A New Standard for Advance Care Planning (ACP) Conversations in the Hospital: Results from a Delphi Panel

Abstract

BACKGROUND: Fewer than half of the US population has an advance healthcare directive. Hospitalizations offer a key opportunity for clinicians to engage patients in advance care planning (ACP) conversations. Guidelines suggest screening for the presence of "serious illness" but do not further specify how to prioritize the 12.4 million patients hospitalized each year. OBJECTIVE: To establish a normative standard for prioritizing hospitalized patients for ACP conversations. DESIGN AND SETTING: A modified Delphi study, with three iterative rounds of online surveys. PARTICIPANTS: Multi-disciplinary group of US-based clinicians with research and practical expertise in ACP. MAIN MEASURES: Indirect and direct elicitation of shortterm and 1-year risk of mortality that prompt experts to prioritize ACP conversations for hospitalized adults. MAIN RESULTS: Fifty-seven of 108 (52%) candidate panelists completed round 1, and 47 completed rounds 2 and 3. Panelists were primarily physicians (84%), with significant experience (mean years 23 [SD 9.8]), who either taught (55%) and/or performed research about ACP (55%). In round 1, > 70% of panelists agreed that all hospitalized adults ≥ 65 years should have an ACP conversation before discharge, but disagreed about the timing and content of the conversation. By round 3, > 70% of participants agreed that patients with either high (> 10%) short-term or high (≥ 34%) 1-year risk of mortality should have a goals of care conversation (i.e., focused on preferences for near-term treatment), while patients with low (≤ 10%) short-term and low (< 19%) 1-year risk of mortality warranted an ACP conversation (i.e., focused on preferences for future care) before discharge. LIMITATIONS: Use of case vignettes to elicit clinician judgment; response rate. CONCLUSIONS: Panelists agreed that clinicians should have an ACP conversation with all hospitalized adults over 65 years in an ACP conversation, adjusting the content and timing of the conversation conditional on the patient's risk of short-term and 1-year mortality.

Crucial Conversations for High-Risk Populations before Surgery: Advance Care Planning in a Preoperative Setting

“…[31][32][33] There are various barriers including time constraints, patient and disease characteristics, concern about receptivity, provider comfort and skill, disease trajectory, and prognostic uncertainty. [15][16][17]34 Change in patient's clinical condition, hospital admission, and surgery have been identified as possible key trigger points for ACP discussion. 10,14,16,17,34 Although it may be appropriate for patients to complete ADs as they become seriously ill, these findings suggest a missed opportunity for identifying higher risk patients early in the trajectory and facilitate goalsof-care conversations and complete ADs in advance.…”

“…[15][16][17]34 Change in patient's clinical condition, hospital admission, and surgery have been identified as possible key trigger points for ACP discussion. 10,14,16,17,34 Although it may be appropriate for patients to complete ADs as they become seriously ill, these findings suggest a missed opportunity for identifying higher risk patients early in the trajectory and facilitate goalsof-care conversations and complete ADs in advance. The preoperative clinic setting provides one touch point with the health care system with a cohort of identifiable high-risk patients and a potential target to initiate ACP discussions to reduce the proportion of patients who die or undergo resuscitation without prior ACP.…”

“…12,13 There is emerging support for ACP in high-risk surgery patients, 10,14 but the ideal timing of ACP discussions is not well defined. [15][16][17] Counseling and documentation of advanced directives (ADs) are not standard in preoperative clinics, though research has demonstrated its feasability. 18 Studies have shown completion of ADs is associated with lower readmission rates 19,20 and decreased ICU utilization.…”

Development of a theory-based video-game intervention to increase advance care planning conversations by healthcare providers

“…To further enrich this information, we performed (a) a Delphi-panel study to generate expert consensus guidelines for ACP conversations in the hospital; (b) semi-structured interviews with a sample of hospital leaders responsible for leading ACP quality improvement efforts across the country. The details of these studies have been published elsewhere [ 21 , 22 ].…”

Videogame intervention to increase advance care planning conversations by hospitalists with older adults: study protocol for a stepped-wedge clinical trial

“…In contrast, experts advocate that these conversations occur prior to discharge for all patients over the age of 65. 7 Efforts to facilitate ACP through textbased education, reminders, incentives and outreach by opinion leaders have had variable success. 8 9 How best to ensure that physicians meet this standard therefore remains unclear.…”