Targeted Team Approach Improves Engagement of Advance Care Planning

San Francisco, CA—Advance care planning (ACP) continues to be a vital part of comprehensive, patient-centered cancer care, but barriers to uptake and implementation remain. The results of a new study, however, show that a targeted team approach to ACP in a large community oncology practice has brought about improvements in communication and engagement in adults with metastatic cancer, thereby increasing the frequency of ACP referrals and counseling visits.

“By developing a focused and concerted process on ACP, the cancer center was able to show that patient engagement process markedly improved. A navigation process for identifying patients who would benefit from ACP counseling was also vital in increasing counseling visits,” said Sabrina Q. Mikan, PhD, RN, CNS, Clinical Nurse Specialist who coordinates the ACP program for Texas Oncology-­Austin Central.

As Dr Mikan reported at the recent Palliative Care in Oncology Symposium, ACP helps patients understand treatment options and offers them a voice in care decisions. However, these conversations are often delayed until times of crisis.

“We should be offering our patients the opportunity to visit with a trained nurse or advanced practice provider early in the care process, to talk openly about their wishes for medical treatment at the end of life. As providers, we need to know what we’re supposed to do if something happens,” said Dr Mikan.

Rather than discussing patients’ values and wishes when they are doing well and in treatment, medical directives are frequently addressed under stressful conditions, such as visits to the emer­­gency department. Providers are often reluctant to broach these difficult topics for fear of perturbing the patient, said Dr Mikan, but, in reality, patients are eager to have these dialogues.

“Patients are usually happy to talk to a nurse or advanced practitioner and complete a medical power of attorney and living will. Most people want those opportunities, and the critical one is knowing the medical power of attorney,” she said.

“We believe that this is the right thing to do for everybody within the oncology world, regardless of age or diagnosis,” she added.

My Choices, My Wishes

As Dr Mikan explained, Texas Oncology offers ACP services through the My Choices, My Wishes program. For this analysis, a process improvement was implemented at an early adopter stage of the program to increase ACP referrals and ACP counseling visits and to identify patient values using a questionnaire.

At a single cancer center, Dr Mikan and colleagues established a leadership team consisting of a practice director, a physician, a nurse manager, and a nurse practitioner.

The ACP leadership team outlined the workflows to be tested and assessed the outcomes of each goal over a period of 107 days. Barriers and challenges were identified and staff received ACP education.

Nurse practitioners and registered nurses (RNs) introduced ACP to patients during “chemo teaching,” when expectations for chemotherapy are outlined. Eligible patients were identified weekly by infusion RNs on the first day of chemotherapy, and given the Values Assessment instrument.

Desk RNs would speak with patients on the second day of chemotherapy to review symptoms and Values Assessment responses; at this time, RNs would offer ACP visits to patients.

“It became the team’s mission to offer this opportunity to every single patient,” she said.

ACP Visits Doubled

During the first 53 days of the project, 20 patients were identified on the first day of chemotherapy, 5 Values Assessments were completed, and 15 ACP visits occurred.

At the beginning of the study, the ACP team held weekly phone meetings to discuss the project status, said Dr Mikan, but after evaluation, the team switched to holding daily huddles. Communication each morning allowed RNs to identify patients on the first day of chemotherapy and convey this information directly to the entire team.

During the second 54 days, 94 patients were identified on the first day of chemotherapy, 46 Values Assessments were completed, and 27 ACP visits occurred.

Within 2 months, a 5-fold increase in patient identification and a 9-fold increase in Values Assessment completion were recorded, while ACP visits nearly doubled, said Dr Mikan. She attributes this success to the team’s collaborative effort. “It’s not just the doctors’ role or the nurses’ role,” she said. “It’s about getting ‘all hands on deck.’”

Furthermore, she added, the more patients who come for visits, the more accepted the program becomes. “As the project progressed, providers who were initially on the fence about this saw that patients want it and will make the effort to come to an appointment.”

Nevertheless, even Dr Mikan, who has spent most of her career in end-of-life care, was surprised at the level of patient interest. Since the program began, Texas Oncology has compiled a list of more than 300 patients who want to complete their advance directive.

Texas Oncology is currently working to implement My Choices, My Wishes ACP counseling at every one of its sites in Texas, and Dr Mikan continues to refine the program to ensure maximum patient benefit.

“Physicians are definitely on board now, and there’s a lot of passion at the nurse level. We’ve started this program at 55 other oncology practices and have 70 sites remaining. The key now is to make sure it’s sustainable by incorporating it into weekly and daily workflow,” she concluded.