An Integrated Approach to Selecting a Prepared Medical Decision-Maker.

BACKGROUND: We implemented a systematic multidisciplinary process to engage new outpatients with cancer in selecting and preparing a medical decision-maker. MEASURES: Templated advance care planning notes and medical power of attorney documents were used in the electronic health record by the third office visit. INTERVENTION: Patients were coached to meet with social work from a "culture of yes," viewed a video about the importance of selecting a prepared medical a decision-maker in English or in Spanish, and referenced cards containing simple explanations of advance directives when responding to advance directive questions. OUTCOMES: A total of 351 patients were evaluated. By visit 3, there was no increase in documented social work advance care planning notes in intervention or scanned medical power of attorney documents in the electronic health record. CONCLUSIONS/LESSONS LEARNED: This systematic multidisciplinary approach did not engage new outpatients with cancer in preparing a medical decision-maker. More active physician involvement and varied ways of engagement are needed.

Systematic Approach to Selecting and Preparing a Medical Power of Attorney in the Gynecologic Oncology Center.

PURPOSE: Advance care planning (ACP) supports national priorities of patient engagement, person-centered care, and safety. A systematic approach is uncommon in most care settings. Our institution offers all patients with cancer new to the institution an opportunity to select and prepare a medical decision maker (MDM) after social work counseling. The goals of this study were to determine the success of a systematic institutional process for selecting a prepared MDM. The primary objectives were that (1) 70% or more of new patients would have one or more documented social work ACP discussions by the third office visit within 4 months, and (2) there would be a two-fold increase in scanned medical power of attorney (MPOA) documents available in the electronic health record (EHR). The secondary objectives were (1) improved surrogate preparedness for medical decision making, and (2) to determine whether patients with metastatic disease demonstrated greater readiness for selection of an MDM than those with localized disease. MATERIALS AND METHODS: We conducted a retrospective chart review of consecutive gynecology oncology outpatients. RESULTS: Of 133 patients, 93 (70%) had metastatic disease. The median number of visits was two (one to three). Forty-seven patients (39.3%) met with social work by visit 3. Review of ACP notes suggested that most patients were in the early stages of selecting a prepared MDM. At visit 1, 39 (29.3%) reported having an advance directive document; 14 (10.5%) had an MPOA in the EHR. There was no increase by visit 3. Fewer patients with metastatic disease than those with localized cancer (32.3% v 67.5%; P = .001) had three visits; no other parameter, including presence of MPOA documents in the EHR, achieved statistical significance between groups. CONCLUSION: Current processes fail to engage patients in selecting and preparing an MDM.