Provider training alone may not be enough to improve advanced care planning

Key takeaways:

• Researchers reported no significant differences in completion of advanced directives before and after provider training.
• Transplant nurse coordinators cited other responsibilities and time as barriers.

BOSTON — An educational program for transplant nurse coordinators did not improve advanced care planning among patients with decompensated cirrhosis, suggesting that provider training alone is “insufficient” to create significant change.

“Patients with decompensated cirrhosis typically do not benefit from early initiation of palliative care principles — they often suffer for years without much consideration of advanced care planning, which is often completed very near to death or during terminal hospitalization,” Janet Gripshover, DNP, MBA, FNP-BC, nurse manager at UCLA Health’s liver and small bowel transplant unit, told Healio. “This is especially true amongst transplant candidates, as the prognosis we all hope for is that these patients will receive a liver transplant before they succumb to liver disease.”

She continued, “Complicating this is that the disease state itself can impair decision-making, making early determination of personal values essential for rendering appropriate care for the patient at later stages.”

According to Gripshover, an advanced directive is a formal document that provides patients an opportunity to communicate their values, including identification of a surrogate decision-maker who can speak for them. Many barriers to earlier completion have been cited in the literature, such as provider discomfort and insufficient advance directive training.

Seeking to test an advanced care planning educational program and improve directive completion rates in adults with decompensated cirrhosis, Gripshover and colleagues conducted a 1-hour educational seminar for eight transplant nurse coordinators.

After completing training, coordinators were encouraged to discuss advanced directive completion during intake appointments with patients before liver transplant. Researchers compared documentation of conversations about advanced care planning, as well as directive completion rates, 12 weeks before and after the training.

According to results, only 10 of the 108 patients (9.3%) had any advanced care planning documentation and five (4.6%) had completed an advanced directive before the intervention. Following provider training, 4.7% of patients had any documentation and 4.7% had completed an advanced directive.

“During the 12-week intervention, improved advanced directive completion rates were not observed,” Gripshover told Healio. “Operational barriers such as competing priorities and time constraints were most cited amongst participants, suggesting that education and provider training is insufficient to produce significant practice change.”

Despite these barriers, the training received high scores from nurse coordinators in acceptability, feasibility and applicability, researchers reported.

“The good news from this project is that the nurses who received the training admitted to feeling more comfortable with subject matter, and they felt that the educational material was appropriate,” Gripshover said. “Hospital leadership has been in discussions to identify resources that can help support advanced directive completion rates based on the findings.”

She continued: “I think it will be up to hospital leadership to determine the risk/benefit of allocating resources specifically to address earlier initiation of advanced directives. Impacts from educating patients and caregivers on end-of-life options and the roles and responsibilities of surrogate decision-makers have not been well-determined and may provide significant ‘bang for your buck’ on improving advanced directive completion rates.”