The ongoing COVID-19 pandemic has brought to the forefront the importance of advance care planning. According to research presented at the virtual 2021 American Society of Clinical Oncology Quality Care Symposium, pairing a highly trained nurse practitioner with a primary care team to engage patients in this process can lead to better healthcare utilization and higher quality end-of-life care.
Results of the pilot program demonstrated the ability of patients to formalize their limits to treatment after only a single advance care planning discussion, and subsequent care aligned with these preferences. In addition, an overwhelming majority of patients found the intervention to be meaningful.
“The COVID-19 pandemic has highlighted the critical importance of advance care planning and the need for improved patient engagement,” noted lead study investigator Aliya Gessling, MD, Internal Medicine Specialist, University of California, Davis Health, in Sacramento. “Prior studies have demonstrated success at educating primary providers to conduct these discussions, but given the limitations imposed by COVID-19 restrictions, this novel and highly cost-effective process was piloted with success.”
As Dr Gessling explained, advance care planning is a process to help patients plan for future medical care in the event that they are unable to participate directly in their own care. It often involves conversations regarding life-sustaining treatments, such as cardiopulmonary resuscitation, intubation, or intensive care unit care.
“These crucial discussions between healthcare providers, patients, and loved ones are required to reflect a patient’s values, goals, and ultimately their choices for life-sustaining treatments,” said Dr Gessling. “Unfortunately, many patients miss chances to discuss these choices and may receive undesired treatments at the end of life, resulting in increased healthcare utilization and patient suffering.”
“The COVID-19 pandemic presents a unique opportunity to increase engagement and awareness of how health can deteriorate unexpectedly,” she added.
For this pilot program, Dr Gessling and colleagues sought to improve the recognition of patients who are appropriate for advance care planning, and to identify a process to educate patients and complete necessary documentation of life-sustaining treatment preferences.
To accomplish this, the Veterans Affairs (VA) Northern California Health Care System Hospice and Palliative Care Section partnered with Patient Aligned Care Teams to expand urgent outreach to high-risk patients needing life-sustaining treatment documentation. High risk was defined as age >80 years, having chronic obstructive pulmonary disease or asthma diagnosis, or having a Care Assessment Need Score >80.
An experienced Hospice and Palliative Care Section nurse practitioner contacted the patients to provide COVID-19 education, conduct a high-quality goals of care conversation, and complete life-sustaining treatment documentation. A representative cohort was then followed up to evaluate concordance of treatment for patients hospitalized or at the end of life with their documented preferences.
Between March 2020 and September 2020, the researchers identified a total of 910 patients who were high risk. Of these patients, 294 agreed to participate in the telehealth visit and complete documentation regarding life-sustaining treatment.
“More importantly, the intervention led 37% of patient participants to limit life-sustaining treatment after only one goals of care discussion,” said Dr Gessling. “As advance care planning is an ongoing process, future discussions with their providers should capture further patients who would limit treatment.”
In addition, 48% of patients created POLST [Physician Orders for Life-Sustaining Treatment] documentation whereas 43% completed advance directives. This additional documentation enables patients’ preferences to inform their care outside of the VA, said Dr Gessling.
The researchers discovered that more than 70% of patients who were hospitalized in the VA received care concordant with the newly documented treatment preferences. A postintervention survey also showed that patients found the outreach to be impactful and their preferences were documented correctly.
Dr Gessling and her team plan to expand their outreach to patients who are at lower risk and utilize a Patient Aligned Care Team to increase participation rates of telehealth visits.
“We will also continue to follow patients who participated longitudinally to assess for satisfaction, concordance of treatment during hospital stay, and potential cost-saving benefit to the healthcare system,” she concluded.
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