64 Improving advance care plan completion in an acute palliative care unit – experience and lessons

<h3>Aim</h3> To describe a Clinical Practice Improvement Program (CPIP) initiative aimed at improving Advance Care Planning (ACP) rates among palliative care inpatients in an acute care hospital, and to discuss the lessons learned. <h3>Background</h3> ACP enables patients’ end-of-life wishes to be better understood, reduces caregiver burden in decision-making, and reduces invasive interventions at the end of life. A baseline audit showed an ACP completion rate of 4.9% in our unit. <h3>Methods</h3> Inclusion criteria: Inpatients under the Palliative Medicine department with no prior ACP done. Exclusion criteria: Inpatients under the department for 3 days or less. A survey was done among staff and patients/families to understand stakeholders’ perceptions. CPIP methodology was applied to identify the top root causes and implement the following interventions: (1) Staff education about ACP; (2) Introduction of documentation templates with senior staff to oversee screening; (3) Introduction of protected time to conduct ACP. <h3>Initial Results</h3> New ACP completion increased from 4.9% to 41.0% 6 months post-intervention (April – September 2022). Sustainability measures included education about ACP for new staff, incorporation of learning materials into the ‘e-learning’ system, incorporation of documentation templates into the electronic system, and regular sharing of results to motivate staff. <h3>Sustainability</h3> In October 2022 following a drop in ACP rates, a review was performed involving obtaining ground feedback and an online staff survey. This led to further interventions to streamline work processes and provide reminders to staff to offer ACP discussions. Improvement in ACP rates was sustained at 51.9% till March 2024. In April 2024, an institutional initiative introduced ACP charges and mandatory signatures from patients and nominated spokespersons. ACP completion rates dropped to 19.6% (April – September 2024). This rose to 31.6% (October 2024 – February 2025) after charges were reduced and signatures were made non-mandatory in October 2024. <h3>Unique Contribution</h3> This experience shows that sustained improvement in ACP completion in an acute palliative care unit can be achieved via a systematic approach to quality improvement. It illustrates how obtaining support from stakeholders on various levels facilitates change in practice culture, and how systemic factors and policy changes play a big role in influencing program implementation. <h3>Implications</h3> There is a need to obtain buy-in from relevant stakeholders and for continual review and fine-tuning of work processes to sustain change. On a larger level, it is important for policymakers to consider the practical downstream effects of policy changes on the success of a program.