More than two decades ago, Anne Feaster, DNP, ANP-BC, CRNP, transitioned from working in hospice to a community oncology practice. “I found a clinical gap area in community oncology regarding underuse and lack of documentation of advance care planning [ACP],” says Feaster, a nurse practitioner at Alliance Cancer Specialists in Langhorne, PA. Some patients had treatable but not curable disease, yet goals of care conversations had never taken place. “Nurses providing treatments, chemotherapy, and immunotherapy to those who were becoming frail and needing assistance to get to the office for treatments were not empowered to discuss advance care planning and choice regarding end-of-life wishes,” reports Feaster.
Educating patients on ACP and documenting this education is within the scope of nursing, emphasizes Feaster. “In my work, my passion has been advocating for improved end-of-life care, which includes ACP with a shared decision-making focus,” says Feaster. Feaster obtained a Doctor of Nursing Practice degree with the goal of establishing a process for improved ACP. She and her colleagues implemented a quality improvement project to educate nurses on the importance of ACP. Eight nurses participated in the educational intervention, which included a 10-minute narrated presentation with an ACP video and the organization’s ACP policy, followed by small group meetings at convenient times for the nurses.
The researchers evaluated ACP documentation of 103 patients two weeks prior to the intervention and 114 patients after the intervention.
ACP documentation increased from 0% to 63%, including documentation of living will, DNR order discussions, and healthcare power of attorney. “There was 0% with the pre-intervention group, as there was no process for documentation of ACP education by the staff, and there was no EMR [electronic medical record] tab for uploading completed documents,” Feaster explains.
The quality improvement project included both nursing documentation and integration of a chart tab for ACP. Nurses’ comfort level also increased.
ACP should start early — during treatment, says Feaster. She offers these strategies to improve ACP communication:
- Provide professional education to nursing staff on how to start the discussion regarding ACP.
- Encourage nurses to provide first-line education to patients on ACP, including written information. “We have been incorporating ACP education as part of our nursing assessment in our infusion room,” says Feaster.
- Offer patients a dedicated visit by a provider for ACP for further discussion and planning. “Nurses, physicians, medical assistants can all offer a dedicated advance care planning visit. I have provided dedicated ACP visits by referral from all these team members,” says Feaster.
- Create a specific ACP documentation area in the EMR. “Without this, the content may be lost in progress notes,” warns Feaster. “If ACP is integrated into the care of the oncology population, there would be no reason for omission of these discussions.”
Nurses are uncomfortable with ACP discussions for multiple reasons, according to Monica M. Olander, RN, CCRN, an ICU nurse and member of the ethics committee at Essentia Health in Duluth, MN. “Some physicians feel that it is not the nurses’ place to be talking about end-of-life decisions, especially if they still feel that the patient will improve enough to leave the acute care setting,” says Olander. Even if physicians are supportive, it takes time and experience to begin an ACP conversation. “The comfort level by and large is dependent on the nurses’ career experience, length of time in service, and life experiences. These together allow for adequate and accurate collection of the information needed to determine where the patient is at,” says Olander.
When patients come in with a sudden change of status from their norm or if a major surgery or other procedure is going to happen, Olander engages the patient in an ACP discussion. “It’s always good to at least set up who would be the go-to if decisions need to be made,” says Olander. Patients’ stated wishes can be helpful to family members faced with making decisions when the patient cannot speak for themselves. Some patients ask nurses, “What would you do if you were me?” Olander turns the question into a conversation — about how much pain is present, the patient’s desire to make it to a goal date (such as a graduation or wedding), or the need to continue to be the caretaker for a spouse. “Each patient is different, and their situations are different, and their reasons are different,” says Olander.
Early discussions in the outpatient setting prevent some end-of-life conflicts in the ICU setting. “If questions are asked and answered as they come up, patients and family seem to have an easier time with some of the decisions that need to be made,” says Olander.
- Feaster A, Thrane SE, DuBois Shihabuddin C, et al. Educational intervention to enhance nursing comfort with advance care planning and documentation. Clin J Oncol Nurs 2023;27:27-32.
