The Effectiveness of an Advance Care Appointment Companion to Increase Completion of Advance Care Planning among Patients with Metastatic Breast Cancer
1Kadie M. Harry, PhD, 1Cathy E. Mitchell, BS, 1Loic Nijiakin, BS, 2Arabella Sykes, BSc, & 1Timothy J. Pluard, MD
1Saint Luke’s Cancer Institute & Koontz Center for Advanced Breast Cancer
2Patient Discovery Solutions, Inc.
Previous research has demonstrated that patients express a desire to discuss advance care planning (ACP). ACP has been associated with numerous positive outcomes including improved patient satisfaction, improved quality of life in terminal illness, and better psychological outcomes. Additionally, ACP has been related to peace of mind that wishes will be followed, less hospital re-admissions, and less use of extreme treatments close to death. Furthermore, it has been linked to increased use of hospice and palliative care and increased concordance between preferred care and the care delivered. However, despite the documented benefit of ACP, these conversations often do not occur due to discomfort with the topic or are communicated inadequately. Documentation rates of ACP in oncology patients have been as low as 10%, with rates of documentation increasing between 30-40% in intervention studies. Specific to women with metastatic breast cancer (MBC), one study found that 66% had written advance directives, but providers were only aware of these in 14% of the cases. Thus, the present study aimed to examine the effectiveness of an online Advance Care Appointment Companion (ACAC) decision-support tool to improve ACP communication between MBC patients and their oncologist and increase completion rates of ACP documents.
Data were collected from 68 patients with MBC during their medical oncology appointments (Time 1) and three months later (Time 2) at the Koontz Center for Advanced Breast Cancer. At their Time 1 clinic visit, patients were introduced to and enrolled on the ACAC platform and then completed questions in the clinic or at home about completion status of a healthcare directive and durable power of attorney (DPOA) for healthcare, comfort in discussing ACP with their care team and loved ones, goals of care at end of life, and discussion topics about ACP for upcoming visits. A summary of these responses with a provider prompt script was securely sent to the oncologist prior to each subsequent appointment over the three-month study period. The oncologist used this summary and scripting to help navigate ACP conversations during each appointment. Descriptive statistics and McNemar’s test were conducted to examine changes in rates of ACP document completion and patient reported levels of comfort in discussing ACP.
Majority of the sample was female (n=68, 100%), white (n=57, 84%), married (n=36, 53%), with a mean age of 64 years. At baseline, 41% of patients reported having a completed healthcare directive and 49% reported having a completed DPOA for healthcare, but only 12% had a healthcare directive and 24% had a DPOA in their electronic medical record (EMR). To-date, 35% (n=24) have a healthcare directive and 47% (n=32) have a notarized DPOA in their EMR; McNemar’s test showed a significant increase in the proportion of patients who completed ACP documents at Time 2 (p< .001). At baseline, 74% of patients reported feeling comfortable discussing ACP with their care team and 69% reported feeling comfortable discussing ACP with their loved ones. Of note, 35% reported that they were unsure if they would want artificial nutrition, 37% reported they were unsure if they would want dialysis, and 37% reported that they were unsure if they would want resuscitation in the event that their heart stops. On average, ACP conversations during medical appointments took 5 minutes to discuss.
Preliminary results suggest that the ACAC is an effective tool to facilitate discussion about ACP, resulting in significantly increased completed ACP documents in patient’s medical records. Assessment of patient-reported outcomes on comfort with discussing ACP and goals of care at Time 2 is ongoing. Results also revealed the potential for this tool to help foster communication about the intricacies of ACP as a large portion of patients reported that they were unsure about decisions that need to be made about end of life care.