Digital Repository Doctoral Projects Fall 2021 Improving Advance Care Planning for the Bone Marrow Transplant Patient and Family Whitney Stryker Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Stryker, W. (2021) Improving Advance Care Planning for the Bone Marrow Transplant Patient and Family Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. Improving Advance Care Planning for the Bone Marrow Transplant Patient and Family by Whitney Stryker A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah December 12, 2021 Mary Anne Hales Reynolds PhD, ARN, ACNS-BC_(signature) Faculty Advisor/Committee Chair Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE (signature) Graduate Programs Director Running Head: IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 1 Improving Advance Care Planning for the Bone Marrow Transplant Patient and Family Whitney Stryker Annie Taylor Dee School of Nursing, Weber State University NRSG 7900 DNP Scholarly Project IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 2 Acknowledgments I would like to dedicate this project to the Bone Marrow Transplant/Acute Leukemia program patients at LDS Hospital in Salt Lake City, Utah. They embody courage and endurance in the most difficult circumstances. No Doctor of Nursing Practice (DNP) project is completed alone, and I had an incredible team that supported me in my efforts. I would like to thank Dr. Suzanne Milne, DNP, ACNP-BC, MBA, Dr. Haley Jangard DNP, ACNP-BC, and Kristi Koger, RN, BSN, for being the best team and providing the support needed to plan, implement and evaluate this DNP project. Their belief and dedication to the importance of this work for the BMT/AL program provided a strong foundation for success. I am also sincerely grateful for the support and mentorship of Dr. Mary Anne Reynolds, RN, Ph.D., ACNS-BC, Associate Professor with the Annie Taylor Dee School of Nursing at Weber State University. Her knowledge and expertise provided guidance and encouragement when I needed it most. Most of all, I want to thank my family for loving me, supporting me, and bringing me diet coke. My husband and children never stopped believing in me, even when it felt hard to believe in myself. I also would like to thank Ashley for being my personal cheerleader and sounding board. The work I do is made better because of them. IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 3 Abstract Advance care planning (APC) is a dynamic process that supports the values and preferences of patients as it relates to future healthcare decisions. Patients diagnosed with leukemia will face many critical treatment decisions during their care. Early ACP conversations and accurate documentation are important for patient outcomes and overall quality of life. The purpose of this Doctor of Nursing Practice project was to implement a standardized ACP protocol with a focus on clinician communication and education for a Bone Marrow Transplant/Acute Leukemia Program in Salt Lake City, Utah. Implementation included clinician education on initiating ACP conversations within a standardized process and using documentation tools to communicate patient decisions within the electronic health record. Data were evaluated from pre-and post-education clinician surveys, patient record reviews of ACP documentation, patient satisfaction surveys, and clinician surveys. Eighty-three providers and 33 patients participated in the program. Results showed patients were 64% more likely to fill out ACP documents and 89% more likely to identify a healthcare agent in their patient record. 100% of patients felt like ACP was beneficial, and 100 % felt better prepared to make future decisions about their healthcare. Implementing a standardized ACP process for at-risk patients increases documentation and the identification of appointed health care agents in the electronic health record. ACP clinician education can increase providers' confidence in initiating critical conversations required for ACP. Patients and clinicians find ACP beneficial and feel it prepares patients to make future health care decisions. Keywords: advance care planning, oncology, allogeneic bone marrow transplant, acute leukemia, Respecting Choices IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 4 Improving Advance Care Planning for the Bone Marrow Transplant Patient Death and dying are part of the most complicated and emotionally driven processes of human experiences (Ferrell, Temel, Temin, & Smith, 2016). When asked, those facing end-of-life decisions have strong opinions about where and how they want to die (Committee on Approaching Death & Institute of Medicine [IOM], 2015). Yet nearly 70 percent of those age 60 or older at the time of death lacked decision-making capacity during the final days of their life (Silveira et al., 2010). Advance care planning (ACP) bridges the gap between patient wishes, quality of life, and medical treatment (Clark et al., 2017). Advance care planning involves ongoing critical conversations between provider and patient that align patient autonomy with best treatment choices (IOM, 2015). These conversations are significant when treatment involves considerable morbidity or mortality risks. The purpose of this DNP project is to implement a standardized ACP protocol for Intermountain Blood and Marrow Transplant/Acute Leukemia (BMTIAL) Program, located in Salt Lake City, Utah. Search Strategies A literature search was organized through the following databases: Weber State University databases, PubMed, Medline, and Google Scholar. Search terms and keywords included in the literary search were: 'Advance care planning' and 'APC,' 'advance directives,' 'oncology and advance directives, 'end-of-life communication'; 'palliative care and advance care planning'; 'hematology-oncology and advance care planning'; 'stem cell transplant and advance care planning'; 'hemopoietic malignancies and advance care planning'; 'outpatient and oncology and advance directives' and 'Respecting Choices.' The search was limited to articles from 2016-2020, with a few exceptions. Advance care planning is a relatively new topic of study for IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 5 patients with hemopoietic bone marrow transplants. Much of the published research focuses on its role in general oncology or other chronic disease processes. Literature Review Advance Care Planning Since the 1960s, medical advancements have developed to the point where seemingly heroic death-defying measures can be used to prolong life during severe illness or disease (Ruiz et al., 2018). Complex and life-extending treatments extend pain and suffering at times, with little benefit for patients and families. For many, using medical interventions to provide a quantity of days does not equal the associated cost of decreased quality of life (IOM, 2015). Advance care planning is a clinical intervention designed to help current and future medical treatment align with the individual's values, goals, and preferences. For patients requiring complex care, ACP provides intentional clinical time to communicate with their healthcare providers and families critical decisions that can potentially alleviate pain and suffering at end-of-life (Temel et al., 2013). Advance care planning can also include education and discussion on advance directive documentation. The purpose of ACP is to educate patients and their families about end-of-life processes and to empower patients to actively participate in the trajectory of future healthcare treatment decisions (Weathers et al., 2016). When clinicians maximize the potential of ACP processes, they enhance patient health literacy, prognostic awareness and create established lines of communication between the patient and providers (Paladino, 2019). Patient decisions made during ACP are recorded through provider notation, code status, and other documentation that helps provide the medical communication needed to help guide clinicians on preferences for life-sustaining treatments (Cappell et al., 2018). IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 6 In 2015, the Institute of Medicine (IOM) published its seminal work Dying in America. This report details critical gaps in end-of-life care. The IOM found that most patients prefer comfort-focused care over acute-care during their last days but lack decision-making capabilities during the last days of life (Silveria, Kim, & Langa, 2010). This places the responsibility directly into the hands of family and providers to decipher the patient preferences and make critical medical choices without patient input. Even stated conversations between loved ones and patients do not always end with patient preferences being honored. In a prospective study of 12 acute care hospitals, Heyland et al. (2017) found decisional discord between patients' expressed value statements and family treatment choices. Critical decisions such as these can be discussed during advance directive planning. From these ACP conversations, patients and families have the time and space to establish patient preferences for goals of care with direction and support from trained clinicians. These defined preferences can be recorded in legally sound, state-specific documents like advanced directives or physician orders for life-sustaining treatment (POLST) orders. For most healthcare institutions, this type of documentation is housed in the patient electronic health records. Conversation between patients, families, and providers about the quality of life and potential treatment outcomes may also benefit the patient-family-provider relationship (Fleuren et al., 2020). Shaw et al. (2018) found that families of patients with complex diagnoses lack understanding about disease processes and feel burdened by the potential of making critical decisions about their loved ones. Advance care planning not only clarifies patient intent and values but allows clinicians to facilitate trust and support in their intention to provide patient-centered care (Dillion et al., 2017). IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 7 End-of-life wishes established in ACP pave the way for a seamless transition from curative treatment to end-of-life palliative or hospice care. When ACP is combined with educational interventions, patients improve their preference for comfort care over-aggressive treatment during a terminal illness (Chen et al., 2020). Family members also reported better end-of-life care and a more peaceful death when patient goals were respected over more aggressive care (Wright, Keating, & Ayanian, 2016). Jimenez (2018) found that ACP interventions decrease hospitalization rates while increasing hospice and palliative services enrollment rates. Schneiter et al. (2019) found that those with documented advance directives or ACP discussions were engaged in palliative care almost three times longer than patients without documentation. Temel et al. (2010) found that patient survival was prolonged by approximately two months with clinically meaningful improvements to the quality of life and mood with early enrollment into palliative care services. Advanced care planning interventions increase the patient's ability to die in the preferred place of death and alleviate the emotional, psychological, and financial burden accompanying prolonged hospitalization (Jimenez, 2018). ACP allows clinicians to be good stewards of resources while promoting quality care (Curtis, Kross, & Stapleton, 2020). General Processes Primary care providers are ideally suited to introduce ACP conversations with patients and families. Because ACP should be initiated before medically catastrophic events, the outpatient care setting allows the provider to address advanced care goals and values before acute health issues occur. Holding these conversations during routine health visits helps avoid placing a heavier burden on patients and families (IOM, 2015). Primary care providers can also maintain consistency in the narrative of conversation. They understand the patient's medical history and have established lines of communication that can allow for a depth of discussion IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 8 while maintaining the efficiency of workflow (Solis, Mancera, & Shen, 2018). Caregivers and designated family members should be involved as much as possible. Primarily, the patient's chosen surrogate must represent the preferences and interests of the patient (Ferrell et al., 2018). Conducting these conversations in the primary care setting normalizes the dialogue and topic and provides patients and families more time to think through emotional and complex decisions (Tieu et al., 2016). When ACP is understood as a continual process, patients, families, and providers have time to adjust their outlook and preferences as health care needs change. As patient care becomes more complex, providers should initiate ACP processes while supporting trained clinicians in a collaborative effort. The involvement of an interdisciplinary team is associated with a higher likelihood of ACP initiation and advance directive documentation than with physician involvement alone (Clark et al., 2017). Involving non-physician providers may positively impact the outlook about end-of-life discussions (Clark et al., 2017). Using a team approach to ACP improves resource and time utilization across diverse healthcare settings (Arnett et al., 2016). There are also significant healthcare savings when patients choose palliative and hospice over aggressive end-of-life interventions, even when accounting for the cost of an interdisciplinary team (Hughes & Smith, 2014). As a patient's health declines, ACP conversations change focus to patient prognosis and help providers individualize a plan of care that aligns with patient preferences (Fahner et al., 2019). Advance Care Planning Conversations Traditionally, ACP meetings were focused solely on completing advance directive documentation (Weathers et al., 2016). Sessions usually were not long enough to do much more than minimally educate patients on the generalities of advance directives (US Department of IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 9 Health and Human Services, 2008). This 'legal transaction' approach proved to have relatively little impact on end-of-life decision-making (Sabatino, 2010). Today, national guidelines and organizations advocate a more communication-oriented approach to ACP (Fleuren et al., 2020). Intentionally directed conversations within the ACP setting allows patients the freedom to voice their values and perspectives and enhance the quality-of-care clinicians can provide. Clinical practice guidelines recommend that patient goals, preferences, and choices are respected and form the basis for a plan of care (Ferrell et al., 2018). Further, the healthcare team should be aware of and address complex ethical issues related to end-of-life care. While educating to reduce overtreatment, understanding patient values and establishing what quality of care means should drive ACP discussions. The moral and ethical nuances of ACP cannot be addressed in a brief, singular conversation (Myers et al., 2018). Ideally, ACP conversations should be followed by specific and actionable medical treatment orders or documentation reflecting treatment preferences considering future medical conditions (Paladino et al., 2019). Although ACP conversations do not need to include discussion on advance directive documentation, the goal should be helping patients see the importance of documenting their wishes in writing. Advance care planning should start broadly, guided by the patient's global values, and as the disease or health status changes, become more specific in detail (Fleuren et al., 2020). To this end, ACP conversations should be semi-structured and explore a patient's baseline understanding of their health status both in the present and the future (Fleuren et al., 2017). Unfortunately, there are still significant barriers to finding a place for structured quality ACP conversations within the medical system. Partially, these barriers stem from a lack of systemic understanding of the purpose and benefit ACP brings to safe, quality patient care (Fahner et al., 2019). IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 10 Barriers to Advanced Care Planning Despite evidence-based research supporting ACP, many healthcare systems struggle to integrate the process as an expectation of patient care (Chen et al., 2020). A Delphi panel consisting of 52 multidisciplinary, international ACP experts, Sudore et al. (2018) found that standardized outcomes are lacking within most clinical ACP approaches. This creates a situation where many providers are asked to incorporate ACP as a standard of care without any valid or reliable method to measure outcomes (Sudore et al., 2018). While guidelines promote ACP as a critical intervention for quality-of-care improvement, details of intervention development are often poorly reported. In a systematic review appraising the conceptual models used in randomized controlled studies on ACP for clinically complex patients, Lin et al. (2019) found that healthcare professionals or researchers could replicate only 50% of the reviewed studies. Without a thorough understanding of the necessary components, many healthcare systems are left to cobble together ACP processes that may not be generalizable even within the system itself. The lack of a specific and replicable ACP process is especially concerning when discussing the quality of care for patients with complex illnesses and disease progression. By nature of their disease, oncology patients are especially vulnerable to intensive yet futile treatment by providers (Ferrell et al., 2016). Early implementation of ACP planning has improved quality of life, decreased hospitalization, and improved understanding of prognosis (Johnson et al., 2016). Benefits of having ACP conversations early and often in oncology treatment include managing symptoms and distress, improving functional status, providing clarity of treatment goals and a better understanding of illness, and building rapport between the care team and the patient and family (El-Jawahri et al., 2016). The American Society of Clinical IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 11 Oncology, the Oncology Nursing Society, and the American College of Surgeons' Commission on Cancer have explicitly endorsed ACP and early palliative care interventions (Loggers, 2016). One stark exception towards this push for integrated APC is found within the field of hematological malignancies. Despite evidence to the contrary, hematology-oncology providers have been slow to embrace ACP integration into practice (Freeman et al., 2017). To date, no endorsements or recommendations to incorporate ACP into early treatment planning have been published by hematology or transplantation professional societies (Moreno-Alonso et al., 2018). A systematic review by Moreno-Alonso et al. (2018) found that these types of patients tend to receive ACP and enrollment into palliative care much later when compared to patients with non-hematological malignancies. Advance Care Planning with Bone Marrow Transplant According to the National Comprehensive Cancer Network's (NCCN) 2017 guidelines, patients suffering from hematologic malignancies present a wide range of risk and aggressive leukemias and lymphomas. Irrespective of presentation, most all hematologic cancers are treated with highly complex and toxic chemotherapy regimens. These treatment protocols typically require months of ongoing discussions between patients and providers about disease response or progression through treatment (Loggers et al., 2016). For many, a hematopoietic stem cell transplant (HCT) is ultimately required. Although these treatments are high-risk, the focus and end-goal are on a potential cure for patients, even those with advanced disease (Freeman et al., 2018). Still, hematopoietic stem cell transplant patients particularly face an uncertain prognosis and future. Depending on the underlying condition, some HCT patients deal with a less than 30% chance of survival three years after transplant (Health Resources and Services Administration, 2019). Further, patients with hematological malignancies are twice as likely to die in the hospital IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 12 when compared to those with other cancer deaths (Wang et al., 2017). These patients are also more likely to die within 24-hours of hospice enrollment than solid tumor patients (LeBlan, Abernethy, Casarett, 2015). There is a need for early ACP interventions for this population. Hemopoietic stem cell transplant patients endure financial, social, emotional, and psychological suffering because of their disease and treatment protocols. Depression and posttraumatic stress disorders have been documented post-transplant in HCT patients (El-Jawahi et al., 2016). These patients are often asked to make critical decisions about their care and treatment without appropriate interventions to help alleviate these stressors. Studies have found that HCT patients are less likely to receive interventions intended to lessen symptom burden than patients with other solid tumor cancers (Moreno-Alonso et al., 2018). Wang et al. (2017) found that 99.2% of patients went into transplantation with their code status as full code, with only 15% changing their code status before the time of death. The need for early and ongoing critical conversations about care and progression of treatment is apparent. Yet, these conversations are not taking place for this high-risk population (Wang et al., 2017). Hematological providers find themselves caught between their responsibility to prolong survival against the need to prepare patients for end-of-life scenarios (Prod' homme et al., 2018). This conflict between curative and potentially palliative efforts explains why HCT providers introduce ACP later than other oncology services (Booker et al., 2019). Provider Reluctance It is hard to determine the exact reason why HCT patients have historically had less access or late access to ACP. Freeman, Wood, Fox, and Hanson (2018) found that provider opinion of implementing ACP is one substantial barrier to the ACP process in hematology-oncology practices. Some hematology oncologists fear ACP discussions may undermine their IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 13 relationship with patients (Prod’homme et al., 2018). Providers cited difficulty in prognostication, creating a reluctance to pinpoint the most appropriate time to bring up ACP considering clinicians could not provide clear answers about the disease or treatment progression (Booker, Simon, Biondo, & Bouchal, 2018). Interestingly, hematologists themselves recognize that most end-of-life discussions occur too late for HCT patients. Many providers reported they were less likely to initiate conversations about resuscitations status at more optimal times instead of waiting until crisis points in medical care. This hesitation to initiate and demonstrate the benefit of ACP concurrent with treatment potentially leads to unrealistic expectations of prognosis by patients and families (Odejide et al., 2016). Family Barriers While respecting patient autonomy has always been foundational in ACP development, shared decision-making with family and designated caregivers are just as key as the individual patient choice in the HCT setting (Fleuren, Depla, Janssen, Huisman & Hertogh, 2020). Because of the risks and complications involved, having a designated caregiver is usually required for treatment (Jim et al., 2014). An essential consideration of the APC process should recognize the caregiver's role as emotional support to the patient and someone affected by the patient's end-of-life decisions (Committee on Approaching Death: Addressing Key End of Life Issues & Institute of Medicine, 2015). This is true for all ACP processes in any population or setting. However, reluctance to introduce ACP by hematology-oncologists has not only hindered patient access to palliative care; it perpetuates patient and family misunderstanding of what end-of-life care means and how it can support patients' quality of life goals (Sudore et al., 2017). IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 14 Advanced care planning has been shown to improve patient goal attainment for end-of-life care and improve family perceptions, and expectations of the quality care their loved one received at the time of death. Wright, Keating & Ayanian (2016) found after interviewing 1146 bereaved family members that over 50% reported excellent end-of-life care for patients who opted out of aggressive treatment before 30 days from the time of death. Comparatively, those patients who received aggressive hospital care at the time of death were associated with lower quality care ratings from family and a lower likelihood that patient preferences were respected. Most designated patients' proxies could not accurately predict a patient's choices for end-of-life cares on their own (Bravo et al., 2016). Advance directives and documented ACP respect a patient's right to self-determination and alleviate the emotional burden on family members in critical end-of-life situations. Environment of Care Patients undergoing allogeneic HCT average 35 days inpatient, and potentially months to years under the primary care of their HCT team (Ballen et al., 2014). This span across inpatient to outpatient and sometimes home health services creates unique complications in the continuity of care, even when the same program and healthcare team actively treat patients. There is a need for early quality of life discussions to alleviate gaps in transitional HCT clinical care (Monterosso et al., 2018). Symptom assessment and management of issues related to transplants can be underestimated by healthcare staff because of this fluctuation in care settings (Ruiz, Reynolds, & Marranzini, 2018). With the focus on curative treatment, many HCT patients do not accurately understand complications in prognosis and consequently experience delays in timely end-of-life conversations with the care team (Chen et al., 2020). Patients and families can often adapt the view that suffering is enviable with post-HCT treatment and do not actively seek IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 15 medical, mental, or emotional relief until much later in the disease process (Gidwani, Joyce, & Kinosian, 2016). Because of the potential for long-term primary care under the HCT outpatient team, early APC discussions related to HCT outcomes seem warranted in this setting. Bone marrow transplant programs that design ACP processes to occur at the pre-transplant phase have a higher chance of overcoming barriers to quality of care and enhancing communication of patient end-of-life preferences (Ruiz, Reynold, & Marranzini, 2018). Early ACP facilitated quicker intervention and symptom management by the healthcare team, regardless of setting. Advanced care planning also provides patients and families with the tools needed to engage physicians and care teams in decisions about the quality of care sooner than those without ACP interventions (Chen et al., 2020). Advance Care Planning Solutions for Hematopoietic Stem Cell Transplant Hematopoietic stem cell transplant programs that incorporate a few critical elements of ACP within their workflow can establish ACP as a standard of care. Advance care planning should occur early in treatment, in a nonemergent, outpatient setting supported by trusted clinicians from their transplant team (Wang et al., 2017). Initiating successful ACP into practice includes involving an interdisciplinary team, providing clinician training, using patient education tools, and standardizing ACP documentation. Interdisciplinary team Essential to any successful integration of services or process models are interdisciplinary approval and teamwork. Providers like Advance Practice Registered Nurses (APRNs) are responsible for initiating ACP and educating patients on end-of-life treatment options (Chen et al., 2020). However, interventions promoted by nursing staff or social work show retained effectiveness and value in the workflows of individual clinics. The inclusion IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 16 of non-physician providers in the workflow is a way to maintain the efficiency and effectiveness of outcomes. Each team members' responsibilities and specific ACP tasks should be clearly defined and standardized. Shaw et al. (2017) found that a lack of role clarity leads to confusion and discomfort with the healthcare team's ACP process. A successful and replicable model of care used to implement ACP within a healthcare system used providers to introduce ACP and then worked with other healthcare team members for follow-up care (Bestvina & Polite, 2017). Nurses are uniquely suited to educate and guide ongoing ACP conversations by nature of their proximity to patient care. Oncology nurses are experienced in broaching the idea of advance care planning for oncology patients (Mohammed et al., 2020). The nature of nursing processes within the ambulatory oncology setting makes nurses the most qualified to 'broker' early palliative interventions with patients and oncologists successfully. The ambulatory workflow should be designed to allow nursing staff the time, opportunity, and support for a more proactive approach to introducing ACP options to oncology patients. Clinician Training After surveying interprofessional teams with experience in ACP across multiple health settings, Arnett et al. (2017) found that the number one resource needed to incorporate ACP into practice successfully was training for providers and staff. When clinician training is prioritized, it supports the importance of systematic integration of ACP into clinical routines. Provider education should include the logistics of process and documentation and delve into more intrinsic aspects of conducting conversations about end-of-life goals and values. Discussions concerning personal values and beliefs can alleviate anxiety, depression, and burden about IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 17 treatment, prognosis, and future healthcare decisions (Fleuren et al., 2020). However, it is this critical element of ACP conversation in which providers stated they are least prepared. Dabney et al. (2020) found in their survey assessing the readiness of ACP integration into an HCT transplant program that most hematology-oncologists received no formal training in goals of care discussion. Nearly all surveyed stated they believed this type of training was essential. Most providers need specific training to achieve quality communication skills that allow for clear discussion on individualized advanced plans of care – particularly oncologists (Fallowfield et al., 2002). Using structured, evidence-based models of ACP curriculum to facilitate coaching and training has proven successful in various studies. Rose et al. (2018) combined two complementary programs – VitalTalk and Respecting Choices – to support provider training on initiating and implementing ACP discussions in various outpatient clinics. This quality improvement project successfully increased ACP documentation from zero at baseline to over 7500 a year later. Using a similarly designed program, Epstein et al. (2017) provided oncologists with communication training and coaching that proved effective in improving patient-centered communication. As clinicians change their communication behaviors and increase their skills, patient outcomes improve. Combining clinician training efforts with other workflow improvements will positively impact patient outcomes. Patient Education Tools Education and training are also needed for patients and families. Educational materials and decision support tools facilitate understanding ACP and improve patient and family attitudes towards end-of-life care. Yun et al. (2019) found that advanced cancer patients significantly increased from baseline knowledge and preferences against CPR and other life-prolonging IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 18 treatments after using a video and booklet intervention. Educational material should be easy-to-read and comprehensive enough to increase understanding of advance care planning documentation with or without provider intervention. Information should include a definition of terminology associated with ACP and end-of-life care, the legalities and limitations of advance care directives, and a concise step-by-step process of completing advance directive materials (Sudore et al., 2017). Education should also facilitate communication between patient and family to understand patient wishes even outside the healthcare setting. However, passive patient ACP education with written materials is less effective than ongoing education by a trained health professional (Sudore et al., 2017). Chen et al. (2020) used clinician-led individualized, interactive ACP interventions to increase patient prognostic awareness of their disease state. Using a workbook, video, and provider lead discussion, patients could move from contemplation of end-of-life care to an action/maintenance stage of advance care planning. These interventions facilitated patients' ability to accept their prognosis and make more informed end-of-life medical decisions. This type of intervention would be significant with HCT patients considering the complex disease process and treatments they endure. Documentation Sharing documentation, including care transitions, should be anticipated, planned, and coordinated to achieve patient goals (National Coalition for Hospice and Palliative Care, 2018). There is a quality gap in end-of-life care for patients with hematologic malignancies, which can be overcome with standardized processes in advance care planning (Wang et al., 2017). Consistent and repeatable documentation practices facilitate communication at the point of care in transplantation and throughout the patient's lifespan. Still, rates of completed ACP are universally low. Freeman, Wood, Fox, and Hansen (2017) found only a limited number of HCT IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 19 patients had complete ACP documentation. Blaschke, Sellars, Detering, Kelly, and Nolte (2019) found that in patients 65 years and older, only 27% had complete advance care directives. When poor documentation practices exist, critical decisions concerning patient care goals can be lost to future clinicians. Many within healthcare are using new tools associated with electronic medical records to increase documentation practices. Electronic documentation workflows are built to help initiate conversation and capture real-time ACP conversations through the continuum of care support best practice (Dillon et al., 2017). In a multidisciplinary Delphi Panel, ACP or completion of advance directives was recommended to be documented as close to the event as possible to ensure medical care aligns with patient wishes (Sudore et al., 2016). Electronic tools like electronic prompts increase ACP and advance directive completion compared to usual care. Because of the high symptom burden many HCT patient experiences, hematology-oncologist can improve the quality of patient care by using electronic records for tracking critical endpoints (Tieu et al. 2016; see also Temel et al., 2013; Yun et al., 2019). Utilizing structured documentation processes creates efficiency, along with consistency in advance care planning. Summary of Review The benefits of advance care planning have been widely published and backed by evidence-based research. These conversations enhance the patient-provider relationship and empower patients with education and knowledge to make informed decisions about the direction of care. Creating systemic processes that support the integration of ACP into clinical workflow is critical. These processes include providing clinician training on initiating ACP, creating space for ACP to occur early in the outpatient setting, using education tools to improve clinician and patient ACP conversation, and using standardized documentation and communication practices. IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 20 Together, these elements of ACP form a foundation that supports patient autonomy and self-advocacy. Identifying patient goals and preferences is critical for patients undergoing a high acuity diagnosis like hematology malignancies. The literature review reveals that patients undergoing allogeneic hemopoietic stem cell transplants are at significant risk for morbidity or mortality due to their treatment protocol. However, these patients rarely receive ACP early on in diagnosis. Research shows this gap in care can be linked to barriers such as provider reluctance to introduce ACP too soon into potential curative treatment options, patient and family perception of ACP in the transplant setting, and a complex environment of care. The Intermountain Blood and Marrow Transplant/Acute Leukemia (BMT/AL) Program, located in Salt Lake City, Utah, struggled to implement a structured process that would allow clinicians to initiate early advanced care planning for allogeneic hematopoietic stem cell transplant patients. Using the reviewed evidence-based methodologies and processes on ACP, a standardized ACP protocol was developed and implemented specifically for allogeneic bone marrow transplant patients identified in the BMT/AL program. This quality improvement project provided bone marrow transplant patients with a way to document their preferred care goals within the electronic medical record. Given the high rate of morbidity and mortality associated with bone marrow transplants, integrating early ACP helped providers respect patient wishes and relieve some of the burden placed on families during end-of-life decisions of care. ARCC Model for Practice Change Theoretical Framework The Advancing Research and Clinical Practice through Close Collaboration (ARCC) model is an evidence-based change model used to implement ACP in the Intermountain Blood IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 21 and Marrow Transplant/Acute Leukemia program. The ARCC model provides a framework that helped guide change and quality outcomes for the sustainability of this project. ARCC model is designed around three steps before implementing new evidence-based practice (Melnyk & Fineout-Overholt, 2019). These steps assess the environment and culture for change, identify strengths and barriers to the change, and use mentors and champions to facilitate change. These champions help shift the cultural paradigm to an environment where evidence-based practice can flourish. The Intermountain Blood and Marrow Transplant/Acute Leukemia (BMT/AL) program consists of an inpatient program and an outpatient clinic serviced by the same team of clinicians. The ARCC Model was an ideal guide because of its attention to assessing the culture and readiness of the environment. While evaluating the program's culture, it was found that ACP patient-provider interaction to date has been informal and limited in scope. However, many clinicians, including program directors, voiced both interest and the need to implement a process that supported an ACP program tailored for HCT patients (D. Hoda, Clinical Director for BMT/AL, personal communications, June 26, 2020). Introducing a structured, evidence-based ACP process was also a practice change for the program, requiring a review of workflow processes to identify key stakeholders and barriers. The ARCC model provided a foundation that emphasized the use of both education and subject experts to champion change (Melnyk & Fineout-Overholt, 2019). Champions included an initial pilot team consisting of two experienced providers, two BMT/AL clinical nurses. As champions for change, this pilot team intimately understood the daily workflow and pressures within the BMT/AL program and quickly addressed unexpected conflict or barriers at the ground level. IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 22 Strategies and lessons learned from ACP implementation were used for other oncology services within the Intermountain Healthcare system. Advance care planning is universally needed in all areas of the healthcare system. The ARCC model promoted successful practice change in one area of the system to create a positive difference in organizational evidence-based practice culture. Expected Outcomes and Objectives The overall goal of this quality improvement project was for all allogeneic transplant patients and their families to participate in advance care planning processes with BMT/AL clinicians. The outcome of this quality improvement project included the successful implementation of a complete ACP protocol that provided integration of ACP steps into the current workflow, clear documentation, communication processes in the EMR, and clinician education. Patient satisfaction with ACP initial discussions was also measured. This DNP project was guided by the four-member pilot team, working with system leaders and tailored a standardized process specific to the needs of both clinicians and patients. The pilot team coordinated ACP process development and implementation in partnership with system leaders using the Respecting Choices model. While this project was a collaborative effort by all team members, clinician education was explicitly developed and led by this Doctor of Nurse Practitioner (DNP) student. The goal of clinician education was to improve provider confidence in the usability of an ACP protocol within the BMT/AL program. The effectiveness of the ACP intervention was evaluated for usability, feasibility, and provider/patient satisfaction. Setting The Blood and Marrow Transplant/Acute Leukemia (BMT/AL) program's primary campus is LDS Hospital, a large 220-bed community hospital in Salt Lake City, Utah. It consists IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 23 of both an inpatient unit and outpatient clinic, and infusion center. It is ranked by the Center for International Blood and Marrow Transplant Research (CIBMTR) among the top twenty programs in the nation for survival rates (CIBMTR, 2018). The program consists of 11 physicians, 14 advance practice providers, and six patient coordinators who rotate between inpatient and outpatient services. Outpatient nursing staff consists of dedicated triage and infusion nurses. Because of its location within a community hospital campus, certain specialty services were not immediately available for the provider or patient use. There is currently no dedicated palliative or hospice team for LDS Hospital. Any patient coordination with palliative or hospice services happens on discharge from the BMT/AL program. In response to this need, the BMT/AL program director approved dedicated provider hours and resources towards creating a task force that can develop a sustainable ACP protocol. The pilot team explored the Respecting Choices model's strengths and limitations and evaluated how this model's processes impacted the BMT/AL workflow. The pilot team also defined a specific and tailored ACP protocol that met the needs of both BMT/AL clinicians and transplant patients and families. This protocol included clinician training and detailed how ACP interventions fit into daily clinical care – from scheduling to documentation, communication, and maintenance of ACP decisions in the electronic medical record. Population The BMT/AL program sees about 120 unique patient referrals each year. The program treats adult patients (18 years or older) with advanced and complicated blood and marrow malignancy. Patients are referred from the Intermountain Healthcare network, Utah, Nevada, Idaho, Wyoming, and Colorado. Patient demographics are comparable to other BMT programs in the region, with the average patient age 59, Caucasian, and male (a little over half). The IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 24 program treated 52 patients with allogeneic transplants in 2019, with a death rate of 19.2% (L.M. Meaux, Program Coordinator, personal communication, June 2, 2020). The BMT/AL provides the patient's primary care through their disease and/or transplant and then discharged back to their referring oncologist or primary care provider. To date, there is no data available on the percentage of BMT/AL patients with completed advanced directives or documented ACP conversations. Practice Change Plan Role of DNP-FNP Leader The pilot ACP team consisted of an APRN, two DNP students, and one clinical nurse. As an integral member of this team, this DNP-FNP student was involved in the overall planning, implementation, evaluation, and analysis of clinician education development. Integration of ACP into clinical practice requires strong leadership to promote participation from key stakeholders. Identification of roles and responsibilities and partnership between organizations and teams is critical for any project's success. DNP standards help navigate potential conflict during project development while ensuring that respect for patient autonomy and interest are held above other interests. Patient autonomy and advocacy are foundational to ACP, and all activities were designed to keep the patient in the forefront as a full partner in care (AACN, 2021). DNP-trained leaders are taught to blend the application of science and data with the art of translating evidence into clinical action (Reavy, 2016). The clinical impact of this quality improvement project aligns precisely with the concepts and ideals of the APRN by using individualized patient-center care and interdisciplinary collaboration. DNP-FNP practitioners can present and implement transformative quality improvement initiatives that positively impact patient outcomes and healthcare systems by functioning within this leadership role. IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 25 Respecting Choices Model of ACP Intermountain Healthcare Systems (IHC) invested and promoted the Respecting Choices evidence-based model of advance care planning for all service lines throughout their organization. The curriculum and strategies of Respecting Choices ACP model are explicitly designed to fit the needs and goals of individual programs or clinics. The BMT/AL program was ideal for integrating the generalizable processes, materials, and training promoted by the Respecting Choices model. In their systematic review of ACP models of care, McKenzie, Smith-Howell, Bomba, and Meghani (2018) found that Respecting Choices increased patient and family understanding of hypothetical end-of-life scenarios and increased the prevalence of completed advance directive or end-of-life documentation. In a longitudinal randomized trial of ACP for oncology patients, Lyon et al. (2013) found that Respecting Choices helped facilitate conversation and shared decision-making between patients and their families. The use of Respecting Choices was associated with fewer ICU admissions and higher use of hospice in a tertiary care setting (Peltier, 2017). Considering the complexity and increased risk of the HCT population, Respecting Choices helped standardize ACP practices and allow for individualized interventions specific to the allogeneic HCT population. This model provided the framework to build a curriculum for provider education on initiating ACP conversation, educational materials for patient and family use, and a detailed workflow process to integrate and document ACP successfully. This model aligned the quality of patient care in the BMT/AL program with Intermountain Healthcare standards, expectations and ethics, and values promoted by governing bodies of nursing professional practice. IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 26 Pre-implementation The project's overall goal was to create a process using Respecting Choices that standardized flow, produced curriculum and scripting for clinician education on initiating ACP conversation, and provided educational content for patients and families. In preparation for the first step, the pilot team participated in an intensive 12-hour training session with system leadership on the Respecting Choices program and implementation practices. All team members were certified in the Respecting Choices curriculum and were approved to tailor the information to the specific needs of the BMT/AL program and workflow. During these training sessions, pre-implementation activities were identified as necessary for project implementation. These included creating provider training on initiating ACP conversation, determining the appropriate patient population using BMT/AL resources, and developing appropriate documentation and communication processes suitable for clinical workflow. One aim of this project was to improve clinician engagement in ACP as an early intervention to provide quality care for pre-transplant allogenic patients. This step required pre-implementation clinician training in the ACP processes developed specifically for the BMT/AL program and workflow. The training consisted of a self-paced online power-point lecture and video reenactment of an ACP discussion using the Respecting Choices standardized discussion guide. Key stakeholders were invited, including BMT/AL physicians and advanced practice providers, outpatient triage RNs, BMT educator, program directors, and unit managers. The Intermountain Healthcare Oncology Clinical Program Director, Medical Director of Hospice, and Palliative Care Systems Director were also invited to attend as a courtesy. Education on documentation processes occurred both during the clinician training session and by email communication as needed. IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 27 The team coordinated with patient navigators to help identify all new allogeneic HCT patients and families. The pilot team then conducted the first month of ACP with these identified patients and families using a preliminary developed ACP process. After this first month, the team reviewed the experiences and processes to help refine clinician training material and evaluate the effectiveness of patient education materials. This allowed the pilot team to understand better the curriculum and tailor material and process appropriate for BMT/AL workflow and population. It also provided the pilot team with knowledge and experience in becoming more expert in the ACP process. This test run was critical for them to become champions for culture change and mentor point of care staff within the BMT/AL program, a necessary element of the ARCC model (Melnyk & Fineout-Overholt, 2019). Lessons learned were incorporated into the ACP process. Pre-implementation activities also required identifying and integrating the documentation tools and communication channels for ACP at the program and system level. Intermountain Healthcare recently rolled out an initiative promoting the collection and storage of advance directives into the electronic medical record for patients entering the healthcare system. This system-wide initiative supported this project's documentation and communication efforts and helped promote a cultural shift towards system recognition of ACP processes in clinical care. This aim also involved coordination on documentation for billing, how BMT/AL provider notes were written and accessed, accessibility of advance directive documents, and training for clinicians. An ACP documentation template was also created to help facilitate the ease of EMR documentation of ACP conversations. The BMT/AL program medical directors and APP oncology system lead evaluated and approved this template. All required EMR documentation of ACP was taught to providers during their online training. An EHR chart review on Allogenic IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 28 transplant patients was conducted every month to track completed or started documentation of ADs and/or POLST forms and provider clinical notes. Implementation Implementation began with clinician training using evidence-based practices provided by the Respecting Choices model of ACP. Respecting Choices model of clinician training has demonstrated increased motivation, confidence, preparedness, and skill in initiating ACP discussion per several studies on provider outcomes (Myers et al., 2018). The staff was trained via a computer module, which involves scripting for initiating conversations, provider guide notes for ACP guided discussions, document ACP in the electronic health record (EHR), and appropriate educational materials for the patient. It is expected that this online curriculum will be used for future clinician training as part of this project’s sustainability plan. Pre-training and post-training clinician surveys were used to assess the understanding and feasibility of advance care planning with patient care (see Table 1). Patient coordinators began communicating via email to the ACP pilot team and front desk staff when a new allogeneic transplant patient was admitted into the program at the start of the implementation period. Once identified by the patient coordinators, the front desk would schedule the patient for an ACP discussion during their pre-transplant conference. Patients were scheduled for an hour conversation regarding advance care planning. Per patient preference, advance directives and POLST were completed at this time. Using the ACP patient note template, documentation on all ACP was conducted immediately after discussion by clinicians trained in the BMT ACP protocol. Participation in the discussion was voluntary for all patients and families. One patient declined due to time constraints, two patients transitioned to hospice before their scheduled meeting, and one was canceled because of administrative IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 29 miscommunication. Otherwise, a clinician trained in the BMT ACP protocol contacted all identified patients within the target population. At the very least, ACP education materials were given to all identified participants minus those previously mentioned. Evaluation and Analysis Evaluation of this quality improvement project continued for six months from the implementation date, starting on January 1, 2021 and ending June 30, 2021. Data was collected on three project outcomes, including evaluation of (a) clinician attendance to education on the initiating the new ACP process as well as pre and post-class surveys on the effectiveness of clinician confidence in engaging in ACP, (b) the usability of the BMT ACP protocol as indicated by chart review of EMR documentation of ACP and (c) patient and provider satisfaction with the ACP process using post-ACP discussion surveys. Analysis of the project occurred at several critical points during project implementation. Program feasibility was measured by how many Allogeneic transplant patients receive ACP before their transplant. The measurement was tracked through the EHR chart review. Sustainability was measured by ACP documentation in the EHR, either completed by a provider or signed off by a provider. Proper documentation is necessary for ACP coding and billing, which was not measured explicitly during this QI project but accounted for during the creation of the provider note template. Program usability of ACP was addressed with both clinician and patient surveys. It was also understood that this QI project represented a shift in the BMT culture and clinician perception and attitudes on early ACP discussions as part of standard treatment with allogeneic transplants. Results from this data provided a strong base for quality improvement and practice change necessary for project sustainability and helped promote cultural change within the BMT program. IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 30 Data Collection Initial attendance of clinician education included physicians, advanced practice providers, clinic RNs, and program directors. Pre-and-post clinician surveys were used as tools to measure efficacy and satisfaction. These surveys provided prompt and straightforward feedback to check for project improvement and progression (Institute for Healthcare Improvement [IHI], 2020). The surveys also indicated improved confidence and understanding of the ACP's role in early treatment workflow. The pre-intervention surveys were given online immediately before presenting a personal computer-based training. Due to constraints set in place by the COVID-19 pandemic, all clinician education was conducted online. Post-education surveys were given a week after training was complete. Provider and patient satisfaction were assessed using Likert surveys and descriptive statistics. Program usability and feasibility were measured through data derived from EHR chart review. The ACP pilot team compared data of the allogeneic patients admitted to the BMT/AL program with completed advance directives and/or POSLT forms to the total number of allogeneic patients admitted without ACP documentation during the implementation time frame. The pilot team also extracted data on initiation of ACP by BMT/AL clinicians, as demonstrated by written ACP patient discussion notes of admitted allogeneic patients. Additionally, data was sorted into four specific categories which were 1) patients who received ACP conversation; 2) patients who received ACP educational handouts; 3) patients who identified a healthcare agent; and 4) patients who participated in ACP and documented AD and/or POLST forms into their medical record. Patient and clinician satisfaction surveys were collected and used as quality indicators of project success. After the initial ACP discussion, patient satisfaction surveys were given and IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 31 collected at the front desk to provide patient anonymity. This survey offered quick continuous feedback for the ACP team and provided a real-time evaluation of the ACP process from the patient perspective. This survey also helped the ACP team tighten the ACP process to accommodate any needs identified by patients and their families. A similar survey was given to all BMT/AL clinicians to assess clinician satisfaction and confidence in the ACP protocol integration into the workflow. Clinician satisfaction surveys were conducted after the end of project implementation. These surveys were sent using an online survey tool to protect clinician anonymity. All data and information related to this project were stored on a drive that was password protected and only accessible by authorized users. Both surveys provided open-ended questions for feedback. Both surveys were analyzed and used as quality indicators for project improvement and sustainability within the BMT program. This quality improvement project was also approved by Weber State University's Institutional Review Board (IRB) review and BMT/AL clinical director. Various government and independent agencies regulate the quality of processes surrounding advance care planning, documentation, and billing in health care systems. All rules and regulations were accounted for during project implementation. Analysis This quality improvement project used descriptive statistics (number, percent, mean, standard deviation). Data collected on the effectiveness of clinician education were analyzed using survey change statistics—the pre-training survey closed-ended questions to post-training survey closed-ended questions utilizing the Wilcoxon signed-rank test. An EHR chart review of the identified population was conducted. Advanced care planning data on the allogeneic patients admitted to the BMT/AL program during the implementation was extracted from the EHR IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 32 monthly and collated at the close of the implementation phase. All identifying patient data were removed before analysis. Results Thirty-seven Allogeneic transplants were scheduled from January 2021 to June 2021. Patients who underwent ACP were reported high satisfaction and confidence in future health care decisions after ACP conversation. In addition, after the initiation of ACP, the percentage of AD/POLST recorded in the EHR increased from 0% to 64%. Of the Allogeneic transplant patient, 89% (n=33) received a discrete scheduled ACP conversation and educational material. Of the patients who received an ACP conversation, 86% (n=32) of them identified a health care agent if they could not make decisions for themselves. 64% (n=21) of Allogeneic transplant patients who participated in an ACP conversation filled out an AD/POLST. 100% of initiated ACP conversations were documented in the EHR by clinicians trained in the ACP process (Figure 1). Secondary to improving the quality of patient care through ACP was enhancing the quality of clinician understanding and confidence in the ACP process. After standardizing clinician education in ACP and initiating difficult conversations, clinicians indicated increased confidence in providing ACP after the intervention. Pre- and post-survey responses were significant for improving confidence in all aspects of engagement in the ACP protocol. Clinicians also indicated they were more likely to talk about ACP to all their patients after education. The use of patient surveys was a vital quality indicator used throughout implementation. Based on the patient survey, patients viewed ACP to be beneficial. They felt better prepared to make future health care decisions and felt like their ACP facilitators helped them with their IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 33 needs. Written comments regarding ACP reflected a high degree of satisfaction. They included statements like “Great to talk this through,” “Important discussion to have, everything was thoroughly explained. Thought-provoking questions to make me really consider my options. Appreciated the help so much.”, and “They were very thorough! Very caring!” (Figure 2). Clinician satisfaction surveys also reflected an increase in the perception that ACP benefits and better prepare patients to make future healthcare needs decisions. 100% of surveyed clinicians found that they saw a benefit from the implemented BMT ACP process. 100% of clinicians felt that the new ACP process helped meet patient and clinician needs with advance care planning. Written comments reflected some need for continued education about the nuances associated with patient preferences. Statements like “continue to work on the timing of discussion as inpatient ACP doesn’t work as well”; “the MD didn’t think DNR/DNI applied to outpatients” or “I don’t believe a patient can be DNR and still transplant” all indicate continued need to work on process improvement and culture change (Figure 3). Discussion Overall findings showed that the BMT program's ACP protocol improved clinician confidence and that the protocol was both feasible and usable within the clinic workflow. Results also showed a high degree of satisfaction and perception of benefit from both clinicians and patients. This project promoted an increase in documentation of ACP, including AD, POLSTs completion, and appointed healthcare agents within the allogeneic BMT patient population at LDS Hospital. ACP education was shown to increase clinician confidence in delivering ACP conversation. Based on the patient survey, patients found ACP to be beneficial. They felt better prepared to make future health care decisions and felt like their ACP facilitators helped them with their needs. This project’s results are consistent with prior studies that found formal ACP IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 34 training and processes increase clinician confidence in conducting ACP (Chan, Ng, Chan, Wong, & Chow, 2019). Provider confidence in participating in ACP and similar critical conversations surrounding quality of life or end-of-life interventions is essential, particularly in hematology-oncology. A pivotal element to standardizing ACP processes is clinician education on overcoming conversation hesitancy through semi-structured scripting. Initiating an ACP discussion early in the hemopoietic stem cell transplant process provides clinicians and their families the structure and vocabulary to seamlessly shift focus towards palliative care should a patient's prognosis unexpectedly worsen. EMR chart reviews validate clinician willingness to engage in ACP during implementation after education on standard ACP processes. The success of this QI project represented a positive shift in the BMT culture and perception about the place of early ACP discussions as part of standard treatment with allogeneic transplants. Implementing an ACP protocol within a program or system offers a unique opportunity to involve interdisciplinary collaboration on a critical aspect of patient healthcare. Standardizing a protocol not only ensures that all patients and families are getting high-quality conversation and education, but it has the ripple effect of improving health literacy within the community. Collaboration with clinical leaders and ancillary staff like patient coordinators, administrative, and informatics departments is needed to augment ACP protocol specifics to support any designed processes. Project implementation also hinges on having a pool of knowledgeable and engaged clinician staff. It is recommended that initiating advance care planning early in the treatment process for allogeneic HCT patients will improve the quality of patient care for all bone marrow transplant programs and provide an example of standard approaches generalizable for other oncology IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 35 systems. Using a standardized, evidence-based conversation guide like Respecting Choices enhances the quality of the ACP conversation and increases patient satisfaction with the process. Standard ACP workflows should be disseminated to other clinics within a system to create a culture of patient advocacy and patient-centered care. The sustainability of such quality improvement projects depends on interdisciplinary teamwork. Sustainability also depends on billable conversations and providers' ability to fit ACP into their workflow. This quality improvement project’s findings are consistent with prior studies showing increased ACP utilization and documentation in standardized ACP programs than ad-doc or as-needed ACP (Weathers et al., 2016). The use of a standardized program builds ACP into the workflow, thereby ensuring that ACP is conducted. However, this project did not indicate a change in clinician workflow time post-intervention, indicating that additional study is needed to ensure providers have the time and support necessary to conduct ACP seamlessly within current clinical practice. Limitations The project had several limitations. Patient coordinators' buy-in was initially lacking, which created some confusion on the ACP scheduling workflow. The patient coordinators are responsible for scheduling various appointments specific to a patient treatment plan. The ACP pilot team overcame scheduling conflicts by integrating the ACP discussion during the allogeneic treatment planning conference. The ACP topic aligned itself naturally during this treatment planning discussion. Timing the ACP discussion during this appointment brought together the treating physician, assigned patient coordinator, and ACP discussion facilitator. Providing this type of individualized intervention also helped address any patient and family reluctance to engage in ACP during the pre-transplant phase of treatment. IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 36 It was not always possible to bill for ACP visits because a provider had to be present for at least 16 minutes of the ACP conversation to legally bill. Due to clinic workflow, a provider was not present at times, and a trained registered nurse ACP facilitator conducted the ACP discussion. An educational PowerPoint was made for new ACP facilitators to communicate the importance of inviting a provider during the ACP conversation. Finally, the project was designed and implemented during the 2020/21 COVID-19 pandemic, causing limitations when meeting with immunocompromised patients. Advance care planning meetings were limited to two ACP facilitators, the patient, and their designated healthcare agent to limit face-to-face interaction. Summary Advance care planning is a dynamic process supported by nursing principles of advocacy, compassion, and respect for the individual. Participating in ACP exemplifies several DNP-FNP core competencies, including interdisciplinary collaboration and communication, advocacy, and therapeutic management. DNP-FNP leaders are charged with disseminating the translation of evidence into practice (AONE, 2011). Research and literature show that ACP promotes the rights, needs, and overall benefit of the patient and provides a way for DNP-FNP clinicians to practice quality patient care at the end of life. Advanced care planning allows clinicians to honor individual patient values with compassion and dignity at the end of life. By facilitating formalized ACP into clinical practice, the DNP-FNP providers engage in critical practice and cultural change that can affect individual and system patient outcomes. This quality improvement project provides standard processes generalizable for other oncology programs. By initiating ACP early in the treatment process for allogeneic transplant patients, the quality of patient care for the BMT/AL program improved. For the allogeneic transplant patient, ACP increases their understanding of their prognosis and treatment plan and IMPROVING ADVANCE CARE PLANNING FOR BMT PATIENT 37 facilitates communication between providers, patients, and families. Advance care planning allows clarity to patient wishes and a measure of control over the final phase of life. 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ACP = advance care planning; EHR = electronic health record; BMT – bone marrow transplant. 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 Delivery of ACP information Introducing Difficult Conversation Documentation of ACP Billing ACP I talk about ACP to all my patients Improvement of BMT Clinician Confidence N = 25 Pre Education Mean Post Education MeanRunning head: ADVANCE CARE PLANNING IN BONE MARROW TRANSPLANT 1 Figure 1 Advance Care Planning With Allogeneic Transplant Patients n=37 Note. ACP = advance care planning; AD = advance directive; POLST = physician order of life-sustaining treatment. 89% 86% 64% RECEIVED ACP CONVERSATION RECEIVED ACP EDUCATIONAL HANDOUTS IDENTIFIED A HEALTH CARE AGENT IF PARTICIPATED IN ACP, AD/POSLT DOCUMENTED Allogeneic Transplant PatientsADVANCE CARE PLANNING IN BONE MARROW TRANSPLANT 53 Figure 2 Patient Survey Questions Post Advance Care Planning Discussion n =17 Note. ACP = advance care planning. 100% Felt ACP was helpful Felt better prepared to make a future health care decision Felt their ACP facilitator helped with their needs Patient Survey QuestionsADVANCE CARE PLANNING IN BONE MARROW TRANSPLANT 54 Figure 3 Clinician Survey Questions Post Advance Care Planning Discussion n=14 Note. ACP = advance care planning. BMT = bone marrow transplant 100% Have seen a benefit to our allo-transplant patients withthe new BMT advanced care planning process. Our patients are better prepared to make decisions about future health care because of the ACP process. I know the BMT advanced care planning process and who to ask if I have questions about the process. The BMT ACP team has helped meet provider/clinician needs with advanced care planning Clinician Post Implementation Survey