Advance Care Planning Documentation Practices and Accessibility in the Electronic Health Record: Implications for Patient Safety

Abstract

Importance Documenting patients’ advance care planning wishes is essential to providing value-aligned care, as is having this documentation readily accessible. Little is known about advance care planning documentation practices in the electronic health record. Objective Describe advance care planning documentation practices and the accessibility of documented discussions in the electronic health record. Design Cross-sectional study between 2013-2015. Setting Primary care clinics at the San Francisco Veterans Affairs Medical Center. Participants Veterans ≥60 years of age with ≥2 chronic/serious health conditions, ≥2 primary care visits, and ≥2 additional clinic/hospital/emergency room visits in the prior year who were participating in an advance care planning trial. Exposure Documentation of advance care planning in the electronic health record. Main Measures Advance care planning documentation, including all prior legal forms/orders and documented discussions within the prior five years. For discussions, the author’s discipline and documentation location in the electronic health record were determined. Discussions were defined as “accessible” if documented in a designated electronic posting location or “not easily accessible” if recorded as free-text in progress notes. Percentages and means were used to describe these measures. Key Results The mean age of 414 participants was 71 years (SD ±8), 9% were women, 43% were non-white, and 51% had documented advance care planning including 149 (36%) with forms/orders and 138 (33%) with discussions. Seventy-four participants (50%) with forms/orders did not have accompanying documented discussions. Most (55%) discussions were not easily accessible. Twenty-seven participants had a subsequent discussion documenting changes in treatment preferences from a prior form/order; however, 70% of these discussions were not easily accessible. Conclusions and Relevance Half of chronically ill, older participants had documented advance care planning wishes, including one third with documented discussions. However, half of the patients with completed legal forms/orders had no accompanying explanatory discussions. The majority of documented discussions were not easily accessible in the electronic health record, including 70% of those documenting a change in treatment preferences. Ensuring that patients’ preferences are documented and easily accessible is an important patient safety and quality improvement target to ensure patients’ wishes are honored.

Engaging Diverse English- and Spanish-Speaking Older Adults in Advance Care Planning

“…30 The magnitude of improvement in documentation is clinically meaningful given the known deficiencies in clinician documentation, especially documented discussions. 31 The high proportion of patient-reported ACP engagement for both documentation (85%) and discussions (94%) in the PREPARE arm further validates our medical record findings and demonstrates that patients engage in a range of ACP behaviors, such as discussions with surrogates and clinicians, in addition to documentation. 19,23,32 …”

Living Wills: One Part of the Advance Care Planning Puzzle

“…4 Although validated patient-reported surveys of ACP are available, it is difficult to abstract this information from the medical record, especially given the notoriously poor documentation by clinicians of these important ACP conversations. 12 Although LWs alone may be insufficient to move the needle on the healthcare utilization outcomes described in the article, this study does not confirm that the broader consensus definition of ACP is ineffective. LWs are only one piece of the ACP puzzle and are only as good as the preparation of patients and surrogates and the communication about the wishes in those documents.…”

“…As described earlier, LWs are often limited to a check‐box approach of life‐sustaining treatments that fail to address the goals and values behind those choices . The forms are also, on average, 5 years old and may not represent current medical wishes . As already stated, ACP should be a process of identifying one's values and goals and communicating these over time.…”

“…Identifying metrics that evaluate goal‐concordant care is vital to examining the effectiveness and quality ACP interventions, yet no standardized metric is currently available . Although validated patient‐reported surveys of ACP are available, it is difficult to abstract this information from the medical record, especially given the notoriously poor documentation by clinicians of these important ACP conversations …”

“…6 The forms are also, on average, 5 years old and may not represent current medical wishes. 12 As already stated, ACP should be a process of identifying one's values and goals and communicating these over time. As the authors point out, LWs have the potential to improve psychological and emotional outcomes for patients and families.…”