Medical & Clinical Reviews

Description

Advance Care Planning (ACP) allows patients to make decisions about healthcare and end-of-life preferences and document their decisions in forms such as advance directives, living wills, health care proxy forms, do-not-resuscitate orders, and physician-orders for life-sustaining treatment. Cancer patients value effective communication and information surrounding ACP. Moreover, when ACP is addressed and implemented, outcomes include greater quality of communication, family satisfaction, concordance between patient preferences and healthcare interventions, and quality of end-of-life care. The American Society of Clinical Oncology’s Quality Oncology Practice Initiative recommends documenting an advance directive and/or ACP discussions by the 3rd office visit. However, cancer patients often lack ACP knowledge and documentation, even when terminally ill. This gap may arise from lack of patient knowledge about the prognosis or disease natural history, anxiety surrounding end-of-life issues, or poor communication between patients and providers. Furthermore, even patients with knowledge of ACP often lack formal ACP documents. The literature specific to gynecologic oncology populations regarding ACP knowledge and uptake is limited, but suggests a gap between patient-reported importance of ACP and ACP document completion rates.

Gynecologic Oncology Patient Factors Associated with Decreased Rates of ACP Completion

Before our study, our institution had no formalized pathway to screen and educate patients regarding ACP or to track ACP discussions or documentation. Patients could be referred to social work for ACP, but only if providers recognized the need to make this referral. Moreover, we did not know the magnitude of the gap between patient-perceived importance of ACP and completed ACP documents among gynecologic oncology patients at our institution. Gynecologic oncology patient factors associated with decreased rates of ACP completion and developed a scale to gauge patient readiness to discuss ACP. Although research in other medical disciplines suggests that the most effective methods of increasing ACP completion include informative material, conversations during clinical visits, and assistance with ACP forms, no such studies have been conducted specifically in gynecologic oncology. To address these gaps, we conducted a single-institution Quality Improvement (QI) project, based on the Plan-Do-Check-Act (PDCA) model, to assess and improve ACP discussions and documentation. First, we completed a baseline needs assessment to gauge ACP awareness among gynecologic oncology patients and identify their preferences for discussing ACP.

Gynecologic Oncology Patients Attitude towards ACP

We then used these data, along with evidence-based strategies to increase completion of ACP documents, to develop and implement an intervention to improve patient knowledge and completion of ACP documents. Our primary outcome in the intervention was patient self-report of having discussed ACP with their gynecologic oncologist. Secondary outcomes included differences in ACP knowledge and completion of ACP documents between those who did and did not receive the intervention. This study provides valuable information regarding gynecologic oncology patients' attitudes toward ACP and can be used to improve uptake of ACP documentation. First, we found that patients desire ACP discussions and prefer to have these discussions in the outpatient setting with their gynecologic oncologist. Second, offering ACP resources in the outpatient setting is feasible. Third, receipt of ACP resources improved patient-centered outcomes including increased ACP discussions with their gynecologic oncology provider and improved proficiency regarding how to complete an ACP document. However, our intervention did not increase overall ACP documentation, indicating that more research is needed to test behavioral interventions that assess and promote patient readiness to bridge the gap between expressed interest in ACP and actual documentation.