ADVANCE CARE PLANNING PRACTICES IN CARING FOR VULNERABLE ELDERS
Elderly patients often receive care from multiple health care providers. Because they face many preference sensitive care decisions, it is critical that their medical records document their preferences in an accessible manner. Poor documentation of patient preferences in the electronic health record (EHR) may jeopardize the ability of health care providers to honor these preferences. Since 2010, the Palo Alto Medical Foundation (PAMF) established a palliative care program across its 4 divisions. We aim to characterize advance care planning (ACP) documentation practices and determine if the palliative care program changed ACP practices, using EHR data from 2005-2014. Both advance health care directives (AHCD) and physician orders for life-sustaining treatment (POLST) are considered ACP.
Method(s):
This analysis included PAMF patients ≥65 between 2013-2014 with no EHR record of ACP before 2013. If their EHR’s Problem List has an ICD-9-code for ACP, it is considered accessible. Logistic regression analysis examined the relationship between having accessible ACP documentation and explanatory variables, including (1) type of serious illness (defined by the presence of those conditions listed in the National Committee for Quality Assurance Palliative Care/hospice measurement set); (2) travel distance to the nearest palliative care specialists; and (3) patient and physician characteristics.
Result(s):
Among 65,253 patients ≥65 who did not have any ACP prior to 2013, 10.24% had accessible AHCD, 0.82% had accessible POLST, 0.54% had accessible AHCD and POLST, leaving 88.4% without accessible ACP at the end of 2014. Among those with at least one serious illness, 12.09% had accessible AHCD, 5.42% had accessible POLST, 3.62% had both, leaving 78.87% without accessible ACP. Patients with chronic obstructive pulmonary disease are more likely to have AHCD (OR=1.094, p<0.01) and POLST (OR=1.215, p<0.01). Patients with brain cancer (OR=4.165, p<0.01), Esophageal cancer (OR=4.697, p<0.05) and debility (OR=1.923, p<0.01) are more likely to have accessible POLST. Male, Asian, Chinese, and Black patients are less likely to have accessible AHCD. The travel distance to palliative care specialists lowers the likelihood of having accessible AHCD (OR=0.904, p<0.01) and POLST (OR=0.866, p<0.01).
Conclusion(s):
Overwhelming majority of older patients’ EHR does not have accessible ACP, even those seriously ill. Systematic efforts are needed to eliminate gender and racial disparities and integrate palliative care into other areas of medical practice to enhance care for vulnerable elders.