Implementing Advance Care Planning in 'The Age of Deferred Death'- the Hong Kong Experience over 4 Years.

OBJECTIVES: To plan, implement and evaluate a series of initiatives to improve patient centred quality of end of life care through raising public awareness, promoting the concept that all health and social care professionals should be engaged in this practice, and carrying out pilot of community care models. DESIGN: Pilot studies of community models of care, training programs for health and social care professionals, public education programmes. SETTING: Selected hospitals, residential care homes for the elderly, and community centres in Hong Kong. PARTICIPANTS: Patients and their families at the end of life stage. MEASUREMENTS: Combination of quantitative and qualitative studies according to different components of the initiative. RESULTS: Effective training for professional staff occurred using training videos, role play, rather than lectures, and when concepts are integrated into daily practice and quality assurance programmes. Members of the public welcomed end of life care discussions and the implementation of advance care planning. The pilot community care program was found to reduce anxiety, depression, physical symptoms, improve communication within the family as well as promoting a feeling of peace among recipients of the service. It also reduced care giver strain and anxiety, as well as hospital visits and duration of stay. Similar findings were also observed among recipients of care in the residential care setting. CONCLUSION: A sustainable model would require uptake by policy makers and chief executives of Social Welfare and Health Bureaus, supported by amendments of relevant legal ordinances, which is in progress after public consultation.

Advance care planning in medicare/medicaid-funded agencies: providing a training in cultural competence.

This study presents a training that was developed for staff members at Medicare/Medicaid agencies to improve their knowledge and comfort levels in working on advance care planning (ACP) with their clients in a culturally competent manner. The training was developed to address the need to clarify the different types and purposes of ACP and to help develop the skills needed to work with clients of diverse cultural backgrounds. The evaluation of findings from the training showed the positive impacts that it had on participants; in particular, they exhibited demonstrated improvement in their knowledge of and comfort levels with ACP. The participants also expressed interest in receiving continued training surrounding ACP to increase their cultural competency skills and to receive updated information on ACP policies and practices.

Virtual reality video promotes effectiveness in advance care planning.

BACKGROUND: In 2019, the Patient Autonomy Act went into effect, allowing Taiwanese citizens to establish legal advance decisions. In an effort to secure a more realistic and accurate perception of situations, a virtual reality video was developed by the palliative care team of Chi-Mei hospital in southern Taiwan for citizens to use before advance care planning. This study explores the change in participants' preference and certainty regarding end-of-life decisions after using this tool. METHODS: Participants were at least 20 years old and capable of reading and understanding the information provided in the written handout with information about the legal process of making an advance decision. They completed pre-test questionnaires, viewed a six-minute 360-degree virtual reality video on a portable headset, and then completed a post-test questionnaire about their preference on the five medical options-CPR, life-sustaining treatments, antibiotics, blood transfusion, and artificial nutrition and hydration-followed by feedback on the helpfulness of the virtual reality. The control group included 40 participants who only read the handout and completed pre-test and post-test questionnaires. RESULTS: After viewing the virtual reality video, preference for not using CPR, life-sustaining treatment, antibiotics, blood transfusion, and artificial nutrition and hydration increased significantly in the virtual reality intervention group. Uncertainty regarding the five medical options mentioned above significantly decreased. The intervention was generally recognized by participants for its help in making decisions. DISCUSSION: The decrease in the number of participants who could not make decisions indicates that the virtual reality video may be helpful for users in making end-of-life decision. According to feedback, the virtual reality video helped equip users with better understanding of medical scenarios, and that it is a good decision tool for advance care planning. CONCLUSION: This is the first study since the Patient Autonomy Act has been passed that explores the effectiveness of using a virtual reality video as a decision tool in advance care planning and reveals decreased preference of CPR, life sustaining treatment, antibiotics, blood transfusion, and artificial nutrition and hydration after intervention. This decision aid proved to be an effective tool for clarifying their end-of-life care preferences.

Assessment of Bereaved Caregiver Experiences of Advance Care Planning for Children With Medical Complexity.

Importance: Advance care planning (ACP) is the process of discussing values and preferences for care to help inform medical decision-making. Children with medical complexity (CMC) often have a shortened life span with an unpredictable clinical course and timing of death; however, there is a paucity of literature that describes the experience of ACP from the perspective of bereaved family caregivers of CMC. Objective: To explore the experiences of bereaved family caregivers with ACP for CMC. Design, Setting, and Participants: This qualitative study included 12 interviews with 13 bereaved family caregivers of CMC whose deaths had occurred in the 5 years before study commencement (2013-2018). Participants were recruited at a single tertiary care pediatric center; CMC were treated by the Complex Care or Long-term Ventilation clinic in Toronto, Ontario, Canada. Data were collected from July to October 2018. Thematic analysis with an inductive approach was used. Exposures: Qualitative interviews were conducted using purposive sampling of bereaved family caregivers using semistructured interviews that were recorded and transcribed. Interviews were conducted until saturation was reached. Main Outcomes and Measures: Transcripts were analyzed to create themes that characterized caregiver experiences with ACP. Results: A total of 13 family caregivers were interviewed in 12 interviews, all of whom were parents (12 [92%] women, 1 [8%] man) of a deceased child (aged 7 months to 12 years). Themes were divided in the 3 following categories, which align with the Donabedian model for health service quality: (1) structure of care, (2) ACP process, and (3) end-of-life experience. Notable subthemes for this population included the importance of accounting for parental expertise in the child's care, recurrent experiences with life-threatening events, relative shock of the timing of death, and the multiple losses that caregivers experienced. Conclusions and Relevance: In this study, parental experiences revealed that there are key aspects of the structure of the child's care, process around ACP, and end-of-life care experiences that provide important reflections on ACP that warrant future study.

Utilization of ACP CPT codes among high-need Medicare beneficiaries in 2017: A brief report.

IMPORTANCE: Medicare beneficiaries with high medical needs can benefit from Advance Care Planning (ACP). Medicare reimburses clinical providers for ACP discussions, but it is unknown whether high-need beneficiaries are receiving this service. OBJECTIVE: To compare rates of billed ACP discussions among a cohort of high-need Medicare beneficiaries with the non-high-needs Medicare population. DESIGN: Retrospective analysis of Medicare Fee-for-Service (FFS) claims in 2017 comparing high-need beneficiaries (seriously ill, frail, ESRD, and disabled) with non-high need beneficiaries. SETTING: Nationally representative FFS Medicare 20% sample. PARTICIPANTS: Medicare beneficiaries were assigned to one of the following classifications: seriously ill (65+), frail (65+), seriously ill & frail (65+); non-high need (65+); end stage renal disease (ESRD) or disabled (<65). All participants had data available for years 2016-2017. EXPOSURE: Receipt of a billed ACP discussion, CPT codes 99497 or 99498. MAIN OUTCOME AND MEASURE: Rates of billed ACP visits were compared between high-need patients and non-high-need patients. Rates were adjusted for the 65+ population for sex, age, race/ethnicity, Charlson comorbidity index, Medicare/Medicaid dual eligibility status, and Hospital Referral Region. RESULTS: Among the 65+ groups, those most likely to have a billed ACP discussion included seriously ill & frail (5.2%), seriously ill (4.2%), and frail (3.3%). Rates remained consistent after adjusting (4.5%, 4.0%, 3.1%, respectively). Each subgroup differed significantly (p < .05) from non-high need beneficiaries (2.3%) in both unadjusted and adjusted analyses. Among the <65 high need groups, the rates were 2.7% for ESRD and 1.3% for the disabled (the latter p < .05 compared with non-high needs). CONCLUSIONS AND RELEVANCE: While rates of billed ACP discussions varied among patient groups with high medical needs, overall they were relatively low, even among a cohort of patients for whom ACP may be especially relevant.

Palliative care for people living with heart failure: European Association for Palliative Care Task Force expert position statement.

Contrary to common perception, modern palliative care (PC) is applicable to all people with an incurable disease, not only cancer. PC is appropriate at every stage of disease progression, when PC needs emerge. These needs can be of physical, emotional, social, or spiritual nature. This document encourages the use of validated assessment tools to recognize such needs and ascertain efficacy of management. PC interventions should be provided alongside cardiologic management. Treating breathlessness is more effective, when cardiologic management is supported by PC interventions. Treating other symptoms like pain or depression requires predominantly PC interventions. Advance Care Planning aims to ensure that the future treatment and care the person receives is concordant with their personal values and goals, even after losing decision-making capacity. It should include also disease specific aspects, such as modification of implantable device activity at the end of life. The Whole Person Care concept describes the inseparability of the physical, emotional, and spiritual dimensions of the human being. Addressing psychological and spiritual needs, together with medical treatment, maintains personal integrity and promotes emotional healing. Most PC concerns can be addressed by the usual care team, supported by a PC specialist if needed. During dying, the persons' needs may change dynamically and intensive PC is often required. Following the death of a person, bereavement services benefit loved ones. The authors conclude that the inclusion of PC within the regular clinical framework for people with heart failure results in a substantial improvement in quality of life as well as comfort and dignity whilst dying.

Factors related to advance care planning among older African American women: Age, medication, and acute care visits.

OBJECTIVES: Advance care planning (ACP) is linked with high-quality clinical outcomes at the end of life. However, ACP engagement is lower among African Americans than among Whites. In this study, we sought to identify correlates of ACP among African American women with multiple chronic conditions for two reasons: (1) African American women with multiple chronic conditions have high risks for serious illnesses, more intensive treatments, and circumstances that may require substitutes' decision-making and (2) identifying correlates of ACP among African American women can help us identify important characteristics to inform ACP outreach and interventions for this group. METHODS: A cross-sectional survey was conducted with 116 African American women aged ≥50 years who were recruited from the central area of a mid-western city. RESULTS: On average, participants were 64 years old (SD = 9.42). The majority were not married (78%), had less than a college education (50%), and had an annual income of $15,000 (54%). Their mean numbers of chronic conditions and prescribed medications were 3.31 (SD = 1.25) and 8.75 (SD = 4.42), respectively. Fifty-nine per cent reported having talked with someone about their preferences (informal ACP); only 30% had completed a living will or a power of attorney for healthcare (formal ACP). Logistic regression showed that age, the number of hospitalizations or emergency department visits, and the number of prescription medications were significantly correlated with both informal and formal ACP; other demographic and psychosocial characteristics (the knowledge of ACP, self-efficacy, and trust in the medical system) were not. SIGNIFICANCE OF RESULTS: Results of this study suggest a need for targeted, culturally sensitive outpatient ACP education to promote ACP engagement in older African American women, taking into account age, the severity of chronic conditions, and levels of medication management.

The exploration of the knowledge, attitudes and practice behaviors of advanced care planning and its related predictors among Taiwanese nurses.

BACKGROUND: Despite the documented and well known patient benefits of ACP, the completion of ACP, only a minority of patients, during the advanced or EOL stage of their illnesses, receive such care. The misconceptions about ACP for healthcare providers, such as nurses, might become potential barriers to the effective implication of ACP. Also, from the transcultural perspective, it is evident essential to explore Taiwanese nurses' attitudes, knowledge, and actions of ACP. The purposes of this study were to explore the implication of ACP or hospice care for nurses caring for non-cancer chronic illness patients at a regional teaching hospital in Taiwan; and, to identify predictors of those nurses' knowledge, attitudes, and actions toward ACP. METHODS: This cross-sectional study with a purposive sample of 218 nurses was conducted at a teaching hospital in southern Taiwan. Structured questionnaires were employed and data were analyzed with descriptive statistics, t-test, one-way ANOVAs, Pearson's correlation and multiple regressions. RESULTS: 16.1% of Taiwanese physicians actively initiated ACP issues or conversations with patients or their family members. Nurses' attitudes toward ACP were fairly positive but their knowledge about ACP was insufficient and actions of ACP were not positively executed. The predictors of ACP-Knowledge (ACP-K) included position title, education hours and lacking of educational training. The predictors of ACP-Attitude (ACP-A) included ACP-K and "fear of patient or family member not accepting", whereas ACP-A, position title, "patients do not feel necessary" and "not sure physician's concern" were the predictors of ACP-Act. CONCLUSION: Continuous education and training for nurses regarding ACP needs to be improved by taking those predictors found in this current study into account, and more studies on the nurse's role in ACP also should be further examined. TRIAL REGISTRATION: KAFGH 106-012. Date of registration 1 May 2017.

Culturally Acceptable Advance Care Planning and Advance Directives for Persons Experiencing Homelessness.

Although the process of dying is a universal human experience, it often magnifies individuals' unique cultural differences. Persons experiencing homelessness (PEHs) have unique barriers, challenges, and wishes for end-of-life care. There is insufficient evidence about how to provide culturally congruent advance care planning (ACP) through advance directive (AD) completion for PEHs. This study addressed this knowledge gap, and its findings serve as the basis for developing additional strategies to promote a satisfying ACP experience for this population when they complete an AD. The purpose of this study was to discover if an AD form recreated for PEHs would positively affect their completion of the AD as well as their overall experience with ACP. Guided by the culture care theory and qualitative ethnonursing methodology, 38 individuals (30 PEHs and 8 student nurses) were interviewed. Data were analyzed using the 4 phases of ethnonursing analysis. The 3 themes abstracted were (1) "it needs to be done," (2) the presence or absence of trusted family support, and (3) ACP for PEHs is facilitated by an AD workshop. Nursing interventions based on study findings can be used to help promote a dignified, meaningful ACP experience for vulnerable populations.

From Barriers to Assets: Rethinking factors impacting advance care planning for African Americans.

OBJECTIVE: We aimed to explore multiple perspectives regarding barriers to and facilitators of advance care planning (ACP) among African Americans to identify similarities or differences that might have clinical implications. METHOD: Qualitative study with health disparities experts (n = 5), community members (n = 9), and seriously ill African American patients and caregivers (n = 11). Using template analysis, interviews were coded to identify intrapersonal, interpersonal, and systems-level themes in accordance with a social ecological framework.ResultParticipants identified seven primary factors that influence ACP for African Americans: religion and spirituality; trust and mistrust; family relationships and experiences; patient-clinician relationships; prognostic communication, care preferences, and preparation and control. These influences echo those described in the existing literature; however, our data highlight consistent differences by group in the degree to which these factors positively or negatively affect ACP. Expert participants reinforced common themes from the literature, for example, that African Americans were not interested in prognostic information because of mistrust and religion. Seriously ill patients were more likely to express trust in their clinicians and to desire prognostic communication; they and community members expressed a desire to prepare for and control the end of life. Religious belief did not appear to negate these desires.Significance of resultsThe literature on ACP in African Americans may not accurately reflect the experience of seriously ill African Americans. What are commonly understood as barriers to ACP may in fact not be. We propose reframing stereotypical barriers to ACP, such as religion and spirituality, or family, as cultural assets that should be engaged to enhance ACP. Although further research can inform best practices for engaging African American patients in ACP, findings suggest that respectful, rapport-building communication may facilitate ACP. Clinicians are encouraged to engage in early ACP using respectful and rapport building communication practices, including open-ended questions.

A Review of the Literature on Native Hawaiian End-of-Life Care: Implications for Research and Practice.

The need for cultural understanding is particularly important in end-of-life (EOL) care planning as the use of EOL care in minority populations is disproportionately lower than those who identify as Caucasian. Data regarding the use of EOL care services by Native Hawaiians in Hawai'i and the United States is limited but expected to be similarly disproportionate as other minorities. In a population with a lower life expectancy and higher prevalence of deaths related to chronic diseases such as cardiovascular disease, diabetes, and obesity, as compared to the state of Hawai'i as a whole, our objective was to review the current literature to understand the usage and perceptions of EOL care planning in the Native Hawaiian population. We searched ten electronic databases and after additional screening, seven articles were relevant to our research purpose. We concluded that limited data exists regarding EOL care use specifically in Native Hawaiians. The available literature highlighted the importance of understanding family and religion influences, educating staff on culturally appropriate EOL care communication, and the need for more research on the topic. The paucity of data in EOL care and decision-making in Native Hawaiians is concerning and it is evident this topic needs more study. From national statistics it looks as though this is another health disparate area that needs to be addressed and is especially relevant when considering the rapid increase in seniors in our population.

Retrospective chart review to assess domains of quality of death (recognition of dying, appropriate limitations, symptom monitoring, anticipatory prescribing) of patients dying in the acute hospital under the care of a nephrology service with renal supportive care support over time.

AIM: To explore the quality of deaths in an acute hospital under a nephrology service at two teaching hospitals in Sydney with renal supportive care services over time. METHODS: Retrospective chart review of all deaths in the years 2004, 2009 and 2014 at St George Hospital (SGH) and in 2014 at the Concord Repatriation General Hospital. Domains assessed were recognition of dying, invasive interventions, symptom assessment, anticipatory prescribing, documentation of spiritual needs and bereavement information for families. End-of-life care plan (EOLCP) use was also evaluated at SGH. RESULTS: Over 90% of patients were recognized to be dying in all 3 years at SGH. Rates of interventions in the last week of life were low and did not differ across the 3 years. There was a significant increase in the prescription of anti-psychotic, anti-emetic and anti-cholinergic medication over the years at SGH. Use of EOLCP was significantly higher at SGH, and their use improved several quality domains. Of all deaths, 68% were referred to palliative care at SGH and 33% at Concord Repatriation General Hospital (not significant). Cessation of observations and non-essential medications and documentation of bereavement information given to families was low across both sites in all years, although this significantly improved when EOLCP were used. CONCLUSION: While acute teams are good at recognizing dying, they need support to care for dying patients. The use of EOLCP in acute services can facilitate improvements in caring for the dying. Renal supportive care services need time to become embedded in the culture of the acute hospital.

Healthcare Providers' Attitudes, Knowledge, and Practice Behaviors for Educating Patients About Advance Directives: A National Survey.

BACKGROUND:: Advance care planning for end-of-life care emerged in the mid-1970's to address the need for tools, such as the advance directive (AD) legal document, to guide medical decision-making among seriously ill patients, their families, and healthcare providers. OBJECTIVE:: Study aims examine providers' perspectives on AD education that involve examining (1) a range of attitudes about educating patients, (2) whether prior knowledge was associated with practice behaviors in educating patients, and (3) specific factors among healthcare providers such as characteristics of work setting, knowledge, attitudes, and behaviors that may influence AD education and documentation. DESIGN:: To examine providers' views, we conducted a cross-sectional, online survey questionnaire of healthcare providers using social media outreach methods for recruitment. METHODS:: This study used a cross-sectional survey design to examine the proposed aims. Healthcare providers, recruited through a broad approach using snowball methods, were invited to participate in an online survey. Logistic regression analyses were used to examine providers' views toward AD education. RESULTS:: Of 520 participants, findings indicate that most healthcare providers said that they were knowledgeable about AD education. They also viewed providing education as beneficial to their practice. These findings suggest that having a positive attitude toward AD education and experiencing less organizational barriers indicate a higher likelihood that providers will educate patients regarding ADs. CONCLUSION:: Various disciplines are represented in this study, which indicates that attitudes and knowledge influence AD discussions. The importance of AD discussions initiated by healthcare providers is critical to providing optimal patient-centered care.

Successful Advance Care Planning in a Rural Nursing Home.

BACKGROUND:: Advance care planning (ACP) often culminates in the completion of advance care directives (ACD), which is a written record of informed decisions specifying the type and extent of desired medical treatment. Documentation of ACD in nursing homes in the United States indicates a 60% to 70% completion rate. There are little data on the time at which ACD are completed in relation to when the resident was admitted to the nursing home facility. OBJECTIVE:: To explore the success of advanced care planning at a large, rural long-term care (LTC) facility. METHODS:: A descriptive approach, using a retrospective chart review, of 167 residents was used to examine resident completion of health-care system documents, legal documents, predisposing factors (resident demographics and psychosocial characteristics), and the actual process of ACP as defined by the rural LTC facility. RESULTS:: This nursing home utilizes a document entitled resident preference for life-sustaining treatment (RPLST). For residents who do not have formal prepared advance directive documents, the RPLST serves to define resident and family choices for resuscitation and implementation of fluids, nutrition, medications, and antibiotics. The most striking finding was the completion rate of the RPLST within 100 days of being admitted to the nursing home. CONCLUSION:: Documentation of end-of-life preferences within 10 days of admission was achieved through the incorporation of RPLST during the resident admission process.

For People Dying to Talk, It Finally Pays to Listen with Reimbursable Advance Care Planning.

Whether at the beginning, middle, or end of life, health care delivery choices abound. Yet only recently have conversations specifically regarding preferences for care at the end of life become a reimbursable intervention, deemed equivalent in importance to a medical procedure. Quite distinct from other procedures, in which expectations for outcomes are explicit and measurable, outcomes have been left intentionally vague for advanced care planning (ACP) conversations. This article will explore the inherent challenges of and opportunities for developing formalized outcomes, methods of measurement, and training to ensure excellence in the performance of ACP conversation procedures. Whether at the beginning, middle, or end of life, health care delivery choices abound. Yet only recently have conversations specifically regarding preferences for care at the end of life become a reimbursable intervention, deemed equivalent in importance to a medical procedure. Quite distinct from other procedures, in which expectations for outcomes are explicit and measurable, outcomes have been left intentionally vague for advanced care planning (ACP) conversations. This article will explore the inherent challenges of and opportunities for developing formalized outcomes, methods of measurement, and training to ensure excellence in the performance of ACP conversation procedures.

A broader understanding of care managers' attitudes of advance care planning: A concurrent nested design.

AIMS AND OBJECTIVES: To examine barriers of advance care planning (ACP) experienced by care managers (CMs) through a mixed methods approach. A concurrent nested design was used to acquire a deeper understanding of ACP and to identify nuances between quantitative and qualitative data. BACKGROUND: Past quantitative studies on providers have identified barriers related to time, culture, knowledge, responsibility and availability of legal documents. These barriers, and accompanying attitudes and feelings, have been taken at face value without rich qualitative data to identify under what conditions and to what extent a barrier impacts care. DESIGN: A two-part multisite, mixed methods study was conducted using surveys and focus groups. METHODS: Surveys were completed by 458 CMs at 10 Area Agencies on Aging and 62 participated in one of eight focus groups. Data were analysed using a concurrent nested design with individual data analysis and a merged data approach. RESULTS: There were three main distinctions between the quantitative and qualitative data. First, while CMs reported on the survey that ACP was not too time consuming, focus group data revealed that time was an issue especially related to competing priorities. Second on the survey 60% of the CMS reported they had enough knowledge, but qualitative data revealed about more nuances. Last, the reported comfort levels in the quantitative data were less overt in the qualitative date where additional feelings and attitudes were revealed, for example, frustration with families, preferences for more physician involvement. CONCLUSIONS: Care managers reported their attitudes about ACP, clarified through a rigorous mixed methods analysis. Care managers can successfully lead ACP discussions, but require further education, resources and team-based guidance. RELEVANCE TO CLINICAL PRACTICE: Advance care planning is essential for reducing emotional, social and financial burdens associated with healthcare decision-making, and CMs can positively impact ACP discussions when appropriately supported by the clinical community. The many nuances in the ACP process that we found illustrate the need for ongoing discussions, education and research on this important topic.

Cultural Aspects of End-of-Life Care Planning for African Americans: An Integrative Review of Literature.

Advance directive completion rates among the general population are low. Studies report even lower completion rates among African Americans are affected by demographic variables, cultural distinctives related to patient autonomy, mistrust of the health care system, low health literacy, strong spiritual beliefs, desire for aggressive interventions, importance of family-communal decision making, and presence of comorbidities. An integrative review was conducted to synthesize nursing knowledge regarding cultural perspectives of end-of-life and advance care planning among African Americans. Twenty-four articles were reviewed. Nurses educate patients and families about end-of-life planning as mandated by the Patient Self-Determination Act of 1991. Implementation of advance directives promote patient and family centered care, and should be encouraged. Clinicians must be sensitive and respectful of values and practices of patients of diverse cultures, and initiate conversations with open-ended questions facilitating patient trust and sharing within the context of complex beliefs, traditions, and lifeways.

Reversing Racial Inequities at the End of Life: A Call for Health Systems to Create Culturally Competent Advance Care Planning Programs Within African American Communities.

Racial and cultural barriers inherent in health systems have made the delivery of culturally relevant end of life care that aligns with patient preferences a particular challenge across African American patient populations. The end of life experience has been cited as a public health crisis by the Institute of Medicine (IOM), and this crisis is one felt even more acutely by patients of this minority race. Structural racism has limited access to the planning mechanisms proven to result in quality end of life care; thus, health systems must initiate remedies in the face of dire need, as African Americans face a disproportionate burden of morbidity and mortality from many serious illnesses. Recognizing that education is essential to overcoming barriers to quality care access, the development of new and culturally appropriate models of community engagement surrounding advance care planning is needed to serve and empower African American patients.

Complexity of Chronic Conditions' Impact on End-of-Life Expense Trajectories of Medicare Decedents.

OBJECTIVE: The aim of this study is to determine if the pattern of monthly medical expense can be used to identify individuals at risk of dying, thus supporting providers in proactively engaging in advanced care planning discussions. BACKGROUND: Identifying the right time to discuss end of life can be difficult. Improved predictive capacity has made it possible for nurse leaders to use large data sets to guide clinical decision making. METHODS: We examined the patterns of monthly medical expense of Medicare beneficiaries with life-limiting illness during the last 24 months of life using analysis of variance, t tests, and stepwise hierarchical linear modeling. RESULTS: In the final year of life, monthly medical expense increases rapidly for all disease groupings and forms distinct patterns of change. CONCLUSION: Type of condition can be used to classify decedents into distinctly different cost trajectories. Conditions including chronic disease, system failure, or cancer may be used to identify patients who may benefit from supportive care.