Careful and early charting of a hospice patient’s end-of-life wishes reduces the chance of an unwanted hospitalization, according to the results of a recent investigation.1 “Patients are making transitions at the end of life, and documentation across care settings is not always consistent,” says Laura Prater, MPH, MHA, the study’s lead author and a postdoctoral researcher in the division of general internal medicine at The Ohio State University College of Medicine.
Researchers analyzed electronic health record (EHR) data for 1,185 cancer patients who were referred to hospice in 2014 and 2015. “We wanted to see if documentation of advance care planning was linked to improved outcomes. The study’s findings supported this,” Prater reports.
A do-not-resuscitate order placed in the EHR before a patient’s last 30 days of life reduced hospitalization rates. Also, notes on end-of-life planning also reduced admission rates, particularly when the notes were created six months before a patient’s death.
If the patient’s wishes are not documented consistently across care settings, unwanted care may be given. “Just uploading a scanned document didn’t have the same improvement in outcome,” Prater notes. Ideally, the discussion happens early — even on the outpatient side, at a time when the patient can fully participate. “Earlier vs. later documentation can hopefully [help] avoid some of these crises that we see at the end of life,” Prater says.
In their own clinical practice, the researchers had seen “what happens when we pass the buck and defer responsibility for talking to patients about their care preferences,” says Seuli Bose-Brill, MD, the study’s senior author.
Clinical ethicists usually become involved only after there is a serious conflict over how to proceed with care. “The vast majority of clinical ethics consultations result from advance care planning that was suboptimally administered,” says Bose-Brill, a clinical ethicist and a primary care physician at Ohio State Wexner Medical Center.
Even when patients present with a life-limiting illness such as advanced heart failure, where any admission could result in critical illness or death, there often is no advance care planning in place. It would come as no surprise to clinicians if the patient ends up in the ICU — and any admission could result in critical illness or death. “In those situations, attention needs to be paid, just like we do with other aspects of care, to the patient’s care preferences,” Bose-Brill says. At a minimum, the patient should know a surrogate decision-maker with whom he or she is comfortable. Clinicians should talk to patients about their prognosis. For instance, the clinician might ask: If you are in the ICU and need to be on long-term ventilation support, when would you want to transition to comfort care vs. curative therapy?
“There needs to be an intentionality on who is documenting the advance care plans, and who’s making sure it’s correct and scanned in,” Bose-Brill says. This requires interdisciplinary collaboration, something on which ethicists are well-versed. “Ethicists can guide challenging conversations about patient preferences,” says Bose-Brill, noting that this is true even if it is not the direct question the ethicist is asked to address. “We can remind the team it should be addressed, and where it should be documented,” Bose-Brill says.
- Prater C, Wickizer T, Bower JK, Bose-Brill S. The impact of advance care planning on end-of-life care: Do the type and timing make a difference for patients with advanced cancer referred to hospice? Am J Hosp Palliat Care 2019; May 14:1049909119848987. doi: 10.1177/1049909119848987. [Epub ahead of print].