Hardwiring Advance Care Planning in BMT: More Than Just the Paper

Topic Significance & Study Purpose/Background/Rationale

BMT offers the hope of cure or prolongation of life, but can result in life-threatening complications.   Preparation for transplant includes assessment of complication risk, but does not routinely include discussions of patient’s choices for care if complications occur.   Advance Care Planning (ACP) is a dynamic process of recurring communication to plan for future medical care.  ACP includes learning, reflecting, discussing, and documenting in an advance directive (AD) one’s choices for future healthcare.  Recognizing the value of ADs, and responding to a need to improve end-of-life care for patients/families and for the healthcare team, our BMT program implemented an initiative to hardwire ACP into the BMT workflow for all new patients. 

Methods, Intervention, & Analysis

An interdisciplinary group, led by Social Work, was formed to establish an ACP process.  The group created two scheduled ACP appointments prior to admission, reassigned resources for ACP facilitation, and established ACP roles for all BMT outpatient and inpatient team members.  The group educated the department on the ACP process and identified/developed educational tools to assist patients and staff.  A baseline audit was performed of AD completion rates for patients admitted for transplant.

Findings & Interpretation

Post-implementation, members have reported increased interdisciplinary engagement in ACP, proactive inquiry about patients’ wishes, routine verbal and written education provided by transplant nurse coordinators, an increase in patient/family meetings around goals of care for inpatients, an increase in use of comfort care orders, a decrease in end of life conflicts, and an increase in hospice referrals.

Audits revealed a 100% reduction in ethics consults, a 19% decrease in LOS for terminally ill patients, a 7-fold increase in palliative care consultations for goals of care discussions and/or transitions to comfort care, and improved completion rates of ADs from 41% at baseline to 93% at last audit.

Discussion & Implications

It is possible to achieve quality end-of-life care with improved teamwork and morale when standard ACP processes are developed and hardwired into existing workflows.  When ACP is normalized and incorporated as a routine part of care, patients and families are willing to talk about and complete ADs.  Continued efforts are underway to improve BMT team members’ communication skills and documentation regarding ACP.