Article Title

Advance Care Planning Practices in Caring for Vulnerable Elders: An Analysis of Electronic Health Record Data and Interviews With Physicians

Publication Date



advance care planning, electronic health record


Background/Aims: Because patients with serious illnesses often reach a point when they cannot speak for themselves, it is critical to discuss advance care planning (ACP) and document patient preferences via advance health care directives (AHCD) and physician orders for life-sustaining treatment (POLST). We aim to characterize ACP discussion and documentation practices and determine how a palliative care program established in 2010 at the Palo Alto Medical Foundation influenced ACP practices.

Methods: We analyzed Palo Alto Medical Foundation patients ≥ 65 years old who presented from 2013 to 2014 and had no record of ACP prior to 2013 in the electronic health record problem list. Logistic regression examined the relationship between ACP documentation and 1) type of serious illness (defined by the National Committee for Quality Assurance Palliative Care measurement set), 2) travel distance to palliative care specialists, and 3) patient and physician characteristics. We also interviewed physicians (N = 15) in primary care, oncology, pulmonology and cardiology about ACP.

Results: Among 65,253 patients with no ACP prior to 2013, 11.6% had ACP documentation by the end of 2014 and 88.4% did not. Among those with serious illness, at the end of 2 years 21.13% had ACP (12.09% AHCD, 5.42% POLST, 3.62% both) and 78.87% had no ACP. Patients with chronic obstructive pulmonary disease were more likely to have AHCD (odds ratio [OR]: 1.094, P < 0.01) and POLST (OR: 1.215, P < 0.01). Greater travel distance to palliative care lowered the likelihood of documented AHCD (OR: 0.904, P < 0.01) and POLST (OR: 0.866, P < 0.01). Male, Asian and black patients were less likely to have AHCD. Patients with brain cancer (OR: 4.165, P < 0.01), esophageal cancer (OR: 4.697, P < 0.05) and debility (OR: 1.923, P < 0.01) were more likely to have POLST. Some interviewed physicians believed ACP discussions were every physician’s responsibility; others preferred appointing a “quarterback” (preferably a primary care physician). Interviewees suggested three stages of ACP: 1) initial patient-physician conversations, 2) patient investigates/discusses with family, and 3) follow-up with physician.

Conclusion: The overwhelming majority of older patients without preexisting ACP do not have ACP documented at the end of a two-year period, even among patients with serious illnesses. Systematic efforts are needed to eliminate gender and racial disparities, integrate palliative care and train current health care teams to improve ACP.




June 17th, 2016


August 12th, 2016