Advanced Directive Forms Rarely Completed by Patients Seen For Palliative Care Consult Interview with:

Kara Bischoff, MD Assistant Clinical Professor, Hospital Medicine & Palliative Care Director of Quality Improvement for the Palliative Care Service UCSF Department of Medicine

Dr. Bischoff

Kara Bischoff, MD
Assistant Clinical Professor, Hospital Medicine & Palliative Care
Director of Quality Improvement for the Palliative Care Service
UCSF Department of Medicine What is the background for this study? What are the main findings?

Response: Care planning, which we define as including both advance care planning and goals of care discussions, are a common need in seriously ill patients and a key function of palliative care teams.

However, few studies have looked at how often and how care planning is being done by inpatient palliative care teams throughout the United States, and similarly few studies have examined the precise impact of these care planning activities. Therefore, using data from a large quality improvement registry in palliative care called the Palliative Care Quality Network, we examined:

1) the characteristics of hospitalized patients who are referred to inpatient palliative care consult services,

2) the activities that occurred during those inpatient palliative care consults, and

3) the outcomes that resulted.

In looking at data from 73,145 patients who referred for an inpatient palliative care consult, we found that care planning was the most common reason for inpatient palliative care consultation, requested for 71.9% of patients who were referred to palliative care. Further, care planning needs were found in more than half (58%) of palliative care patients even when the consult was requested for reasons other than care planning. Patients referred to palliative care for care planning were somewhat older than patients referred for other reasons, they were less likely to have cancer, and were more often full code at the time of referral. Through care planning conversations, palliative care clinicians frequently identified surrogates and clarified patients’ preferences for life-sustaining treatments (including code status). For instance, 31% more patients chose a code status of DNR/DNI after a conversation with the palliative care team.

However, we also found that legal forms such as advance directives and Physician Orders for Life-Sustaining Treatments (POLST) forms were completed for just 3.2% and 12.3% of the patients see by palliative care teams, respectively. This highlights an important quality gap in need of improvement. What should clinicians and patients take away from your report?

Response: Care planning is a very common need in hospitalized seriously ill patients, it’s a key function of inpatient palliative care teams, and important outcomes results from this work including identifying and documenting who patients would like to make decisions for them and what type of end of life care they would like to receive.

However, further work is needed to ensure that these wishes are documented on legal forms to ensure that patients receive care that is consistent with their preferences in the future. What recommendations do you have for future research as a result of this study?

Response: Through the Palliative Care Quality Network, which is a national quality improvement registry in palliative care, we have a multisite quality improvement project that is ongoing with the aim of improving the rate of POLST form completion, particularly for patients who express a desire to limit life-sustaining treatments. Through this project, we are learning from best performing teams in the network and striving to identify specific strategies that have been successful and can be disseminated to other teams. In addition to doing this as part of a quality improvement project, in the future we would also like to do this more systematically as part of a qualitative study, in order to have more of an opportunity to directly and thoroughly observe the activities of high-performing teams and hone in on the actions, processes and attitudes that make these teams successful and can be disseminated to improve care. Is there anything else you would like to add?

Response: We are extremely grateful to all of the clinicians who have participated in the Palliative Care Quality Network and have contributed to this study by collecting data about what they do and their patients’ outcomes. It is their expressed commitment to share experiences for the purpose of improving care that makes it possible to gain this broad view into real-world practice in our field. We have no disclosures to report. Thank you for your contribution to the community.


Kara Bischoff, David L. O’Riordan, Angela K. Marks, Rebecca Sudore, Steven Z. Pantilat. Care Planning for Inpatients Referred for Palliative Care Consultation. JAMA Intern Med. Published online November 20, 2017. doi:10.1001/jamainternmed.2017.6313



Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.


[wysija_form id=”1″]






Last Updated on November 20, 2017 by Marie Benz MD FAAD