When to begin? A chart-based review of advanced care planning in cancer patients one year prior to death.

Abstract

e24043 Background: Timely goals of care (GOC) conversations are a critical component of high-quality oncologic care. Despite increasing awareness of their benefit and importance, numerous studies have identified significant barriers to their completion for both patients and physicians. In this study, we review the chart documentation of patients who died on our oncology service at a large urban hospital. By reviewing the timeline of events and chart-documented language in the year prior to death, we hope to provide a new frame of reference for the known barriers to advanced care planning in actual practice. Methods: We performed a retrospective chart review of the last 90 deaths on the oncology service at two hospitals within our large, urban, academic medical center. Patients were included if they were age ≥ 20 and had a primary oncologist within our health system that they saw outpatient at least once. Reviewers used a chart abstraction form to track dates of diagnosis and death, dates of all GOC discussions within one year of death, who was present, and what topics were covered in both inpatient and outpatient visits. These data were then reviewed for factors that contributed to the timeliness of advanced care planning. Results: 97% of our patients (n= 87) had at least one GOC discussion in the year before death. Of those, 70% (n= 61) occurred within the last month of life during the terminal hospitalization. Only 16% (n=14) had any documented GOC discussion in the outpatient setting. GOC with patients and families was frequently limited to the last days of life and often initiated by a consult to the inpatient palliative care service. A number of records did reveal attempts to begin these discussions earlier, however with mixed success. Several factors appeared to challenge these efforts. These included: (1) patient or family lack of readiness to engage in advance care planning, (2) provider uncertainty or discomfort, and (3) rapid demise of the patient. No clear reason was apparent on chart review in some cases. Conclusions: In this retrospective review of 90 inpatient oncologic deaths, we see that despite strides made by major oncology institutions to promote advanced care planning early on in the patient’s disease course, significant delays continue to exist. While our data is limited to what is documented in the chart, it sheds new light on known barriers to completing GOC conversations in the inpatient setting for cancer patients.