Improving Advanced Care Planning Discussions at an Internal Medicine Clinic

Abstract

Objective: The project aimed to standardize advanced care planning (ACP) at an internal medicine clinic by initiating physician-patient communication regarding the patient’s knowledge, understanding, and openness to pursuing advanced medical directives.

Methods: Data collection was conducted from February 1 to April 1, 2024, with the study concluding on April 24, 2024. ACP was facilitated through an initial standardized six-question pre-intervention survey in both English and Spanish. This pre-survey included questions on prior survey exposure within the past three months, current age, existing or previous medical conditions, possession of an advance directive (e.g., living will or durable power of attorney for healthcare), and interest in learning more about advanced medical directives. For patients interested in learning more, standardized educational materials from the National Institute on Aging were provided, along with a Texas out-of-hospital do-not-resuscitate (OOH-DNR) order, a Medical Power of Attorney form, and instructions in both English and Spanish. Post-education, patients completed a post-intervention survey asking if they had previously discussed advanced medical directives with a physician. The survey also included Likert scale questions about the discussion’s usefulness, comfort with end-of-life discussions, perceived importance of advanced directives, and likelihood of completing an advance directive.

Results: During the three months, 52 patients completed the pre-intervention survey, with an average age of 59 years. Hypertension, dyslipidemia, and diabetes were the most common conditions among participants. Statistical tests indicated no significant difference between patients’ age or number of comorbidities and possession of an advance directive (p > 0.05), nor was there a significant association between these variables and interest in learning more about advanced directives (p > 0.05). However, post-intervention survey results showed a significant correlation between age and prior discussions about advanced directives (p = 0.013) and between the number of comorbidities and having had past discussions (p = 0.025). Only 1.2% of patients reported having advanced directives before this study, highlighting a substantial gap in documentation.

Conclusion: This project revealed a notable gap in ACP documentation among patients at the internal medicine clinic, with very few patients having advanced directives prior to the intervention. While age and comorbidity count were not significantly associated with interest in advanced directives, older patients and those with more comorbidities were more likely to have had previous discussions. This underscores the need for targeted efforts to encourage ACP, particularly among younger patients and those with fewer medical conditions. Standardized educational resources effectively facilitated discussions, raising awareness and promoting engagement in ACP.

Discussion

This article describes a quality-improvement project in an academic internal medicine clinic that set out to standardize advance care planning (ACP) conversations with adult patients. Resident physicians used a brief, bilingual pre-visit survey (English/Spanish) to ask about prior exposure to ACP, whether patients already had documents (living will, medical power of attorney, out-of-hospital DNR), and whether they wanted more information.

Patients who were interested received standardized education from the National Institute on Aging plus printed Texas OOH-DNR and medical power of attorney forms with bilingual instructions; afterward they completed a short post-visit survey about the usefulness of the conversation, their comfort with end-of-life discussions, and their likelihood of completing directives.

Over three months, 52 patients (average age 59) completed the pre-survey; hypertension, dyslipidemia, and diabetes were the most common comorbidities. Baseline ACP documentation was extremely low. Only a handful of patients reported having any advance directive, and many were unsure. Age and number of comorbidities were not linked to who had completed directives or who was interested in learning more.

However, in the subgroup who completed post-surveys (n=23), older patients and those with more comorbidities were more likely to have had prior ACP conversations with a clinician. After the intervention, most patients said the discussion was helpful, strongly agreed that directives are important, and the vast majority reported that they now plan to complete advance directives in the future.

Takeaways for hospice agencies?

For hospice agencies, the message is clear: by the time people arrive on hospice, most still may not have had structured ACP or created documents, even if they live with serious chronic illness.

This study shows that short, scripted, bilingual conversations plus simple, printed forms can meaningfully move patients toward planning. This is something hospice agencies could adapt in their own admissions, routine visits, and community outreach.

Practical questions for hospice agencies to consider include: Do we assume referring clinics have “already done” ACP, or do we build it into our own workflows and track completion rates? Are we offering culturally and linguistically appropriate ACP materials like this clinic did? Could we partner with local primary-care practices to co-host ACP days, share standardized scripts, or co-branded NIA-based education? In our marketing, are we explicitly presenting hospice as part of a continuum that starts with good ACP in clinic, reassuring families that our role is to honor the choices they put in writing and to support them in having those hard conversations earlier, not only at the very end?

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