An advance care planning long‐term care initiative in response to COVID‐19

Abstract

Objective Describe a systematic approach to address advance care planning (ACP) during a COVID‐19 outbreak and its impact on the incidence of new do‐not‐hospitalize (DNH) directives among long‐term care (LTC) residents. Design Prospective quality improvement initiative. Setting Two long‐term chronic care campuses within a large academic healthcare organization. Participants LTC residents with activated healthcare proxies who lacked DNH directives based on documentation in the electronic medical record (EMR) as of April 13, 2020. Intervention Using a structured discussion guide, trained healthcare staff from various disciplines contacted the residents' proxies to conduct COVID‐19 focused ACP discussions. Residents without DNH directives with COVID‐19 were prioritized. Preferences ascertained in the discussion were communicated to the residents' primary care teams and directives were updated in the EMR accordingly. Measurements Residents who acquired a new DNH directive during the study initiative were determined using the EMR. Subsequent changes in DNH orders, hospitalizations, and deaths were ascertained by retrospective chart review from the date of new DNH through August 5, 2020. Results At baseline, 315/581 (54%) of LTC residents did not have a DNH directive. Their mean age was 87 (±9) years and 70% were female. Following ACP discussions, 124/315 (39%) of residents acquired a new DNH directive. Among residents with new DNH directives, 65/124 (52%) were diagnosed with COVID‐19 from April 2, 2020 to May 21, 2020. During follow‐up, only 6/124 (4.8%) residents had their DNH order reversed, 2/124 (1.6%) residents were hospitalized with illnesses unrelated to COVID‐19, and 29/124 (23%) died. Conclusions There was substantial opportunity to increase the proportion of LTC residents with DNH orders during the COVID‐19 pandemic through a systematic ACP initiative which utilized real‐time EMR data. New directives to avoid hospitalizations were sustained among the majority of residents beyond the peak of the pandemic.

Occurrence of Advance Care Planning and Hospital Course in Patients Admitted for Coronavirus Disease 2019 (COVID-19) During the Pandemic

“… 37 Similar results were also seen by Canter et al, 38 which showed a substantial increase in DNR, do-not-intubate (DNI), and DNH orders after ACP conversations. Through a systematic proactive ACP initiative, Berning et al 39 showed that the use of structured discussion guides and training increased new DNH directives to 39% with only 5% of those orders being revered after diagnosis of COVID-19. In addition, several studies have shown the benefit of the use of telehealth to promote ACP conversations and the completion of forms like electronic medical orders for life-sustaining treatments during the pandemic.…”

“… 10 - 13 In the setting of the COVID-19 pandemic, there have been multiple interventions developed, such as communication guides, 14 - 16 new workflows 17 and COVID-19 goals of care videos, 18 to help providers conduct ACP discussions in the context of COVID-19 infection. 19 - 23 However, despite the overwhelming consensus on their necessary roles during the COVID-19 pandemic, the rates of ACP for patients admitted for COVID-19 remains understudied. 6 , 8 , 24 - 26 …”

Advanced Care Planning (ACP) in the early phase of COVID-19: A rapid review of the practice and policy lessons learned

“…PRS indicated increasing emphasis on ACP for vulnerable groups, such as older adults (Berning et al, 2021; Biswas et al, 2020; Farrell, Ferrante, et al, 2020; Farrell, Francis, et al, 2020; Gilissen et al, 2020; Kotze & Roos, 2020; Kuzuya et al, 2020; Rivet et al, 2020; Valeri et al, 2020; Vipperman et al, 2021; West et al, 2021; Ye et al, 2021), and high-risk groupswith pre-existing life-limiting and/or chronic conditions, such as HIV (Nguyen et al, 2021), cancer or organ failure (Biswas et al, 2020; Rivet et al, 2020; Salins et al, 2020), cardiovascular/cerebrovascular disease (Liao et al, 2020) or severe mental illness (Kotze & Roos, 2020). These recommendations were supported by commentaries (Reja et al, 2020) (Kluger et al, 2020), (Prost et al, 2021).…”

Stakeholders' views on priorities essential for establishing a supportive environment for clinical trials in nursing homes

“…For example, this team understood the nursing home workflow and were flexible and willing to adapt by engaging retired staff members and redeploying other staff to implement their intervention. 6 While temporary staffing was discontinued at the completion of the study, this approach could be replicated during future outbreaks or crises. These researchers also emphasized the importance of engaging leaders to serve as champions for the project as a factor crucial to their success.…”