Documentation Of Patient Preferences Research Articles

Interventions aiming to improve advance care planning uptake in oncology: a scoping review of recent randomized controlled trials.

The evidence regarding the effectiveness of interventions aiming to improve ACP uptake appears mixed. The purpose of this scoping review is to summarize findings from recent RCTs assessing the efficacy of interventions designed to increase ACP uptake in cancer care. The PubMed database was searched for studies published between 2021 and 2023. Ten RCTs were identified that evaluated a wide range of interventions aimed at encouraging or facilitating ACP communication among patients with advanced cancer, caregivers, and HCPs. Three RCTs developed ACP facilitation tools for patients and sometimes caregivers. Six RCTs involved integrating trained ACP facilitators into patient care, and one RCT used nudges to encourage oncologists trained in ACP discussions to initiate discussions with patients at highest risk of short-term mortality. Most of the reviewed interventions were based on previously tested intervention approaches or tools. The key effects identified in this review are the facilitation of ACP discussions among patients, caregivers, and HCPs, and the documentation of patient preferences in the medical record. The direct involvement of facilitators in ACP document drafting and inclusion in patient files, as well as interventions prompting end-of-life discussions, contributed to this effect.

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.

Discussing patient preferences for levels of life-sustaining treatment: development and pilot testing of a Danish POLST form

BackgroundMedically frail and/or chronically ill patients are often admitted to Danish hospitals without documentation of patient preferences. This may lead to inappropriate care. Modelled on the American Physician Orders for Life-Sustaining Treatment (POLST) form, the purpose of the study was to develop and pilot test a Danish POLST form to ensure that patients’ preferences for levels of life-sustaining treatment are known and documented.MethodsThe study was a mixed methods study. In the initial phase, a Danish POLST form was developed on the basis of literature and recommendations from the National POLST organisation in the US. A pilot test of the Danish POLST form was conducted in hospital wards, general practitioners’ clinics, and nursing homes. Patients were eligible for inclusion if death was assessed as likely within 12 months. The patient and his/her physician engaged in a conversation where patient values, beliefs, goals for care, diagnosis, prognosis, and treatment alternatives were discussed. The POLST form was completed based on the patient’s values and preferences. Family members and/or nursing staff could participate. Participants’ assessments of the POLST form were evaluated using questionnaires, and in-depth interviews were conducted to explore experiences with the POLST form and the conversation.ResultsIn total, 25 patients participated, 45 questionnaires were completed and 14 interviews were conducted. Most participants found the POLST form readable and understandable, and 93% found the POLST form usable to a high or very high degree for discussing preferences regarding life-sustaining treatment. Three themes emerged from the interviews: (a) an understandable document is essential for the conversation, (b) handling and discussing wishes, and (c) significance for the future.ConclusionThe Danish version of the POLST form is assessed by patients, families, physicians, and nurses as a useful model for obtaining and documenting Danish patients’ preferences for life-sustaining treatment. However, this needs to be confirmed in a larger-scale study.

Workflow Process Mapping: A Novel Approach to Promote Implementation of Evidence Based Practices [39I

INTRODUCTION: National guidelines recommend offering immediate postpartum long-acting reversible contraception (LARC). However, hospitals lack evidence-based approaches for embedding this care into existing workflow. We used a multiple case study to understand immediate postpartum LARC workflow at early-adopter sites and create a tool to help embed this care into practice at new sites. METHODS: A systematic literature search identified hospitals offering immediate postpartum contraceptive care. We purposively sampled information-rich sites. From 8/2017 to 9/2018, we conducted site visits with semi-structured key informant interviews informed by the Consolidated Framework for Implementation Research (CFIR). Workflow process mapping was used to develop detailed workflow maps and describe drivers of observed workflow variation. Institutional IRB approval was obtained. RESULTS: After interviewing 79 key informants at 11 hospitals, workflow process mapping revealed variation across sites, especially related to timing and staff involved in 1) counseling, consent, and documentation of patient preferences, 2) addressing insurance coverage, 3) device ordering, 4) contraceptive insertion technique, and 5) post-insertion management. Observed variation was often driven by context (e.g., degree of integration between inpatient and outpatient teams, variation in L&D staff composition) and gaps in clinical evidence (e.g., uncertainty about the comparative effectiveness of intrauterine device insertion techniques). Only two sites prospectively designed a workflow. At other sites, workflows were often inefficient, requiring adaptations after initial implementation and clarification about roles and responsibilities. CONCLUSION: Pre-implementation workflow process planning using the self-assessment tool may help sites engage key stakeholders, customize workflow to local needs, and minimize need for future adaptations.

Medical Record Documentation of Goals-of-Care Discussions Among Older Veterans With Incident Kidney Failure

Elicitation and documentation of patient preferences is at the core of shared decision making and is particularly important among patients with high anticipated mortality. The extent to which older patients with incident kidney failure undertake such discussions with their providers is unknown and its characterization was the focus of this study. Retrospective cohort study. A random sample of veterans 67 years and older with incident kidney failure receiving care from the US Veterans Health Administration between 2005 and2010. Demographic and facility characteristics, as well as predicted 6-month mortality risk after dialysis initiation and documentation of resuscitation preferences. Documented discussions of dialysis treatment and supportive care. We reviewed medical records over the 2 years before incident kidney failure and up to 1 year afterward to ascertain the frequency and timing of documented discussions about dialysis treatment, supportive care, and resuscitation. Logistic regression was used to identify factors associated with these documented discussions. The cohort of 821 veterans had a mean age of 80.9±7.2 years, and 37.2% had a predicted 6-month mortality risk>20% with dialysis. Documented discussions addressing dialysis treatment and resuscitation were present in 55.6% and 77.1% of patients, respectively. Those addressing supportive care were present in 32.4%. The frequency of documentation varied by mortality risk and whether the patient ultimately started dialysis. In adjusted analyses, the frequency and pattern of documentation were more strongly associated with geographic location and receipt of outpatient nephrology care than with patient demographic or clinical characteristics. Documentation may not fully reflect the quality and content of discussions, and generalizability to nonveteran patients is limited. Among older veterans with incident kidney failure, discussions of dialysis treatment are decoupled from other aspects of advance care planning and are suboptimally documented, even among patients at high risk for mortality.

Identifying the gap in goals of care communication across care settings in a flagship cancer research and treatment facility.

180 Background: There is widespread recognition of the importance of having and documenting timely Goals of Care (GOC) conversations with seriously ill patients. Inpatient oncology teams at UPMC have noted the limited availability in the Electronic Medical Record (EMR) of documentation of patient preferences about end of life care. This project aims to identify the gaps in GOC communication across care settings for cancer patients at UPMC. Methods: We identified sources of information regarding goals of care available to inpatient oncology providers. Using the EMR we accessed the following for each patient of interest: CPR status, GOC documentation, scanned Advance Directives and/or POLST and last two available outpatient notes. Patients of interests were older than 65 years with metastatic cancer and 2 hospital admissions in the past year, or any cancer patient > 90 years. We reviewed outpatient notes for words suggesting that GOC conversations had occurred, and for a subset (50%), we did a detailed review identifying documentation of prognosis, treatment options, treatment decisions and patient values. Results: Of a total 114 high risk patients admitted over a 6-month period, 73 (64%) died within 6 months, with 52 (46%) dying within one month of their last hospitalization. Thirty nine (34%) patients had at least 5 admissions. Only 35% patients had GOC documented using the EMR template, and only 38% had a completed POLST. Rates of CPR status completion were high (95%). However, when tracking CPR status across multiple admissions, 73% of patients were full code on their first admission, with 31% of patients with five admissions remaining full code. The qualitative analysis of outpatient notes revealed that most documentation (87%) reflected continued treatment with minimal discussion of hospice or patient values. Conclusions: In a cohort of patients with advanced cancer, documentation of GOC discussions is limited in both inpatient and outpatient settings. Available documentation suggests minimal discussion of the limited benefits of medical interventions to prolong life. Future efforts will be designed to improve the quality and frequency of documentation of GOC conversations.

Assessment and documentation of bowel care management in palliative care: incorporating patient preferences into the care regimen.

Nurses in a palliative care unit (PCU) recognized that there were several inconsistencies relating to assessment and documentation of patient preferences in bowel care management. Although bowel care is recognized as of key importance to the wellbeing of palliative care patients, there is little evidence in current literature about accommodation of patient preferences in bowel care management. A questionnaire was developed to assess whether patient preferences were elicited on admission to the PCU, were documented, and were included in the bowel care regimen. Data were collected from 100 patients in two PCUs in Australia. The findings suggested that little was assessed or documented about bowel care management on admission except functional or pharmacological information. According to patients in the study, their preferences were seldom incorporated into the bowel care regimen. Lack of documentation of bowel care preferences was also found following an audit of patient notes. Techniques for eliciting information, awareness of alternative or complementary methods of bowel care and better documentation procedures are all recommended for inclusion in nursing practice in the palliative care setting.