Advance Care Planning in a Dementia Specialty Practice

Friday, 20 July 2018

Valerie T. Cotter, DrNP1
Maryam Hasan, MD2
Jheesoo Ahn, SN3
Chakra Budhathoki, PhD4
Esther Oh, MD2
(1)Department of Community Public Health, Johns Hopkins School of Nursing, Baltimore, MD, USA
(2)Division of Geriatric Medicine and Gerontology, Johns Hopkins School of Medicine, Baltimore, MD, USA
(3)Johns Hopkins School of Nursing, Baltimore, MD, USA
(4)The Johns Hopkins University School of Nursing, Baltimore, MD, USA

By 2050, the number of people age 65 and older with Alzheimer’s disease (AD) may nearly triple, from 5.2 million to a projected 13.8 million (Alzheimer’s Association, 2016). In the early stages, persons with dementia are able to take an active role in discussing values and preferences for future care (Harrison King, Jones, Vickerstaff, & Sampson, 2016; Orsulic-Jeras et al, 2016) and prefer to participate in decision making for as long as possible (Fetherstonhaugh, Tarzia, & Nay, 2013). Advance care planning (ACP) is defined as conversations which cover the patient’s specific health conditions, their options for care and what care best fits their personal wishes, including at the end of life, and the importance of sharing those wishes in the form of a written document (PerryUndum Research/Communication, 2016, p. 15). There is consensus in recommending that ACP in Alzheimer’s disease and other progressive dementias should begin at the time of diagnosis to engage persons with dementia in making future choices and decisions (European Association of Palliative Care, 2013; Palliative Care Australia, 2015; Worldwide Hospice Palliative Care Alliance, 2015). The goal of this quality improvement project was to enhance the rate of ACP conversations in a dementia specialty practice by increasing physician knowledge, skill and confidence in having ACP conversations and using relevant Medicare codes. This study used a sample of 10 physicians in a multi-disciplinary dementia specialty practice (Geriatrics n = 2; Psychiatry n = 5; Neurology n = 3). We used a pre-post single sample design, measuring physician knowledge, skill, and confidence based on a 10-item survey. We also assessed the prevalence of ACP documentation, including an advance directive (AD), Medical Order for Life Sustaining Treatment (MOLST), and discussions in progress notes in the three months before and after the educational intervention. In the pre-test data analysis, we found that physicians believed ACP improves outcomes in patients with dementia (100%), and it is their responsibility to initiate ACP conversations in the early stages of dementia (90%). Most were unfamiliar with the Medicare billing codes and requirements for ACP (90%). We reviewed progress notes for 407 patient visits; mean age of patients was 74 years, diagnosed with any type of dementia. The prevalence of AD documentation in the medical record was low (1%-25%), and power of attorney was the most frequent term mentioned that may reflect ACP discussions (3%). We are continuing to enroll physicians, and plan an ACP educational intervention. The pre and post-intervention data analysis will be presented. Physician’s documentation of ACP planning with patients diagnosed with dementia is not consistent with their opinions of its importance and role in initiating conversations. Increasing physician knowledge and awareness of ACP in dementia could improve patient outcomes.