Advance Care Planning in Advanced Heart Failure

Abstract

Background. Nearly one in five patients recently admitted to the hospital for heart failure will die within 30 days of discharge. Despite this poor prognosis, most do not recall discussing end of life preferences with a health care provider. Advance care planning helps to ensure that patients receive care that aligns with their goals and wishes, and helps engage them in shared decision making with providers in an ongoing and iterative process. The American College of Cardiology 2017 ACC Pathway for Optimization of Heart Failure Treatment recommends the use of patient decision aids followed by personalized advance care planning conversations. Local Problem. Patients with advanced heart failure who are referred to the outpatient heart failure clinic are generally not candidates for advanced interventions such as transplant or ventricular assist devices and are at high risk for hospital readmission. The purpose of this project was to align clinic practice with current recommendations by increasing the number of ACP conversations conducted by nurse practitioners through implementation of a patient video decision aid as a catalyst for conversation. Interventions. During a follow-up outpatient visit to the clinic after hospitalization, patients were shown a 6-minute video introducing them to ACP. The video describes levels of medical care they may choose if they become sick including life prolonging care, limited medical care, and comfort care. The video was shown by clinic staff, which included a community health worker, a nurse coordinator and an infusion nurse. Follow-up conversations were conducted by clinic nurse practitioners and documented in the electronic health record using standardized documentation. Data collection occurred over 10 weeks and data were compared to a comparable period in the preceding year. Results. Nearly one third (n=62, 30%) of eligible patients were shown the ACP video and nearly two thirds (n=40, 65%) of those who saw the video had a follow up ACP conversation with a nurse practitioner. This was a 20-fold increase from two documented ACP conversations in a comparable period in the preceding year. A chi-square test was used to test associations of the occurrence of ACP conversations at baseline and after the instructional video was added to visits. Using a nominal scale, patients seen after the video was added were significantly more likely to have an ACP conversation initiated by the provider (x 2 = 19.66, df = 1, p =<.001). There was no difference between the baseline and implementation groups in whether patients had an advance directive in the medical record (x 2 = .14, df = 1, p < .05). Conclusion. Use of a video decision aid was an effective way to increase the number of ACP conversations with patients who have advanced heart failure. The sustainability of this practice change hinges on access to appropriate patient video decision aids. The use of Medicare ACP billing codes may offset the cost of video access.