Increasing Advance Care Planning and Advance Directive Discussion in Primary Care Settings

Advance care planning (ACP) and advance directives (ADs) involve an active medical decision making process regarding one's end-of-life care in the event that a patient becomes incapacitated. The process includes patients and family members as well as well-trained, motivated, knowledgeable health care providers who are willing to initiate such discussions and provide the necessary information to make informed decisions. The goal of this project is to increase advance directive discussions in primary care settings by increasing the knowledge and comfort level of primary care providers (PCPs). Currently, there is a lack of ACP and AD discussions in primary care settings although the need to initiate ACP and AD discussions is rising. An increasing number of people are suffering from chronic illnesses and this raises their risks of receiving invasive life-prolonging measures, even if it is against their wishes. PCPs are in a key position to initiate the discussion while patients are still physically and mentally well. ACP and ADs coincide with basic medical ethics including autonomy, beneficence, and non-maleficence. The biggest advantage of having an ACP and AD in place is so care-givers can respect a patient's autonomy by following advance directives. This may also decrease the unnecessary burden on family members and healthcare providers to make health care decisions for their loved ones and patients. There are many obstacles for PCPs to initiate such discussions. This includes time limitations, the sensitivity of the topic, difficulty identifying the right moment to initiate such discussions and a lack of awareness of ACP and ADs. However, there are also facilitators for PCPs to initiate the discussion. These include a PCP's perceived usefulness of ACP and ADs and reimbursement for time spent on ACP and AD discussion by the center of Medicaid and Medicare The goal of this project was to increase the number of PCPs that initiate this discussion with their patients in the primary care setting and to increase the knowledge and comfort levels of PCPs with the discussion. To achieve this goal, an educational presentation and algorithm were developed and these materials were presented in a primary care setting. To evaluate the effectiveness of the presentation, pre- and post-educational surveys were conducted. In addition, data for the use of the CPT codes for ACP discussions was collected and analyzed for outcome measurements one month before the presentation and one month after. The pre and post-educational surveys showed an increase in knowledge about ACP and ADs knowledge (3.00 ±1.27 pre-education, and 4.33 ± 1.03 post-education, Wilcoxon p value =0.046) and there is a trend toward a significant difference in PCP's wiliness to use CPT codes after the presentation (1.00 ± 0.00 prior and 2.67 ± 1.51 after the presentation, Wilcoxon p= 0.059). However, one month after the presentation, there was no difference in actual CPT code usage by providers. These results may suggest that PCPs perceived obstacles bigger than expected or one-month is too short to follow-up and measure meaningful changes in practice. Furthermore, except financial compensation, PCPs may require an extra layer of support and training to facilitate ACP/AD discussions.