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

Abstract

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.

Just-in-Time Decision Making: Preliminary Findings of a Goals of Care Rapid Response Team

“…These conversations typically do not take place early in the health care continuum or at all. ( 1 , 7 , 8 ) When they do, often they are not conducted in a manner that is meaningful to the patient's current situation; additionally, patients’ preferences may change. ( 1 , 2 ) The GOC RRT process was to supplement processes supporting downstream GOC discussion and was targeted at critically ill individuals without documented GOC discussions.…”

“…( 1 , 6 ) At our institution, despite increasing efforts over the years, quality improvement projects focused on selecting and preparing a medical decision maker have not yielded a significant increase in scanned Medical Power of Attorney documents available in the electronic health record (EHR) from a low baseline frequency. ( 7 , 8 )…”

Patient Engagement With Early Stage Advance Care Planning at a Comprehensive Cancer Center

“…Many had no or minimal physician follow-up. 29 , 30 As our institution is a comprehensive cancer center, often people come for a second opinion and then remain in their local community. Some are quite ill, limiting their ability to return.…”

“…Questions used to support education are shown in Supplementary Table S1 . 29-31 In phase II, ideally coordinated with phase I, the oncologist/advance practice provider (APP) team discusses prognosis and treatment goals with the patient and his/her family caregiver. Phase III revolves around more in-depth goals of care discussions.…”

“…A number of factors were identified that might have contributed to the failure of the process. 29-31 …”