Advance Care Planning

Percentage of patients aged 18 and older at the beginning of the measurement period with an inpatient encounter who have either an advance care planning (ACP) document or documentation of an advance care planning discussion in the medical record by the time of hospital discharge. The measure includes all inpatient hospitalizations for patients aged 18 and older at the beginning of the measurement period that resulted in discharge during the measurement period.

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This measure aims to advance person-centered care by ensuring that hospitals provide patients and their caregivers the opportunity to discuss their goals of care and/or capture patients’ existing ACP decisions. ACP is widely recognized as important to patient care by patients, surrogates, and clinicians, and is associated with improvements in numerous outcomes for patients’ and their caregivers’ experiences and satisfaction with end-of-life (EOL) care (McMahan et al., 2021).  The 1990 Patient Self Determination Act (1990) mandates healthcare facilities to inform patients of their medical decision-making rights and document their ACP decisions in medical records. Yet engagement in ACP remains low across United States populations.

There are numerous evidence-based benefits to advance care planning, including: ensuring that patients receive care that is consistent with their preferences and increasing the likelihood that providers and families understand and comply with a patient’s preferences for medical care when the patient lacks decision-making capacity (Silveira et al., 2010; Hammes & Rooney, 1998). ACP is also associated with improvements in patient self-efficacy and reductions in patient anxiety, caregiver distress, complicated grief, and clinician distress (McMahan et. al, 2021; Rosa et al., 2023). Additionally, ACP has been linked to enhanced communication among patients, surrogates, and clinicians, as well as increased satisfaction with clinicians who initiate discussions about EOL care (Aasmul et al., 2001; Doorenbos et al., 2016; Tierney et al., 2001). ACP is also associated with decreased hospital length of stay and is in alignment with patient’s preferred place of death (McMahan et al., 2021; Martin et al., 2019).

Increased score indicates improvement

Reference Type: Citation

Reference Text: 'Aasmul, I., Husebo, B. S., Sampson, E. L., & Flo, E. (2018). Advance Care Planning in Nursing Homes - Improving the Communication Among Patient, Family, and Staff: Results From a Cluster Randomized Controlled Trial (COSMOS). Frontiers in psychology, 9, 2284. https://doi.org/10.3389/fpsyg.2018.02284 '

Reference Type: Citation

Reference Text: 'Doorenbos, A. Z., Levy, W. C., Curtis, J. R., & Dougherty, C. M. (2016). An Intervention to Enhance Goals-of-Care Communication Between Heart Failure Patients and Heart Failure Providers. Journal of pain and symptom management, 52(3), 353–360. https://doi.org/10.1016/j.jpainsymman.2016.03.018 '

Reference Type: Citation

Reference Text: 'Hammes, B. J., & Rooney, B. L. (1998). Death and end-of-life planning in one midwestern community. Archives of internal medicine, 158(4), 383–390. https://doi.org/10.1001/archinte.158.4.383 '

Reference Type: Citation

Reference Text: 'Martin, R. S., Hayes, B. J., Hutchinson, A., Tacey, M., Yates, P., & Lim, W. K. (2019). Introducing Goals of Patient Care in Residential Aged Care Facilities to Decrease Hospitalization: A Cluster Randomized Controlled Trial. Journal of the American Medical Directors Association, 20(10), 1318–1324.e2. https://doi.org/10.1016/j.jamda.2019.06.017 '

Reference Type: Citation

Reference Text: 'McMahan, R. D., Tellez, I., & Sudore, R. L. (2021). Deconstructing the Complexities of Advance Care Planning Outcomes: What Do We Know and Where Do We Go? A Scoping Review. Journal of the American Geriatrics Society, 69(1), 234–244. https://doi.org/10.1111/jgs.16801'

Reference Type: Citation

Reference Text: 'Patient Self Determination Act of 1990.; 1990. Retrieved from https://www.congress.gov/bill/101st-congress/house-bill/4449'

Reference Type: Citation

Reference Text: 'Rosa, W. E., Izumi, S., Sullivan, D. R., Lakin, J., Rosenberg, A. R., Creutzfeldt, C. J., Lafond, D., Tjia, J., Cotter, V., Wallace, C., Sloan, D. E., Cruz-Oliver, D. M., DeSanto-Madeya, S., Bernacki, R., Leblanc, T. W., & Epstein, A. S. (2023). Advance Care Planning in Serious Illness: A Narrative Review. Journal of pain and symptom management, 65(1), e63–e78. https://doi.org/10.1016/j.jpainsymman.2022.08.012 '

Reference Type: Citation

Reference Text: 'Silveira, M. J., Kim, S. Y., & Langa, K. M. (2010). Advance directives and outcomes of surrogate decision making before death. The New England journal of medicine, 362(13), 1211–1218. https://doi.org/10.1056/NEJMsa0907901'

Reference Type: Citation

Reference Text: 'Tierney, W. M., Dexter, P. R., Gramelspacher, G. P., Perkins, A. J., Zhou, X. H., & Wolinsky, F. D. (2001). The effect of discussions about advance directives on patients' satisfaction with primary care. Journal of general internal medicine, 16(1), 32–40. https://doi.org/10.1111/j.1525-1497.2001.00215.x'

Reference Type: Citation

Reference Text: 'Yadav, K. N., Gabler, N. B., Cooney, E., Kent, S., Kim, J., Herbst, N., Mante, A., Halpern, S. D., & Courtright, K. R. (2017). Approximately One In Three US Adults Completes Any Type Of Advance Directive For End-Of-Life Care. Health affairs (Project Hope), 36(7), 1244–1251. https://doi.org/10.1377/hlthaff.2017.0175'

ACP: Based on expert consensus, ACP is defined as “a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care" (Silveira et al., 2010).  ACP is dynamic and shaped by changes in health status. ACP is an iterative process that can and should be updated across the span of a person’s life, particularly if there is evolution in a patient’s goals for medical treatment. The process of ACP involves conversations with patients or their designated caregivers about their goals, wishes, and preferences for medical treatment and documentation of ACP discussions and/or completion of formal documents to ensure patients or their caregivers’ decisions are captured.

Advance Directives (AD): Advance directives are legal documents that outline an individual's preferences for medical treatment and/or decision making in the event that they become incapacitated and unable to communicate their wishes. AD typically consists of a living will and/or a power of attorney for health care. 

Code Status: Code status refers to a patient's preference regarding life-sustaining measures in the event of cardiac or respiratory arrest. It typically includes decisions about cardiopulmonary resuscitation (CPR). Common code status options include “do not resuscitate” and "do not intubate" (Hammes & Rooney, 1998).

Do Not Resuscitate Order (DNR Order): Rosa et al. (2023) define a DNR as a portable medical order that specifies that a patient does not want emergency responders or healthcare providers to perform CPR if they stop breathing or their heart stops. 

Living Will: A living will is a type of AD that specifies the medical treatments and interventions that a person would or would not want to receive if they become incapacitated due to a terminal illness or permanent unconsciousness. 

Medical Orders for Life Sustaining Treatment or Physician Orders for Life Sustaining Treatment forms (MOLT/POLST forms): MOLST/POLST forms are portable medical orders forms that allow seriously ill or frail people to communicate their EOL care wishes to healthcare facilities and providers (Aasmul et al., 2018). While it does encompass instructions regarding resuscitation preferences (similar to code status and DNR Order), it also includes directives concerning other specific medical interventions (Hammes & Rooney, 1998). 

Health Care Agent: A health care agent is an individual who has been designated by a person to make medical decisions on their behalf in the event the person is not able to make decisions for themselves. Health care agents are assigned through a type of AD called a Power of Attorney for Health Care (HCPOA). A Power of Attorney for Healthcare may also be called a Health Care Proxy in some states.

To calculate the hospital-level measure result, divide the numerator by the total number of eligible patients (denominator). 

Denominator:
Patients 18 years of age and older at the beginning of the measurement period with a discharge from an acute care hospital or critical access hospital inpatient setting during the measurement period

The numerator logic looks for evidence of an ACP document available in the patient’s medical record prior to the measurement period or during any hospitalization in the measurement period. This allows for the inclusion of legal documents that may have been obtained prior to the measurement period and are still valid. For any patients without an ACP document available in the medical record, the numerator logic will look for evidence of an ACP discussion having taken place during any hospitalization in the measurement period. Finally, the numerator logic will remove any ACP discussion from consideration for the numerator if the date stamp occurs after the last discharge date in the measurement period.

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Patients 18 years of age and older at the beginning of the measurement period with a discharge from an acute care hospital or critical access hospital inpatient setting during the measurement period

Equals Initial Population

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Patients who have either an advance care planning document before end of the last hospitalization or last documentation of an advance care planning discussion that occurred during the hospitalization during the measurement period. The numerator may be satisfied by any one of the following:

1. ACP document as evidenced by:
-Healthcare agent [Healthcare proxy or HCPOA] 
-AD (or living will) 
-Portable Medical Orders [MOST, MOLST, POLST, DNR Order Form]
-Do Not Resuscitate 

2. Documentation that an ACP discussion occurred during the index hospitalization, as evidenced by:
-ACP note 
-ACP

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For every patient evaluated by this measure also identify payer, race, ethnicity, and sex