title: Outpatient advance care planning for patients with metastatic cancer: a pilot quality improvement initiative.
abstract: BACKGROUND
  Despite American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer Network (NCCN) guidelines recommending that oncologists discuss advance care planning (ACP) with patients with stage IV cancer early in treatment, in standard practice ACP remains a late step of a terminal illness. ACP preserves comfort and dignity at the end of life, ensuring patients receive the care that they desire.
  
  
  METHODS
  A feasibility study in patients with stage IV cancer was developed to test whether incorporating ACP immediately after a stage IV cancer diagnosis is feasible. Inclusion criteria were consecutive new gastrointestinal and thoracic oncology patients treated by one of two oncologists. The project included creation of new workflow; development of an ACP patient education guidebook; training seminars for oncology staff; and enhancements to the electronic health record (EHR) to improve ACP documentation.
  
  
  RESULTS
  The oncologists recorded 33 of 48 (69%) advance directive notes (ADNs) and 22 of 48 (46%) code status orders (CSOs) in the EHR of patients newly diagnosed with stage IV cancer by following ACP protocol during the 6-month trial period. Twenty-one of 33 ADNs were entered within 7 days of first consultation. The median time to ADN placement was 1 day after consultation. Twenty-two of 33 patients with ADNs had CSOs placed, of which 16 were do-not-resuscitate (DNR) and 6 were full code. One year prior to the feasibility study, only 1 of 75 deceased patients of the two oncologists had outpatient ADNs and CSOs.
  
  
  CONCLUSIONS
  Outpatient ACP is feasible early in the care of patients with stage IV cancer through systematic improvement in workflow and motivated providers. Education and infrastructure were pivotal to routine development of advance care plans.
authors.affiliation: NorthShore University HealthSystem , Evanston, Illinois.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Obel
authors.forename: Bruce
authors.initials: B
authors.lastname: Brockstein
authors.forename: Michael
authors.initials: M
authors.lastname: Marschke
authors.forename: Ari
authors.initials: A
authors.lastname: Robicsek
authors.forename: Chad
authors.initials: C
authors.lastname: Konchak
authors.forename: Meredith
authors.initials: M
authors.lastname: Sefa
authors.forename: Nicole
authors.initials: N
authors.lastname: Ziomek
authors.forename: Tiffany
authors.initials: T
authors.lastname: Benfield
authors.forename: Carrie
authors.initials: C
authors.lastname: Peterson
authors.forename: Cory
authors.initials: C
authors.lastname: Gustafson
authors.forename: Joann
authors.initials: J
authors.lastname: Eriksson
authors.forename: Abigail
authors.initials: A
authors.lastname: Harper
authors.forename: Cory
authors.initials: C
authors.lastname: Tabachow
authors.forename: Michael
authors.initials: M
authors.lastname: Raymond
authors.forename: Thomas
authors.initials: T
authors.lastname: Hensing
mesh_terms: D032722:Advance Care Planning / Q000592:standards*; D004282:Documentation; D057286:Electronic Health Records; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008297:Male; D008495:Medical Oncology / Q000592:standards*; D009367:Neoplasm Staging; D009369:Neoplasms / Q000473:pathology* / Q000628:therapy; D010045:Outpatients; D010865:Pilot Projects; D058996:Quality Improvement; D013727:Terminal Care / Q000592:standards*