Houston's M. D. Anderson Cancer Center serves approximately 400 inpatients and 2,000 outpatients daily and provides indigent hospital care for Texans with cancer.
The Breakthrough Series team aimed to improve advance care planning for its gynecologic cancer patients. The goal was for 75 percent of these patients to participate in a Gynecology Advance Planning (GAP) consult and to have an advance care planning note in their charts. The preprinted note provided a prompt for physicians to cover important end-of-life issues and documented the content of the physician discussion. The physician intervention was followed by conversations with support personnel trained to help patients with end-of-life planning, dubbed "GAP consults" by the team.
To encourage this process, physicians and others participated in a "breaking bad news" workshop, which was based on a model first described in 1992 by Robert Buckman. A physician at M. D. Anderson tailored Buckman's model to the specific needs of gynecologic cancer patients; the workshops featured didactic sessions and role-play.
In a survey of patient satisfaction with physician discussions, physicians received high marks for sensitivity and truthfulness and lower marks on time spent with patients and listening. During the GAP consults, patient concerns focused on faith and spirituality (83 percent), family issues (75 percent), and medical concerns (58 percent).
Convincing clinicians and others to include advance care planning notes proved to be a challenge. The same procedure is now being piloted in the gastrointestinal center. The "breaking bad news" workshops have been well received, and that process is continuing with residents and fellows.
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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved.
For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ].