<b>Initiating and Documenting Goals of Care Discussion in Patients with Advanced Pancreatic and Colorectal Cancers</b> : <b>A Quality Improvement Project in a Low Resource Setting</b>

Patients with advanced malignancies often end up receiving aggressive interventions which are not aligned with their preferences especially during terminal stages. Discussing and documenting the goals of care (GOC) early in the course of the illness will help patients receive interventions based on their preferences. In resource-constrained settings such as our institution, a regional cancer center in India, a lower-middle socioeconomic country, this also enables effective utilization of life-saving equipment and Intensive care unit care. Since we did not have a standard GOC discussion and documentation process, we initiated a quality improvement (QI) project. This QI initiative was done using the A3 methodology between September 2023 to May 2024 and it was followed up till March 2025. For this project, we chose patients with advanced pancreatic and colorectal cancer with a life expectancy of less than one year. We followed various steps of the QI project such as defining the problem, setting SMART goals, process mapping, root cause analysis, identifying key drivers and interventions to solve the problem, and also planned sustainability measures. As a result of this QI project, we were able to increase the rates of GOC documentation from 0% to 92% in patients with advanced pancreatic and colorectal cancer. Root cause analysis revealed that the absence of a standard operating procedure/document and limited awareness about GOC were the main barriers for which we derived key drivers and interventions. Though creating awareness help to increase the number of patients referred for GOC discussion, our goal was achieved after we created a color-coded GOC document. Introducing a standardized, color-coded GOC documentation process through a QI initiative significantly improved discussion and documentation rates in patients with advanced cancer. Such QI initiatives are feasible in low- and middle-income settings and help align care with patient preferences and save resources.