Emergency Department Intervention Program for Enhancing Choice at the Endof Life: A Quality Improvement Project at a Comprehensive Cancer Center

Abstract

Background: Advance care planning (ACP) for end-of-life care is especially important for individuals with terminal illnesses such as advanced cancer. It ensures that patients’ wishes are honored and alleviates the decisionmaking burden on family members and medical providers. It reduces unnecessary medical costs, and prevents waste of valuable resources. We proposed a quality improvement project to improve documentation of advanced care directives in the Emergency Department (ED) of a tertiary cancer center. Methods: We developed a pocket card to help emergency physicians screen patients in need of ACP. The goal was to assist ED staff in initiating conversations about end-of-life issues, and encourage patients and their caregivers to get involved in decisions about their medical treatment. Intervention: The project was implemented in a Plan-Do-Study-Act design. Baseline data was collected from the medical records of all patients visiting the ED on seven consecutive days prior to the distribution of the pocket card tool. After the launch of the intervention, the charts of all patients visiting the emergency center were reviewed for documentation of advanced care planning. Metrics polled included presence of a health care power of attorney and determination of code status, specifically the do-not-resuscitate (DNR) status. Results: 429 patients who visited the ED seven consecutive days prior to institution of the screening tool. Of these, we found that 66 (15.4%) had indicated their do-not-resuscitate (DNR) status in their charts, and 82 (19.1%) had a health care power of attorney. Post launch of the intervention, 391 patients visited the ED over seven consecutive days. Of these, 125 (32.0%) indicated their DNR status in their charts before leaving the ED, and 95 (24.3%) had a health care power of attorney. After implementation of our screening tool, there was a 107.8% increase in documentation of DNR status and a 76% increase in patients with a health care power of attorney. Conclusions: In this quality improvement project, a straightforward, low cost intervention was successfully implemented to improve documentation of patients’ ACP goals.