Advance Directives for Blood and Marrow Transplantation Recipients

Topic Significance & Study Purpose/Background/Rationale Blood and Marrow Transplantation (BMT) is a potentially curative therapy, but despite clinical advancements it continues to be associated with significant morbidity and mortality. Advance Directives (AD) ensure that patients receive the care that is consistent with their values, goals, and preferences at end of life (EOL). Yet, fewer than a quarter of BMT recipients at this Academic Medical Center have a documented AD. This leads to an increase in unnecessary treatments, care escalations, and discrepancy of care expectations which heightens distress for the patient, family, and provider. In May 2019, a nurse driven interprofessional team was assembled to conduct a performance improvement project. Methods, Intervention, & Analysis The goal was to increase the percent of completed AD for BMT recipients at this Center before transplant (Day 0), from 21% to 40% by September 2019. Through team-based problem solving, analyzation of possible causes for gaps in practice related to AD completion was performed. The identified key focus areas included: the absence of AD discussions in both the clinic and inpatient settings, lack of staff training and education, and no standard workflow for AD completion or collection. These findings were addressed in June 2019, by implementing a standard operating procedure within the BMT program for AD completion, delivery, and submission into the electronic health record. Training was also developed and provided to all BMT interprofessional teams. Findings & Interpretation Between July 2019 and September 2019, 74 patients received a transplant at this center, of those patients 30 had an AD completed by Day 0. The overall AD completion rate was 40.5% (Table 1). Furthermore, an increase in patients providing their Social Workers with a completed AD in the clinic setting was identified as well as the referrals to inpatient Spiritual Care services for assistance with AD completion. Discussion & Implications Early completion of AD offers the opportunity for goal-concordant care at EOL, and the BMT population can greatly benefit from this care. This has the potential to reduce hospitalization at the EOL, decrease ICU utilization and costly invasive interventions, increase utilization of hospice services, and promote a higher satisfaction with the quality of care.