24 Improving the referral rate for advance care planning among oncology inpatients: a single centre experience

<h3></h3> The Medical Oncology department in TTSH is one of the largest Oncology departments in Singapore. ACP improves quality of life and is especially relevant for patients with cancer. ACP rates have however been on the downward trend, with only one ACP completed among inpatients between 2022–2023. We aimed to improve ACP referral rate among Oncology inpatients with advanced cancer. We focused on patients admitted to the Oncology inpatient service who had metastatic cancer or on palliative cancer treatment. Patients in collusion, lacking mental capacity or critically ill and those with existing ACP were excluded. At baseline in June 2024, no patient was referred for ACP despite 71 inpatients being suitable. 56 causes for low ACP uptake were identified. Following voting and plotting of Pareto chart, the top causes by 80–20 rule included (a) No screening criteria, (b) Focus on acute medical issues and (c) Heavy inpatient and clinic workload. We addressed these causes sequentially in Plan-Do-Study-Act cycles. In July 2024, we defined screening criteria and added a section on ACP to daily rounding notes. A mean referral rate of 24.4% was achieved. Following feedback from junior doctors, our intervention in August 2024 involved weekly reminders to senior doctors. The mean referral rate however dropped to 12.9%. In September 2024, we switched focus to addressing causes (b) and (c). We adopted a multidisciplinary approach with a senior doctor screening cases weekly and an Advanced Practice Nurse (APN) assisting with ACP discussion. There was provision of dedicated time for the APN and majority of inpatients were referred for completion of ACP in our outpatient ACP clinic. Mean referral rate improved to 28.7%. Over 4 months, referral rate for ACP successfully increased from near 0% to 23% and ACP completion improved significantly. With this submission, we share our experience and challenges and highlight interventions that were successful in improving referral rates in our Oncology unit in an attempt to increase knowledge and guide strategies to improve ACP uptake among Oncology patients worldwide. We propose that interventions helpful for improving ACP rates include clear definition of referral criteria, multidisciplinary involvement and provision of dedicated time, having majority of ACPs completed as outpatient and having ACP champions to sustain efforts. Reminders to the healthcare team were insufficient to improve ACP rates. Oncology APNs have now been integrated into our inpatient teams and this represents a significant step in our department’s efforts to improve ACP rates.