Advance Care Planning in Cancer: Using a Novel SOI Tool
Background: In cancer patients, advance directives are often not addressed until near the end of life. Medical care is often not aligned with patients’ goals given inconsistent communication between health-care providers, patients, and caregivers. At Boston Medical Center (BMC), a 496-bed Academic Safety Net Medical Center, a 6-months retrospective readmissions study was performed in 2014 on the hematology-oncology inpatient population. Of this study population, 21% had a documented DNR order, 12% received a Palliative Care consult, and 17% had an end of life discussion, demonstrating that goals of care are not consistently addressed.
Patients with advanced disease and high symptom burden benefit from palliative care and Advance Care Planning (ACP). Twaddle et.al (2007) urges the development of systematic methods that identify seriously ill patients early in their admission to address goals of care and improve access to palliative care.
- To standardize triggers for palliative care and/or ACP discussions in patients with advanced disease who are on the hematology-oncology inpatient service at BMC
- To standardize ACP documentation in the Electronic Medical Record (EMR) at BMC to facilitate communication amongst providers regarding patient/family goals.
Methods: A novel Severity of Illness (SOI) tool was created. ACP discussions and/or palliative care consults were indicated within 72 hours for those who score 4 or greater on the tool. Hematology-oncology providers were educated about the intervention during their grand rounds. All patients admitted to the hematology-oncology service from January 4, 2016 through June 30, 2016 were scored during multi-disciplinary rounds. Retrospective chart reviews determined whether the proposed interventions were completed. BMC providers created a new ACP documentation template in the EMR.
Results: 352 patients admitted to the Hematology/Oncology inpatient service were scored using the SOI tool. 111 (31.53 %) of these patients received a score of 4 or greater; 53 (47.74%) of this group received a palliative care consult and/or an ACP discussion.
Conclusions: The SOI tool promoted awareness among staff of the need for ACP discussions and/or palliative care involvement in identified patients. Although significantly increased from baseline, the tool alone did not translate into consistent application of these interventions. Barriers included inconsistent communication amongst providers. Only the senior resident was present at multi-disciplinary rounds and thus the attendings were not always informed about their patients' scores. Also, the ACP documentation template was inconsistently utilized, creating ambiguity regarding previously held ACP discussions. There is a need for education about ACP and exploration of beliefs about ACP among providers.
Implications: The data highlights the need to validate the SOI tool and formalize its use in the EMR. Further study, including interviews of providers, is needed to identify and address barriers and facilitators to standardizing triggers for ACP discussions and their documentation. This research has the potential to improve the quality of care cancer patients receive by consistent identification of patients that would benefit from ACP discussions and palliative care involvement.
- Sandhya Rao, MD
- Director, Palliative Care Consult Service
- Boston Medical Center
- 801 Massachusetts Ave
- Boston, MA 02118
- (617) 638-8000
- Alexandra Dobie, MSW, LCSW
- Diane Sarnacki, RN, MSN, AOCN
- Gretchen Gignac, MD
- Nicole Lincoln, MS, RN, APRN-BC, CCRN