Leveraging Electronic Health Record Tools and Social Work to Improve Advance Care Planning Documentation in Older...

Despite its proven benefits, many older adults with cancer do not engage in advance care planning (ACP). Although ACP is beneficial for all patients, older adults often have different priorities compared with younger patients and have higher rates of cancer-related mortality. A default ACP intervention for older adults could increase completion of ACP documents and promote goal-concordant cancer care.

We conducted a quality improvement pilot in a community oncology practice targeting patients age 65 years and older with a documented geriatric assessment. An electronic health record (EHR) dashboard was used to flag patients without ACP documents on file. We implemented a default offer of an ACP-focused social work visit during already-scheduled oncology visits. Any ACP documentation was defined as an advance directive (AD), physician orders for life-sustaining treatment (POLST), durable power of attorney, living will, or structured ACP note. The proportion of patients with ACP documents on file was obtained at baseline and 9 months.

A total of 142 patients were included in the analytic cohort. Over 9 months, the proportion of patients with any ACP documents on file increased from 32% to 65%. AD completion increased from 21% to 53%, POLST completion increased from 15% to 31%, and patients with an ACP note on file increased from 17% to 23%. Patients of White race were more likely to have ACP documents on file (P = .006), as were patients with lower performance status (P = .009). There were no significant differences between those who completed ACP documentation and those who did not in terms of age, sex, marital status, cancer diagnosis, or stage.

A social worker-led, EHR-embedded ACP intervention more than doubled ACP documentation. This multidisciplinary approach may represent a scalable strategy to promote goal-concordant care in older adults with cancer.