An initiative that combined increasing clinician awareness of a best practice, regular reporting on its progress to oncologists, and strong institutional support successfully increased advanced care planning (ACP) completion for patients with metastatic cancer. These findings were published in JCO Oncology Practice.

Conversations about goals of care between patients with advanced cancer and their providers are necessary to ensure they’re receiving the care they want, and the American Society of Clinical Oncology (ASCO) recommends the practice. Therefore, researchers at Cedars-Sinai Medical Center in California launched a quality improvement initiative to improve their ACP completion rate for outpatients with metastatic cancer.

The researchers screened 5000 unique patients each year from 2017 to 2020 from 3 Cedars-Sinai facilities for patients with high-mortality cancers who were most likely to require ACP. Patients were initially identified by ICD-10 codes C77-80, which had a high sensitivity and specificity for advanced cancer. However, these codes do not indicate metastatic status, so the identification method was changed to an electronic health record entry status of M1, which more consistently identified optimal patients for ACP.

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Three specific activities were determined to qualify as meeting the patient’s ACP activity goal within the past 1 year: the presence of physician orders for life-sustaining treatment (POLST) in the EHR, an ACP note in the EHR, or a referral to a palliative medicine (PM) physician. The 1-year interval was chosen because care goals and the designation of surrogate decision makers should be revisited at least every year, explained the researchers.

Oncologists and care teams were briefed on the initiative. They received a monthly list of patients with metastatic cancer without ACP activities, along with quarterly scorecards comparing their ACP completion rates with their peers’. The initiative also included free educational classes for staff members, patients, and patients’ families about ACP and advanced directive (ADs) completion.

Documented ACP activities for patients with metastatic cancer increased from 37% in July 2017 to 57% by the end of 2020, the rate of outpatient PM consultations increased from 12% to 39%, and the rate of ACP note inclusion increased from 16% to 29%.

Strong institutional support and regular data reporting to oncologists contributed to the success, the researchers reported. However, there was no significant change in completion rates for ADs or POLST.

Limitations included accuracy in identifying cases, until the use of M1 designation replaced ICD-10 codes; quality of ACP notes varied; data reporting methods evolved during the study, and the effects of increased ACP activities on quality or outcomes were unknown.

The researchers also suggested setting up EHR alerts to call attention to missing ACP documentation and standardizing ACP conversations and documentation templates.

Disclosures: One author declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures.


Oppenheim S, Figlin RA, Seferian EG, Reed M, Irwin SA, Rosen BT. Advance care planning in patients with metastatic cancer: a quality improvement initiative. JCO Oncol Pract. 2022;18(10):e1562-e1566. doi:10.1200/OP.22.00160