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Initiative Increases Advance Care Planning Activities for Metastatic Cancer Patients

Cedars-Sinai Cancer investigators were able to increase the rate of advance care planning activities by 20% for patients with advanced cancer. The 3 ½-year initiative aimed to prompt more advance care conversations between physicians and patients, facilitate palliative medicine consultations, and increase the number of completed advance directives or physician orders for life-sustaining therapy. 

The findings were published in JCO Oncology Practice, an American Society of Clinical Oncology journal.

Steven Oppenheim, MD“Communicating with cancer patients and families about advance care planning is extremely important and beneficial, as it can improve quality of life, decrease conflicts around treatment decisions, reduce unwanted medical interventions and more,” said the study’s lead and corresponding author, Steven Oppenheim, MD, assistant medical director, Supportive Care Medicine/Oncology, and assistant professor of Medicine at Cedars-Sinai. “Goal-concordant care is an essential component of the comprehensive patient support for which Cedars-Sinai is known.” 

Advance care planning is recommended by the American Society of Clinical Oncology as part of a cancer patient’s care to ensure that treatment is consistent with their preferences if they become unable to make their own healthcare decisions. It can improve patient outcomes, improve quality of life at end of life, reduce the burden on families to make care decisions and improve the bereavement experience after a loved one’s death, among other benefits.

The Cedars-Sinai initiative, which began in 2017 and concluded at the end of 2020, involved over 15,000 outpatients diagnosed with any type of metastatic cancer. Before it began, 37% of patients completed some advance care planning activity. By the end of the initiative, 57% were participating. In addition, consultations for supportive care medicinealso known as palliative careincreased from 12% to 39%, and the rate of advance care planning notes in patients’ electronic health records increased from 16% to 29%. 

The initiative initially focused on patients with high-mortality cancers, like metastatic lung, pancreatic, colon, ovarian and glioblastoma, who were most likely to require advance care planning. After a year, the focus was expanded to all patients with metastatic solid tumors. 

Advance care planning activities include completion of an advance directive or physician orders for life- sustaining therapy, documentation of advance care planning in the patient’s electronic health record, and a referral to a supportive care medicine physician. As part of the initiative, any of these activities within the previous year qualified as having met the advance care planning activity goal for metastatic cancer patients.

Investigators noted that low advance care planning rates prior to the initiative launch were likely due to several factors: limited medical visit time and training of providers, fear of reducing hope, and assumptions about whose responsibility it was. 

The initiative increased awareness about the need for advance care planning activities, provided regular feedback to oncologists about their patients’ advance care planning completion, and encouraged palliative medicine referrals.

The study team included members of Cedars-Sinai’s quality committee, Performance Improvement Department, oncologists, palliative medicine specialists, nurses and social workers. Data was reviewed monthly, and the initiative went through yearly plan-do-study-act cycles to encourage adjustments as needed. 

Robert A. Figlin, MD“Our quality committee had focused on goal-concordant care prior to this initiative,” said second author Robert A. Figlin, MD, deputy director of Cedars-Sinai Cancer, the Steven Spielberg Family Chair in Hematology-Oncology and a professor of Medicine and Biomedical Sciences. “But we knew that there were opportunities for improvement and, as such, worked to bring practitioners from various specialties together for a specific initiative that would place even greater emphasis not only on the role of oncologists, but other healthcare providers as well, in discussing with patients the benefits of advance care planning.”

Among engagement activities with oncologists, palliative medicine consultants were embedded in tumor boards and oncology care team meetings, and they shared oncology clinic space. In addition, free educational classes about advance care planning were made available to patients, families and staff members. 

The investigators noted that the initiative did not change the rate of completion for advance directives or physician orders for life-sustaining therapy. They added that given that the main source of increased advance care planning activities during the initiative was in supportive care medicine referrals, further progress would depend on strengthening the oncology care teams’ advance care planning skills and motivation for completion.

Measuring the impact of advance care planning completion on care outcomes is a potential future direction of study. 

Other Cedars-Sinai investigators who worked on the initiative include Edward G. Seferian, MD; Margaret Reed, MHA; Scott A. Irwin, MD, PhD; and Bradley T. Rosen, MD.