Advance Care Planning Among Users of a Patient Portal During the COVID-19 Pandemic: Retrospective Observational Study

Abstract

Background Advance care planning is the process of discussing health care treatment preferences based on patients’ personal values, and it often involves the completion of advance directives. In the first months of 2020, a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), began circulating widely in the American state of Colorado, leading to widespread diagnosis of coronavirus disease (COVID-19), hospitalizations, and deaths. In this context, the importance of technology-based, non–face-to-face methods to conduct advance care planning via patient portals has increased. Objective The aim of this study was to determine the rates of use of a web-based advance care planning tool through a health system–based electronic patient portal both before and in the early months of the COVID-19 pandemic. Methods In 2017, we implemented web-based tools through the patient portal of UCHealth’s electronic health record (EHR) for patients to learn about advance care planning and complete an electronically signed medical durable power of attorney (MDPOA) to legally appoint a medical decision maker. Patients accessing the portal can complete and submit a legally valid MDPOA, which becomes part of their medical record. We collected data on the patients’ date of MDPOA completion, use of advance care planning messaging, age, sex, and geographic location during the early phase of the COVID-19 pandemic (December 29, 2019, to May 30, 2020). Results Over a 5-month period that includes the early phase of the COVID-19 pandemic in Colorado, total monthly use of the advance care planning portal tool increased from 418 users in January to 1037 users in April and then decreased slightly to 815 users in May. The number of MDPOA forms submitted per week increased 2.4-fold after the stay-at-home order was issued in Colorado on March 26, 2020 (P<.001). The mean age of the advance care planning portal users was 47.7 years (SD 16.1), and 2206/3292 (67.0%) were female. Women were more likely than men to complete an MDPOA, particularly in younger age groups (P<.001). The primary use of the advance care planning portal tools was the completion of an MDPOA (3138/3292, 95.3%), compared to sending an electronic message (148/3292, 4.5%). Over 50% of patients who completed an MDPOA did not have a prior agent in the EHR. Conclusions Use of a web-based patient portal to complete an MDPOA increased substantially during the first months of the COVID-19 pandemic in Colorado. There was an increase in advance care planning that corresponded with state government shelter-in-place orders as well as public health reports of increased numbers of COVID-19 cases and deaths. Patient portals are an important tool for providing advance care planning resources and documenting medical decision makers during the pandemic to ensure that medical treatment aligns with patient goals and values.

Building a Comprehensive Advance Care Planning Approach in a Community Health System during COVID-19

“…We are adopting a single, integrated EHR, which will address the disparity of having multiple EMRs across our health system's care continuum. Furthermore, we anticipate staff training and use of tablets will improve the operational process of AD completion as noted in other institutions [31,32]. Additional challenges included patients unable to communicate verbally due to health status, visitation restrictions that limited access to alternative decision makers, and a desire to limit staff's infectious exposure and use of personal protective equipment (PPE).…”

Optimal Supportive Care for Patients With Metastatic Breast Cancer According to Their Disease Progression Phase

“…Consideration for the limitation, priority of medical resources, and needs for web-based tools are the key features of advance care planning in this COVID-19 era. 35,36 OPTIMAL SUPPORTIVE CARE FOR MBC Table 2 provides checklists for palliative or supportive care for MBC with consideration of the priorities of acute versus stable phases. In the acute phase, close monitoring of the patient's status and symptom management take priority.…”

Value of Advance Care Directives for Patients With Serious Illness in the Era of COVID Pandemic: A Review of Challenges and Solutions

“…11 Similarly, Portz et al had 2.4 times as many medical durable power of attorney forms submitted through electronic medical record after CoVID-19 stay-at-home orders. 12 These allow for automatic updates throughout the medical record system so that patient directives travel with them across settings. With such high usage, the remote approach to ACD completion appears promising.…”

“…The CoVID-19 pandemic is an immense challenge for many reasons, but it also presents unique opportunities to do right by patients in terms of improving ACD implementation. For example, ACD uptake among patients remains low, [8][9][10] but studies show that leveraging electronic health records during this crisis could drastically improve usage 11,12 ; healthcare professionals frequently report lack of comfort talking about advance directives, 13,14 but increased discussion around CoVID-19 presents ample opportunities for sensitive, healthrelated conversations; certain populations are more vulnerable to CoVID-19 and to not have ACDs, [15][16][17][18][19] so righting these inequities is positively impactful in multiple ways. Though solutions to big problems are rarely straightforward, addressing these issues is a worthwhile task, since doing so will improve end-of-life care in the US and better prepare our healthcare systems to face current and future crises.…”