Date of Publication


Project Team

Project Advisor: Marcia Bosek, DNSc, RN; Site Advisor: Margaret Aitken, DNP, APRN;


Purpose/Objective. Patients receiving advance care planning (ACP) are more likely to receive care that is congruent with their goals and values. The purposes of this project are to (1) improve the process of reviewing ACP documentation and (2) improve ACP patient education.

Methods. The target population were persons moderate to very high utilizers of healthcare resources within a primary care office. Of the 200 charts reviewed, 74 patients met inclusion criteria: 65 years or older, and diagnosed with COPD, CHF, and/or DMT2. The electronic health record (EHR) was then reviewed for advance directives, and COLST forms. If present, the EHR was further reviewed to identify triggers for ACP review. A note was placed in the EHR notifying providers of the need to review ACP documentation. A patient education brochure was created and attached to the advance directive forms located in exam rooms.

Results. Of the 74 patients, there was an 1.4% increase in updated advance directives and 7.04% increase in COLST forms. The most common reasons to review ACP documentation were decade birthday (n=34) and deterioration (n=33). 77.8% of documented ACP education took place during annual wellness visits, 22.2% took place during chronic disease management visits.Additionally, 39 advance care planning patient education brochures were distributed.

Discussion/Conclusions. This project supports the established literature that states ACP should be incorporated into routine care. Future areas of study include expanding the process for reviewing ACP during Medicare Annual Wellness Visits, and bolstering ACP patient education through community-based education events.

Document Type


Included in

Nursing Commons