Completion Of Advance Directives Research Articles

A Resident-Led Quality Improvement Initiative to Increase End-of-Life Planning in Primary Care.

Background Despite many benefits of end-of-life (EOL) planning, only 1 in 3 adults has EOL documentation, with low rates in resident primary care clinics as well. Objective To increase clinic completion of life-sustaining treatment (LST) notes and advance directives (AD) for veterans at highest risk for death. Methods The setting was a Veterans Affairs (VA) internal medicine primary care clinic. All clinic residents in the 2021-2022 academic year and all clinic patients identified through a VA risk-stratification tool as highest risk for death were included. Baseline AD and LST completion rates were determined through manual chart review. Our interventions included 2 hours of teaching to increase resident knowledge of EOL planning and a systematic process improvement to complete EOL planning appointments. Outcomes assessed included anonymous resident pre- and post-surveys of self-assessed knowledge and comfort with EOL conversations, as well as rates of LST and AD completion determined through serial chart review. Results In the 2021-2022 academic year, 22 residents (100%) and 54 patients were included. Post-intervention surveys (n=22, 100%) showed improved self-assessed knowledge of EOL concepts and comfort with patient discussions (median Likert increase 3 to 4). The number of residents who completed an EOL planning visit increased from 9 of 22 (41%) to 15 (68%). LST completion increased from 9 of 54 (17%) to 29 (54%), and AD completion increased from 18 of 54 (33%) to 33 (61%). Conclusions A brief teaching intervention to prepare residents for comprehensive EOL visits combined with process improvement to offer EOL planning visits improved self-reported knowledge and comfort and completion of EOL visits.

Feasibility and Effectiveness of Virtual Group Advance Care Planning Visits During the COVID-19 Pandemic.

The COVID-19 pandemic necessitated the transition from in person to virtual advance care planning (ACP) engagement efforts. This pilot initiative evaluated virtual group visits (GVs) and in-person GVs for ACP to determine their feasibility and effectiveness. Participants included patients in a Geriatric Medicine clinic who were referred by their primary care physician to an ACP GVs intervention. The ACP GVs had 2 sessions, led by clinicians with ACP expertise who facilitated a discussion on patients' values, goals, and preferences. Participants were provided with technical assistance to support use of the virtual platform. Evaluation included an ACP readiness survey, post-session feedback, GV observations, and electronic health record review at baseline and a 6month follow-up for goals of care documentation and advance directives. Seventy patients attended 46 ACP GVs from August 2019 to February 2022, including 16 in-person GVs and 54 virtual GVs. At a 6month follow-up, for virtual GVs participants (n = 54), goals of care documentation increased from 31% to 93%, and advance directives increased from 22% to 30%. For in-person GVs participants (n = 16), goals of care documentation increased from 25% to 100%, and advance directives increased from 69% to 75%. All surveyed patients in both formats would recommend ACP GVs. ACP GVs are feasible and effective for supporting ACP, demonstrating an increase in both goals of care conversations and advance directives completion.

The association of religion with advance care planning

Personal preferences influence end-of-life (EOL) decision-making and are commonly associated with engagement in the advance care planning process. Completing an advance directive (AD) allows individuals to formally document and legally report their EOL care preferences. This study explored how two aspects of religion—personal religious beliefs and formal religion practices—may be associated with advance care planning. A national sample of healthy adults in the United States aged 50 years and older (n = 514; 74% cisgender women) completed surveys detailing their EOL preferences, advance care planning, personal religious beliefs, and formal religion practices. Using Ordinary Least Squares (OLS), we find that a higher belief in God’s role at EOL was associated with a higher preference for life-prolonging measures. Using logistic regression, those with a higher belief in God’s role at EOL had lower odds of AD completion. Multiple dimensions of religion should be considered when studying health care preferences and decision-making.

Characteristics associated with the intention to complete advance directives and end-of-life preferences in Brazilians with heart failure.

To identify characteristics associated with an intention to complete advance directives (ADs) and end-of-life treatment preferences for outpatients with heart failure (HF). A cross-sectional, analytical study. Sociodemographic and clinical data were collected from 108 patients with HF in an outpatient clinic in São Paulo, SP, Brazil. Quality of life (QoL) was assessed using the Minnesota Living with Heart Failure Questionnaire; knowledge about HF and the intention to complete ADs were assessed using a script. The relationships among variables were assessed through the chi-square and Mann-Whitney tests, with p<0.05 considered significant. The intention to complete ADs was significantly associated with reporting adherence to pharmacological recommendations (99% vs. 88.1%, p=0.02), worse QoL (29.7±18.2 vs. 20.9±11.0; p=0.0336), perceived knowledge about HF (89.7% vs. 63.6%, p=0.0495), not wishing the healthcare providers would decide about treatment (27.3% vs. 2.15, p=0.0026), and considering ADs useful (91.8% vs. 27.3%, p<0.001). End-of-life treatment preferences included living as long as possible (50.5%), not being sedated (37.1%), and staying close to family and friends for as long as possible (32.0%). Characteristics associated with an intention to complete ADs and end-of-life treatment preferences were identified in patients with HF. These results can help facilitate patients' completion of their ADs or activate their intention to maximize opportunities to exercise autonomy.

Role of Uncertainty in Illness and Coping Strategies in Advance Directive Completion in Patients With End-stage Liver Disease.

We examined the associations among advance directives (ADs) completion, coping, uncertainty in illness, and optimism and pessimism in patients with end-stage liver disease (ESLD). Although associations among ADs, coping, and uncertainty have been studied in patients with other life-limiting illnesses, these concepts have not been studied together in patients with ESLD. Patients were recruited at 2 health care institutions as part of a larger prospective study. They were enrolled if they had a diagnosis of nonhepatocellular carcinoma ESLD, Sodium Model for End-Stage Liver Disease ≥15, and no prior history of liver transplantation. Uncertainty, coping, optimism, and pessimism were assessed using the Uncertainty in Illness Scale for Adults, Revised Ways of Coping Checklist, and Life Orientation Test-revised. AD documentation at the time of study enrollment was retrospectively extracted from patient medical records. In the sample [N = 181; median age = 57 y, 115 (64%) males], male sex [odds ratio (OR) = 4.66; 95% CI: 1.53, 14.17], being listed or under evaluation for liver transplantation (OR = 3.09; 95% CI: 1.10, 8.67), greater Sodium Model for End-Stage Liver Disease scores (OR = 1.10; 95% CI: 1.01, 1.20), and greater uncertainty (OR = 1.04; 95% CI: 1.01, 1.07) were positively associated with AD documentation. Higher coping avoidance was negatively associated with AD documentation (OR = 0.915; 95% CI: 0.840, 0.997). Clinicians should consider the role of uncertainty and coping measures to improve patient-specific advance care planning conversations and expand opportunities for all patients with ESLD to file an AD, especially women and patients not listed or under evaluation for transplantation.

Pragmatic implementation of comprehensive dementia care management: The Cedars-Sinai C.A.R.E.S. Program preliminary data.

The United States faces a growing challenge with over 6.5 million people living with dementia (PLwD). PLwD and their caregivers struggle with cognitive, functional, behavioral, and psychosocial issues. As dementia care shifts to home settings, caregivers receive inadequate support but bear increasing responsibilities, leading to higher healthcare costs. In response, the Centers for Medicare & Medicaid Services (CMS) introduced the Guiding an Improving Dementia Experience (GUIDE) Model. The study explores the real-world implementation of the Cedars-Sinai C.A.R.E.S. Program, a pragmatic dementia care model, detailing its recruitment process and initial outcomes. The Cedars-Sinai C.A.R.E.S. Program was integrated into the Epic electronic health record system and focused on proactive patient identification, engagement, interdisciplinary collaboration, care transitions, and ongoing care management. Eligible patients with a dementia diagnosis were identified through electronic health record and invited to join the program. Nurse practitioners with specialized training in dementia care performed comprehensive assessments using the CEDARS-6 tool, leading to personalized care plans developed in consultation with primary care providers. Patients benefited from a multidisciplinary team and support from care navigators. Of the 781 eligible patients identified, 431 were enrolled in the C.A.R.E.S. Enrollees were racially diverse, with lower caregiver strain and patient behavioral and psychological symptoms of dementia (BPSD) severity compared to other programs dementia care programs. Healthcare utilization, including hospitalizations, emergency department (ED) admissions, and urgent care visits showed a downward trend over time. Completion of advanced directives and Physician Order of Life-Sustaining Treatment (POLST) increased after enrollment. The Cedars-Sinai C.A.R.E.S. Program offers a promising approach to dementia care. Its real-world implementation demonstrates the feasibility of enrolling a diverse population and achieving positive outcomes for PLwD and their caregivers, supporting the goals of national dementia care initiatives.

Factors Associated with Completion of Advance Directives among Advanced Care Planning Outpatients at a Regional Hospital in Southern Taiwan

&lt;p&gt;目的：在台灣，民眾可以透過「預立醫療照護諮商」門診簽署「預立醫療決定」，然而諮商門診目前仍未被廣泛使用。本研究目的是希望了解影響民眾來本院參與預立醫療照護諮商門診和簽署完成預立醫療決定的相關因素。&lt;/p&gt; &lt;p&gt;方法：我們使用回朔性病歷研究，研究對象為針對2019年1月1日到2020年2月28日來本院諮商門診的參與者。校正相關共變項後，使用羅吉斯回歸評估完成預立醫療決定的相關影響因素。&lt;/p&gt; &lt;p&gt;結果：總共144位參加者被納入研究，預立醫療決定完成率為90.2%。較多的參加者為年齡較大、女性、較為健康、費用較低和之前已簽過預立安寧緩和醫療暨維生醫療抉擇意願書。校正相關共變項後，之前已簽過預立安寧緩和醫療暨維生醫療抉擇意願書的參加者有較高的機會完成預立醫療決定(aOR 14.56, 95% CI 1.62-131.23)；參加者與有社工參與的諮商團隊進行諮商有較高的機會完成預立醫療決定(aOR 5.59, 95% CI 1.05-28.87)。&lt;/p&gt; &lt;p&gt;結論：諮商門診的參加者其預立醫療決定完成率高，之前已簽過預立安寧緩和醫療暨維生醫療抉擇意願書的參加者有較高機會完成預立醫療決定。諮商時，針對參加者個別情況進行討論和使用輔助資料理解諮商內容，協助完成預立醫療決定。未來能針對社區民眾衛教宣導預立醫療照護諮商門診的諮詢服務，針對從未簽過預立安寧緩和醫療暨維生醫療抉擇意願書的民眾更需進一步的推廣。&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;&lt;p&gt;Purpose: Advance care planning (ACP) is the process of communicating a person&amp;rsquo;s preferences regarding future medical care. In Taiwan, people can visit an ACP outpatient clinic and complete advance directives (AD). ACP is an emerging medical service, and information about completing AD is lacking. The aim of this study was to investigate the factors affecting AD completion among ACP clinic outpatients at a regional hospital in southern Taiwan.&lt;/p&gt; &lt;p&gt;Methods: This retrospective study used chart reviews to evaluate participants who attended an ACP outpatient clinic from 1 January 2019 to 28 February 2020. AD completion was analyzed using logistic regression after adjusting for covariates including previously signing do-not-resuscitate (DNR) forms.&lt;/p&gt; &lt;p&gt;Results: A total of 144 participants were included, and the AD completion rate was 90.2%. Participants attending ACP sessions were more likely to be older, female, having a high school education and below, better health status, paying less for ACP sessions, and previously signing DNR forms. After adjusting for the covariates, participants who had previously signed DNR forms were more likely to complete AD (aOR 14.03, 95% CI 1.56-126.06). In addition, the presence of a social worker in the ACP team was significantly associated with higher AD completion (aOR 5.74, 95% CI 1.05-31.32).&lt;/p&gt; &lt;p&gt;Conclusions: Participants previously signing DNR forms were more likely to completion AD. In addition to tailoring ACP discussions about the benefits of AD and providing supplement materials to improve AD completion, further strategies are needed to encourage the public in southern Taiwan to visit ACP outpatient clinics, especially for those who were unfamiliar with concepts such as DNR or life-sustaining treatment at the end of life.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

Factors affecting advance directives completion among older adults in Korea.

Advance directives (ADs) provide an opportunity for patients to enhance the quality of their end-of-life care and prepare for a dignified death by deciding treatment plans. The purpose of this study was to explore the multiple factors that influence the advance directives completion among older adults in South Korea. This was a secondary analysis of a cross-sectional study of 9,920 older adults. The differences in ADs based on subjects' sociodemographic characteristics, health-related characteristics, and attitude toward death were tested using the chi-squared and t-test. A multinomial logistic regression model was used to identify the influencing factor of ADs. The number of chronic diseases, number of prescribed medications, depression, insomnia, suicide intention, and hearing, vision, or chewing discomfort were higher in the ADs group compared to the non-ADs group. The influencing factors of the signing of ADs included men sex, higher education level, exercise, death preparation education, lower awareness of dying-well, and experience of fracture. Information dissemination regarding ADs should be promoted and relevant authorities should consider multiple options to improve the physical and psychological health of older adults, as well as their attitude toward death to increase the ADs completion rate.

Factors related to advance directives completion among cancer patients: a systematic review

IntroductionAdvance directives (ADs) has recently been considered as an important component of palliative care for patients with advanced cancer and is a legally binding directive regarding a person’s future medical care. It is used when a person is unable to participate in the decision-making process about their own care. Therefore, the present systematic review investigated the factors related to ADs from the perspective of cancer patients.MethodsA systematic review study was searched in four scientific databases: PubMed, Medline, Scopus, Web of Science, and ProQuest using with related keywords and without date restrictions. The quality of the studies was assessed using the Hawker criterion. The research papers were analyzed as directed content analysis based on the theory of planned behavior.ResultsOut of 5900 research papers found, 22 were included in the study. The perspectives of 9061 cancer patients were investigated, of whom 4347 were men and 4714 were women. The mean ± SD of the patients’ age was 62.04 ± 6.44. According to TPB, factors affecting ADs were categorized into four categories, including attitude, subjective norm, perceived behavioral control, and external factors affecting the model. The attitude category includes two subcategories: “Lack of knowledge of the ADs concept” and “Previous experience of the disease”, the subjective norm category includes three subcategories: “Social support and interaction with family”, “Respecting the patient’s wishes” and “EOL care choices”. Also, the category of perceived control behavior was categorized into two sub-categories: “Decision-making” and “Access to the healthcare system”, as well as external factors affecting the model, including “socio-demographic characteristics”.ConclusionThe studies indicate that attention to EOL care and the wishes of patients regarding receiving medical care and preservation of human dignity, the importance of facilitating open communication between patients and their families, and different perspectives on providing information, communicating bad news and making decisions require culturally sensitive approaches. Finally, the training of cancer care professionals in the palliative care practice, promoting the participation of health care professionals in ADs activities and creating an AD-positive attitude should be strongly encouraged.

Impact on End‐of‐life Planning of a Care Coordination Program for persons living with dementia

AbstractBackgroundAlzheimer’s disease and related dementias (ADRD) afflict over five million persons in the U.S., and persons living with dementia (PLWD) have been shown to receive poor quality care and have worse health outcomes compared to those without ADRD. We developed a population‐based dementia care management program to support the care of PWLD in a large U.S. healthcare system.MethodsIn a large multi‐specialty medical group practice, we identified patients enrolled in a value‐based insurance program (Medicare Advantage) using the EPIC electronic health record (EHR), and eligible patients were invited to enroll in the CARES dementia care program. Patients were eligible if they had an ICD‐10 diagnosis of ADRD in the EHR problem list and/or past medical history, or currently taking an FDA‐approved medication for ADRD. We additionally included patients with ADRD who have a primary care provider in the affiliated academic health system. During an in‐person intake visit, a study‐assigned nurse practitioner (NP) engaged in advance care planning discussion with patients and caregivers and completed advance directives (AD) and Physician Order for Life Sustaining Treatment (POLST). We assessed the rate of completion of the AD and POLST pre‐program and post‐enrollment.ResultsWe enrolled 195 patients in the CARES dementia care program. After enrollment, participants increased completion of advanced directives from 27.7% to 30.8% (p = 0.25) and the POLST from 13.3% to 23.1% (p = 0.006). Of the POLST forms completed, 70.7% indicated that the patient was ‘do not attempt resuscitation’ (DNAR) (65.2% of those who completed the POLST pre‐program, 77.8% for those who completed after enrollment, p = 0.19). Among those who completed the POLST, 55.0% indicated selective medical interventions (63.6% pre‐program, 47.1% post‐enrollment, p = 0.15), 40.0% wanted full medical interventions (31.8% pre‐program, 52.9% post‐enrollment, p = 0.10), and 5.0% wanted comfort‐focused interventions (4.5% pre‐program, 5.9% post‐enrollment, p = 0.43). Trial period of nutritional supports was indicated by 69.2% (72.7% pre‐program, 64.7% post‐enrollment, p = 0.28), while 28.2% wanted no artificial treatment (27.2% pre‐program, 29.4% post‐enrollment, p = 0.45), and 2.6% wanted long‐term nutritional support (0% pre‐program, 5.9% post‐enrollment, p = 0.13).ConclusionA dementia care coordination program shows signs of increased completion of end‐of‐life planning, with the majority choosing ‘do not attempt resuscitation’ (DNAR).

Patient and Family Outcomes of Community Neurologist Palliative Education and Telehealth Support in Parkinson Disease

Parkinson disease and related disorders (PDRD) are the fastest growing neurodegenerative illness in terms of prevalence and mortality. As evidence builds to support palliative care (PC) for PDRD, studies are needed to guide implementation. To determine whether PC training for neurologists and remote access to a PC team improves outcomes in patients with PDRD in community settings. This pragmatic, stepped-wedge comparative effectiveness trial enrolled and observed participants from 19 community neurology practices supported by PC teams at 2 academic centers from March 8, 2017, to December 31, 2020. Participants were eligible if they had PDRD and moderate to high PC needs. A total of 612 persons with PDRD were referred; 253 were excluded. Patients were excluded if they had another diagnosis meriting PC, were receiving PC, or were unable or unwilling to follow study procedures. Patients received usual care or the intervention based on when their community neurologist was randomized to start the intervention. Data were analyzed from January 2021 to September 2023. The intervention included (1) PC education for community neurologists and (2) team-based PC support via telehealth. The primary outcomes were differences at 6 months in patient quality of life (QOL; measured by the Quality of Life in Alzheimer Disease Scale [QOL-AD]) and caregiver burden (Zarit Burden Interview) between the intervention and usual care. A total of 359 patients with PDRD (233 men [64.9%]; mean [SD] age, 74.0 [8.8] years) and 300 caregivers were enrolled. At 6 months, compared with usual care, participants receiving the intervention had better QOL (QOL-AD score, 0.09 [95% CI, -0.63 to 0.82] vs -0.88 [95% CI, -1.62 to -0.13]; treatment effect estimate, 0.97; 95% CI, 0.07-1.86; P = .03). No significant difference was observed in caregiver burden (Zarit Burden Interview score, 1.19 [95% CI, 0.16 to 2.23] vs 0.55 [95%, -0.44 to 1.54]; treatment effect estimate, 0.64; 95% CI, -0.62 to 1.90; P = .32). Advance directive completion was higher under the intervention (19 of 38 [50%] vs 6 of 31 [19%] among those without directives at the beginning of the study; P = .008). There were no differences in other outcomes. PC education for community neurologists and provision of team-based PC via telehealth is feasible and may improve QOL and advance care planning. Overall treatment effects were small and suggest opportunities to improve both the intervention and implementation. ClinicalTrials.gov Identifier: NCT03076671.

Unveiling the Influencers: An Exploration of Factors Determining Advance Directive Completion Among Community-Dwelling Adults.

Advance directives (AdvDirs) align end-of-life care with personal values, averting unnecessary treatments. This study explores factors influencing AdvDir completion. We conducted a cross-sectional study with community-dwelling adults (n = 166) age range 18-93, using a survey to gather sociodemographics, beliefs, and AdvDir experiences. Multivariate logistic regression quantifies associations between selected covariates and AdvDir completion. We found that 36% of respondents had completed AdvDirs. The majority were comfortable discussing death (77%) and end-of-life care (84%) and recognized the importance of AdvDirs (79%). Age, education level, self-perceived health status, exposure to end-of-life planning, and the preference to limit treatment in potential future Alzheimer's scenarios significantly influenced AdvDir completion. In conclusion, the study highlights: (1) The need for age-specific, personalized AdvDir education initiatives, and (2) The necessity of intensified AdvDir awareness efforts, particularly for individuals favoring unlimited treatment in Alzheimer's or dementia scenarios.

Outcomes of a 3-Year Quality Improvement Study to Improve Advance Care Planning in Patients With Decompensated Cirrhosis.

To report outcomes of a 3-year quality improvement pilot study to improve advance directive (AD) completion. The pilot consisted of champions, education, electronic health record templates, and workflow changes. We assessed changes, predictors, and effects of AD completion. The pilot led to greater (8.3%-36%) and earlier AD completion, particularly among those divorced, with alcohol-associated liver disease, and with higher Model of End-Stage Liver Disease-Sodium score. Decedents whose AD specified nonaggressive goals experienced lower hospital lengths of stay. Advance care planning initiatives are feasible and may reduce health care utilization among decedents requesting less aggressive care.

Associations of health literacy, personality traits, and pro-individualism with the willingness to complete advance directives in Taiwan

BackgroundStudies indicated that patients with advance directives (ADs) have a generally better quality of life near death. Yet, the concept of ADs is relatively new in East Asian countries. This study examined the associations between health literacy, pro-individualism in end-of-life (EOL) decisions (i.e., EOL pro-individualism), and master-persistence personality traits with the willingness to complete ADs.MethodsThe data is from a representative data of 1478 respondents from the 2022 Taiwan Social Change Survey. Generalized structural equation modeling (GSEM) was used to conduct path analysis.ResultsNearly half of the respondents (48.7%) were willing to complete ADs. Health literacy has direct and indirect effects through EOL pro-individualism values on the willingness to complete ADs. Noncognitive factors such as mastery-persistence personality traits and EOL pro-individualism values enhanced the willingness to complete ADs.ConclusionA personalized communication strategy, mindful of personality dimensions and cultural values, can address individual fears and concerns, promoting the benefits of advance care planning (ACP). These influences can provide a roadmap for healthcare providers to customize their approach to ACP discussions, improving patient engagement in AD completion.

Exposure to a Loved One's Death and Advance Care Planning: Moderating Effects of Age.

Background: Despite documented benefits of Advance Care Planning (ACP), it is still under-utilized in the U.S. Our study aimed to examine whether experiencing a loved one's death is associated with one's own ACP behavior among adults in the U.S. and the potential moderating effect of age. Method: Using a nationwide cross-sectional survey design with probability sampling weights, our study included 1006 adults in the U.S. who participated in and completed the Survey on Aging and End-of-Life Medical Care. Three binary logistic regression models were established to investigate the relationship between death exposure and different aspects of ACP (i.e., informal conversations with family members and doctors and formal advance directives completion). The moderation analysis was subsequently conducted to examine moderating effects of age. Results: The exposure to a loved one's death was significantly associated with higher odds of having conversations with family about end-of-life medical care preferences among the 3 indicators of ACP (OR = 2.03, P < .001). Age significantly moderated the association between death exposure and ACP conversations with doctors (OR = .98, P = .017). The facilitation effect of death exposure on informal ACP engagement in discussing end-of-life medical wishes with doctors is stronger among younger adults than older adults. Conclusions: Exploring an individual's previous experience with a loved one's death might be an effective way to broach the concept of ACP among adults of all ages. This strategy may be particularly useful in facilitating discussions of end-of-life medical wishes with doctors among younger adults than older adults.

The association of demographic factors and disease stage on palliative care (PC) referral rates and completion of advanced directives in a lung cancer (LC) patient population.

e24150 Background: Early referral to PC improves quality of life among patients with lung cancer and is associated with improvement in overall survival in patients with stage 4 disease. However, PC utilization remains low. Few studies examined the disparities in PC access and use in real life SCLC and NSCLC patient populations. Objective: To determine the prevalence of PC use among a sample of LC patients and assess the role of PC in facilitating directives and goals of care discussion. Methods: A retrospective cohort analysis was conducted utilizing a randomly selected subset of LC patients treated at the IU Simon Comprehensive Cancer Center between 1/1/18 and 12/31/20. We collected information on advanced directives in the form of designated medical decision maker (Healthcare representative or Healthcare power of attorney) and code status preferences (DNR or POST form). Signed DNR order/POST forms information, demographics (sex, race), LC stage, and LC type were analyzed using descriptive analyses. Chart search identified the dates of first palliative care visit and number of total palliative care visits. Results: Patient characteristics (n = 209): Females 51.7%; White 86.7%; NSCLC 88.5%; stage IV 44.1%. The percentage of total patients who were referred to palliative care was 21.1%. No significant difference in referral rates was found between NSCLC and SCLC patients. 22.3% of male patients and 19.8% of female patients were referred to PC (p = 0.61). No difference was noted in the percentage of white and non-white patients referred to PC (21% and 26.1%, p = 0.97). Palliative referral rates and time from diagnosis to first palliative contact was significantly associated with disease stage, as 27.9% of patients with stage 4 were referred to palliative compared to 15.6% of patients with stages 1-3 (p = 0.036); median time from diagnosis to first palliative contact in stage 4 patients was 355.7 days vs 573.7 days in stages 1-3. Disease stage was associated with the median time from diagnosis to signing POST/DNR forms: 213.6 days in stage 4 patients vs. 409.1 days in stage 1-3 patients. Discussing and signing POST/DNR and HCPOA/HCR forms was associated with palliative care referrals; 53.7% and 63.6% of those referred to palliative signed POST/DNR and HCPOA/HCR forms respectively vs. 11.4% and 16.9% for patients who were never referred to PC. Conclusions: Stage 4 LC was associated with higher likelihood of referral to palliative care than stages 1-3 but PC was underutilized in LC. Demographic factors (race, sex) were not significantly associated with PC referral rates. Patients referred to PC were more likely to address advanced directives than patients who were never offered PC. Strategies to increase palliative care utilization and barriers limiting PC utilization in LC patients need to be further investigated.

Clinical benefit (rate) of geriatric assessment in a Veterans Affairs (VA)-based oncology clinic according to the Geriatric 5Ms framework.

e24010 Background: The geriatric assessment (GA) is a validated, multi-system assessment tool that can detect vulnerabilities often not captured with standard oncology assessments in older adult patients with cancer. The Geriatric 5Ms is a novel communication framework used to describe core competencies in geriatrics. Prior studies have shown GA integration in oncology practice can significantly reduce grade 3 or higher chemotherapy-related toxicities, falls, polypharmacy, hospital length of stay (LOS), increase completion of advanced directives, and improve quality of life measures. Despite these benefits, implementation into clinical practice has remained low. This study aimed to utilize telemedicine to integrate GA into a busy VA oncology practice. Methods: In this quality improvement study design, we enrolled adult patients aged 70 years and older with solid tumors or hematologic malignancy, either newly established or receiving active systemic treatment through an urban, academic VA oncology clinic. Patients were assigned to the intervention (GA conducted via telemedicine by a geriatric specialist) if they scored ≤14 on G8, a validated screening tool. Outcomes were compared with a historical control cohort who received usual care (no virtual GA). Reported here are the clinical benefits measured qualitatively according to the geriatric 5Ms framework. Results: Between January 1, 2022 and March 30, 2022, we enrolled 116 patients (n = 57 intervention, 59 control) from a US VA-based population. Patients had a mean age of 76.8 (SD 6.2) between both cohorts and all patients were male (100%). Among patients in the intervention cohort, all patients (100%) derived benefit in at least one element of the 5M’s framework (Mind, Mobility, Medications, Multicomplexity, and Matters Most) from GA. Based on findings from the GA, services were provided in each of the 5M’s categories in the following frequencies: multicomplexity (88%), matters most (71%), medication (58%), mentation (50%), and mobility (46%). Conclusions: Incorporating GA via telemedicine into routine oncologic care was feasible within this VA-based population of older adult patients with cancer. Further, this project led to clinic recognition as an Age Friendly Health System by the Institute for Healthcare Improvement (IHI). When routinely performed, geriatric assessment led to clinical benefit among all patients receiving the intervention according to the 5M’s framework. Future studies will compare the clinical benefits of this intervention to clinical outcomes measures such as hospital length of stay, emergency room utilization, therapy toxicity, and survival among this patient population.

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.

Factors Impacting Advance Decision Making and Health Care Agent Appointment among Taiwanese Urban Residents after the Passage of Patient Right to Autonomy Act.

We identified 2337 ACP participants from consultation records between 2019 and 2020. The relationships among the participants' characteristics, AD completion, and HCA appointment were investigated. Of 2337 cases, 94.1% completed ADs and 87.8% were appointed HCAs. Welfare entitlement (OR = 0.47, p < 0.001), the place ACP progressed (OR = 0.08, p < 0.001), the participation of second-degree relatives (OR = 2.50, p < 0.001), and the intention of not being a family burden (OR = 1.65, p = 0.010) were significantly correlated with AD completion. The probability of appointing HCAs was higher in participants with family caregiving experience (OR = 1.42, p < 0.05), who were single (OR = 1.49, p < 0.05), and who expected a good death with dignity (OR = 1.65, p < 0.01). Our research shows that adopting ACP discussion in Taiwan is feasible, which encourages ACP conversation and facilitates AD completion. Male and younger adults may need extra encouragement to discuss ACP matters with their families. due to sampling restrictions, our data were chosen from an urban district to ensure the integrity of the results. Furthermore, interview data could be collected in future research to supplement the quantitative results.

Using Preanesthesia Clinic Visits to Improve Advance Directives Completion: An Interrupted Time Series Analysis.

Advance directives documentation can increase the likelihood that patient's wishes are respected if they become incapacitated. Unfortunately, completion rates are suboptimal overall, and disparities may exist, especially for vulnerable groups. We assessed whether implementing an initiative to standardize advance directives discussions during preanesthesia visits was associated with changes in rates of advance directives completion over time, and whether the association depends on race, insurance type, or income. We conducted a before-after interrupted time series evaluation between January 1, 2015 and June 30, 2019 in a single-center, outpatient preanesthesia clinic. Participants were adults who visited the preanesthesia clinic at Cleveland Clinic and had >1 comorbidity before a noncardiac surgery of either medium or high risk. The intervention in March of 2017 consisted of training staff to help patients complete and witness advance directives documents during visits. We measured advance directives completion, by race, payor, and income (using the 2019 Federal Poverty Line). We assessed the confounder-adjusted association between intervention (pre versus post) and proportion of patients completing advanced directives over time using segmented regression to compare slopes between periods and assess changes at start of the intervention. We used similar models to assess whether changes depended on race, insurance type, or income level. We included 26,368 visits from 22,430 patients. We analyzed financial status for 16,788 visits from 14,274 patients who had address data. There were 11,242 (43%) visits preintervention and 15,126 (57%) visits postintervention. Crude completion rates for advance directives increased from 29% to 78%, with odds of completion an estimated 18 times higher than preintervention (odds ratio [95% CI] of 18 [16-21]; P < 0.001). Regarding race, Black patients had lower completion rates preintervention than White patients, although the gap steadily closed after the intervention (P = .001). Postintervention, both race groups immediately increased, with no difference in amount of increase (P = .17) or postintervention change in slope difference (P = .17). Regarding insurance, patients with Medicaid had lower preintervention completion rates than those with private. Intervention was associated with increases in both groups, but the difference in slopes (P = .43) or proportions (P = .23) between the groups did not change after intervention. Regarding the Federal Poverty Line, the completion rate gap between those below (<100%) and above (139%-400%) narrowed by approximately half (0.51: 95% CI, 0.27-0.98; P = .04). Standardizing advance directives discussions during preanesthesia visits was associated with more patients completing advance directives, particularly in vulnerable patient groups.