Creating a Protocol to Increase Advance Care Planning Conversations with Heart Failure Patients in an Outpatient Clinic

Abstract

Problem: Heart failure is a chronic, progressive disease with a high symptom burden and mortality rate. Many patients in this population do not understand the disease trajectory, nor do many cardiologists have advance care planning (ACP) conversations with their patients. This combination increases the probability that patients and families will experience aggressive care with unnecessary pain at the end of their lives. ACP conversations can decrease the distress of both families and patients with chronic diseases; however, only 5-15% of physicians have these discussions with their patients. There are various tools available in the literature to assist providers in engaging in ACP conversations, but there is a lack of protocol that addresses comprehensive aspects of ACP conversations at outpatient heart failure clinics. Project Aim: The aim of this quality improvement project was to chronicle the development and evaluation of an evidenced-based protocol to improve ACP processes in a heart failure clinic. This comprehensive protocol incorporated various tools and resources regarding ACP. Project Method: This quality improvement project was conducted using a literature search, gathering, analyzing and synthesizing the data and producing a protocol for ACP in an outpatient heart failure clinic. The protocol was reviewed and evaluated by cardiology experts in the field using the modified AGREE II tool. Results: Two cardiology providers with expertise in heart failure reviewed the protocol and responded with quantitative data from the modified AGREE II tool and qualitative data including implementation feasibility, protocol usefulness, and suggested protocol improvements. There were five domains in the modified AGREE II tool, with a score of 70% required to be considered high quality. Domain scores ranged from 79%-92%. Both experts stated the protocol would be useful but did identify barriers including administrative barriers, length of appointment times, and need for additional staff. Conclusion: A protocol for increasing ACP conversations in an outpatient heart failure clinic is feasible and would be useful to both patients and staff, however known barriers would need to be overcome to facilitate implementation.