Evaluating the frequency, quality, and timing of advance care planning among patients with metastatic breast cancer.

305 Background: Advance care planning (ACP) improves prognostic understanding, supports shared decision making, and decreases acute care events for patients with advanced cancer. Assessing the frequency, quality, and timing of ACP can provide a baseline for identifying current gaps in end-of-life care for patients with metastatic breast cancer (MBC). Methods: We identified a cohort of patients with MBC in the electronic health record of a large academic medical center and affiliated community sites between 2018-2023. We measured the frequency of documented ACP activities, defined as designated healthcare decision maker, code status with limitations, ACP notes, and hospice referral. We evaluated ACP note quality by measuring key elements of serious illness communication: documented prognosis; cancer stage; treatment goals; patient values; treatment options; and treatment decisions. We measured the time from ACP note to death in days. We used descriptive statistics to describe the frequency and timing of ACP and used Fisher's exact test to compare ACP note quality by clinical setting/author role and timing relative to death. Results: We identified a cohort of 1,112 patients with MBC with a median age of 62 years and time since MBC diagnosis of 1.4 years. ACP was generally low (Table), and only 11% of patients (n = 126) had an ACP note. Within ACP notes, documentation of key elements of serious illness communication was low: 23% for prognosis, 41% for metastatic diagnosis, 18% for non-curative treatment goals, 51% for patient values, 50% for treatment options, and 69% for treatment decisions. We defined high-quality notes as having 2 or more key elements. Notes by inpatient clinicians had higher quality (44%) when compared to outpatient oncologists (14%), outpatient palliative care providers (3%), and primary care providers (5%, p < 0.0001). Most notes were completed more than 90 days before death (62%) and had lower quality (52%) than notes closer to death (88% for < 90 days, p < 0.0001). Conclusions: The low frequency, poor quality, and late delivery of advance care planning and documentation among patients with metastatic breast cancer represent a gap in cancer care quality. Future studies will evaluate the impact of clinician nudges, including an MBC prognostic tool, on the frequency, quality, and timing of ACP and serious illness communication. Advance care planning activities among a cohort of patients with metastatic breast cancer, 2018-2023, classified according to the highest level of advance care planning delivered, with hospice being the highest level. Advance care planning activities Frequency within cohort N=1,112 Percent of all patients in cohort (%) Hospice referral 132 12 Advance care planning note 126 11 Code status with do not resuscitate 74 7 Code status with limitations 4 <1 Healthcare decision maker designated 324 29 No advance care planning documented 451 41