Exploring Advance Care Planning in Taiwanese Indigenous Cancer Survivors: Proposal for a Pilot Case-Control Study

Perceptions of Behavioral Awareness, Intention, and Readiness for Advance Care Planning: A Mixed-Method Study among Older Indigenous Patients with Late-Stage Cancers in Remote Areas of Eastern Taiwan

The first Patient Right to Autonomy Act enacted in Asia in 2019 has enabled every Taiwanese citizen to plan for his/her end-of-life (EOL) in case of incompetency. Advance care planning (ACP) has been highly promoted for individuals with terminal, life-threatening illnesses, particularly in the mainstream society, and efforts have been made by the Taiwanese government to train health care providers in order to optimize patients' quality of dying. However, such advanced decisions and discussions regarding life-sustaining treatment and EOL care remain scarce among older ethnically minority patients. A multiple-case study employing a mixed-method (n = 9) was undertaken to explore indigenous patients' ACP perceptions. Both quantitative and qualitative information was obtained from indigenous patients, a minority group whose socio-economic and educational status are different from the general Taiwanese population. An initiative was made to describe ACP behavioral awareness, intention, and readiness of older terminal patients from four tribes with seven late-stage cancers in remote, mountainous areas of eastern Taiwan. Our findings showed that according to the Transtheoretical Model, terminal indigenous patients' ACP readiness was at a precontemplation stage. Their lack of fundamental ACP awareness, insufficient healthcare resources, life-sustaining value in a Christian faith context, and the prevalent health disparity in the remote communities have negatively affected indigenous patients' intention to participate in ACP. We provide suggestions to further promote ACP in this group and suggest that health information should be tailored at various readiness stages in order to overcome barriers and decrease ACP literacy discrepancies. This study calls attention to an understudied area of ACP behaviors, an overlooked need in EOL care for older cancer patients of unique cultural backgrounds, and the imperativeness to ensure cultural minority group's EOL care is consistent with patients' preferences.

Young Adult Knowledge and Readiness to Engage in Advance Care Planning Behaviors

Although advance care planning (ACP) has increased in importance and discussion, little is known about young adults' engagement in ACP. The purpose of this study was to identify associations among college-age students' characteristics, knowledge of ACP, and readiness to engage in ACP-related behaviors. One hundred forty-seven students at the University of Texas at Austin (aged 18-26 years) participated in an online survey regarding ACP knowledge, perceptions, and behavior engagement. Although 98% of the students had no advance directive, 85% rated themselves as "pro" ACP. Regarding ACP behaviors, at least 83% of participants had never considered completing a living will or health care proxy, but 33% and 45% of participants had talked with loved ones about being kept alive on machines or about quality of life, respectively. Greater knowledge of ACP correlated weakly with a favorable view of ACP (P = .002). Young adults should be made aware of their ability to dictate the care they want to receive in situations in which they are incapacitated, as well as advocate for their family members to engage in ACP. Discovering characteristics associated with readiness to engage in ACP can enable hospice and palliative care nurses to tailor discussions with young adults regarding ACP.

Validation of a Novel Electronic Health Record Patient Portal Advance Care Planning Delivery System

BACKGROUND

Advance care planning allows patients to articulate their future care preferences should they no longer be able to make decisions on their own. Early advance care planning in outpatient settings provides benefits such as less aggressive care and fewer hospitalizations, yet it is underutilized due to barriers such as provider time constraints and communication complexity. Novel methods, such as patient portals, provide a unique opportunity to conduct advance care planning previsit planning for outpatient care. This follow-up to our pilot study aimed to conduct pragmatic testing of a novel electronic health record-tethered framework and its effects on advance care planning delivery in a real-world primary care setting.

OBJECTIVE

Our intervention tested a previsit advance care planning workflow centered around a framework sent via secure electronic health record-linked patient portal in a real-world clinical setting. The primary objective of this study was to determine its impact on frequency and quality of advance care planning documentation.

METHODS

We conducted a pragmatic trial including 2 sister clinical sites, one site implementing the intervention and the other continuing standard care. A total of 419 patients aged between 50 and 93 years with active portal accounts received intervention (n=200) or standard care (n=219). Chart review analyzed the presence of advance care planning and its quality and was graded with previously established scoring criteria based on advance care planning best practice guidelines from multiple nations.

RESULTS

A total of 19.5% (39/200) of patients who received previsit planning responded to the framework. We found that the intervention site had statistically significant improvement in new advance care planning documentation rates (P<.01) and quality (P<.01) among all eligible patients. Advance care planning documentation rates increased by 105% (19/39 to 39/39) and quality improved among all patients who engaged in the previsit planning framework (n=39). Among eligible patients aged between 50 and 60 years at the intervention site, advance care planning documentation rates increased by 37% (27/96 to 37/96). Advance care planning documentation rates increased 34% among high users (27/67 to 36/67).

CONCLUSIONS

Advance care planning previsit planning using a secure electronic health record-supported patient portal framework yielded improvement in the presence of advance care planning documentation, with highest improvement in active patient portal users and patients aged between 50 and 60 years. Targeted previsit patient portal advance care planning delivery in these populations can potentially improve the quality of care in these populations.