Original Research

Importance of Early Initiation of Advance Care Planning

Fed Pract. 2015 March;32(3):30-34

References

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This project endorses findings from a previous case study that demonstrated better patient-centered, goal-directed care results when patients have the opportunity to complete an AD, thereby improving health care quality and patient/family satisfaction.³ Previous studies suggested one way to increase the AD completion rate involves the PCP initiating a discussion with the patient.⁵ This project supports that conclusion.

Limitations

All the project providers expressed support regarding the importance of discussing ACPs with their patients. The major limitation identified by the project providers was time constraints in a busy primary care clinic. One provider suggested initiation of an EMR reminder once per year to prompt discussion. The same provider also recommended rescheduling an additional clinic visit to have an in-depth discussion regarding ACP.

Another limitation to this project involved the EMR. Currently, there is no way to have information in the postings section without a separate note. The project providers all agreed that it was not always possible to open a new note to use the template due to limited clinic time. This allowed information regarding health care surrogates and discussions regarding code status and organ donation to be embedded in a clinic note, which can make it difficult for other providers at different levels of care to effectively locate. Incorporating a method to allow information from an EMR reminder to be automatically placed in the postings section would alleviate this limitation.

A further limitation involved the setting. The VA provides care only to veterans. The project can be generalized to other VA primary care clinics, but generalizability beyond the VA may be limited.

This QI project took place over 3 months, another potential limitation due to the limited study period. Also, due to the short time frame of the project, a small sample size was used. Further investigation of this topic by expanding the time frame and sample size would further develop this body of knowledge.

The VA uses an EMR that is accessible to all VA providers locally and nationwide. Due to the nationwide network, expansion of the project would be possible with the support of facility leadership and the EMR reminder staff. By using the education and the template for discussion, the project could be replicated throughout the system.

Conclusion

Advance care planning and ADs should be a regular part of the health care process, especially for veterans with noncancer diagnoses, such as CHF and COPD. Clear communication about disease trajectory and prognosis are an important part of this discussion. Primary care providers are in the optimal setting to initiate this discussion.

This project supports previous findings that a PCP initiating or participating in the ACP discussion would result in an improved completion rate for ADs.⁵ Theoretically, improved AD completions result in patient-centered care, leading to higher patient satisfaction.

Acknowledgements
The authors would like to acknowledge the VA Northern Indiana Health Care System for its support of this project.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.