Implementation of Advance Care Planning Discussions and Completion of Advance Directives

Abstract

Problem: In the Heart Failure Clinic of a tertiary care, academic institution, the advanced directive (AD) completion rate is marginal and the documentation surrounding advance care planning (ACP) discussion is suboptimal. A retrospective chart review between September and November 2020 revealed a 15% AD completion rate with no documentation of ACP discussions. The impact of not having an AD on record potentiates misalignment of the patient’s future goals and wishes, in addition to unnecessary life-sustaining measures utilized, and prolonged hospitalizations. Purpose: The purpose of this quality improvement (QI) project was to implement and monitor the effectiveness of a multistage approach to documenting ACP discussions and completing ADs. Methods: This QI project took place in an ambulatory heart failure clinic from September 2021 - December 2021. The individuals involved in carrying out this QI project included a multidisciplinary team impacting nearly 200 patients during the implementation phase. The stakeholders instituted evidence-based structure and workflow changes to attain the goals of this project, including integration of an ACP discussion and end-of-life goals documented via the utilization of smart phrases within the electronic health record (EHR). An inpatient heart failure census was audited daily for patient enrollment. Smart phrase utilization reports were extracted weekly from the EHR while ADs were manually totaled on a weekly basis from the EHR. Results: This project yielded a 95% (177/187) consistent trend in documentation of ACP conversations. Initial shifts were noted in the documentation of patient goal alignment totaling 73% (136/187). A total of 18% (34/187) of ADs were completed which was an increase of 3% in comparison to the preceding year. Conclusion: The aim of this project was to enhance clinical practice at a heart failure clinic related to standardizing ACP discussions to increase AD completion rates. Future implications include assessment of literacy levels and comprehension of ADs. Translating this evidence into practice was reasonable, yet limitations include episodic care provided post-discharge in this care transition clinic, highlighting the need to engage with community primary care providers (PCP) to further address this practice gap.