internationally. A scoping review was performed in accordance with the JBI (formerly Joanna Briggs Institute) guidelines and the PRISMA 2020 checklist, prospectively registered on Open Science Framework (https://osf.io/xnrg3). MEDLINE, EMBASE, PsycINFO, ACM Digital, IEEE Xplore and CINAHL were searched in February 2023. Only publications in English, published from 2008 onwards were considered. Eligibility criteria included a focus on ACP and electronic systems. Out of 2,393 records, 34 reports were included, predominantly from the USA (76.5%). ACP documentation is typically stored in electronic health records (EHRs) (67.6%), with a third (32.4%) enabling limited patient access. Non-standard approaches (n = 15;44.1%) were the commonest study design of included reports, with outcome measures focusing on the influence of systems on the documentation (i.e. creation, quantity, quality, frequency or timing) of ACP information (n = 23;67.6%). Digital approaches to support ACP are being implemented and researched internationally with an evidence base dominated by non-standard study designs. Future research is needed to extend outcome measurement to consider aspects of care quality and explore whether the content of existing systems aligns with aspects of care that are valued by patients.

Participation in Advance Care Planning Among Medically At-Risk Rural Veterans: Protocol for a Personalized Engagement Model.

Many of the challenges in advanced care planning (ACP) conversations are linked to the waxing and waning progress of serious illnesses. Conversations with patients about future medical care decisions by a surrogate decision maker have historically been left until late in the patient's disease trajectory. These conversations often happen at a time when the patient is already very ill. The challenge in effective early ACP and serious illness conversations is to create a situation where patients appreciate the link between current and future medical care. Setting the stage to make these conversations more accessible includes using telehealth to have conversations at the patient's place of choice. The personalization used includes addressing the current medical and social needs of the patient and ensuring that expressed needs are addressed as much as possible. Engaging patients in these conversations allows the documentation of patient preferences in the electronic health record (EHR), providing guidelines for future medical care. The objective of our telehealth serious illness care conversations program was to successfully recruit patients who lacked up-to-date documentation of ACP in their EHR. Once these patients were identified, we engaged in meaningful, structured conversations to address the veterans' current needs and concerns. We developed a recruitment protocol that increased the uptake of rural veterans' participation in serious illness care conversations and subsequent EHR documentation. The recruitment protocol outlined herein used administrative data to determine those patients who have not completed or updated formal ACP documentation in the EHR and who are at above-average risk for death in the next 3-5 years. The key features of the telehealth serious illness care conversations recruitment protocol involve tailoring the recruitment approach to address current patient concerns while emphasizing future medical decision-making. As of September 2022, 196 veterans had completed this intervention. The recruitment method ensures that the timing of the intervention is patient driven, allowing for veterans to engage in ACP at a time and place convenient for them and their identified support persons. The recruitment protocol has been successful in actively involving patients in ACP conversations, leading to an uptick in completed formal documentation of ACP preferences within the EHR for this specific population. This documentation is then available to the medical team to guide future medical care. RR1-10.2196/55080.

Advance Care Planning Documentation in High-grade Glioma (P5-6.010)

Advance Care Planning Documentation in High-grade Glioma (P5-6.010)

Implementation and evaluation of the Supportive and Palliative Care Indicators Tool (SPICT™) in acute care.

The Supportive and Palliative Care Indicators Tool (SPICT™) has been used to identify patients at risk of deteriorating and dying within 1 year. Early identification and integration of advance care planning (ACP) provides the opportunity for a better quality of life for patients. The aims of this study were to identify the number of patients who were SPICT™ positive; their mortality rates at 6 and 12 months of the SPICT™ assessment; and level of adherence to ACP documentation. A retrospective audit of the Supportive and Palliative Care database was conducted at an acute aged care precinct in a major metropolitan tertiary referral hospital in New South Wales, Australia. Data comprising demographics, clinical conditions, SPICT™ positivity and compliance with ACP documentation were collected. SPICT™-positive patients and mortality were tracked at 6 and 12 months, respectively. Data from 153 patients were collected. The mean age of the patients was 84.1 (±7.8) years, and the length of hospital stay was 10 (±24.7) (range 1-269) days. Approximately 37% were from residential care, and 80% had family deciding on their care. About 15% died during hospitalisation, and 48% were discharged to a care facility. The ACP documentation showed various levels of completion. Mortality rates at 6 and 12 months were 36% and 39%, respectively. Most patients (99%) were SPICT™-positive, with indicators correlating with higher mortality rates at both follow-ups. The study emphasises the critical need for addressing ACP and palliative care among older patients with life-limiting conditions. It underscores the importance of timely discussions, documentation, and cessation of futile interventions.

Factors Associated With Hospital Admission in the Last Month: A Retrospective Single Center Analysis

ContextDriven by concerns about care quality, patient experience, and national metrics, health systems are increasingly focusing on identifying risk factors for patients who are hospitalized in the last month of life. ObjectiveTo evaluate patient factors associated with hospital admission in the last month (30 days). MethodsWe analyzed a retrospective cohort of 8488 patients with a primary care visit in a tertiary health system in the last year of life using a linked electronic health record and decedent dataset. We examined healthcare utilization (primary care, emergency, hospital, intensive care unit encounters) and end-of-life related outcomes (palliative care consultation, do-not-resuscitate orders, advance care planning documentation, hospice at hospital discharge, death in health system). Multivariable logistic regressions identified patient factors associated with admission in the last month. ResultsAbout 2202 (25.9%) patients had a hospital admission in the last month. Among the 1282 (15.1%) who died in a health system facility, most (1103/1282, 86.0%) were admitted to the hospital in the last month. Among patients with a hospital admission and discharged in the last month, 60.9% (686/1126) were discharged on hospice. Compared to those without these diseases, metastatic cancer, liver disease, or heart failure had the highest odds of admission in the last month (adjusted OR 2.36 95%CI 2.05–2.72; 2.28, 95%CI 1.98–2.62; and 2.17 95%CI 1.93–2.45 respectively). ConclusionsAs patients with heart or liver disease or metastatic cancer had the highest odds of admission in the last month, collaborative interventions between primary, palliative, and specialty care may improve quality of care at the end of life.