Intervention to Improve Advanced Care Planning in a Family Medicine Office

Context: Goals of care discussions often occur in the hospital setting when patients are acutely ill. This timing often relies on families and healthcare providers to make difficult decisions in a time of stress. A shift towards having these discussions in the outpatient setting would make it easier for healthcare providers to deliver care consistent with patients’ wishes.

Objective: The aim of this study is to assess if a standardized pre-charting process that identifies patients without an Advanced Care Planning (ACP) document and provide those patients with a blank ACP document in a pre-stamped, pre-addressed return envelope increases ACP completion rates.

Study Design and Analysis: We performed a randomized control trial. Investigators reviewed the schedules of eight physicians and identified adults aged 50 or older without an ACP document on file in the electronic medical record (EMR). Patients were randomized into two groups: an intervention group who received a blank ACP document in a pre-stamped, pre-addressed return envelope, and a control group who received standard of care. Investigators reviewed the EMR two approximately 2 months after each visit to record if an ACP document was completed. Investigators used a chi square analysis to compare the response rates between the groups.

Setting: Family Medicine clinic in Fairfax, VA.

Results: 99 patients were identified for participation between March 2022 and June 2022. 53 patients were assigned to the intervention and 46 assigned to the control group. Two months after the intervention, 5 patients (9.4%, n=53) in the intervention group had submitted an ACP document and 1 patient (2.2%, n =46) in the control group had submitted an ACP document. There was no difference in the return rates for the groups, p=0.13.

Conclusion: ACP completion rates were not statistically different between the two groups. We hypothesized that lack of a physical document prevented ACP completion, however, it seems other barriers such as provider or patient discomfort surrounding goals of care discussions or lack of time dedicated to such discussions prevent completion. Clinical effort may be better spent creating time for providers to have dedicated discussions about advanced care planning.