Prior Advance Care Planning Research Articles

Acceptability and usability of the Planning Advance Care Together (PACT) website for improving patients' engagement in advance care planning

ObjectivesMost prior advance care planning (ACP) interventions lack integration of the social context of patients' ACP process, which patients indicate is critically important. The current study developed the Planning Advance Care Together (PACT) website to foster inclusion of loved ones in the ACP process. MethodsTo provide feedback about the PACT website, patients with advanced cancer (N = 11), their caregivers (N = 11), and experts (N = 10) participated in semi-structured interviews. Patients and caregivers also completed standardized ratings of acceptability and usability. ResultsOverall, patient (n = 11) and caregiver (n = 11) ratings of acceptability and usability of the website exceeded benchmark cut-offs (≥24 on the Acceptability E-Scale and ≥ 68 on the System Usability Scale). Patients, caregivers, and experts liked the topic of ACP but felt that it could be emotionally challenging. They recommended focusing more on planning and less on end of life. They appreciated being able to include loved ones and recommended adding resources for caregivers. ConclusionsStudy findings support the preliminary usability and acceptability of the PACT website. Findings will be used to inform a modified prototype of the PACT website that is interactive and ready for field testing with patients with advanced cancer and their loved ones. InnovationWe utilized a novel application of the shared mind framework to support patients with advanced cancer in engaging their loved ones in the ACP process.

Advance directives among community-dwelling stroke survivors.

Advance directives (ADs) are integral to health care, allowing patients to specify surrogate decision-makers and treatment preferences in case of loss of capacity. The present study sought to identify determinants of ADs among stroke survivors. In this cross-sectional study (Care Attitudes and Preferences in Stroke Survivors [CAPriSS]), community-dwelling stroke survivors were surveyed on ADs; validated scales were used to query palliative care knowledge and attitudes towards life-sustaining treatments. Logistic regression was used to determine variables associated with ADs. Among 562 community-dwelling stroke survivors who entered the survey after screening questions confirmed eligibility, 421 (74.9%) completed survey components with relevant variables of interest. The median age was 69 years (IQR 58-75 years); 53.7% were male; and 15.0% were Black. Two hundred and fifty-one (59.6%) respondents had ADs. Compared to stroke survivors without ADs, those with ADs were more likely to be older (median age 72 vs. 61 years; p<0.001), White (91.2% vs. 75.9%, p<0.001), and male (58.6% vs. 46.5%, p = 0.015), and reported higher education (p<0.001) and income (p = 0.011). Ninety-eight (23.3%) participants had "never heard of palliative care". Compared to participants without ADs, participants with ADs had higher Palliative Care Knowledge Scale (PaCKS) scores (median 10 [IQR 5-12] vs. 7 [IQR 0-11], p<0.001), and lower scores on the Attitudes Towards Life-Sustaining Treatments Scale (indicating a more negative attitude towards life-sustaining treatments; median 23 [IQR 18-28] vs. 29 [IQR 24-35], p<0.001). Multivariable logistic regression identified age (OR 1.62 per 10 year increase, 95% CI 1.30-2.02; p<0.001), prior advance care planning discussion with a physician (OR 1.73, 95% CI 1.04-2.86; p = 0.034), PaCKS scores (OR 1.06 per 1 point increase, 95% CI 1.01-1.12; p = 0.018), and Attitudes Towards Life-Sustaining Treatments Scale scores (OR 0.91 per 1 point increase, 95% CI 0.88-0.95; p<0.001) as variables independently associated with ADs. Age, prior advance care planning discussion with a physician, palliative care knowledge, and attitudes towards life-sustaining treatments were independently associated with ADs.

Advance Directives Among Community-Dwelling Stroke Survivors (P6-5.016)

<h3>Objective:</h3> To identify determinants of Advance Directives (ADs) among community-dwelling stroke survivors. <h3>Background:</h3> Advance directives (ADs) are integral to health care, allowing patients to specify surrogate decision-makers and treatment preferences in case of loss of capacity. The present study sought to identify determinants of ADs among stroke survivors. <h3>Design/Methods:</h3> In this cross-sectional study (Care Attitudes and Preferences in Stroke Survivors [CAPriSS]), community-dwelling stroke survivors were surveyed on ADs; validated scales were used to query palliative care knowledge and attitudes towards life-sustaining treatments. Logistic regression was used to determine variables associated with ADs. <h3>Results:</h3> The median age among the 421 participants was 69 years (IQR 58–75 years); 53.7% were male; and 15.0% were Black. Two hundred and fifty-one (59.6%) respondents had ADs. Compared to participants without ADs, participants with ADs had higher Palliative Care Knowledge Scale (PaCKS) scores (median 10 [IQR 5–12] vs. 7 [IQR 0–11], p&lt;0.001), and lower scores on the Attitudes Towards Life-Sustaining Treatments Scale (indicating a more negative attitude towards life-sustaining treatments; median 23 [IQR 18–28] vs. 29 [IQR 24–35], p&lt;0.001). Multivariable logistic regression identified age (OR 1.62 per 10 year increase, 95% CI 1.30–2.02; p&lt;0.001), prior advance care planning discussion with a physician (OR 1.73, 95% CI 1.04–2.86; p=0.034), PaCKS score (OR 1.06 per 1 point increase, 95% CI 1.01–1.12; p=0.018), and Attitudes Towards Life-Sustaining Treatments Scale score (OR 0.91 per 1 point increase, 95% CI 0.88–0.95; p&lt;0.001) as variables independently associated with ADs. <h3>Conclusions:</h3> Age, prior advance care planning discussion with a physician, palliative care knowledge, and attitudes towards life-sustaining treatments were independently associated with ADs. <b>Disclosure:</b> Ms. Gupta has nothing to disclose. Miss Chen has nothing to disclose. Miss Suolang has nothing to disclose. Ms. Cooper has nothing to disclose. Dr. Gottesman has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for American Academy of Neurology. The institution of Dr. Gottesman has received research support from NIH. Dr. Faigle has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for several law firms. The institution of Dr. Faigle has received research support from The Morninstar Foundation.

Predictors of Documented Goals-of-Care Discussion for Hospitalized Patients With Chronic Illness.

Goals-of-care discussions are important for patient-centered care among hospitalized patients with serious illness. However, there are little data on the occurrence, predictors, and timing of these discussions. To examine the occurrence, predictors, and timing of electronic health record (EHR)-documented goals-of-care discussions for hospitalized patients. This retrospective cohort study used natural language processing (NLP) to examine EHR-documented goals-of-care discussions for adults with chronic life-limiting illness or age ≥80 hospitalized 2015-2019. The primary outcome was NLP-identified documentation of a goals-of-care discussion during the index hospitalization. We used multivariable logistic regression to evaluate associations with baseline characteristics. Of 16,262 consecutive, eligible patients without missing data, 5,918 (36.4%) had a documented goals-of-care discussion during hospitalization; approximately 57% of these discussions occurred within 24 hours of admission. In multivariable analysis, documented goals-of-care discussions were more common for women (OR=1.26, 95%CI 1.18-1.36), older patients (OR=1.04 per year, 95%CI 1.03-1.04), and patients with more comorbidities (OR=1.11 per Deyo-Charlson point, 95%CI 1.10-1.13), cancer (OR=1.88, 95%CI 1.72-2.06), dementia (OR=2.60, 95%CI 2.29-2.94), higher acute illness severity (OR=1.12 per National Early Warning Score point, 95%CI 1.11-1.14), or prior advance care planning documents (OR=1.18, 95%CI 1.08-1.30). Documentation of these discussions was less common for racially or ethnically minoritized patients (OR=0.823, 95%CI 0.75-0.90). Among hospitalized patients with serious illness, documented goals-of-care discussions identified by NLP were more common among patients with older age and increased burden of acute or chronic illness, and less common among racially or ethnically minoritized patients. This suggests important disparities in goals-of-care discussions.

Adherence to the TQIP Palliative Care Guidelines Among Patients With Serious Illness at a Level I Trauma Center in the US

The American College of Surgeons Trauma Quality Improvement Program (TQIP) guidelines encourage trauma service clinicians to deliver palliative care in parallel with life-sustaining treatment and recommend goals of care (GOC) discussions within 72 hours of admission for patients with serious illness. To measure adherence to TQIP guidelines-recommended GOC discussions for trauma patients with serious illness, treated at a level I trauma center in the US. This retrospective cohort study included 674 adults admitted to a trauma service center for 3 or more days between December 2019 and June 2020. The medical records of 486 patients who met the criteria for serious illness using a consensus definition adapted to the National Trauma Data Bank were reviewed for the presence of a GOC discussion. Patients were divided into 2 cohorts based on admission before or after the guidelines were incorporated into the institutional practice guidelines on March 1, 2020. The primary outcomes were GOC completion within 72 hours of admission and during the overall hospitalization. Patient and clinical factors associated with GOC completion were assessed. Other palliative care processes measured included palliative care consultation, prior advance care planning document, and do-not-resuscitate code status. Additional end-of-life processes (ie, comfort care and inpatient hospice) were measured in a subset with inpatient mortality. Of 674 patients meeting the review criteria, 486 (72.1%) met at least 1 definition of serious illness (mean [SD] age, 60.9 [21.3] years; mean [SD] Injury Severity Score, 16.9 [12.3]). Of these patients, 328 (67.5%) were male and 266 (54.7%) were White. Among the seriously ill patients, 92 (18.9%) had evidence of GOC completion within 72 hours of admission and 124 (25.5%) during the overall hospitalization. No differences were observed between patients admitted before and after institutional guideline publication in GOC completion within 72 hours (19.0% [47 of 248 patients] vs 18.9% [45 of 238]; P = .99) or during the overall hospitalization (26.2% [65 of 248 patients] vs 24.8% [59 of 238]; P = .72). After adjusting for age, GOC completion was found to be associated with the presence of mechanical ventilation (odds ratio [OR], 6.42; 95% CI, 3.49-11.81) and meeting multiple serious illness criteria (OR, 4.07; 95% CI, 2.25-7.38). The findings of this cohort study suggest that, despite the presence of national guidelines, GOC discussions for patients with serious illness were documented infrequently. This study suggests a need for system-level interventions to ensure best practices and may inform strategies to measure and improve trauma service quality in palliative care.

Does advance care planning affect relatives’ healthcare-seeking behaviour?

Background Relatives of terminally ill patients most often experience distress. Advance Care Planning (ACP) has been developed to plan end-of-life care and support patients and relatives. ACP has been shown to have a positive impact on relatives of terminally ill patients and may affect their healthcare-seeking behaviour. The aim of the study was to investigate associations between ACP and relatives’ contacts with general practitioners (GPs) and hospital admissions. Methods Based on a prior randomized controlled trial we conducted a prospective longitudinal study. Relatives of patients formerly randomized into one ACP conversation or control group were included. Information regarding relatives’ GP and hospital contacts was achieved through healthcare registries using personal Civil Registration numbers. The content, distribution, and median number of GP and hospital contacts were analyzed in two time windows: the caregiving period (from randomization until loss) and the bereavement period (from loss until six months after). Results No significant difference in the median number of GP or hospital contacts between the two groups was found. However, in the caregiving period, we found a significant difference in the distribution of GP contacts (p = 0.022); More relatives in the control group had no contact with their GP. Conclusion The prior ACP conversation did not affect the median number of GP or hospital contacts among relatives, but statistically significantly more relatives in the ACP group had a least one GP contact in the caregiving period. The study emphasizes the importance of performing ACP trials with outcomes in relation to relatives and patients.

Voicing their choices: Advance care planning with adolescents and young adults with cancer and other serious conditions.

To determine whether engaging in advance care planning (ACP) using a formal tool, Voicing My CHOiCES (VMC), would alleviate adolescent and young adults (AYAs) anxiety surrounding ACP and increase social support and communication about end-of-life care preferences with family members and health care providers (HCPs). A total of 149 AYAs aged 18-39 years receiving cancer-directed therapy or treatment for another chronic medical illness were enrolled at seven US sites. Baseline data included prior ACP communication with family members and HCPs and measures of generalized anxiety, ACP anxiety, and social support. Participants critically reviewed each page of VMC and then completed three pages of the document. ACP anxiety was measured again immediately after the completion of VMC pages. One month later, participants repeated anxiety and social support measures and were asked if they shared what they had completed in VMC with a family member or HCP. At baseline, 50.3% of participants reported that they previously had a conversation about EoL preferences with a family member; 19.5% with an HCP. One month later, 65.1% had subsequently shared what they wrote in VMC with a family member; 8.9% shared with an HCP. Most (88.6%) reported they would not have had this conversation if not participating in the study. No significant changes occurred in social support. There was an immediate drop in anxiety about EoL planning after reviewing VMC which persisted at 1 month. Generalized anxiety was also significantly lower 1 month after reviewing VMC. Having a document specifically created for AYAs to guide ACP planning can decrease anxiety and increase communication with family members but not necessarily with HCPs. Future research should examine ways ACP can be introduced more consistently to this young population to allow their preferences for care to be heard, respected, and honored, particularly by their healthcare providers.

TH23. EDUCATIONAL ATTAINMENT, BRAIN STRUCTURAL PHENOTYPES, AND ALZHEIMER'S DEMENTIA: INSIGHTS FROM MENDELIAN RANDOMIZATION

The “Goals of Patient Care” (GOPC) process uses shared decision making to incorporate residents' prior advance care planning (ACP) or preferences into medical treatment orders, guiding health care decisions at a time of clinical deterioration should they be unable to voice their opinions. The objective was to determine whether GOPC medical treatment orders were more effective than ACP alone in preventing emergency department (ED) visits (no hospitalization), ED visits (with hospitalization), and deaths outside the residential aged care facility (RACF).The study was a prospective cluster randomized controlled trial, with the intervention being the completion of GOPC process by a geriatrician, following a shared decision-making process, incorporating ACP documents or residents' preferences.The study took place in 6 RACFs in Northern Metropolitan Melbourne, Australia. Eligible participants included all permanent residents in participating RACFs for whom written informed consent could be obtained.The primary outcome was the effect on ED visits and hospitalizations at 6 months. Secondary outcomes included a difference in hospitalization rates at 3 and 12 months, total hospital bed-days, and in-RACF and in-hospital mortality rates.More than 75% of residents participated, 181 randomized to Intervention and 145 to Control. The intervention did not result in a statistically significant change at 6 months; however, at 12 months, it reached statistical significance with 40% reduction in ED visits and hospitalizations compared with Control, with an incident rate ratio 0.63 [95% confidence interval (CI) 0.41-0.99, P = .044]. Mortality rates show increased likelihood of dying in the RACF, with statistical significance at 6 months at a relative risk ratio of 2.19 (95% CI 1.16-4.14, P = .016).In the RACF population, GOPC medical treatment orders were more effective than ACP alone for decreasing hospitalization and likelihood of dying outside the RACF. GOPC should be considered by both RACF staff and health services to decrease hospitalization and in-hospital mortality.

Clinician Perspectives on Animated Video Vignettes to Support Advance Care Planning Communication for Veterans.

Background: Despite availability of educational resources and documentation methods for advance care planning (ACP), few video tools exist. Animation relevant to Veteran experiences may enhance clinical conversations by illustrating relatable scenarios. Objective: To explore clinician perspectives on four novel video vignettes created by the study group. Design: Online survey with attention to perceived appropriateness, usefulness, and uptake intention. Settings/Subjects: Virtual video presentation with feedback poll for Veterans Affairs clinicians. Measurements: Descriptive and univariant analyses of responses to questions extracted from the validated Video Engagement Scale and prior ACP assessments. Results: Thirty respondents rated video appropriateness and usefulness at a mean 4.8 (range 4-5). Videos were relatable, relevant, and motivating with 90% respondents reporting ready intention to use in clinical practice. Conclusions: Veteran-specific animated video vignettes are received affirmatively by Veteran Affairs clinicians. These videos have potential to foster early engaged discussions about ACP.

The PREPARE for Your Care program increases advance care planning engagement among diverse older adults with cancer.

Advance care planning (ACP) is low among older adults with cancer. In a secondary analysis of randomized trial data, the authors compared the efficacy of the PREPARE for Your Care (PREPARE) website plus an easy-to-read advance directive (AD) with an AD only among older adults with and without cancer. Safety net, primary care patients in San Francisco were included if they were 55 years old or older, were English- or Spanish-speaking, and had 2 or more chronic conditions. The authors determined cancer diagnoses by using International Classification of Diseases, Ninth Revision/Tenth Revision codes. The primary outcome was new ACP documentation in the medical record at 15 months; the secondary outcomes were self-reported ACP engagement, ease of use, satisfaction, and depression/anxiety. The authors used mixed effects logistic and linear regression adjusted for prior ACP, health literacy, and clinician, including a cancer interaction term. Of 986 participants, 220 (22%) had cancer. The mean age was 63 years (SD, 6 years), 61% were women, 81% were of a minority race/ethnicity, 45% were Spanish-speaking, 39% had limited health literacy, and 27% had prior ACP. New ACP documentation was higher in the PREPARE arm versus the AD-only arm among participants with cancer (62% vs 43%; P = .01) and without cancer (38% vs 28%; P = .01), as was ACP engagement in both arms (P < .001), with no interactions by cancer. Ease of use and satisfaction were high, and depression/anxiety was low, with no differences by study arm or by cancer/no cancer. PREPARE plus an easy-to-read AD increased ACP documentation and engagement among diverse older adults with cancer more than an AD alone, with no increase in depression or anxiety between study arms or by cancer. PREPARE may help to decrease ACP disparities among patients with cancer. Advance care planning (ACP) is the process of sharing values, goals, and preferences for medical care, but engagement in ACP is low among older adults with cancer. Among 986 English- and Spanish-speaking older adults from a safety net hospital, an interactive, multimedia, web-based ACP program (PREPARE for Your Care at https://prepareforyourcare.org/) plus an easy-to-read advance directive increased ACP documentation and engagement more than an advance directive alone. There were no differences in this increase in ACP between older adults with cancer and older adults without cancer. Also, engaging in ACP did not result in increased depression or anxiety.

English and Spanish-speaking vulnerable older adults report many barriers to advance care planning.

Advance care planning (ACP) rates are low in diverse, vulnerable older adults, yet little is known about the unique barriers they face and how these barriers impact ACP documentation rates. Validated questionnaires listing patient, family/friend, and clinician/system-level ACP barriers and an open-ended question on ACP barriers. Two San Francisco public/Department of Veterans Affairs hospitals. One thousand two hundred and forty-one English and Spanish-speaking patients, aged 55 and older, with two or more chronic conditions. The open-ended question on ACP barriers was analyzed using content analysis. We conducted chart review for prior ACP documentation. We used chi-square/Wilcoxon rank-sum tests and logistic regression to assess associations between ACP barriers and demographic characteristics/ACP documentation. Participant mean age was 65 ± 7.4 years; they were 74% from racial/ethnic minority groups, 36% Spanish-speaking, and 36% with limited health literacy. A total of 26 barriers were identified (15 patient, 4 family/friend, 7 clinician/system-level), and 91% reported at least one ACP barrier (mean: 5.6 ± 4.0). The most common barriers were: (patient-level) discomfort thinking about ACP (60%), wanting to leave health decisions to "God" (44%); (family/friend-level) not wanting to burden friends/family (33%), assuming friends/family already knew their preferences (31%); (clinician/system-level) assuming doctors already knew their preferences (41%), and mistrust (37%). Compared with those with no barriers, participants with at least one reported barrier were more likely to be from a racial/ethnic minority group (76% vs 53%), Spanish-speaking (39% vs 6%), with fair-to-poor health (48% vs 34%), and limited health literacy (39% vs 9%) (p < 0.001 for all). Participants who reported barriers were less likely to have ACP documentation (adjusted odds ratio=0.64, 95% confidence interval [0.42, 0.98]). English- and Spanish-speaking older adults reported 26 unique barriers to ACP, with higher barriers among vulnerable populations, and barriers were associated with lower ACP documentation. Barriers must be considered when developing customized ACP interventions for diverse older adults.

English- and Spanish-Speaking Vulnerable Older Adults Report Many Unique Barriers to Advance Care Planning (W215A)

1.Identify common barriers to advance care planning for diverse English- and Spanish-speaking older adults.2.Recognize which vulnerable subpopulations report the most barriers to advance care planning.3.Recognize that barriers to advance care planning are associated with lower rates of ACP documentation (e.g. advance directive, POLST). Advance care planning (ACP) rates are low in diverse, vulnerable older adults, yet little is known about the unique barriers they face and how these barriers impact ACP documentation rates. To describe patient-reported barriers to ACP among older adults and the association between barriers and ACP documentation. We used baseline data from 1241 English and Spanish-speaking patients enrolled in two trials at two safety-net San Francisco hospitals. We used validated questionnaires to ask participants about ACP barriers using a list of patient, family/friend, and clinician/system-level barriers and an open-ended question, analyzed using content analysis. We conducted chart review for prior ACP documentation. We used Chi-square/Wilcoxon rank-sum tests and linear/logistic regression to assess associations between ACP barriers and demographic characteristics/ACP documentation. Participant mean age was 65+7.4 years; they were 74% racial/ethnic minority groups, 36% Spanish-speaking, and 36% with limited health literacy. 26 barriers were identified (15 patient, 4 family/friend, 7 clinician/system-level), and 91% reported ≥1 ACP barrier (mean: 5.6±4.0). The most common barriers were: (patient-level) discomfort thinking about ACP (60%), wanting to leave health decisions to “God” (44%); (family/friend-level) not wanting to burden friends/family (33%), assuming friends/family already knew their preferences (31%); (clinician/system-level) assuming doctors already knew their preferences (41%) and mistrust (37%). ACP barriers were more common among racial/ethnic minorities vs. non-minorities (76% vs. 53%), Spanish- vs. English-speakers (39% vs. 6%), and those with fair-to-poor vs. good-to-excellent health (48% vs. 34%) or limited vs. adequate health literacy (39% vs. 9%) (p<0.001 for all). Participants who reported barriers were less likely to have ACP documentation (adjusted OR = 0.64, 95% CI [0.42, 0.98]). English- and Spanish-speaking older adults reported 26 unique barriers to ACP, with higher barriers among vulnerable populations, and barriers were associated with lower ACP documentation.

Factors influencing palliative care referral for hospitalised patients with heart failure: an exploratory, randomised, multi-institutional survey of hospitalists and cardiologists

ObjectiveTo identify factors influencing cardiologists’ and hospitalists’ decisions regarding palliative care referral among hospitalised patients with advanced heart failure.DesignAn exploratory, randomised vignette-based survey.SettingCardiology and hospitalist divisions at three Michigan State...

Barriers and Facilitators of Advance Care Planning for Older Adults with Sickle Cell Disease

Background Life expectancy for individuals with sickle cell disease (SCD) has improved significantly in the last 50 years, creating a new population of older adults with SCD; however, life expectancy of adults with SCD is still up to 30 years shorter than African Americans in the general population and much lower than whites. SCD complications cause significant morbidity, requiring patients to make complex decisions about end of life care. Yet, there is a paucity of literature on SCD advance care planning (ACP), to guide providers on how to address ACP in this population. Thus, the purpose of this study was to assess barriers and facilitators to ACP for older adults with SCD. Methods We recruited 19 older adults with SCD (age &amp;gt; 50) from a comprehensive SCD center in the Southeastern United States. We conducted semi-structured interviews by phone or in person. Interview questions addressed aging with SCD, living beyond SCD life expectancy, experience with health care, experience with end of life care, comfort discussing death and end of life care, presence and nature of prior ACP discussions, and preferences for future ACP discussions. Audio-recorded interviews were transcribed verbatim. The data were analyzed using conventional content analysis. Results The mean age of participants was 57 years (range 50-71) and 47% (n = 9) were female. Most participants were diagnosed with SCD several years after birth and were told that they were not expected to live past age 18. Four of 19 participants had written advanced directives. Most participants were comfortable and willing to discuss ACP and thought that SCD ACP discussions should ideally start in early adulthood. Barriers to ACP included lack of communication, inappropriate contexts for ACP discussions, lack of trust, difficulty navigating ACP documents, and spirituality (Figure 1). Lack of communication included limited to no communication from trusted healthcare providers about ACP preferences. Inappropriate contexts for ACP discussions included being approached at difficult times by unfamiliar providers, such as being asked to complete advance directives while sick in the hospital by a provider who did not know the patient well. Trust was a barrier, as several participants were concerned that being asked about ACP while sick meant providers were giving up on them; others were unsure if they could trust providers or family members to carry out their end of life wishes as written. They reported difficulty navigating ACP documents and several participants incorrectly assumed a lawyer was required to finalize ACP documents. Finally, spirituality was a barrier as some participants reported that end of life planning was inconsistent with their religious beliefs. Facilitators of ACP included discussion at the right time, provider familiarity and knowledge, presence of family, and assistance in completing ACP documents. Participants expressed a desire to have an opportunity to openly communicate their end of life wishes with their provider when they were not sick in the hospital. They preferred discussing ACP with a provider whom they had a good relationship with, was familiar with their history, and they perceived was knowledgeable about SCD. Participants identified their SCD provider, PCP, or pulmonologist as suitable providers to talk to about ACP. Most preferred their family to be present during the ACP discussion. Those that had already completed advance directives at the time of the study received assistance from someone outside the health system to do so, such as help from their church, a lawyer, or their family. Conclusion Older adults with SCD expressed a desire for communication about ACP from trusted providers who are knowledgeable about SCD and want to have ACP conversations when they are feeling well. In addition, having the patient's family present and giving them assistance may increase the patient's comfort in completing their advance directives. The lack of communication from trusted providers or communication from unfamiliar providers about ACP during hospitalizations for acute complications are major barriers to creating advance directives for older adults with SCD. Future research is needed to obtain providers' perspectives on barriers to initiating conversations about ACP with adults with SCD. We will use these results to inform development of patient-centered and culturally-sensitive interventions to improve ACP in adults with SCD. Disclosures Strouse: Takeda: Research Funding.

The Impact of Prior Advance Care Planning Documentation on End-of-Life Care Provision in Long-Term Care.

BackgroundThe impact of prior advance care planning (ACP) documentation on substitute decision-makers’ (SDMs) knowledge of values for end-of-life (EOL) care, and its correlation with SDM satisfaction with EOL care provision, have not been assessed in long-term care (LTC).MethodsA cross-sectional survey of 2,595 SDMs from 27 LTC homes assessed: 1) knowledge of pre-existing ACP documentation and values for EOL care, and 2) the importance and satisfaction of EOL care provision in LTC. Knowledge of values for EOL care was compared to administrative documentation. Importance and satisfaction were plotted on a performance-importance grid. Multiple linear regression assessed whether knowledge of pre-existing ACP documentation correlated with satisfaction.ResultsThe response rate was 25% (658/2,595); 69% of LTC residents had pre-existing ACP documentation. Discordance was noted between SDMs’ knowledge of values for EOL care and administrative documentation. Pre-existing knowledge of ACP documentation was not correlated with EOL care provision satisfaction. Priority areas for increasing satisfaction include illness management, SDM communication, and relationships with LTC clinicians.ConclusionsThe discordance between SDMs’ knowledge of values for EOL care and formal documentation needs to be addressed. Although pre-existing ACP documentation does not impact satisfaction, EOL care provision could be improved by targeting illness management, SDM communication, and relationships with LTC clinicians.

Health Literacy Matters More Than Experience for Advance Care Planning Knowledge Among Older Adults

Advance care planning (ACP) engagement is low among vulnerable populations, including those with limited health literacy (LHL). Limited knowledge about ACP may be a modifiable mediator of the relationship between LHL and ACP. Our goal was to determine whether health literacy is associated with ACP knowledge. Cross-sectional design. A public health delivery system and Veterans Affairs Medical Center in San Francisco, CA. English- and Spanish-speaking patients (N = 1400). ACP knowledge was assessed with seven validated multiple-choice questions. Health literacy was measured using a validated scale. Sociodemographic measures included age, sex, language, education, race, health status, and social support. Prior ACP experience was defined as having documented legal forms and/or goals-of-care discussions in the medical record. We used Kruskal-Wallis tests and linear regression to examine associations of ACP knowledge with LHL, prior ACP experience, and sociodemographic factors. Mean age of participants was 65 (±10) years, 48% were women, 34% had LHL, 32% were Spanish speaking, 47% had high school education or less, and 70% were nonwhite. Mean 7-point knowledge scores were lower for those with limited vs adequate health literacy (3.8 [SD = 1.9 vs 5.5 (SD = 1.7); P < .001). In multivariable analysis, ACP knowledge scores were 1.0 point lower among those with LHL; 0.6 points lower among Spanish speakers and those with high school education or less; and 0.5 points lower among individuals of nonwhite race (P < .001 for all). Knowledge scores were 0.02 points lower per year of older age (P = .007) and 0.01 points higher per point of greater social support (P = .005). Prior ACP experience was not associated with knowledge after adjustment (P = .7). Health literacy and sociodemographics are stronger predictors than prior ACP experience of ACP knowledge. This study suggests that providing easy-to-understand ACP materials is paramount and should be offered even if patients have previous experience with the ACP process. J Am Geriatr Soc 67:2151-2156, 2019.

Introducing Goals of Patient Care in Residential Aged Care Facilities to Decrease Hospitalization: A Cluster Randomized Controlled Trial

ObjectivesThe “Goals of Patient Care” (GOPC) process uses shared decision making to incorporate residents' prior advance care planning (ACP) or preferences into medical treatment orders, guiding health care decisions at a time of clinical deterioration should they be unable to voice their opinions. The objective was to determine whether GOPC medical treatment orders were more effective than ACP alone in preventing emergency department (ED) visits (no hospitalization), ED visits (with hospitalization), and deaths outside the residential aged care facility (RACF). DesignThe study was a prospective cluster randomized controlled trial, with the intervention being the completion of GOPC process by a geriatrician, following a shared decision-making process, incorporating ACP documents or residents' preferences. Setting and participantsThe study took place in 6 RACFs in Northern Metropolitan Melbourne, Australia. Eligible participants included all permanent residents in participating RACFs for whom written informed consent could be obtained. MeasuresThe primary outcome was the effect on ED visits and hospitalizations at 6 months. Secondary outcomes included a difference in hospitalization rates at 3 and 12 months, total hospital bed-days, and in-RACF and in-hospital mortality rates. ResultsMore than 75% of residents participated, 181 randomized to Intervention and 145 to Control. The intervention did not result in a statistically significant change at 6 months; however, at 12 months, it reached statistical significance with 40% reduction in ED visits and hospitalizations compared with Control, with an incident rate ratio 0.63 [95% confidence interval (CI) 0.41-0.99, P = .044]. Mortality rates show increased likelihood of dying in the RACF, with statistical significance at 6 months at a relative risk ratio of 2.19 (95% CI 1.16-4.14, P = .016). Conclusions and implicationsIn the RACF population, GOPC medical treatment orders were more effective than ACP alone for decreasing hospitalization and likelihood of dying outside the RACF. GOPC should be considered by both RACF staff and health services to decrease hospitalization and in-hospital mortality.

Do Advance Care Panning Tools Incorporate Trade-offs About Values? A Systematic Review

During serious illness or at the end of life (EOL), patients or their surrogates may need to make difficult decisions about medical treatments. Decisions about treatments such as the use of life-sustaining treatments should be informed by a person's values, sometimes through prior advance care planning (ACP). Well-designed ACP decision-aids help patients recognize trade-offs between values (e.g. having more time versus avoiding machines). Literature shows that patients have difficulty recognizing trade-offs in EOL treatments. We conducted a systematic review of ACP tools to describe how values clarification is addressed in English language ACP tools and how many incorporated trade-offs. We obtained tools from a systematic review published in 2014, then searched literature from 2014-2017. The two authors divided and scanned titles/abstracts and reviewed relevant full text articles to include articles. Using the final included set, we each independently extracted information on characteristics of the ACP tool, whether the values clarification question wording incorporated trade-offs, and we coded the wording according to a published taxonomy of values relevant to EOL treatment decisions. We reviewed each other's data extraction and achieved consensus through discussion. Twenty-seven ACP tools were included. Five tools incorporated trade-offs, almost all by a single item asking about quality versus quantity of life in regards to accepting life-sustaining treatments. The tools addressed: longevity (78%), emotional well-being and relationships (67%), autonomy and independence (63%), adhering to religious or spiritual beliefs (63%), maintaining bodily integrity (59%), avoiding burdensome symptoms (56%), maintaining cognitive function (52%), maintaining physical function (37%), preferred place of death (26%) and not being a financial burden (7%). A minority of ACP tools explicitly incorporated trade-offs when asking patients to consider their values. Attention should be given in developing ACP tools to helping patients recognize trade-offs in values, rather than simply asking which are important.

2439 Depression, anxiety, and planning for the future: Associations with advance care planning

OBJECTIVES/SPECIFIC AIMS: Millions of diverse, older adults live with serious and chronic illness for which they will face complex, ongoing medical decisions. Advance care planning (ACP) has been conceptualized as a health behavior that supports adults in understanding and sharing their values, goals, and preferences for future medical care. Depression and anxiety are known barriers to participation in health behaviors. It is unknown whether depression and anxiety are associated with ACP participation or with patients’ values for future medical care. Understanding whether depression and anxiety are associated with ACP would be important to tailor ACP interventions. METHODS/STUDY POPULATION: In total, 908 English-speaking and Spanish-speaking participants ≥55 years of age were recruited from a San Francisco county hospital. We measured depression (Patient Health Questionnaire 8-item scale) and anxiety (Generalized Anxiety Disorder 7-item scale), dichotomized into none-to-mild Versus moderate-to-severe. We measured ACP engagement using a validated survey of Behavior Change Processes (e.g., knowledge, self-efficacy, readiness; 5-point Likert) and Action Measures (e.g., ask, discuss, and document one’s wishes; yes/no). We elicited values concerning life extension categorized as “life is always worth living no matter the health situation” Versus “some health situations would make life not worth living.” To explore associations, we usedχ2, Mann-Whitney tests, linear and logistic regressions. RESULTS/ANTICIPATED RESULTS: Mean participant age was 64 years±6, 80% were non-White, 40% had limited literacy, 45% were Spanish-speaking, and the prevalence of depression and anxiety was 12% and 10%, respectively. Depression and anxiety were not associated with ACP Engagement, p&gt;0.05. However, participants with depression had an increased odds of reporting “some health situations would make life not worth living” than those not depressed, p=0.02. In multivariate linear and logistic regression, controlling for age, gender, literacy, and health status, having depression increased the odds of not valuing life extension OR 2.9 (CI: 1.7–4.9). Anxiety was not associated with values concerning life extension, p&gt;0.05. DISCUSSION/SIGNIFICANCE OF IMPACT: Depression and anxiety were not associated with prior ACP engagement suggesting engaging patients in ACP does not increase these conditions. However, depression was associated with an increased odds of not valuing life extension and, therefore, may influence treatment choices. Longitudinal randomized controlled trials of an ACP intervention are currently underway to investigate these associations further.

Awareness and Attitudes of Community-Dwelling Individuals in Singapore towards Participating in Advance Care Planning

Advance care planning (ACP) is an important aspect of end-of-life care that has been shown to improve patient autonomy in decision-making and reduce stress for surviving family members. Given the rapidly ageing population in Singapore, a greater emphasis on end-of-life care planning is needed. This study therefore sought to examine the awareness and attitudes of the general Singaporean community towards participating in ACP, which are not known hitherto. A 24-item interviewer-administered questionnaire was constructed and administered via door-to-door survey amongst community-dwelling residents living in Housing and Development Board (HDB) flats across Singapore, selected via a two-stage stratified random sampling. Of the 406 completed surveys, 14.4% of respondents had heard of ACP (n = 58), mostly through the media (67.9%), from family and friends (21.4%) and healthcare providers (21.4%). Only 26.8% of those who had previously heard of ACP knew how to begin an ACP discussion and 12.5% of them had a prior ACP discussion. After education, the majority of respondents were willing to begin an ACP discussion (n = 236, 60.1%). Being of an older age, having a life threatening illness, and having more knowledge about ACP were significant factors associated with willingness to have an ACP discussion. Barriers included perceiving oneself as still healthy and preferring the family to make decisions instead. There is a low awareness but high expressed willingness to engage in an ACP discussion amongst the Singaporean community. More efforts are needed to educate the public about ACP, engage the family unit and correct the present misconceptions.