Abstract
This quality improvement study examines the effectiveness of having a board-certified chaplain conduct advance care planning conversations and end of life preferences with patients at the time of a routine office visit with a physician.
Although many patients do not want aggressive care at the end of life (EoL),1 such care is not uncommon2 and may be associated with poorer quality of life and psychological distress.3 Advance care planning (ACP) permits patients to express preferences for EoL care and increase concordance between care that is desired and care that is delivered at EoL.4 Rather than waiting for an urgent health crisis, regular office visits are a preferred time for ACP discussions.4 With the new Centers for Medicare policy, lack of reimbursement for time spent in ACP discussions should no longer be a barrier to conducting them.5 However, other structural (eg, competing demands) and professional barriers (eg, lack of training) remain.6 These persistent barriers suggest consideration of nonphysicians for such discussions.5 Board-certified chaplains have training and experience in discussing EoL preferences with patients and families. The aim of this pilot quality improvement project was to determine whether having a board-certified chaplain conduct ACP conversations with patients in the physician’s office would be feasible, effective, and acceptable to all stakeholders.
Methods
This was a quality improvement project that did not require institutional review board approval and written informed consent was not required. The project was conducted in a primary care group practice affiliated with a community hospital in suburban Chicago where the chaplain was an employee. Criteria for inclusion in the project were age 70 years or older, decisional, and no record of an Advance Directive (AD) in the patient’s electronic medical record (EMR). Between April and October 2016, a board-certified chaplain scheduled time for AD consultations in the office of 1 primary care physician. From the physician’s appointments, the chaplain identified patients who met the project criteria. At the end of consultation the physician introduced the patient to the project and the chaplain and invited the patients’ participation. The consultation with the chaplain took place in the examination room once the physician’s visit was completed. The chaplain documented consultation in the patient’s EMR and any completed AD was scanned into the patient’s EMR.
Results
Sixty patients were invited to meet with the chaplain; all agreed to do so. Forty-eight (80%) patients completed an AD or provided documentation of an existing AD for their medical record (Table). These patients were also encouraged to discuss their wishes with loved ones. The mean time of the chaplain’s consultations was 23 minutes.
Table. Sample Characteristics and Completion of Advance Directivesa.
| Variable | No. (%) | |||
|---|---|---|---|---|
| Total Sample (n = 60) |
AD Completion During Consultation | |||
| No (n = 12 [20%]) |
Document Prior AD (n = 8 [13%]) |
Yes (n = 40 [67%]) |
||
| Age, mean (SD) [range], y | 78.6 (6.6) [70-95] | 78.3 (6.0) | 78.1 (6.0) | 78.7 (7.0) |
| Sex | ||||
| Male | 15 (25) | 1 (7) | 2 (13) | 12 (80) |
| Female | 45 (75) | 11 (24) | 6 (13) | 28 (62) |
| Race | ||||
| White | 25 (42) | 4 (16) | 4 (16) | 17 (68) |
| Black | 31 (52) | 8 (26) | 4 (13) | 19 (61) |
| Other | 4 (7) | 0 | 0 | 4 (100) |
| Accompanied in consultation | ||||
| Alone | 34 (57) | 8 (24) | 3 (9) | 23 (68) |
| Spouse | 13 (22) | 0 | 1 (8) | 12 (92) |
| Child | 10 (17) | 3 (30) | 3 (30) | 4 (40) |
| Friend | 3 (5) | 1 (33) | 1 (33) | 1 (33) |
| Length of consultation, min | ||||
| Mean (SD) [range] | 23.2 (7.8) [10-40] | 20.8 (8.2) | 21.3 (8.3) | 24.3 (7.6) |
| Median (IQR) | 20 (20-25) | |||
Abbreviations: AD, advance directives; IQR, interquartile range.
For the total sample percents are column percent; for the AD completion subgroups percents are row percent.
The topics explored with the chaplain included: patient’s current life circumstances, family members, support systems, experience with critical illness (their own or a loved one), experience with EoL decisions, palliative care and hospice, the role of faith in their lives and the influence of their beliefs on health care decision-making, and the level of medical interventions they might wish for themselves.
Patients’ degree of comfort talking about their future health care needs varied. “It’s very hard to talk about it,” and “My family know I never want to be kept alive on machines,” were some of the responses from patients. Most patients could identify a surrogate decision maker but had not formalized it. Faith and values had some influence on the patients’ desired level of medical intervention; experience with the dying or death of a loved one appeared to have greater impact.
Discussion
The project demonstrated that it is feasible and acceptable for a qualified chaplain to conduct ACP conversations in a medical office and that most of these conversations (80%) led to completion or documentation of ADs. The physician’s introduction of the chaplain was vital to the initiation of an ACP conversation in the context of a time limited office visit. The impact of these conversations and documented ADs on future treatment preferences and care is unknown. Nonetheless, a crucial step has been taken by initiating the discussion of patients’ EoL preferences.
References
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