Understanding Best Practices in Advance Care Planning
This five-year project is aimed at improving the quality of decision-making for seriously ill, hospitalized older adults
Healthcare ChallengeAs the U.S. population ages, hospitals and health systems around the country are grappling with how to integrate advance care planning (ACP) into routine practice. On one hand, the adaption of palliative care principles into clinical practice has reduced the prevalence of treatment-limiting advance directives, such as, do-not-resuscitate orders (DNRs). At the same time, earlier diagnosis and treatment of such conditions as severe sepsis and acute myocardial infarction, combined with changes in healthcare delivery, such the increase in rapid response teams, have led to an increase in acute care and a decrease in fatality rates among seriously ill, older adults. Yet, rates of DNRs (and other treatment-limiting advance directives) implemented in the hospital vary widely from hospital to hospital for otherwise similar seriously ill, older adults. Rates of CPR and mechanical ventilation among ICU patients with DNR orders in place also vary from ICU to ICU—most likely reflecting both overuse and underuse of life-supporting treatment.
How we’re meeting it
In order to improve care for seriously ill, older adults in a hospital setting, researchers from The Dartmouth Institute have partnered with a national physician management group on a 5-year, multi-phase study to better understand best practices in advance care planning. The group represents 2,500 hospital-based physicians at 250 community hospitals across the U.S. who manage approximately half a million admissions among patients 65 and older each year. Led by Susan J. and Richard M. Levy Distinguished Professor in Health Care Delivery Amber Barnato, MD, MS, MPH, the project has three primary aims:
- Understand the cognitive decision-making process influencing the likelihood of hospital-based physicians’ ACP discussions for seriously ill
- Explore the association between acute care ACP and patient care outcomes
- Test the effect of interventions designed to influence the cognitive processes on the likelihood of ACP discussions using a randomized trial
“Based on our prior research, we believe that much of the variation in care in treating seriously ill, older adults is attributable to the judgement of hospital physicians—specifically their assessment of whether a patient is near the end of life, ”Barnato says. “So, ultimately, the goal of our research is to improve the quality of ACP for these patients by better understanding and supporting physician decision making.”
In one of the first studies associated with the project, the research team analyzed Medicaid and Medicare-associated ACP billing at the national physician management group for the first quarter of 2017 and found that despite training and moderate financial incentives, the rate of ACP was low and that there was wide variation among physicians and practice sites.
The researchers say the project, which is supported by the National Institute on Aging of the National Institutes of Health (NIH), will help to address the call for greater advance care planning by translating innovation from decision science to healthcare delivery science to impact patient outcomes.