Advance Directive Completion Rates Research Articles

Advance Directives for Patients With Breast Cancer: Applying the Right Info/Right Care/Right Patient/Right Time Oncology Model.

Background Advance directives (AD) are an important component of life care planning for patients undergoing treatment for cancer; however, there are few effective interventions to increase AD rates. In this quality improvement project, the authors integrated AD counseling into a novel right info/right care/right patient/right time (4R) sequence of care oncology delivery intervention for breast cancer patients in an integrated health care delivery system. Methods The authors studied two groups of patients with newly diagnosed breast cancer who attended a multidisciplinary clinic and underwent definitive surgery at a single facility. The usual care (UC) cohort (N = 139) received care from October 1, 2019 to September 30, 2020. The 4R cohort (N = 141) received care from October 1, 2020 to September 30, 2121 that included discussing AD completion with a health educator prior to surgery. The authors used bivariate analyses to assess whether the AD intervention increased AD completion rates and to identify factors influencing AD completion. Results The UC and 4R cohorts were similar in age, gender, race/ethnicity, interpreter need, Elixhauser comorbidity index, National Comprehensive Cancer Network distress score ≥ 5, surgery type, stage, histology, grade, and Estrogen receptor/Progesterone receptor/ human epidermal growth factor receptor 2 (ER/PR/HER2) status. AD completion rates prior to surgery were significantly higher for the 4R vs UC cohort (73.8%, 95% confidence interval [CI] [66.5%-81.0%] vs 15.1%, 95% CI [9.2%-21.1%], p < .01) and did not significantly differ by age, race, need for interpreter, or distress scores. Conclusion Incorporation of a health educator discussion into a 4R care sequence plan significantly increased rates of time-sensitive AD completion.

Prevalence and predictors of advance directive among terminally ill patients in Taiwan before enactment of Patient Right to Autonomy Act: a nationwide population-based study

BackgroundSigning advance directives (ADs) ensures that terminally ill patients receive end-of-life care, according to their wishes, thereby promoting human dignity and sparing them from unnecessary suffering. Despite the enactment of the Hospice Palliative Care Act in Taiwan in 2000, the completion rates of ADs have been found to be low among patients with chronic illness conditions. To date, limited existing research is available regarding the factors associated with AD completion in terminally ill patients in Taiwan. To explore signed AD characteristics, compare differences in signing ADs between patients with and without cancer, and examine the factors associated with signing ADs in terminally ill patients.MethodsA nationwide study was conducted using data collected via a retrospective review of medical death records from 18 randomly selected hospitals in the northern, central, and southern parts of Taiwan. We collected 200 records, including both cancer and non-cancer-related deaths, from each hospital. Univariate and multivariate logistics regressions were conducted to examine factors associated with signing advance directives among all patients- with and without cancer.ResultsAmong the 3004 reviewed medical records, 79% had signed ADs, with most (95%) being signed by patients’ caregivers. A higher education level (OR = 1.52, 95% CI = 1.10, 2.08, p = 0.010); cancer diagnosis (OR = 2.37, 95% CI = 1.79, 3.16, p < 0.001); having family members (OR = 5.62, 95% CI = 2.95, 10.69, p < 0.001), care homes (OR = 4.52, 95% CI = 1.97, 10.38, p < 0.001), friends, or maids (OR = 3.82, 95% CI = 1.76, 8.29, p = 0.001) as primary caregivers; and patients knowing about their poor prognosis (OR = 15.39, 95% CI = 5.66, 41.83, p < 0.001) were associated with a higher likelihood of signing ADs.ConclusionsPatients with non-malignant chronic illnesses were less likely to have ADs signed by either patients or family caregivers than those with cancer, with the lowest likelihood observed in patients with cardiovascular diseases. Whenever possible, primary caregivers should be involved in discussing ADs with patients, and the importance of truth telling should be reinforced. Following these principles, each patient’s end-of-life care preferences can be respected, thereby promoting quality of care before the patient’s death.

Increasing advance directive completion within the 4R oncology model in patients with breast cancer prior to surgery in a racially diverse patient population.

54 Background: Advance directives (ADs) are an important part of life care planning in patients with cancer. There is a lack of effective interventions to increase AD rates in breast cancer patients prior to surgery. In this quality improvement project, we implemented an intervention for breast cancer patients receiving care in an integrated healthcare delivery system. 4R (Right Info / Right Care / Right Patient / Right Time) is a novel care planning and delivery model that enables the patient and oncology care team to manage complex time-sensitive care using a multi-modality 4R Care Sequence plan, coupled with follow-up workflows. Methods: We studied two groups of patients with newly diagnosed non-metastatic breast cancer who attended a multidisciplinary clinic and underwent definitive surgery at one facility. The Usual Care (UC) cohort received care from 10/1/19 to 9/30/20. The 4R Intervention (4R) cohort received care from 10/1/20 to 9/30/21 using a 4R Care Sequence plan that included AD completion prior to surgery; those without an AD were referred for follow-up to a health educator to discuss AD completion. Bivariate analyses were used to compare the UC and 4R cohorts on demographics, NCCN thermometer distress scores, and AD completion rates. Results: Characteristics of age, gender, race/ethnicity, needing interpreter, Elixhauser Comorbidity Index, NCCN distress scores &gt; 4, surgery type, grade, ER/PR/HER-2 status were similar in the UC (N = 140) and 4R cohorts (N = 141). AD completion prior to surgery was significantly higher for the 4R vs. UC cohort, both overall (15% vs 74%, p &lt;.01), and for White, Black, and Asian/PI subgroups (Table). The Hispanic subgroups were too small to compare AD completion. AD completion did not significantly differ by higher vs. lower distress scores. Conclusions: Implementation of a 4R Care Sequence plan coupled with health educator follow-up can significantly increase rates of time-sensitive AD completion, regardless of patient distress score and patient race/ethnicity. Use of an effective standardized care delivery model like 4R can promote equitable care.[Table: see text]

Increasing advance directive completion within the 4R oncology model in breast cancer patients prior to surgery in a racially diverse patient population.

e13511 Background: Advance directives (ADs) are an important part of life care planning in patients with cancer. There is a lack of effective interventions that increase AD rates in breast cancer patients prior to surgery. In this quality improvement project, we implemented a 4R Oncology intervention in a community-based cancer center within an integrated health care system. 4R (Right Info / Care / Patient / Time) is a novel care planning and delivery model, which enables patients and care teams to manage complex time-sensitive care with a multi-modality 4R Care Sequence plan, coupled with follow-up workflows. Methods: Patients with newly diagnosed non-metastatic breast cancer who attended a multidisciplinary clinic and underwent definitive surgery at one facility were included in the study. Patients received usual care from 10/1/19 to 9/30/20 (usual care cohort). From 10/1/20 to 9/30/21 (intervention cohort), patients were provided a 4R Care Sequence, which included AD completion prior to surgery, and those without AD were referred for follow-up with a health educator to discuss AD completion. Demographics, NCCN thermometer distress scores, and AD completion rates were compared between the usual care and intervention cohorts using descriptive statistics. Results: Characteristics of age, gender, race/ethnicity, language interpreter usage, Elixhauser Comorbidity Index, NCCN distress scores &gt; 4, surgery type, tumor grade, ER/PR/HER-2 status were similar between the usual care (N=140) and intervention cohorts (N=141). The intervention improved AD completion rates in a time-sensitive fashion prior to surgery between usual care and intervention cohorts, both in total (15% vs 74%, p&lt;.01), and in 3 of the 5 race/ethnicity groups (Table). AD completion rates increased in patients of all races/ethnicities, but increases were not statistically significant for Hispanic patients, likely due to low numbers of these patients in both cohorts. Patients with higher distress scores completed ADs at similar rates to those with lower distress scores. Conclusions: Delivery of 4R Care Sequences, coupled with a health educator follow-up can significantly increase rates of time-sensitive AD completion, regardless of patients’ distress score. Patients across race/ethnicity groups benefited from the intervention, but further efforts are needed to understand the impact of this intervention in patients who are Hispanic. Through an effective care delivery model, patients can be provided with standardized equitable care. [Table: see text]

Comparing Variations in Advance Directives Timing among Older Adults with End-Stage Renal Disease versus Cancer.

Background: Having an advance directive (AD) is associated with better care at end of life and better quality of death. However, AD completion rates among End-Stage Renal Disease patients are lower than among cancer patients. ESRD patients commonly experience cognitive impairment, reducing their ability to make their own care choices as their disease progresses. Thus, having an AD earlier in the disease trajectory is important. Little is known about differences in AD completion timing among ESRD and cancer patients. Therefore, the purpose of this study was to (1) investigate difference in AD completion and timing between ESRD and cancer patients; and, (2) identify factors associated with the early and late AD completion. Setting and Participants: A retrospective cohort study was conducted. Data was drawn from the Health and Retirement Study, a United States representative longitudinal survey of older adults, using exit interviews conducted from 2006 to 2016 among 1886 proxy reporters of deceased participants with ESRD or cancer. Results: ESRD patients had lower rates of AD completion compared to those with cancer. Higher education and being older were negatively associated with late AD completion in the last 3months of life. Additionally, decedents with a diagnosis of ESRD, older age, and with higher education had higher odds of completing ADs one year or more before death. Discussions/Conclusions: While ESRD patient were less likely to have ADs, those that had ADS were more likely than cancer patients to develop ADs earlier in the disease trajectory. Further studies are needed to determine effective strategies to increase the AD completion rate among patients with ESRD.

Attitudes and Intentions of Adult Patients With Cancer Toward Advance Directive: Direct and Indirect Relationships.

Advance directives (ADs) are used to respect the will of patients experiencing a terminal illness regarding preferred medical treatment and to protect their rights. However, the AD completion rate is low. The aim of this study was to explore the factors influencing patient intentions toward AD. The Theory of Planned Behavior was used as the framework for this study. This study used a cross-sectional design using a face-to-face interview with structured questionnaires. A total of 230 patients with cancer were recruited. Path analysis was used to examine the hypotheses. Demographic variables were not correlated with patients' attitudes toward AD. Patients' knowledge of AD ( β = .68, t = 16.15, P < .00) and recognition of important others' attitudes toward AD ( β = .30, t = 10.74, P < .00) were predictors of patients' attitudes toward AD. Patients' attitudes toward AD ( β = .27, t = 3.74, P < .00) and behavior control over AD ( β = .09, t = 1.99, P < .04) predicted patients' intentions toward AD. Patients' knowledge of AD, the patients' important others' attitudes, and behavior control toward AD are predictively associated with the intention toward AD completion. Only when patients with cancer are provided an accessible approach for obtaining knowledge regarding AD and are given sufficient time and space can they and their significant others understand the meaning of AD and decide to complete one on their own terms.

Impact of advance care planning consults on advance directives completion.

Advance care planning (ACP) consults have been credited with increasing the likelihood that patients will receive desired care at the end of life, including reduced hospitalization and spending.We aimed to investigate whether implementation of ACP consults leads to improved advance directive (AD) completion rates. Retrospective case-control evaluation. Chart review was conducted among patients in hematology/oncology and primary care to compare AD completion rates of patients in each clinical area offered ACP consults between July 1, 2017, and June 30, 2018, and those not offered ACP consults prior to July 1, 2017. Completed ADs increased from historic rates of 1% to 65.9% of primary care patient records. Among hematology/oncology patients offered consults, completed ADs were present in 28.1% of patient records compared with historic rates of 3%. Patients offered ACP consults had significantly higher AD completion rates than those without consults in both primary care and hematology/oncology practices. The difference in ACP consult attendance between the primary care and hematology/oncology groups clearly suggests that further improvements can be made to assist patients in accessing AD education and completion support.

Factors associated with willingness to complete advance directives in older adults

This study aimed to examine the factors associated with willingness to complete advance directives (ADs) in community-dwelling older adults. In total, 121 community-dwelling older adults in Korea completed the questionnaires inquiring about their willingness and perceptions in completing ADs (susceptibility, severity, benefits, barriers, and cues to action), which were based on the Health Belief Model. The mean score for willingness to complete ADs was 6.2 (SD = 3.6). A multiple linear regression analysis showed that higher scores of perceived severity (β = 0.199, p = 0.021), perceived benefits (β = 0.221, p = 0.016), and cues to action (β = 0.159, p = 0.030) were associated with a greater willingness to complete ADs. However, higher scores of perceived barriers (β = -0.409, p < 0.001) were likely to lower the willingness to complete ADs. This study highlights that future interventions aimed at increasing AD completion rates in older adults should consider improving perceived severity, benefits, and cues to action and minimizing perceived barriers.

Increasing the completion rate of the advance directives in primary care setting \u2013 a randomized controlled trial

BackgroundThe completion rate of Advance Directives (ADs) has been low. This study aims to examine the effectiveness of two interventions 1) active counseling sessions coupled with passive patient education pamphlets, and 2) patient education pamphlets alone, compared with 3) control group (usual care), in increasing the completion rates of ADs in the primary care setting.MethodsMulticenter randomised controlled trial in four public primary care clinics in Singapore under Singapore Health Services. Randomization was performed via block randomization with Sequential Numbered Opaque Sealed Envelopes. Participants were randomized into 1) active intervention group (both counseling by primary care physicians and patient education pamphlets) or 2) passive intervention group (only patient education pamphlets), and 3) control group (usual care) with follow-up at 6 weeks. The main outcome measure is the proportion of participants who completed / planned to complete) ADs six weeks post-intervention.ResultsFour hundred five participants were eligible to participate in the study. One hundred eighty-eight participants were recruited into the study (response rate = 46.4%), of which 158 completed the study. There was no significant difference between the control group, passive intervention group, and active intervention group, in terms of completion rates of ADs (29.4, 36.4, and 30.8% respectively).ConclusionsThis randomized controlled trial did not support the use of patient education pamphlets with or without active counseling sessions in increasing the completion of ADs in a primary care setting in Singapore. The optimal intervention strategy depends on each health system’s context and resources, taking into consideration patients’ profiles, which deserves further studies.Trial registrationRegistered on April 17, 2018 clinicaltrials.gov (NCT03499847).

Completion Rates of Advance Directives in a Trauma Emergency Room: Association with Age.

Introduction An advance directive (AD) is a written legal document in which a person can express wishes and preferences for medical treatment for the moment when that person is no longer able to make medical decisions because of a serious illness or injury. While ADs have emerged in public, it is unclear, how many adults in Germany have completed an AD, and frequencies differ among different patient cohorts and medical settings. The aim of this study was to evaluate how many patients visiting a trauma emergency room (ER) in an academic teaching hospital had completed an AD. Furthermore, patient characteristics were compared between patients who had completed an AD and those who had not completed an AD. Methods. Patients with a traumatic injury or disease who attended the ER of an academic teaching hospital in the period from October 2015 to March 2016 (n = 499) were surveyed for completion rates of ADs. Results. Prior to their visit to the ER, 12.8% of the included patients possessed a completed AD. Patients with a completed AD had a higher age (median age: 54 (IQR: 34–66) vs. 35 (IQR: 25–50) p < 0.001) and were less often living in an urban residential location (UR) (UR: 23.5% vs. 39.4%, p=0.029). Groups did not differ between sex (p=0.115), frequencies of high school graduates (p=0.482), and possession of a private health insurance (p=0.072), disability insurance (p=0.291), or an accident insurance (p=0.790). Conclusion. Completion rates of ADs remain low among patients visiting an ER of an academic teaching hospital in Germany. Increasing age but not factors such as sex, educational background, or insurance status were associated with a higher frequency of completed ADs.

Prospective Randomized Study of Advance Directives in Allogeneic Hematopoietic Cell Transplantation Recipients

Patients undergoing allogeneic hematopoietic cell transplantation (HCT) are at risk for high morbidity and mortality. Advance directives (AD) allow patients to express wishes regarding their care at the end of life, but these are not completed in the majority of patients undergoing HCT, with only 44% of deceased allogeneic HCT recipients at this institution completing an AD in the past decade. Increasing the AD completion rate can improve the quality of care for allogeneic HCT recipients. Our objective was to evaluate whether an alternative AD instrument can increase AD completion rate and patient satisfaction. We conducted a prospective, randomized controlled study of the traditional California AD versus a novel Letter AD, the Stanford What Matters Most Letter, in adult allogeneic HCT recipients. Patients age ≥18 years undergoing first allogeneic HCT at Stanford University were eligible. Prior to HCT conditioning, enrolled patients were assigned at random to complete either the traditional AD or the Letter AD. The primary endpoint was AD completion. The chi-square test was used to compare the AD completion rate between arms. The Wilcoxon rank-sum test was used to compare uncertainty, satisfaction with decision making, and satisfaction with the AD. Of the 212 patients who were eligible, 126 (59.4%) were enrolled and randomized. The mean age was 53.7 years, 57 (45.2%) were female, and 74 (58.7%) were non-Hispanic white. The overall AD completion rate was 71.4% and did not differ between the traditional and Letter AD arms (70.3% versus 72.6%; P=.78). Of those who completed the Letter AD, 66.7%, 42.2%, and 46.7% of patients wished to die gently/naturally, at home, and/or with hospice, respectively. In the traditional AD arm, 60.0% wished to not prolong life if recovery was unlikely. Opinion surveys did not find differences in levels of satisfaction between the traditional AD and Letter AD. Completion rates of AD on this study were high (71.4%) compared with historically reported completion rates and did not significantly differ based on AD version.

The Effect of Health Literacy on a Brief Intervention to Improve Advance Directive Completion: A Randomized Controlled Study.

ObjectiveCompletion of an advance directive (AD) document is one component of advanced care planning. We evaluated a brief intervention to enhance AD completion and assess whether the intervention effect varied according to health literacy.MethodsA randomized controlled study was conducted in 2 internal medicine clinics. Participants were over 50, without documented AD, no diagnosis of dementia, and spoke English. Participants were screened for health literacy utilizing REALM-SF. Participants were randomized in a 1:1 ratio to the intervention, a 15-minute scripted introduction (grade 7 reading level) to our institution’s AD forms (grade 11 reading level) or to the control, in which subjects were handed blank AD forms without explanation. Both groups received reminder calls at 1, 3, and 5 months. The primary outcome was AD completion at 6 months.ResultsFive hundred twenty-nine subjects were enrolled; half were of limited and half were of adequate health literacy. The AD completion rate was 21.7% and was similar in the intervention vs. the control group (22.4% vs 22.2%, P = .94).More participants with adequate health literacy completed an AD than those with limited health literacy (28.4% vs 16.2%, P = .0008), although the effect of the intervention was no different within adequate or limited literacy groups.ConclusionA brief intervention had no impact on AD completion for subjects of adequate or limited health literacy.Practice ImplicationsOur intervention was designed for easy implementation and to be accessible to patients of adequate or limited health literacy. This intervention was not more likely than the control (handing patients an AD form) to improve AD completion for patients of either limited or adequate health literacy. Future efforts and research to improve AD completion rates should focus on interventions that include: multiple inperson contacts with patients, contact with a trusted physician, documents at 5th grade reading level, and graphic/video decision aids.Trial Registration NumberNCT02702284, Protocol ID IRB201500776

PREPARE-ing South Dakota Farm and Ranch Women for Advance Care Planning

Purpose: Evaluate the impact of an advance care planning (ACP) educational session utilizing PREPARE for Your Care for South Dakota farm and ranch women and its ability to increase engagement in ACP and documentation of medical wishes in the form of an advance directive.&#x0D; Sample: A convenience sample of women (n = 23) represented members of the farm and ranch community in South Dakota who were participating in the Power of Women as AgVocates Conference. Inclusion criteria for this study included being 18 years old or older, female, and conference participation. Exclusion criteria included men and those under the age of 18.&#x0D; Method: This was a cross-sectional investigation, consisting of three phases, and included comparisons of the same sample population before and after an ACP intervention at different time intervals (baseline, 1 week after the educational session and 3 months after the educational session). Increased engagement in ACP was evaluated using a pre-test, post-test design and utilized the 15-item Advance Care Planning Engagement Survey. Demographic information including age and highest level of education completed was collected.&#x0D; Findings: In total, 23 women participated in education session. The median age range was 35-44 years of age. There were statistically significant increases in self-efficacy and readiness to complete ACP reported by participants. The objectives of this education session were met. Per the participants, this was an effective format for ACP. Advance directive completion rates did not increase.&#x0D; Conclusions: The use of PREPARE for Your Care during an education session on ACP can increase self-efficacy and readiness to engage in ACP. The format of this program is appropriate for future use in community settings with the farm and ranch population.&#x0D; Keywords: Advance Care Planning, farm and ranch womenDOI: http://doi.org/10.14574/ojrnhc.v20i2.632

Cultural Aspects of End-of-Life Advance Care Planning for African Americans: An Ethnonursing Study.

Advance directive completion rates among the general population are low, with even lower completion rates among African Americans (AAs). This study's purpose was to identify culturally based meanings, expressions, and traditions of end-of-life (EOL) advance care planning (ACP) and decision making in order to promote culturally congruent nursing care among African Americans. Leininger's Culture Care Theory and Ethnonursing Research Method guided the study. A convenience sample of 21 informants were interviewed in community settings. Data analysis was guided using Leininger's phases of ethnonursing data analysis for qualitative data. Three themes emerged that affect EOL decision making: (a) faith in God and belief in life after death, (b) a strong matriarchal family structure, and (c) fear of talking about death and mistrust of the U.S. health care system. AA culture, beliefs, and traditions influence EOL ACP and practices, and must be considered while providing culturally congruent care.

Group-based educational intervention for advance care planning in primary care: a quasi-experimental study in Japan

Background: Older adults who have health conditions with good prognoses typically fall outside the scope of efforts encouraging advance care planning. We developed group and individual versions of an advance care planning program for use in primary care.&#x0D; Methods: We conducted a quasi-experimental trial in a rural family clinic in Japan. Medically stable patients aged ≥65 years were invited to watch an educational video on advance care planning, followed by an individual (n=46) or group-based (n=63) discussion. Advance directive completion was tracked over four months. Participants completed baseline and follow-up questionnaires and reported occurrence of family discussions about advance care planning and attitudes toward advance care planning. Group discussions were recorded and thematically analyzed to identify barriers and facilitators to engaging in advance care planning.&#x0D; Results: Advance directive completion rates were high for both intervention versions but did not significantly differ between arms (85.7% vs. 80.4%, p=0.45). Only one-fifth of patients in both arms discussed advance care planning with their family after the intervention (20.7% and 21.7%, p=0.89). Patients in the group arm rated their experience slightly higher than those in the individual arm (4.2 and 3.9 out of 5, p=0.023). Qualitative analysis of group discussions revealed that patients were affected by their perceptions of societal norms that prioritize family consensus over patient autonomy; however, these perceptions influenced advance care planning behaviors in inconsistent ways.&#x0D; Conclusions: Group-based advance care planning intervention among medically stable older patients is as effective as an individually-focused discussion in promoting advance directive completion. Future research is needed on ways to enhance patients’ ability to discuss advance care planning with their family members.

Prospective Randomized Study of Advance Directives in Allogeneic Hematopoietic Cell Transplant Recipients

Background Advance directives (AD) offer the opportunity for goal-concordant care at the end of life (EOL). However, fewer than half of HCT recipients have a documented AD. We hypothesized that the use of a novel AD-the Stanford What Matters Most Letter (Letter AD)-developed to assess patients' values, goals, and EOL wishes would result in a greater proportion of AD completion among HCT recipients. We therefore conducted a prospective, randomized, controlled study of the traditional California AD vs. the Letter AD in adult allogeneic HCT recipients. Methods Patients >= 18 years old undergoing first allogeneic HCT at Stanford University were eligible. Prior to HCT conditioning, enrolled patients were randomly assigned to complete either the traditional California AD or the Letter AD, and all patients received a sociodemographic survey and a survey evaluating their opinions regarding the AD form they received. Patients were asked to return all research forms at the time of their transplant admission; a research assistant placed a reminder call to each patient prior to scheduled transplant. The primary endpoint was AD completion; secondary endpoints included EOL wishes as documented on the AD and patient preferences and opinions regarding the AD version they received. Results Between March 2017 and August 2018, 212 patients were eligible, of whom 126 (59.4%) were enrolled and randomized. Among the 84 who declined, the primary reason was already having an AD (N=34). The median age was 57 years (IQR 45-64); 54.8% were male; 58.7% were non-Hispanic White; and 72.3% had AML/MDS. There were no statistically significant differences in baseline socio-demographics between study arms. The overall AD completion rate was 71.6% and did not differ between the Traditional and Letter AD study arms (70.3% vs 72.6%, P=0.78). Preferences for EOL among responders are described in Table 1. The Letter AD uncovered that 66.7%, 42.2%, and 46.7% of patients actively wished to die gently/naturally, at home, and/or with hospice, respectively, whereas the traditional AD found that 62.2% wished to not prolong life if recovery was unlikely. Figure 1 portrays participant responses to the AD opinion survey; non-significant trends suggested that patients found the Letter AD favorable in terms of identifying what matters most to them, describing medical preferences to family, and stimulating thinking about the topic. Conclusion Completion rates of AD amongst allogeneic HCT recipients on this study were high and did not differ based upon AD version. Most patients wish to die naturally/do not wish to prolong care at EOL. Non-significant trends favored the Letter AD over the Traditional AD across several domains of patient preference.

Evaluation of the national implementation of the VA Diffusion of Excellence Initiative on Advance Care Planning via Group Visits: protocol for a quality improvement evaluation

BackgroundTraditionally, system leaders, service line managers, researchers, and program evaluators hire specifically dedicated implementation staff to ensure that a healthcare quality improvement effort can “go to scale.” However, little is known about the impact of hiring dedicated staff and whether funded positions, amid a host of other delivered implementation strategies, are the main difference among sites with and without funding used to execute the program, on implementation effectiveness and cost outcomes.Methods/designIn this mixed methods program evaluation, we will determine the impact of funding staff positions to implement, sustain, and spread a program, Advance Care Planning (ACP) via Group Visits (ACP-GV), nationally across the entire United States Department of Veterans Affairs (VA) healthcare system. In ACP-GV, veterans, their families, and trained clinical staff with expertise in ACP meet in a group setting to engage in discussions about ACP and the benefits to veterans and their trusted others of having an advance directive (AD) in place. To determine the impact of the ACP-GV National Program, we will use a propensity score-matched control design to compare ACP-GV and non-ACP-GV sites on the proportion of ACP discussions in VHA facilities. To account for variation in funding status, we will document and compare funded and unfunded sites on the effectiveness of implementation strategies (individual and combinations) used by sites in the National Program on ACP discussion and AD completion rates across the VHA. In order to determine the fiscal impact of the National Program and to help inform future dissemination across VHA, we will use a budget impact analysis. Finally, we will purposively select, recruit, and interview key stakeholders, who are clinicians and clinical managers in the VHA who offer ACP discussions to veterans, to identify the characteristics of high-performing (e.g., high rates or sustainers) and innovative sites (e.g., unique local program design or implementation of ACP) to inform sustainability and further spread.DiscussionAs an observational evaluation, this protocol will contribute to our understanding of implementation science and practice by examining the natural variation in implementation and spread of ACP-GV with or without funded staff positions.

Advance Directives for Blood and Marrow Transplantation Recipients

Topic Significance & Study Purpose/Background/Rationale Blood and Marrow Transplantation (BMT) is a potentially curative therapy, but despite clinical advancements it continues to be associated with significant morbidity and mortality. Advance Directives (AD) ensure that patients receive the care that is consistent with their values, goals, and preferences at end of life (EOL). Yet, fewer than a quarter of BMT recipients at this Academic Medical Center have a documented AD. This leads to an increase in unnecessary treatments, care escalations, and discrepancy of care expectations which heightens distress for the patient, family, and provider. In May 2019, a nurse driven interprofessional team was assembled to conduct a performance improvement project. Methods, Intervention, & Analysis The goal was to increase the percent of completed AD for BMT recipients at this Center before transplant (Day 0), from 21% to 40% by September 2019. Through team-based problem solving, analyzation of possible causes for gaps in practice related to AD completion was performed. The identified key focus areas included: the absence of AD discussions in both the clinic and inpatient settings, lack of staff training and education, and no standard workflow for AD completion or collection. These findings were addressed in June 2019, by implementing a standard operating procedure within the BMT program for AD completion, delivery, and submission into the electronic health record. Training was also developed and provided to all BMT interprofessional teams. Findings & Interpretation Between July 2019 and September 2019, 74 patients received a transplant at this center, of those patients 30 had an AD completed by Day 0. The overall AD completion rate was 40.5% (Table 1). Furthermore, an increase in patients providing their Social Workers with a completed AD in the clinic setting was identified as well as the referrals to inpatient Spiritual Care services for assistance with AD completion. Discussion & Implications Early completion of AD offers the opportunity for goal-concordant care at EOL, and the BMT population can greatly benefit from this care. This has the potential to reduce hospitalization at the EOL, decrease ICU utilization and costly invasive interventions, increase utilization of hospice services, and promote a higher satisfaction with the quality of care.

Improving Advance Care Planning in Outpatients With Decompensated Cirrhosis: A Pilot Study

BackgroundDespite significant morbidity and mortality among patients with decompensated cirrhosis, reported rates of advance directive (AD) completion and goals of care discussions (GCDs) between patients and providers are very low. We aimed to improve these rates by implementing a hepatologist-led advance care planning (ACP) intervention. MeasuresRates of AD and GCD completion, as well as self-reported barriers to ACP. InterventionProvider-led ACP in patients with decompensated cirrhosis without a prior documented AD. OutcomesSixty-two patients were seen over 115 clinic visits. After the intervention, AD completion rates increased from 8% to 31% and GCD completion rates rose from 0% to 51%. Women (P = 0.048) and nonmarried adults (P = 0.01) had greater changes in AD completion compared to men and married adults, respectively. Needing more time during visits was seen as the major barrier to ACP among providers. Conclusions/Lessons LearnedAddressing provider and system-specific barriers dramatically improved documentation rates of ACP.

Advance directives of lung cancer patients and caregivers in China: A cross sectional survey

BackgroundThis study aimed to investigate lung cancer patients and attitudes of their caregivers toward advance directives (ADs) in China.MethodsA cross sectional study was conducted in the Department of Oncology outpatient clinic in West China Hospital, Sichuan University. A questionnaire was used to survey the attitudes of lung cancer patients and caregivers toward ADs.ResultsA total of 148 lung cancer patients and 149 caregivers were enrolled into the study. Of these, 94.6% and 89.9% of patients and caregivers had not heard of AD and none of those in the study had ever signed an AD. A total of 79.7% patients and 75.2% caregivers were willing to sign ADs after they were provided with information. Patients who preferred the end of life period to sign ADs were 5.4 times more likely to have ADs than patients who chose to sign ADs when their disease was diagnosed (P < 0.05, 95%CI [1.27–22.93]). Caregivers who were reluctant to undergo chemotherapy when diagnosed with cancer were 2.16 times more likely to sign ADs than those willing to receive chemotherapy (P < 0.05, 95%CI [1.20–3.90]).ConclusionsIn China, lung cancer patients and their caregivers showed lack of knowledge about ADs, and the completion rate of ADs was extremely low. However, participants were positive about ADs and public education on ADs may help to increase the completion rate of ADs in China.