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INTRODUCTION: Many times, advanced care planning happens too late in patients with metastatic gastrointestinal cancer, patients and families are not educated on prognostic awareness and are often not well and poorly equipped to make informed end of life decisions.
AVAILABLE KNOWLEDGE: A Serious Illness Conversation guide was developed and implemented in a Boston hospital to aid practitioners (oncology nurse practitioners and oncologists) in facilitating advanced care planning. The aim of this study was to describe provider experience with the conversation guide and understand facilitators and barriers to implementation of advanced care planning.
METHODS: The Plan Do Study Act Method of quality improvement was used for this project. In a Boston gastrointestinal oncology clinic, three medical oncologists and two oncology nurse practitioners were trained in December 2018 on use and documentation of A Serious Illness Conversation Guide. We then reviewed the electronic medical records of 121 patients with metastatic gastrointestinal cancer, with a final sample size of 72 patients, receiving their care in a solo hospital to identify documentation of ACP, as well as health care utilization outcomes. Three cohorts were chosen for this analysis: Cohort 1: 25 newly diagnosed GI oncology patients, medical records were reviewed one year prior to the Serious Illness Conversation Training of providers (N = 25); Cohort 2: Medical records were reviewed on an additional 25 newly diagnosed GI oncology patients. They were eligible if they had newly diagnosed metastatic gastrointestinal cancer, this was three months prior to implementation of the Serious Illness Conversation training (N = 25); and the final Cohort, number 3: was a consecutive medical record review of 25 newly diagnosed patients with metastatic gastrointestinal cancer of the same trained 5 providers. This groups chart were reviewed three months after implementation of the training (N=25). We examined rates of ACP documentation and health care utilization (ED visits, hospitalizations, ICU admissions, code status, and ACP documentation and hospice use) in these cohorts. Literature review and listserv query were conducted to identify serious illness conversations.
INTERVENTION: Serious Illness Conversation Training was performed for each individual provider. Post training for 3 months, January 2019 - March 2019, weekly individual support was given to the 5 providers to reinforce workflow and documentation. Individual interviews were conducted post training in addition to chart reviews at 3 separate time points.
RESULTS: We enrolled 5 clinicians (3 medical oncologists and 2 oncology nurse practitioners) working in Gastrointestinal Oncology for Serious Illness Conversation Training. A chart review was performed on newly diagnosed patients with GI oncology
There were no differences between groups from time of diagnosis to an advanced care planning conversation. Patients in the post-intervention cohort had a shorter time from diagnosis to ACP (advanced care planning) conversation compared to those diagnosed one year prior to the intervention (B = -293.58, 95%CI -1003, 446, P = 0.407), but this was not statistically significant.
CONCLUSIONS: Training a small cohort of clinicians in Serious Illness Conversations, documentation in the EHR and coaching has aided these practitioners in implementation of formal advanced care planning that is accessible and visible. This study was conducted in GI oncology to demonstrate feasibility, barriers and facilitators to use of this guide. It also has illustrated that it is possible for earlier serious illness conversations leading to more informed advanced care planning.
Photopoulos, Rhaea N., "Implementing Serious Illness Conversations in a Gastrointestinal Oncology Clinic: A mixed method evaluation of a quality improvement initiative in a Boston Hospital" (2019). DNP Scholarly Projects. 20.