Nurse-led presentation of advance directives (AD) for patients in the outpatient oncology setting at Reading Hospital-Tower Health is currently not a standard of practice for patient care. For patients with no advance directives, vital conversations about advance care planning (ACP) can occur late with respect to the patients’ well-being; they can experience a precipitous decline in their health condition, therefore rendering them unable to verbalize their end-of-life (EOL) wishes. Family members and loved ones who are entrusted to advocate for the patient may not necessarily know what those EOL wishes are. In addition, family members may find themselves ensnared in vulnerable dispositions and plagued with overpowering emotions as to what would be best for the patient. The result can be undesired invasive treatments for the patient when ACP has not been established. This quality improvement (QI) project was initiated after identifying a need to increase completion of ADs for adult oncology patients. Nurses have a pivotal role in creating relationship-based caring with patients and these meaningful connections can translate to conversations about ACP, and eventual completion of advance directives. This QI project aims to understand the likelihood that patients’ completion of advanced directives will increase when presented by a nurse.
The critical need for nurses to advocate for AD is transforming into a significant issue in the current health care system. Our population is aging and technology is advancing rapidly that it has changed the trajectory of medical care with chronic, terminal health conditions into protracted debility (Gardner, 2013). When patients have no ADs in place, family members and health care providers are compelled to make grueling healthcare decisions, potentially intensifying stress and further complicating family dynamics (Lowey, Norton, Quinn, & Quill, 2013). Timely conversations about EOL is necessary to ensure the patient’s increased quality-of-life (Walczak et al., 2014). Nurses have the unique opportunity to educate patients and their families on the significance of AD and EOL decisions. In addition, nurses are poised to build the foundation to facilitate conversations about the patient’s EOL wishes early in the medical treatment process (Ryan & Jezewski, 2012). Patients with advanced cancer experience precipitous deterioration in quality of life (Zimmerman et al., 2014), but continue to receive inappropriate, aggressive treatment near the end of life (Ferrell et al., 2016). According to the Centers for Disease Control and Prevention (CDC), there is an estimated 70% of Americans who have not explored ACPs and completed ADs (Centers for Disease Control and Prevention [CDC], 2017). Advance care planning should be an ongoing process of discussion between patients, family, and the health care team intended to elucidate goals for future care and when the patient is unable to communicate their preferences (Sinclair et al., 2017). ACP can provide opportunities for patients to express their wishes for EOL and ensure that the care provided for them by the health care team is consistent with their values. Discussions about AD can reduce unnecessary costs associated with invasive diagnostics and interventions, increase patient and caregiver satisfaction, and improve the patients’ quality-of-life (Walczak et al., 2014). The Agency for Healthcare Research and Quality (AHRQ) recommends initiation of directed discussions, and assistance in ACP with the intent to document, implement and revise annually throughout the trajectory of patient care. Discussing ACP and completing ADs improves patient outcomes and satisfaction (Agency for Healthcare Research and Quality [AHRQ], 2014).
Oncology registered nurses (RNs) are in the best position to deliver meaningful support for their patients by having conversations about ACP. These conversations can provide opportunities to coordinate care provided for the patient in determining their needs. Oncology RNs have the ability to spend more time with patients, answer questions about their health conditions, and discuss EOL issues when the patients are emotionally prepared to do so. In addition, they can have opportunities to assess caregivers’ dispositions and ascertain how involved they want to be in helping patients make important EOL decisions (Kaplan, 2018). Oncology RNs provide most of the care for cancer patients; they can spend more time at the bedside or in the community assessing and managing these patients and their loved ones (Malloy, Takenouchi, Kim, Lu, & Ferrell, 2017). In primary care settings, a care-management type approach has been successfully utilized to help patients and their family members in managing chronic illnesses and related psychosocial problems. This strategy effectively reduces the need for specialized medical services. When this strategy is performed by trained RNs paired with effective communication with physicians, it can result in a feasible, acceptable, and effective care of complex patients (Vayne-Bossert, Richard, Good, Sullivan, & Hardy, 2017). The interest of this QI project is whether this strategic model could translate well into an outpatient oncology setting.
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