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Advance Care Planning: Implications for Health Care Quality at the End of Life

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2018, Doctor of Philosophy, Ohio State University, Public Health.
Advance Care Planning (ACP) refers to the communication of decisions regarding end-of-life treatment decisions prior to incapacitation. ACP has been associated with better health outcomes at the end of life such as less aggressive care prior to death, improved bereavement outcomes, earlier acceptance of a terminal condition and earlier acceptance of palliative care and hospice. The completion and documentation of ACP in the Electronic Health Record (EHR) is important so that end-of-life treatment decisions can be honored when patients are unable to speak for themselves. This process is multi-faceted and burdened with inconsistencies. Through three related studies, this dissertation used Donabedian's Structure, Process, and Outcome model as a framework for understanding the problem. Study one focused on the structural component of the EHR as it relates to the functionality and documentation of ACP. Results from a survey of over 400 end-of-life physicians indicated a mutual understanding of the importance of ACP documentation in the EHR coupled with critical challenges. Specific challenges included a lack of time and training. Having a consistent tab or area within the EHR was cited as a specific opportunity for facilitating the completion of ACP in the EHR. Study two analyzed the association between several process-related predictors and the completion of ACP documentation in the EHR. Findings indicated that older adults (over age 70) were less likely to have several process-related components of ACP and more likely to operationalized elements of ACP such as a verified Do Not Resuscitate (DNR) order. These findings indicate that there may be a gap in comprehensive communication with older adults, and they are more likely to have a DNR without documentation of a prior conversation or a scanned document in the medical record. Study three examined the association between outcomes and the documentation of ACP in the EHR. Findings indicate that having a DNR documented in the EHR and having an ACP note in the problem list are associated with reduced odds of an admission in the last 30 days of life. Having ACP documentation in the EHR was not associated with reduced charges at the end of life. The results of this dissertation may be used to strengthen the case that improvement in the documentation and functionality of ACP in the EHR is required. There are several key practical considerations resulting from these studies that could be applied in the form of local quality improvement initiatives aimed at improving consistency in documentation. Other implications from these studies point toward continuing to support efforts to reimburse physicians for ACP conversations and improving standardized end-of-life communication training requirements for all clinicians.
Thomas Wickizer, PhD, MPH (Advisor)
124 p.

Recommended Citations

Citations

  • Prater, prater, L. C. (2018). Advance Care Planning: Implications for Health Care Quality at the End of Life [Doctoral dissertation, Ohio State University]. OhioLINK Electronic Theses and Dissertations Center. http://rave.ohiolink.edu/etdc/view?acc_num=osu1534344349446923

    APA Style (7th edition)

  • Prater, prater, Laura. Advance Care Planning: Implications for Health Care Quality at the End of Life. 2018. Ohio State University, Doctoral dissertation. OhioLINK Electronic Theses and Dissertations Center, http://rave.ohiolink.edu/etdc/view?acc_num=osu1534344349446923.

    MLA Style (8th edition)

  • Prater, prater, Laura. "Advance Care Planning: Implications for Health Care Quality at the End of Life." Doctoral dissertation, Ohio State University, 2018. http://rave.ohiolink.edu/etdc/view?acc_num=osu1534344349446923

    Chicago Manual of Style (17th edition)