Advance Care Planning Documentation Practices and Accessibility in the Electronic Health Record: Implications for Patient Safety

Abstract

Context:
Documenting patients' advance care planning wishes is essential to providing value-aligned care, as is having this documentation readily accessible. Little is known about advance care planning documentation practices in the electronic health record.

Objectives:
Describe advance care planning documentation practices and the accessibility of documented discussions in the electronic health record.

Methods:
Participants were primary care patients at the San Francisco VA Medical Center, were ≥60 years old, and had ≥2 chronic/serious health conditions. In this cross-sectional study, we assessed the prevalence of advance care planning documentation, including any legal forms/orders and discussions in the prior five years. We also determined accessibility of discussions (i.e., accessible centralized posting vs. inaccessible free-text in progress notes).

Results:
The mean age of 414 participants was 71 years (SD ±8), 9% were women, 43% were non-white, and 51% had documented advance care planning including 149 (36%) with forms/orders and 138 (33%) with discussions. Seventy-four participants (50%) with forms/orders lacked accompanying explanatory documentation. Most (55%) discussions were not easily accessible, including 70% of those documenting changes in treatment preferences from prior forms/orders.

Conclusion:
Half of chronically ill, older participants had documented advance care planning, including one third with documented discussions. However, half of the patients with completed legal forms/orders had no accompanying documented explanatory discussions, and the majority of documented discussions were not easily accessible, even when wishes had changed. Ensuring that patients' preferences are documented and easily accessible is an important patient safety and quality improvement target to ensure patients' wishes are honored.

Full text

Advance Care Planning Documentation Practices and
Accessibility in the Electronic Health Record: Implications for
Patient Safety
Evan Walker, MD1, Ryan McMahan, BS, BA2, Deborah Barnes, PhD3,4,5, Mary Katen, BA6,
Daniela Lamas, MD7,8, and Rebecca Sudore, MD3,6
1Department of Medicine, UCSF, San Francisco, CA
2UCSF School of Medicine, San Francisco, CA
3San Francisco Veterans Affairs Medical Center, San Francisco, CA
4Department of Psychiatry, UCSF, San Francisco, CA
5Department of Epidemiology & Biostatistics, UCSF, San Francisco, CA
6Division of Geriatrics, Department of Medicine, UCSF, San Francisco, CA
7Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and
Women’s Hospital, Boston, MA
8Ariadne Labs at Brigham and Women’s Hospital and Harvard T.H. Chen School of Public Health,
Boston, MA
Abstract
Importance—Documenting patients’ advance care planning wishes is essential to providing
value-aligned care, as is having this documentation readily accessible. Little is known about
advance care planning documentation practices in the electronic health record.
Objective—Describe advance care planning documentation practices and the accessibility of
documented discussions in the electronic health record.
Design—Cross-sectional study between 2013-2015.
Corresponding Author: Evan J Walker, MD, University of California, San Francisco Department of Internal Medicine, 505 Parnassus
Ave., Room 987, San Francisco, CA 94143-0119, Evan.Walker@ucsf.edu, Phone: 415-476-1528.
Author Contributions:
Study concept and design: Sudore, Barnes
Acquisition, analysis, or interpretation of data: All authors
Drafting of the manuscript: All authors
Critical revision of the manuscript for important intellectual content: All authors
Statistical analysis: Walker, Sudore
Obtained funding: Sudore
Administrative, technical, or material support: Sudore, Katen, McMahan
Study supervision: Sudore
Conflict of Interest Disclosures: None reported.
Neither this manuscript nor one with substantially similar content under our authorship has been published or is being considered for
publication elsewhere.
Additional Contributions: None
HHS Public Access
Author manuscript
J Pain Symptom Manage
. Author manuscript; available in PMC 2018 February 02.
Published in final edited form as:
J Pain Symptom Manage
. 2018 February ; 55(2): 256–264. doi:10.1016/j.jpainsymman.2017.09.018.
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Setting—Primary care clinics at the San Francisco Veterans Affairs Medical Center.
Participants—Veterans ≥60 years of age with ≥2 chronic/serious health conditions, ≥2 primary
care visits, and ≥2 additional clinic/hospital/emergency room visits in the prior year who were
participating in an advance care planning trial.
Exposure—Documentation of advance care planning in the electronic health record.
Main Measures—Advance care planning documentation, including all prior legal forms/orders
and documented discussions within the prior five years. For discussions, the author’s discipline
and documentation location in the electronic health record were determined. Discussions were
defined as “accessible” if documented in a designated electronic posting location or “not easily
accessible” if recorded as free-text in progress notes. Percentages and means were used to describe
these measures.
Key Results—The mean age of 414 participants was 71 years (SD ±8), 9% were women, 43%
were non-white, and 51% had documented advance care planning including 149 (36%) with
forms/orders and 138 (33%) with discussions. Seventy-four participants (50%) with forms/orders
did not have accompanying documented discussions. Most (55%) discussions were not easily
accessible. Twenty-seven participants had a subsequent discussion documenting changes in
treatment preferences from a prior form/order; however, 70% of these discussions were not easily
accessible.
Conclusions and Relevance—Half of chronically ill, older participants had documented
advance care planning wishes, including one third with documented discussions. However, half of
the patients with completed legal forms/orders had no accompanying explanatory discussions. The
majority of documented discussions were not easily accessible in the electronic health record,
including 70% of those documenting a change in treatment preferences. Ensuring that patients’
preferences are documented and easily accessible is an important patient safety and quality
improvement target to ensure patients’ wishes are honored.
Introduction
Advance care planning (ACP) is a process that supports adults in understanding and sharing
their personal values, life goals, and preferences regarding future care.1 Although the
prevalence of ACP documentation is increasing2 and may continue to increase with both
federal and local reimbursement programs for ACP,3 the rates of ACP documentation are
still low,4 especially among older and disenfranchised populations. A lack of documented
ACP can lead to medical interventions misaligned with patients’ wishes5 as well as worse
quality of life and stress for patients and surrogate decision-makers.6–11 Furthermore, ACP
is a dynamic process which should be revisited as patients’ wishes and clinical context
changes. Having up-to-date ACP information at the point of care is essential to providing
value aligned care, however, little is known about ACP documentation practices.
The Veterans Affairs (VA) healthcare system, which treats over 10 million Veterans over the
age of 65 years,12 is a leader in ACP quality improvement.13 Prior studies at the VA have
sought to improve patient education and preparation for informed decision-making as well
as increase rates of advance directive completion.14–17 The VA has also created ACP note
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templates and a centralized posting section for ACP discussion documentation in the
electronic health record (EHR) to better capture patient preferences.
While prior studies, and a recent Institute of Medicine report, have stressed the need for
standardized and up-to-date documentation of ACP in the medical record,18–23 it is unknown
how well clinicians are utilizing EHR documentation tools, which disciplines are
documenting patients’ preferences, and whether this information is easily accessible in the
medical record. Better understanding of ACP documentation practices will lead to quality
improvement opportunities to ensure patient safety and patients’ wishes are honored. This
study aimed to quantify the rates and timing of ACP documentation, which disciplines were
documenting ACP discussions, and whether ACP discussion information was placed in an
easily accessible EHR location that could be retrieved at the point of care. Based on our
clinical experience and prior research,18 we hypothesized that the majority of documented
discussions would not be easily accessible in the EHR.
Methods
This is a cross-sectional study of primary care patients at the San Francisco Veterans Affairs
Medical Center (SFVAMC). Baseline data were obtained from records of patients enrolled
in a randomized controlled trial from 2013-2015 comparing the efficacy of a patient-
centered ACP website (www.prepareforyourcare.org) plus an easy-to-read advance directive
versus an advance directive alone on ACP documentation. The methods and results of this
trial have been published.24,25
Patient Population
Eligibility was defined by chart review, physician assessment, and study staff assessment.
Patients at the SFVAMC were eligible if they were at least 60 years of age, fluent in English,
had at least two serious/chronic health conditions (defined by ICD-9 codes matching
conditions listed in validated measures of comorbidity),26,27 had been seen at least twice in
the prior year by a primary care provider in the General Medicine, Geriatrics, or Women’s
Clinics, and had two additional clinic/hospital/emergency visits in the past year. Patients
with evidence of dementia, blindness, cognitive impairment, delirium, psychosis, or active
substance abuse by chart review or screening were ineligible. We obtained permission from
primary care providers to approach their patients and then recruited participants by letters,
flyers, phone calls, and in-clinic recruitment. Participants provided informed written
consent. The study was approved by the University of California, San Francisco (UCSF) and
the SFVAMC institutional review boards.
Measures
Measures included the frequency of ACP documentation, defined as legal forms/orders and
documented ACP discussions (Figure 1). Forms/orders included any prior scanned advance
directives or living wills, durable power of attorney for healthcare (DPOAHC) forms, and
orders including outpatient Do Not Resuscitate/Do Not Intubate (DNR/DNI) orders or
Physician Orders for Life Sustaining Treatment (POLST). For ACP discussions, chart notes
were reviewed within the prior five years. Two independent coders reviewed all medical
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records. Disagreements were resolved by consensus. To qualify as a documented ACP
discussion, written evidence of participant engagement and input in a conversation was
required; documentation that participants were only provided educational materials was not
counted.
For legal forms/orders, we assessed the type (e.g., advance directive, DPOAHC, POLST, and
code order), overall frequency, and mean elapsed time between form/order completion and
study enrollment. For participants with multiple forms/orders, all types were described and
the most recent form/order was used to calculate overall frequency and timing. Also,
because patients with completed legal forms/orders should ideally have accompanying ACP
discussions to explain their decision-making process, we determined how many patients
with a legal form/order had a documented ACP discussion.
For ACP discussions, we assessed the frequency, type, and timing of documented
information, the author of the note, and location and accessibility in the EHR. Rates of
discussion completion, as a percentage of all study participants, as well as mean elapsed
time between discussion completion and study enrollment, were computed. For participants
with multiple documented discussions, the most recent discussion was used. The type of
documented discussions was categorized as follows: “goals of care” (i.e., a discussion
describing participants’ wishes, reasoning, and thought processes), “code status only” (i.e.,
DNR/DNI or Full Code or Comfort Care noted in discussion documentation without
documentation of participants’ reasoning or thought processes), “surrogate decision maker,”
and discussions about “legal documents.” Discussions often included multiple categories.
Data are presented for each content category as percentages of the total number of
participants with discussions. Authorship was categorized by discipline: primary care
provider, inpatient/outpatient social worker, inpatient medical team, or outpatient
psychologist. The location of each ACP discussion was determined by the note type. The
SFVAMC EHR uses note templates for ACP which are captured in a central posting area on
the face page of the patients’ medical record. The accessibility of each ACP discussion was
determined by whether it could be located in the centralized posting area. If it could, the
discussion was deemed “easily accessible.” Documented discussions which could only be
found by searching free-text from chart notes, including hospital admission, discharge,
emergency department, outpatient primary care, specialty clinic, social work, and surgical/
anesthesia pre-operative notes, were deemed “not easily accessible.”
For both ACP forms/orders and ACP discussions, we assessed preferred level of treatment
using categories based on POLST and other scope-of-treatment documents.22 Preferences
were categorized as “Aggressive” care (i.e., documented Full Code or affirmative to
intubation, CPR, and all other life sustaining treatments without evidence of wanting to limit
treatments in any situation), “Limited Aggressive” care (i.e., documented Full Code,
affirmative to CPR and intubation but not indefinitely and not in every situation), “DNR/
DNI-Limited” (i.e., negative response to intubation or CPR, but affirmative to surgery,
antibiotics, or feeding tubes), or “DNR/DNI-Comfort” (i.e., negative responses to CPR and
intubation with specific documentation of the term “comfort measures only”). The category
of “No Wishes Documented” was used if preferences could not be categorized by these
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criteria. Rates of each desired level of treatment are presented as percentages of all
participants with completed forms or discussions, respectively.
Once treatment preferences were categorized, we determined whether physician orders
accompanied DNR/DNI documentation in advance directives or discussions. An
accompanying DNR/DNI physician order or POLST is considered appropriate so that
patients’ wishes can be honored across health settings.28 Thus, we assessed rates of POLST
or outpatient DNR/DNI orders for participants whose advance directives and/or ACP
discussions were categorized as DNR/DNI.
We also assessed changes in treatment preferences between forms/orders and subsequent
ACP discussions with discernible levels of desired treatment (e.g., Aggressive, DNR/DNI-
Comfort, etc.). Levels of desired treatment were categorized as “changed” if they differed
between forms/orders and subsequent ACP discussions. For these participants, we
categorized the changes as “more aggressive” or “less aggressive” based on how their
preferences changed in more recent documented ACP discussions relative to prior forms.
Determining the accessibility of ACP discussions that document changes in treatment
preferences is important so that patients’ most updated wishes can be honored. Therefore,
we assessed time between form completion and subsequent ACP discussions and the
accessibility of the ACP discussion that documented the treatment change.
Statistical Analysis
To describe participant characteristics and our measures, we used percentages and means
with standard deviations. Analyses were conducted using SAS statistical software (version
9.4; SAS Institute Inc.).
Results
Participants
The mean age of the 414 participants was 71 years (SD ±8) (Table 1). Participants were
mostly men (91%), 43% were non-white by self-report, 18% had less than a high school
education, 20% had limited health literacy, 29% self-rated their health as fair-to-poor on a 5-
point Likert scale, and 92% reported having a potential surrogate decision maker. Of the 414
participants, 212 (51%) had some type of ACP documented in the EHR.
ACP legal forms and Physician Orders
One hundred forty-nine participants (36%) had completed ACP legal forms at any time,
including 130 advance directives/living wills and 103 DPOAHC forms. These forms were
completed an average of 4.6 years (SD ±3.2) prior to study enrollment (Table 2). Three
POLST forms were completed and two participants had outpatient DNR/DNI orders. Of 149
participants with ACP legal forms/orders, 75 (50%) had an accompanying documented ACP
discussion.
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ACP discussions
In the five years prior to study enrollment, 138 (33%) study participants had documented
ACP discussions. These discussions occurred 2.1 years (SD ±1.4) prior to study enrollment
and focused on surrogate decision makers (n=115, 83% of participants with discussions),
goals of care (n=45, 33%), legal documents (n=36, 26%), and code status (n=23, 17%).
Overall, discussions were documented predominantly by social workers (n=75, 54%) and
outpatient primary care providers (n=49, 36%) (Table 3). Inpatient primary teams
documented 12 discussions (9%), while one discussion each was documented by an
outpatient palliative care provider, and an outpatient psychologist.
Of 138 ACP discussions, 62 (45%) were easily accessible and 76 (55%) were not easily
accessible from the EHR. Of the easily accessible discussions, 58 (94%) were documented
by social workers, two by inpatient primary teams, and one each by a primary care provider
and an outpatient palliative care provider. Of the not easily accessible discussions, 48 (63%)
were documented as free-text by primary care providers in progress notes and 17 (22%)
were documented in social work notes. By provider type, 58 (77%) of 75 discussions
documented by social workers were easily accessible, while one (2%) of 49 discussions
documented by primary care providers was easily accessible.
Treatment Preferences and Physician Orders
Participants expressed preferences for desired level of treatment in 83% of completed ACP
forms/orders and 39% of discussions (Table 4). In legal forms/orders, the most frequently
desired level of treatment was DNR/DNI-Limited (56%). Among ACP discussions, the most
frequently desired level of treatment was Limited Aggressive (46% of those with discernible
wishes). Among the 88 participants with DNR/DNI wishes in advance directives, two (2%)
had active DNR/DNI orders and two (2%) had completed POLST forms. Of the 15
participants with DNR/DNI wishes in discussions, no participants had active DNR/DNI
orders and two (13%) had completed POLST forms.
Changes in Preferences
During the 5-year retrospective review of the EHR, 34 participants had completed a legal
form/order and then had a subsequent ACP discussion where levels of preferred treatment
were documented. Discussions occurred an average of 3.9 years (SD ±3.4) after form/order
completion. For 27 (79%) of these participants, discussions documented a change in
participants’ treatment preferences: nine (33%) to more aggressive treatment and 18 (67%)
to less aggressive treatment. For 19/27 (70%) participants with changed preferences, the
documented ACP discussions were not easily accessible in the EHR: nine (100%) of those
documenting more aggressive treatment preferences and 10 (56%) of those documenting
less aggressive treatment preferences.
Discussion
To our knowledge, this is the first study to describe the comprehensive type, authorship,
location, and accessibility of ACP documentation through detailed electronic chart review.
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The VA is an exceptional national model of ACP documentation in that it includes a
centralized posting section in the EHR for ACP, is dedicated to ACP initiatives,13–17,25,29
and half of chronically ill, older Veterans in this study had documented ACP wishes, well
above national norms.30 However, given that many non-VA health systems do not have
similar established EHRs and dedicated ACP programs, these study findings point to a likely
widely generalizable quality improvement gap for patient safety in ACP. For example, 50%
of patients with a completed form or physician order in this study did not have an
accompanying documented ACP discussion about that form/order in the EHR. In addition,
the majority of ACP discussions were not easily accessible, though they were more up-to-
date (i.e., on average two years versus five years prior) and often represented changes in
wishes from prior forms/orders. A majority of ACP discussions, including those which were
easily accessible, were also documented by social workers rather than primary care
providers.
These results are similar to a Canadian study of hospitalized patients demonstrating that
patients’ and families’ wishes were not being documented correctly in the medical record.22
Lack of accurate and accessible ACP documentation represents an important patient safety
issue that could have devastating ramifications on patients’ care.23 Having up-to-date, easily
accessible descriptions of patients’ wishes for medical care in an ACP discussion note in the
EHR is essential to ensuring patients engage in fully informed shared decision-making about
their preferences, interpreting the meaning behind legal forms/orders, conveying important
information to other treating physicians about real-time and ongoing changes in patients’
preferences, and ensuring that patients’ wishes are honored. The insight provided by
documented discussions also provides crucial context for future discussions with additional
medical providers.
However, in this study, half of participants with completed ACP legal forms had no
accompanying documented discussions. Ensuring all forms/orders are accompanied by a
corresponding ACP note may be an important quality improvement metric in addition to
advance directive or form/order completion. In addition, the majority of ACP discussions
were not easily accessible and were documented as free-text in progress notes without any
associated notification or flag in the central posting section of the EHR. This minimizes the
likelihood that a future clinician would notice and be able to use this information in an
actionable way at the bedside. Although many providers are having detailed ACP
discussions with patients, the lack of standardized documentation practices limits the clinical
utility of these discussions.
The lack of standardization was most concerning when documented preferences changed
between legal forms/orders and subsequent discussions, especially as 70% of these changes
in preferences were not easily accessible in the EHR. Future providers who do not notice or
cannot find subsequent free-text discussions in the EHR are likely to default to more easily
located forms/orders which may contain outdated patient preferences. These forms/orders
were, on average, completed five years prior to study enrollment, and more frequent updates
are needed as demonstrated by the high rate of changed preferences among those with
subsequent discussions. Use of such out-of-date documentation may lead to care misaligned
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with patients’ preferences. When extrapolated on a population level, these misaligned
documented wishes could affect many patients.
ACP discussions were most frequently documented by social workers followed by primary
care providers. The involvement of social workers in this process is a strength of the
integrated Patient Aligned Care Teams (PACT) in the VA system and likely positively
impacts ACP documentation overall. However, in some cases, the additional involvement of
the primary care provider to provide context regarding patients’ medical conditions and
prognoses may also be important. Primary care providers documented only 2% of ACP
discussions in an easily accessible location compared to 77% of social workers’
documentation. This discrepancy may reflect differences between training curricula and
could likely be improved with educational interventions. The extremely low use of POLST
and DNR/DNI orders for the subset of patients with preferences for DNR/DNI also reveals
an opportunity for improvement of the ACP documentation process.
While prior research has focused on increasing rates of legal form completion31–33 or
techniques to conduct effective ACP discussions,34–36 interventions focusing on appropriate
documentation of ACP discussions are less prevalent.14 Such an intervention could have a
large impact on clinical care and patient safety23 and may require minimal behavioral
change from clinicians since our study demonstrated that many are already having and
recording rich ACP discussions. In addition, changes to the EHR that would allow clinicians
to easily flag goals of care conversations within other progress notes, to be placed in
important central EHR posting areas, may negate the need for remembering specific note
titles.
The strengths of this study include the comprehensive nature of chart review performed by
two independent reviewers. Limitations include the predominantly older and male
population of Veterans recruited from a single medical center who were participating in a
study of ACP, which may restrict generalizability. However, the study population was
diverse in other demographic characteristics. In this cross-sectional study, we were unable to
assess changes in behavior over time, nor determine whether patients received care
consistent with their most up-to-date preferences. However, our data provide an assessment
of the current state of practice which can be used to inform future studies.
Conclusions
These results suggest potential areas for EHR redesign and quality improvement to ensure
patient safety and patient-centered care in ACP. Quality improvement targets include
clinician education concerning documentation of ACP discussions in an easily accessible
location in the EHR, especially to help explain preferences for patients with completed ACP
legal forms and changes to patients’ preferences over time. More frequent updating of
patient’s wishes and completion of physician orders for patients with clear and stable
DNR/DNI wishes may also be needed. Further study, including the design of the EHR, is
needed to better understand how to improve ACP documentation practices and help ensure
patients’ wishes are honored.
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Acknowledgments
Drs. Walker and Sudore had full access to all the data in the study and take responsibility for the integrity of the
data and the accuracy of the data analysis.
Funding/Support: The U.S. Department of Veterans Affairs
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study, data collection,
management, analysis, and interpretation of data, or in preparation, review, or approval of the manuscript.
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Key Points
Question
What are the current advance care planning documentation practices at a VA Medical
Center and how accessible are documented advance care planning discussions in the
electronic health record?
Findings
In this cross-sectional study of 414 chronically ill Veterans, half had documented advance
care planning wishes, including one third with documented discussions. Most (55%)
discussions were not easily accessible in the medical record, including 70% of those
documenting treatment wishes which had changed from prior legal forms/orders.
Meaning
Efforts to improve standardization and accessibility of advance care planning
documentation are imperative to ensure patient safety and patients’ wishes are honored.
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Figure 1. All study measures assessed by chart review
ACP indicates Advance Care Planning; DNR/DNI, Do Not Resuscitate/Do Not Intubate;
DPOAHC, Durable Power of Attorney for Health Care; EHR, Electronic Health Record;
POLST, Physician Orders for Life Sustaining Treatment.
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Table 1
Demographic characteristics of study participants.
Demographic Characteristics
Age: N=414, mean (SD) 71.1 (7.8)
Sex: Women, N=414, No. (%) 38 (9%)
Race/Ethnicity: N=413, No. (%)
White 235 (57%)
African American 88 (21%)
Latino/Hispanic 33 (8%)
Native American 5 (1%)
Asian/Pacific Islander 26 (6%)
Multi-ethnic/Other 26 (6%)
Education ≤ high school: N=413, No. (%) 74 (18%)
Finances, not enough to make ends meet: N=412, No. (%) 49 (12%)
In a married/long term relationship: N=414, No. (%) 187 (45%)
Have a potential surrogate: N=414, No. (%) 382 (92%)
Self-Rated Health, fair-to-poor: N=412, No. (%) 120 (29%)
Limited Health Literacy, N=411, No. (%) 83 (20%)
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Table 2
ACP legal forms and physician orders.
Type of ACP Forms/Orders Completed Forms/Orders N=414, No. (%) Time prior to study enrollment (mean years ± SD)
Advance Directive 130 (31%) 5.0 ± 3.3
DPOAHC Form 103 (25%) 5.6 ± 3.7
POLST 3 (0.7%) 1.9 ± 1.5
DNR/DNI Order 2 (0.5%) 4.1 ± 0.7
Any ACP Forms/Orders 149 (36%) 4.6 ± 3.2
ACP indicates Advance Care Planning; DNR/DNI, Do Not Resuscitate/Do Not Intubate; DPOAHC, Durable Power of Attorney for Health Care;
POLST, Physician Orders for Life-Sustaining Treatment.
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Table 3
Location and authorship of documented ACP discussions in the EHR
a
Easily Accessible N = 62 (45%)
Author Location in EHR No. (%)
Inpatient Social Worker ACP Posting
b
35 (25%)
Outpatient Social Worker ACP Posting 23 (17%)
Inpatient Medical Team ACP Posting 2 (1.4%)
Primary Care Provider ACP Posting 1 (0.7%)
Outpatient Palliative Care Provider ACP Posting 1 (0.7%)
Not Easily Accessible N = 76 (55%)
Author Location in EHR No. (%)
Primary Care Provider Outpatient Progress Note 48 (35%)
Inpatient Social Worker Inpatient Social Work Note 13 (9.4%)
Inpatient Medical Team Admission Note 5 (3.6%)
Outpatient Social Worker Outpatient Social Work Note 4 (2.9%)
Inpatient Medical Team Discharge Summary 2 (1.4%)
Inpatient Medical Team Inpatient Progress Note 1 (0.7%)
Inpatient Medical Team Inpatient Progress Note Addendum 1 (0.7%)
Inpatient Medical Team Inpatient Pre-Operative Note 1 (0.7%)
Outpatient Psychologist Outpatient Progress Note 1 (0.7%)
Time between ACP discussion documentation and study enrollment (mean years ± SD) 2.1 ± 1.4
a
n = 138 documented advance care planning discussions.
b
The ACP posting location is a centralized, easily accessible location on the face page of a participant’s electronic health record. ACP indicates
Advance Care Planning; EHR, Electronic Health Record.
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Table 4
Desired level of treatment documented in legal forms and ACP discussions.
Level of Treatment Desired ACP legal forms N = 149, No. (%) ACP discussions N = 138, No. (%)
Aggressive 9 (6%) 14 (10%)
Limited Aggressive 26 (17%) 25 (18%)
DNR/DNI-Limited 83 (56%) 10 (7%)
DNR/DNI-Comfort 5 (3%) 5 (3%)
No Wishes Documented 26 (17%) 84 (61%)
ACP indicates Advance Care Planning; DNR/DNI, Do Not Resuscitate/Do Not Intubate.
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