Running head: BEING PROACTIVE IN GERIATRIC ADVANCE CARE PLANNING

Being Proactive in Geriatric Advance Care Planning
Hija Mae Bautista
Arizona State University

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Abstract
Disease burden is higher in the United States than in comparable countries. The Patient Self
Determination Act of 1990 requires healthcare facilities to provide Advance Care Planning
(ACP) information to all Medicare patients. The healthcare staffs’ (n=7) commitment to 3-days
of ACP training increase ACP rates in the primary care setting. The Medicare Incentive Program
is the platform for this initiative. This quantitative project used a valid and reliable pre and
posttest design that consisted of 27 items on a Likert-scale. A 3.5-month chart audit (n=91) was
conducted to assess the completion rate. Descriptive statistics was used to describe the
demographic data. The results of the two-tailed Wilcoxon signed rank test were significant
based on an alpha value of 0.05, V = 0.00, z = -2.37, p = .018. There was a significant increase
in the post-readiness to change average scores. A Mann Whitney test was used to analyze the
statistically significant difference between the averages in two ACP types and electronic health
record documentation (EHR). Staff did not always code (Mdn = 0.00) but they documented in
the EHR (Mdn =1.00; 512.00, p = 0.003). ACP discussion was performed 63% of the time
during Annual Wellness Visits (AWV), and there was a 49% increase in the EHR
documentation. Trained staff are key stakeholders in guiding ACP conversations. They
understand the barriers, impact, and consequences related to the lack of advance directives.

Key words: Advance care planning, end of life care, advance directives, quality of life

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Being Proactive in Geriatric Advance Care Planning
The national public opinion poll on ACP report that only 10% of adults discussed ACP
with their primary care provider (Scholten et al., 2018; Bernard, 2018. Disease burden is higher
in the United States than in comparable countries (Sawyer & McDermott, 2019). This
contributes to more frequent hospital admissions for congestive heart failure, respiratory distress,
infections, and poorly controlled diabetes. Despite the statistical increase in disease burden and
hospital admissions compared to other countries, the United States continues to lack disease
trajectory discussions and future planning. Future planning means creating a guide for an
individual in case an illness, accident, or fatal event occurs. The majority of older adults appear
to understand the terminology future planning as opposed to advance care planning (ACP).
The United States health infrastructure can deter providers from completing advance
directives caused by higher patient load, emergency care, and lack of time. The time constraints
affect providers’ ability to provide quality, comprehensive, and holistic care for their patients.
Advance care planning conversations require time and can create an emotional burden for
everyone involved. The national public opinion poll on ACP report that only 10% of adults
discussed ACP with their primary care provider (Scholten et al., 2018; Bernard, 2018). Clinic
staff have a limited amount of time to discuss their patient’s diagnosis and treatment plan. The
Medicare patient population is living longer with many chronic conditions and need more time
for health management, which makes ACP less of a priority for both patients and clinic staffs
(Scholten et al., 2018; Bernard, 2018). They cannot thoroughly explain options, prognosis, and
possible plan of care in such a short time frame (Scholten et al., 2018; De Caprariis et al., 2017).
Some patients are required to review ACP documents at home and to return for another
visit for ACP discussion (Bernard, 2018). This disrupts ACP completion causing more delays

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and incomplete documentation; usually, advance care planning document completion occurs
during critical situations, primarily in the last six months of life (De Caprariis et al., 2017; Dyess,
Tappen, & Hennekens, 2014; Edward & Landon, 2014). These factors negatively impact ACP
rates. The older adult population is growing, living longer with chronic conditions and
comorbidities. The Geriatric population is more at risk for more acute and critical illnesses due
to the aging process, decreased immune systems, and multiple acute on chronic condition
management. Being proactive in Geriatric advance care planning will decrease emotional
trauma, family burden, invasive health measures, financial expenditures, and most importantly,
increase patient autonomy and healthy aging in older adults
Problem Statement
The United States has low rates of ACP. The Medicare reimbursement incentives and
awareness program can help increase national advance directive rate, currently at 33.3%, because
an estimation of 97% of Americans are agreeable to participate in end of life (EOL) care
discussions (De Caprariis et al., 2017; Edward & Landon, 2014). Despite the promotion of
advance directives that has occurred, only 5% to 20% Arizonans completed advance directives
(Kirk, 2010).
Advance directives, unfortunately are rarely discussed until a patient is quickly declining
or given a terminal diagnosis. Patients and their family members are oftentimes forced to make
“in the moment” types of decisions that lead to confusion, indecisiveness, and guilt. This
disrupts ACP completion causing more delays and incomplete documentation; usually, advance
care planning document completion occurs during critical situations, primarily in the last six
months of life (De Caprariis et al., 2017; Dyess, Tappen, & Hennekens, 2014; Edward &

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Landon, 2014) Consequently, this creates a quandary between prolonging life or suffering (De
Caprariis et al., 2017; Cottingham et al., 2018).
The healthcare professionals’ confidence contributes to low advance directive rates.
Various factors can affect a clinic staff’s comfort level such as years of experience, specialty
area, and personal bias (De Caprariis et al., 2017; Dyess, Tappen; Hennekens, 2014; Edward &
Landon, 2014; Bernard, 2018). Training the staff in assisting patients with ACP may result in
increased confidence; thereby, increasing advance directive rates in primary care settings.
Purpose and Rationale
Healthcare staff working with older adults in primary care settings need enhanced end
of life care discussion training to learn specialized skills regarding these discussions. The
training and discussing end of life plans in a meaningful way with patients may result in a
reduction in increased spending and unnecessary administration of aggressive treatments. Also,
advocating for patient quality of life can be improved by highly trained clinic staffs who are
confident in discussing end of life care (Auriemma et al., 2016). The Medicare reimbursement
initiative effective January 1, 2016 will pay for ACP discussion and documentation during
Annual Wellness Visits (AWV) (Center for Medicare and Medicaid Services, 2018). This
Physician Fee Schedule payment system will impact about 55 million Medicare beneficiaries and
their healthcare providers (Center for Medicare and Medicaid Services, 2018). The Patient Self
Determination Act of 1990 requires healthcare facilities to provide written ACP information to
all Medicare patients. The patients have the right to access advance directives, complete
documents, and ACP education (Kirk, 2010).
The purpose of this evidence-based practice (EBP) project was to evaluate the followings
questions:

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1) For staff in a primary care organization, does their organizational readiness for
implementing change (ORIC) in the area of Advance Care Planning (ACP) with Medicare
patients increase before and after training?
2) In older adults in a primary care setting, does the completion of ACP short and long form
documentation and billing/coding increase after Medicare annual wellness visits with trained
staff?
Background/Significance
According to Scholten et al. (2018), clinic staffs can be properly trained to discuss ACP
but this type of conversation requires time and can create an emotional burden for everyone
involved. Clinic staff have a limited amount of time to discuss their patient’s medical diagnosis
and treatment plan. Many people are living longer with multiple chronic conditions and need
more time for medical management, which makes ACP less of a priority for both patients and
clinic staffs. When attempting to incorporate advance care planning during episodic or followup visits, clinic staffs do not have enough time to perform a comprehensive assessment. They
cannot thoroughly explain options, prognosis, and possible plan of care in such a short time
frame (Scholten et al., 2018; De Caprariis et al., 2017). The patient was required to return for
another visit for ACP discussion and document completion causing delays and incomplete
documentation; usually, advance care planning document completion occurs during critical
situations, primarily in the last six months of life (Dyess, Tappen, & Hennekens, 2014; Edward
& Landon, 2014).
Well-informed patients are more likely to participate in completing ACP when provided
with step-by-step directions (Scholten et al., 2018). Scholten et al., (2018) propose the use of
social workers in ACP is beneficial but difficult to incorporate in the ambulatory settings.

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However, all clinic staffs must be readily available to explain options, prognosis, and treatment
plans. The embedded ACP program within primary care clinics starts with the front office staff,
providers thorough ACP and EOL discussions, and printed advance directives and education
pamphlets help increase the rates. It takes all healthcare disciplines to create awareness,
encourage discussion, and complete documentation.
There are multiple programs, tools, and theories used to help patients understand the
importance of advance care planning (Cottingham et al., 2018; McGlade et al., 2017; Payne et
al., 2010). The Conversation Project movement, for example, created tools and programs to
better assess patient’s mental capabilities to make their own informed decisions or assign a
medical power of attorney or health proxy (The Conversation Project, 2018; Cottingham et al.,
2018; McGlade et al., 2017; Payne et al., 2010). Once the emotional burden was addressed,
patients are presented with the motivational reasoning for completing ACP; the majority of
patients were receptive and understanding. Nearly all of the participants understand that they are
healthy and capable of making informed decisions and they are in control of their health.
Healthy aging promotes autonomy, control, and responsibility. The crisis of decision-making
was eliminated from use of the medical power of attorney and health proxy when ACP was
executed by a confident clinic staff in the ambulatory settings (De Caprariis et al., 2017; Karnik
& Kanekar, 2016). The manner of the presentation sets the tone for the ACP discussion. When
a clinic staff was trained properly and has confidence in ACP discussions, patients and their
family members take this matter seriously and are more likely to complete ACP documentation
(De Caprariis et al., 2017; Karnik & Kanekar, 2016).
Researchers suggested that electronic medical record (EMR) based ACP could potentially
help increase the rates and improve clinic staff adherence to completion of advance care

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directives. A group of medical doctors assessed the effectiveness of an EMR based reminder in
improving advance directive completion in an outpatient setting (Hayek et al., 2014). They
reported that easily accessible online ACP documents increased rates to 66%. Further, ACP was
simple, cost effective, and did not require extra financial or human resources (Hayek et al.,
2014). The implementation of EMR supported health promotion by being proactive in patient’s
health care planning and making ACP a priority. In addition, well-informed patients are more
likely to participate in completing ACP when provided with step-by-step directions (Scholten et
al., 2018). Scholten et al., (2018) proposed the use of social workers in ACP. However, clinic
staffs must be readily available to explain options, prognosis, and treatment plans.
PICOT Question
A private practice in the southwestern United States suburb health care providers and
staff had minimal experience with end of life (EOL) care discussions; lacked advance directive
training; inconsistently inquired about advance directives; and did not have a formal
embedded system to implement ACP. The practice is very busy, seeing a high volume of older
adult patients with multiple comorbidities, which makes it difficult for clinic staff to start
advance directive discussions. Current practice, staff members reported that advance directive
discussions are brief and quickly noted but no official method was established. This inquiry has
led to the PICOT question, “in Healthcare Clinic staff (P), how does ACP education (I)
compared to no education (C) affect ACP rates (O)?
Evidence Synthesis
A review of literature of research studies addressing the various aspects of ACP,
illustrated diverse factors that affected low ACP rates: current ACP knowledge, language use,
lack of provider education, lack of formal training, lack of patient education, time constraints,

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negatives thoughts associated with death, time filling out documentation, and heavy emotional
burdens (De Caprariis, et al., 2017; Dyess et al., 2014; Scholten et al., 2018; Yap, Chen,
Detering, Fraser, 2017). Former and current trends about ACP and Geriatric advocacy continue
to shape the need for ACP awareness and how the lack of advance planning affects older adults
(Appendix A, B, & C). This evidence led to the development and implementation of the
Medicare Reimbursement Incentive Program. The Medicare Reimbursement Incentive Program
is positively impacting the advocacy for increasing ACP rates. There are more states and
federally funded end of life care coalitions that educate the public and providers about advance
care planning.
Search Strategy
A search strategy was developed and implemented which captured the primary literature
in the following databases: Cumulative Index of Nursing and Allied Health Literature
(CINAHL), PsychInfo, and PubMed initially meeting abstracts. A search system was conducted
for existing guidelines, systematic reviews, and primary literature within the last five years of
publication. Inclusion criteria were English language, patients living with chronic illnesses,
health-care provider direct involvement, includes outcome of interest, and comparative data. No
specific exclusion criteria noted. This review was conducted by one reviewer.
CINAHL
A search for primary articles uncovered 50 documents. Of these 50, two underwent a
full-text review. Initial MESH terms used were nurse practitioners AND living will education
AND increased advance care planning rates which yielded zero articles. The final phrase and
Boolean connectors used retrieved articles that focused on providers AND advance care planning

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AND rates which resulted in 50 articles. A slight change in similar key terms yielded the final
higher search results.
PsychInfo
A search for primary articles uncovered 31 documents. Of these 31, one underwent a full
text review. Initial and final MESH terms were staff members OR providers OR nursing staff
AND advance care planning education OR living will education AND advance care planning
rates OR advance care planning increase. This database did not require additional keywords or
MESH terms to generate results.
PubMed
A search for primary articles uncovered 114 documents. Of these 114, three underwent a
full text-review; same articles found in other databases. The same initial and final MESH terms
as PsychoInfo were used. No additional keywords or MESH terms used.
Theoretical Framework
The Health Action Process Approach (HAPA) model illustrated the motivational and
volitional phases of action (Appendix L). This applied to ACP regarding the clinic staffs’
willingness to complete the advance care documents. After making a definite choice to
participate in the Advance care planning (ACP) advocacy, there were barriers to finalizing the
documents. The motivational phase illustrated that the clinic staff was intentionally acting
towards their goal as an organization. The clinic staff understood the risks and outcomes that
could happen if directives were not finalized for patients and their family members. During this
time, the clinic was motivated to carry out the patient’s wishes, while promoting patient
autonomy, and maintaining their patients’ self-efficacy.

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The volitional phase involved executing the desired action. This was the stage that
exhibited potential barriers to advance directive completion. Once the clinic staff was committed
to the action, they had the self-regulatory skills and strategies to reach the goal of advance care
completion regardless of barriers, time constraints, and difficulty. This model allowed the clinic
staff to understand that benefits of completing a documented advance directive that will help
eliminate the potential futile care for their patient population.
Implementation Framework
Quality Improvement Model
The model chosen to help clinic staffs guide application of the synthesized evidence was
the Plan-Do-Study-Act (PDSA) Cycle (Appendix M). This was a systematic series of steps for
gaining valuable learning and knowledge for continual improvement of a process. The intial
stage of the cycle was to idenfity an opportunity for improvement and to test how it worked
within the system using metrics and indicators to assess progress towards the goal. Then, putting
the plan in action allowed for a testing period that could be as short as one day and implemented
with a small number of participants. The results and outcomes were thoroughly examined.
Based on the testing period and results, adjustments were made to establish quality improvement
plans. This was fitting for a small private practice because it allowed adjustments to be made in
a short period of time and with a small number of participants (Appendix M). The system
change that was implemented took several cycles of change and improvement at regular
intervals, allowed for refining ACP education materials, rehearsed execution and tactics for
information delivery to patients and family members, practiced use of appropriate ACP billing
and coding process, completion of ACP documents, and the tracked ACP rates within the small
private practice.

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Methods
A quantitative evidence-based practice project (EBP) used a pre and posttest design to
assess readiness to change of the staff and a chart audit was conducted to assess the advance care
planning (ACP) completion rate. The EBP project was approved by the Arizona State University
Institutional Board Review (IRB).
Setting
An EBP project was be implemented in a primary care clinic in Arizona that serves
Medicare patients. The participants were 2 providers, 1 office manager, 2 medical scribes and 2
medical assistants. The private practice had 2 exam rooms where the discussions took place.
There was a main lobby where the patients waited to be seen. General questions were answered
in the waiting area, then more personal detailed questions were answered in the private exam
rooms with the providers of the practice. Then, chart audits were performed on Medicare charts.
Population
Staff Members
The project facilitator was responsible for recruitment of staff and patients. The
recruitment process included the use of flyers to recruit staff employed in the primary care clinic.
The flyer introduced the advance care planning advocacy for the older adults education/training,
project conductor, time/location/length of session, conductor contact information, and invitation
to attend training. The flyers located in the primary care private practice office break room and
front desk staff/office area. Recruiting all subjects at the private practice started after IRB
approval. The inclusion criteria requirements were 18 years of age, can read, write, and speak
English, and clinic staff willing and voluntarily to participate in advance care planning education
and training, discussions, documentation, and appropriate billing/coding based on Medicare

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guidelines. The exclusion criteria requirements were less than 18 years of age and does not read,
write, and speak English, and no advance care planning training.
Medicare Patients
ACP informational flyers were provided to help with voluntary ACP participation. If the
Medicare patients chose to participate, he or she could start filling out the short or long form
ACP documents. This was included with Annual Wellness Visit (AWV) forms. The Medicare
patients was instructed to write their questions down for discussion with the provider during the
timed visit. After ACP discussions took place, providers signed off for completion. The
documents were scanned and checked off in the EMR. The inclusion criteria requirements
consisted of an electronic medical record (EMR) chart audit of Medicare patients who were 65
years of age or older.
Project Description
Staff participated in advance care planning training, which included completing forms,
electronic/EMR documentation, and detailed discussions with the Medicare patients. The
education occurred during the clinic staffs’ lunch hour. After the training was completed, the
subjects were given a Starbuck’s gift card.
The clinic staff received a 1-hour education training session. The education was a faceto-face interactive presentation that focused on the reasons for advance care planning in the older
adults, family quandary, grief, and caregiver burden. A primary objective was providing tips on
how to start and execute a productive advance care planning discussion and completion of
directives short and long form. The topics discussed with the clinic staff members and Medicare
patients consisted of advance directives, living wills, healthcare power of attorney, DNR or
Orange form, change in decisions, and storing documentation. Staff were instructed to scan the

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documents and include them in patients’ electronic medical record (EMR). Patients also had the
option to be in the ACP state registry and a copy was sent home with them. The Medicare
patients were encouraged to make multiple copies and give them to their loved ones in order to
make their wishes known. Education training included instruction on Medicare Reimbursement
Incentive and appropriate coding/billing protocols. It was recommended that ACP discussions
are addressed during their annual visit; however, for the purpose of this project staff members
discussed ACP with all patients over the age of 65 in order to increase ACP completion rates in
the clinic.
After the education session and training, the goal was for clinic staff to have a better
understanding of the following: advance care planning; implementing end of life care
discussions; Medicare billing and coding use; advance directive electronic medical record
(EMR) documentation; and increase confidence in guiding the conversations with the Medicare
patients. This was a 1-3-day process dependent on how many subjects were present on the first
day of training. An additional second or third day was implemented in case of scheduling
conflicts or personal reasons. The education session was recorded using zoom technology to
enhance learning and left at the clinic to enhance the sustainability of the project. The project
implementation phase timeline took about 4 months to complete.
Data Collection and Instrumentation
Readiness to Change. Pre-test and post-test data were collected to test and retest the
subjects’ readiness for change. Prior to training, the subjects were provided a pre-test using the
Readiness to Change Survey that measured readiness to change practice in the area of advance
care planning. The objective was to collect baseline data about clinic staff members’ need for
change, leadership and management commitment to change, attitude to change, communications,

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and preparation for change. The instrument consisted of 27 items on a Likert-scale with
response options ranging from strongly disagree to strongly agree. The instrument consisted of
five domains. The first domain measured need for change and the total score is 25. The second
domain measured leadership and management and the total score is 20. The third domain
measured attitude to change and the total score is 10. The fourth domain measured the
communication and the total score is 20. The fifth domain measured preparation for change and
the total score is 20. The overall instrument measured that staff members’ readiness to change
and the total score is 95. It takes approximately 5-10 minutes to complete the survey. However,
it took approximately 15-20 minutes to complete because a couple of subjects needed more
guidance. This instrument was reported as a valid and reliable. The ORIC instrument was found
to be valid and reliable. The construct validity was ascertained using Confirmatory Factor
Analysis (CFA): CFI =.838, RMSEA =.113 and CMIN/DF = 4.796, p <.001 and good reliability
Cronbach α = 0.88 (Storkholm, Mazzocato, Tessma, & Savage, 2018).
After the presentation, the subjects completed the same readiness to change post-test with
additional evaluation questions of education. The instrument consisted of 27 items on a Likertscale with response options ranging from strongly disagree to strongly agree. It took
approximately 15-20 minutes to complete the survey. The outcomes were to have ACP
awareness, monitoring implementation, and Medicare Reimbursement.
Chart Audits. Charts were randomly reviewed immediately after training. The data
collection took place once a week for a period of 3 1/2 months. The data was collected and
documented on a chart audit form. The chart audit was promising in terms of feasibility in
collecting ACP documents without affecting workflow, and efficacious in addressing Medicare
patients who need ACP planning/documentation (Thompson, McClement, Labun, and Klassen,

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2018). The data collected from patients’ electronic medical records (EMR) on the following
variables: age, gender, race, education, type of visit, EMR documentation, billing codes, and type
of ACP forms used. The goal was to perform a chart review/audits of 168 charts. According to
Thompson, McClement, Labun, and Klassen (2018), between 58-90 charts was an acceptable
number of charts to review. The project facilitator collected the data, and observed the following
outcome variables: advance care planning (ACP) completion rates and Medicare reimbursement
documentation related to implementing ACP during annual visits.
Data Analysis Plan
IntelluctusStatistics TM (IntellectusStatistics, 2020), software was used to store and
manage the data. Descriptive statistics was used to describe the sample and outcome variables.
Inferential statistics was used to analyze and interpret the findings pertaining to the outcome
variables of interest; readiness to change and advance care planning completion rates.
A two tailed test was used for testing the null hypothesis and statistical significance; the
critical value was set at p < .05.
Budget and Funding
There was no budget and funding received for the project.
Results
Readiness to Change
The subjects consisted of medical providers (n=2), office manager (n=1), medical
assistants (n=3), and medical scribes (n=2). The total sample size was n=7. The average age of
subjects was 37 (SD = 12.93), the ages range from 22 to 52 years of age (Appendix D). Majority
of the sample were female (n = 6, 86%) and Caucasian (n = 6, 86%). Most have college degree
education (n = 3, 43%). Most of the staff consisted of healthcare providers 2 (29%) and medical

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assistants 2 (29%). For the pre-test, all of the subjects did not receive previous training. More
than half of the subjects were comfortable discussing advance care planning (n = 4, 57%). All
subjects feel that this training would be meaningful (n = 7, 100%) (Appendix E).
The pre-readiness to change domains descriptive statistics of the domains are located in
table 3. The average readiness to change total score on the pre-test is 66.7 (SD =12.20), and the
scores ranges from 51 to 87 points (Appendix F). The post-readiness to change domains
descriptive statistics of the domains are located in table 4 (Appendix G). The average readiness
to change total score on the post-test is 78.71 (SD = 9.59), and the scores ranges from 70 to 95
points (Appendix G & H).
To answer the following evaluation question: For staff in a primary care organization,
does their organizational readiness for implementing change (ORIC) in the area of Advance Care
Planning (ACP) with Medicare patients increase before and after training? A two-tailed
Wilcoxon signed rank test was conducted to examine whether there was a significant difference
between the pre-readiness to change and post-readiness to change average scores. The two-tailed
Wilcoxon signed rank test is a non-parametric alternative to the paired samples t-test and does
not share its distributional assumptions (Conover & Iman, 1981). The results of the two-tailed
Wilcoxon signed rank test were significant based on an alpha value of 0.05, V = 0.00, z = -2.37, p
= .018 (Figure 1). This indicates that the differences between Pre-Test Readiness to Change
Total Score and Post- Test Readiness to Change Total Score are not likely due to random
variation. There is a significant increase in the post-readiness to change average scores
(Appendix I).
Documentation and Billing

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The subjects consisted of Medicare Patients (n= 91) who had an average age of 73 (SD =
10.48), the ages range from 38 to 97 years of age (Appendix X). Majority of the sample were
female (n = 50, 56%) and Caucasian (n = 89, 99%). During the Annual Wellness Visits (AWV),
the favored advance care planning document was the short form (n = 57, 100%). For the follow
up (F/U) visits, the favored advance care planning document was the short form (n = 33, 100%).
During the AWV, advance care planning discussion or advance directive documents (n = 31,
54%) were documented or scanned into the electronic medical record (EMR). For the F/U
appointments, advance care planning discussion or advance directive documents (n = 13, 39%)
were documented or scanned into the EMR.
To answer the following evaluation question: in older adults in a primary care setting,
does the completion of ACP short and long form documentation and billing/coding increase after
Medicare annual wellness visits with trained staff? A Mann Whitney test was used to test
whether there is a statistically significant difference between the means in two advance care
planning type and electronic medical record documentation. The billing code use was not being
billed 91% of the time during annual wellness visits. However, the electronic medical record
documentation was performed 54% of the time during annual wellness visits. The average for
billing code was 0.00 and the average for the EMR was 1.00. Staff members did not always
code (Mdn = 0.00) but they documented in the electronic medical record (Mdn =1.00; 512.00, p
= 0.003) (Appendix J).
The practice did not bill for (n = 52, 91%) of their AWV and (n = 30, 91%) of their F/U
services. However, when the practice did choose to bill for their services, the code 99497 was
used (n=5, 9%) during AWV and (n=3, 9%) during the F/U (Appendix K).
Clinical Significance

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Readiness to Change
The subjects consisted of well-educated medical providers, office manager, medical
assistants, and medical scribes. The proponent stakeholders were the medical providers and the
office manager. They were invested in developing and implementing a systematic change that
benefited their patients’ future planning; making their wishes known before an illness or accident
occurs. Before the education session, the medical providers and the office manager were strong
advocates for advance care planning advocacy due to their own clinical and personal experiences
(De Caprariis et al., 2017; Edward & Landon, 2014). Though there were barriers such as
increase patient load, time constraints, negatives thoughts associated with death, time filling out
documentation, and heavy emotional burdens, the healthcare members persevered and completed
the advance directives because their patients’ wishes mattered most (De Caprariis et al., 2017;
Edward & Landon, 2014). There were healthcare members who had no previous experience in
advance care discussions and end of life care planning reported that more than half of them were
comfortable and found that the education sessions were helpful and meaningful in their practice.
The education training strengthened their understanding of the ACP knowledge and language use
(Yap, Chen, Detering, Fraser, 2017). The formal training allowed them to practice within their
primary care setting and gain confidence to guide these discussions with their Medicare Patients.
Documentation, and Visit Types
The implementation of the ACP process was based on previous studies which produced
similar outcomes for patients. Medicare patients who presented to the clinic for an Annual
Wellness Visit (AWV) were receptive to completing their advance directive forms; short forms
were favored. The advance directive forms were discussed and personally reviewed with their
medical provider. The medical scribes documented the advance care planning discussions into

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the electronic medical record (EMR). Then, the advance directives were witnessed, copied, and
scanned into the EMR. Most importantly, the patients were educated about having easy access
to the forms and sent two copies home; one for them and one for their assigned medical power of
attorney (MPOA) (Cottingham et al., 2018; McGlade et al., 2017; Payne et al., 2010; CMS,
2020; Bernard, 2018).
Advance Care Planning Type and Billing/Coding.
If the practice chose to bill for their services, they may have profited between $4,332 and
$4,902 for Annual Wellness Visits, and between $2,508 and $2,838 for follow-up visits within a
3 1/2-month time frame (CMS, 2018; American Academy of Family Physicians, 2020). The
Physician Fee Schedule is payment system is predicted to impact about 55 million Medicare
beneficiaries and their healthcare providers (CMS, 2018; American Academy of Family
Physicians, 2020). If advance care planning is discussed outside of AWV, this service will be an
out of pocket expense for the Medicare patients. The practice rarely used the billing codes for
the advance care planning discussions and documentation.
Discussion
Implications
The older population commonly endorse a range of goals for their health care: comfort,
living longer, improved quality of life, independence, completion of life goals, and support from
loved ones (CMS, 2018; American Academy of Family Physicians, 2020). The American
culture indicated that they would rather spend their last days at home with their families.
However, most Americans die in institutions such as the hospital or nursing homes. The reason
for this is that the older adults have not clearly conveyed their wishes to their providers and
family members (CMS, 2018; American Academy of Family Physicians, 2020). The lack of

BEING PROACTIVE IN GERIATRIC ADVANCE CARE PLANNING

21

advance directives makes the dying process prolonged, painful, and expensive. Older adults are
kept alive on life-sustaining support, artificial hydration, and feedings tubes though they can be
in a vegetative state or have advance cognitive impairment (Scholten et al., 2018; Bernard,
2018).
Advance care planning and EOL discussions reduce healthcare expenditures. The
Medicare beneficiaries and vulnerable populations make up two thirds of Medicare spending.
Only one third of Americans have advance directives that outline their wishes when they are not
able to speak for themselves (Scholten et al., 2018; Bernard, 2018). The majority of the severe
or terminally ill patients do not have advance directives. The Patient Self Determination Act of
1990 requires healthcare facilities to provide written ACP information to all Medicare patients.
The patients have the right to access advance directives, complete documents, and ACP
education (Kirk, 2010).
Providers play a key role in guiding the detailed ACP conversations. The purpose of
ACP is to inform patients about their health options, understanding the realities of illness, quality
of life, treatment options pros and cons, and prognosis. The providers are key stakeholders in
assuring that patients comprehend, reflect, and express their wishes before a health crisis occurs
(CMS, 2018; American Academy of Family Physicians, 2020).
Recommendations
Stakeholders can receive specialized training in end of life care and ACP discussions that
are guided by Centers for Medicare and Medicaid Services (CMS). The Medicare Incentive
Reimbursement program is a motivational factor to provide education for patients to make
informed decisions. Though Medicare does not make Advance Care Planning documentation
mandatory for healthcare teams, a systematic design implementation to ambulatory clinics can

BEING PROACTIVE IN GERIATRIC ADVANCE CARE PLANNING

22

increase ACP documentation rates (Cottingham et al., 2018; McGlade et al., 2017; Payne et al.,
2010; CMS, 2020; Bernard, 2018). There are resources, tools, and properly trained healthcare
teams that are available to help patients complete advance care documents. Advance care
planning creates better adherence to treatment plans, promotes proper allocation for resources,
and increases Medicare reimbursements (Cottingham et al., 2018; McGlade et al., 2017; Payne et
al., 2010; CMS, 2020; Bernard, 2018).
Sustainability Factors
The education session audio and PowerPoint education materials are tools available for
the practice to keep and to continue to implement with their new hires training program. During
the project an ACP website resource page was designed by office manager, that provides the
patients and their family members reliable and credible resources about advance care planning.
Limitations and Challenges
There were many limitations throughout the implementation process and statistic findings.
Limitations to the process were as follows: the staff members demographic data minimum age
was 22 years old and maximum age was 52 years old. The pre-test evaluation question assessed
if the subjects had previous advance care planning training. However, the conductor did not
inquire about previous advance care planning experience. Advance care planning experience
may have been a helpful additional evaluation question to assess readiness to change. Subjects
who shared that they had previous experience were more invested in the training, process, and
success of the increase ACP rates. Furthermore, those with ACP personal or clinical experience
were quick learners and adapted to the system change. Therefore, the medical providers and
office manager were the key stakeholders who educated the patients about the importance of

BEING PROACTIVE IN GERIATRIC ADVANCE CARE PLANNING

23

advance care planning. The other staff members were able to enforce the importance of having
available ACP copies that are easily accessible in case of an emergency.
There was lack in patient education materials because the quality improvement project
focused on staff members’ education. However, the staff members did educate their own
patients based on the information that was provided for them. The staff members used credible
and evidence-based practice resources to better guide their Medicare patients in finalizing
advance directive documents (Cottingham et al., 2018; McGlade et al., 2017; Payne et al., 2010;
CMS, 2020; Bernard, 2018). The ACP rates were significantly increased but the evidencebased-practice project did not measure the emotional burden that advance care planning and end
of life care discussions would have on the staff members.
Limitation in the area of statistical findings were as follows. The private practice chose to
not bill Medicare for their services. Therefore, not all billing codes were used during the 3 1/2month study; limited statistical analyses were run because the lack of variables. The profit
margins could not be calculated because there was lack in use of codes and reimbursements.
These limitations provided a better comprehensive understanding of the evidence-based-practice
project for improvements and data archiving.
Conclusion
The older population commonly endorse a range of goals for their health care: comfort,
living longer, improved quality of life, independence, completion of life goals, and support from
loved ones. However, most Americans die the hospital or nursing homes. The reason for this is
that the older adults have not clearly conveyed their wishes.
ACP discussions have shown to reduce healthcare expenditures. The Medicare
beneficiaries and vulnerable populations make up two thirds of Medicare spending. Only one

BEING PROACTIVE IN GERIATRIC ADVANCE CARE PLANNING

24

third of Americans have advance directives that outline their wishes when they are not able to
speak for themselves. The majority of the severe or terminally ill patients do not have advance
directives. A primary care setting is a very fitting environment with trained/confident primary
care providers who play a key role in guiding the sensitive conversations during annual wellness
visits. It is important to note that patients are receptive but they need professional guidance.
The purpose of ACP is to inform patients about their health options, understanding the
realities of illness, quality of life, treatment options pros and cons, and their prognosis. The
healthcare staff are key stakeholders in assuring that patients comprehend, reflect, and express
their wishes before a catastrophic event occurs.
Overall, disease burden is much higher in the United States. The Geriatric population is
living longer with many chronic conditions and comorbidities. The aging process, decreased
immunity, and acute on chronic conditions management increases the morbidity and mortality
scores of older adults. However, the consequences are far more detrimental to the patients,
family members, healthcare professionals, and the United States if action is not taken to increase
ACP rates.
Invested, trained, and confident staff can play a key role in guiding the detailed ACP
conversations once they have a clear understanding of the barriers, impact, and consequences if
patients lack advance directives. The use of short ACP form, which was favored by the patients
and staff members, and Medicare Guidelines support the older adults in making their wishes
known. The lack of direction, lack of advance directives will negatively affect the patient,
family members, healthcare professionals, and the United States’ economy (Dyess et al., 2014;
Edward & Landon, 2014; Hayek et al., 2014; Scholten et al., 2018).

Running head: BEING PROACTIVE IN GERIATRIC ADVANCE CARE PLANNING

25

References
American Academy of Family Physicians. (2020). Advance Care Planning. Retrieved from
https://www.aafp.org/practice-management/payment/coding/medicare-coordinationservices/acp.html
Bostwick, D., Wolf, S., Samsa, G., Bull, J., Taylor, D.H., Kimberly, S.J., & Kamal, A.H. (2017).
Comparing the palliative care needs of those with cancer to those with common noncancer serious illness. Journal of Pain and Symptom Management, 53(6), 1079-1084.
Doi:10.1016/j.jpainsymman.2017.2014
Centers for Medicare and Medicaid Services. (2020). Advanced Planning. Retrieved from
https://www.cms.gov/Outreach-and-Education/American-Indian-AlaskaNative/AIAN/LTSS-TA-Center/planning/advanced-planning
Choudhuri, A. H. (2012). Palliative care for patients with chronic obstructive pulmonary disease:
Current perspectives. Indian Journal of Palliative Care, 18(1), 6-11. doi:10.4103/09731075.97342
Conover, W. J., & Iman, R. L. (1981). Rank transformations as a bridge between parametric and
nonparametric statistics. The American Statistician, 35(3), 124-129.
De Caprariis, P. J., Rucker, B., & Lyon, C. (2017). Discussing advance care planning and
directives in the general population. Southern Medical Journal, 110(9), 563-568.
doi:10.14423/SMJ.0000000000000697
Edward, S., & Landon, B. (2014). Medicare’s chronic care management payment reform for
primary care. The New England Journal of Medicine, 371(22), 2049-2051. Doi:
10.1056/NEJMp1410790

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Goldstein, N. E., & Mather, H. (2018). The complexities of advance care planning in individuals
with advanced dementia. Nursing Ethics, 24(1), 87-99.
doi:10.1001/jamainternmed.2018.1490
Halpern, N.A., & Pastores, S.M. (2017). Critical care medicine beds, use ,occupancy, and cost
in the United States: A methodological review. Critical Care Medicine, 43(11), 24522459. doi:10.1097/CCM.0000000000001227
Hayek, S., Nieva, R., Corrigan, F., Zhou, A., Mudaliar, U., Mays, D., & Ilksoy, N. (2018). Endof-life care planning: Improving documentation of advance directives in the outpatient
clinic using electronic medical records. Journal of Palliative Medicine, 17, 1348-1352.
doi:10.1089/jpm.2013.0684
Howard, M., & Bernard, C. (2018). Barriers to and enablers of advance care planning with
patients in primary care. Canadian Family Physician, 64(4), 190-198.
Intellectus Statistics [Online computer software]. (2020). Intellectus Statistics.
https://analyze.intellectusstatistics.com/
McGlade, C., Daly, E., McCarthy, J., Cornally, N., Weathers, E., O’Caoimh, R., & Molloy,
D.W. (2017). Challenges in implementing an advance care planning programme in longterm care. Nursing Ethics, 24(1), 87-99.
Payne, K. L., Prentice-Dunn, S., & Allen, R. S. (2010). A comparison of two interventions to
increase completion of advance directives. Clinical Gerontologist, 33(1), 49-61.
doi:10.1080/07317110802678375
Sawyer, B., & McDermott, D. (2019). How does the quality of the U.S healthcare system
compare to other countries? Retrieved from https://www.healthsystemtracker.org/chart-

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collection/quality-u-s-healthcare-system-compare-countries/#item-percent-of-sickeradults-who-have-experienced-a-medical-error-in-last-two-years-2016
Scholten, G., Bourguignon, S., Delanote, A., Vermeulen, B., Van Boxem, G., & Schoenmakers,
B. (2018). Advance directive: Does the GP know and address what the patient wants?
advance directive in primary care. BMC Medical Ethics. Retrieved from
https://bmcmedethics-biomedcentral-com.ezproxy1.lib.asu.edu/articles/10.1186/s12910018-0305-2
Schwarzer, R. 2008. Modeling health behavior change: how to predict and modify the adoption
and maintenance of health behaviors. Applied Psychology: An International Review,
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Van Scoy, L.,J., Green, M. J., Reading, J. M., Scott, A. M., Chuang, C. H., & Levi, B. H. (2017).
Can playing an end-of-life conversation game motivate people to engage in advance care
planning. American Journal of Hospice and Palliative Medicine, 34(8), 754-761.
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Westfall, P. H., & Henning, K. S. S. (2013). Texts in statistical science: Understanding
advanced statistical methods. Taylor & Francis.

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28

Appendix A
Table 8
Evaluation Table of Qualitative Studies
Citation

Cain. (2016).
Implementing Aid
in Dying in
California:
Experiences from
Other States
Indicates the Need
for Strong
Implementation
Guidelines.
Health Policy
Brief.
Country: United
States of America

Conceptual
Framework

Improving
quality of life
Aid in Dying
Death with
Dignity Act

Design/
Method/
Sampling
(Grounded
Theory,
phenomenolo
gy,
Narrative…)

Sample/Setting
(describe)

Inclusion:
terminally ill
patients with
a clear mental
state who are
cleared by
psychiatrist
(inferred)

N was not given

Exclusion:
potential
vulnerable
patients who
are not
capable of
making EOL

Sample: Patients
who requested
AID in dying
Setting:
Washington,
Oregon, and
California
Demographics
Race: white
(97.1%), Nonwhite (3%)

Major
Variables
Studied and
Their
Definitions

Measurement/
Instrumentation
(focus group,
1:1, open-ended
survey)

Data
Analysis

Findings/
Themes

Level/Quality
of Evidence;
Decision for
practice/
application to
practice/
Generalization

Ethical
critiques of
AID: concerns
for vulnerable
persons/racial/
ethnic minority
groups/low
incomes/low
education/
publicly
funded health
insurance

Verbal concerns
shared by
physicians

Qualitative

Better Data
Collection

LOE: VII
(Health Policy
influenced by
policy makers)

Health
Policy

Required
surveillance
of AB 25
should be
adjusted to
collect
higher
quality data

Weakness: did
not state sample
size

Documenta
tion at each
step

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

BEING PROACTIVE IN GERIATRIC ADVANCE CARE PLANNING
Bias: UCLA
Fielding School of
Public Health is
part of UCLA
Center for Health
Policy Research,
analyses,
interpretations,
conclusions, and
views expressed
are those of the
authors and do not
necessarily
represent UCLA
Center for Health
Policy Research
Funding: UCLA
Fielding School of
Citation
Public Health
from Thomas
Weinberger

Conceptual
Framework

decisions
because of
Design/
Method/
Sampling
(Grounded
Theory,
phenomenolo
gy,
Narrative…)
mental state
(inferred)
Purpose of the
policy:
The
implementatio
n of AB 15
Act could aid
in legalization
of AID to
improve
knowledge
and practices
for EOL care
generally, and
creating
ongoing
educational
opportunities
for clinic

Education: less
than high school
Sample/Setting
(describe)
(6%), high
school graduate
(21.9%), some
college (26.2%),
Baccalaureate or
higher (45.9%)
Insurance:
private (60.2%),
Medicare/Medic
aid (38.3%), and
no insurance
(1.5%)

29
Major
Variables
Studied and
Their
Definitions
Concerns
identified by
physicians:
lack of
knowledge,
privacy, legal
consequences,
other
consequences,
and problems
in the process

Measurement/
Instrumentation
(focus group,
1:1, open-ended
survey)

Data
Analysis

Findings/
Themes
Expanded
data
collection
Improve
EOL care
generally
Better
measureme
nt
Broader
discussions
Continuous
support
Educational
research
Public
education
campaigns
Education
for state
regulators

Level/Quality
of Evidence;
Decision for
practice/
application to
practice/
Generalization
Strength:
Policies are in
place in
Washington,
Oregon, and
California for
AID in dying,
encourages
additional
research
investments,
using
legalization of
AID to improve
knowledge and
practices for
EOL care
generally,
creating
ongoing
educational
programs for

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

BEING PROACTIVE IN GERIATRIC ADVANCE CARE PLANNING

Conceptual
Framework

staffs and the
general
public.
Design/
Method/
Sampling
(Grounded
Theory,
phenomenolo
gy,
Narrative…)

Sample/Setting
(describe)

30
Major
Variables
Studied and
Their
Definitions

Measurement/
Instrumentation
(focus group,
1:1, open-ended
survey)

Data
Analysis

and
officials

clinic staffs and
general public

Findings/T
hemes

Level/Quality
of Evidence;
Decision for
practice/
application to
practice/
Generalization

Training
clinic staffs

PICOT question
utility:
educational
opportunities
can help quality
EOL care

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

BEING PROACTIVE IN GERIATRIC ADVANCE CARE PLANNING

Karnik &
Kanekar. (2016).
Ethical Issues
Surrounding Endof-Life Care: A
Narrative Review.
Healthcare.
Country: United
States of America
Bias: no conflict
of interest
Funding: no
source of funding

Conceptual
Framework
Quality of life
based on the
Federal Patient
SelfDetermination
Act (Inferred)
Egoistic theory
– do good for
the patient
Virtue Theory
of Ethics –
family and
clinic staff
working for the
greater good of
the patient

Design/
Method/
Sampling
(Grounded
Theory,
phenomenolo
gy,
Narrative…)

Sample/Setting
(describe)

Inclusion:
none noted

Setting: United
States Centered
Study

Exclusion:
none noted
Purpose of
Narrative: to
discuss issues
such as
autonomous
decision
making,
importance of

Sample: not
mentioned in
detail, other than
focus is EOL
care patients

31

Major
Variables
Studied and
Their
Definitions

Measurement/
Instrumentation
(focus group,
1:1, open-ended
survey)

V1:
autonomous
decision
making –
patients right
to control their
treatment
according to
their
preference

NO mention of
tools used

V2:Physicians’
role and
responsibilities
to resolve issue
– providing
detailed
information

Data
Analysis

Findings/
Themes

Qualitative

Having
advance
directive
documentat
ion as an
admission
process per
policy
makers

Highlights
the ethical
dilemmas
(SEE
variables
studied)

Setting
guidelines
and policies
per facility
Resources
for
palliative
treatment
care
choices

Level/Quality
of Evidence;
Decision for
practice/
application to
practice/
Generalization
LOE: VI
Weakness:
Narrative
review, expert’s
opinion
Strength: clinic
staffs play a key
role in
communication,
education, and
EOL
discussions,
public
dialogues can

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

BEING PROACTIVE IN GERIATRIC ADVANCE CARE PLANNING

Conceptual
Framework

Citation

advance
directives,
rationing of
care in futile
treatments
and costs
involved in
providing
EOL care.
Design/
Method/
Sampling
(Grounded
Theory,
phenomenolo
gy,
Narrative…)

Sample/Setting
(describe)

32
about advance
medical
treatment,
reviewing
benefits,
limitations, and
drawbacks to
treatment
Major
Variables
Studied and
Their
Definitions
V3: Advance
directives –
enables
competent
individuals to
design and
document their
health care
decision plan
in advance in
case of future
disability or
terminal illness
V4:Rationing
care and futile
treatment –

Cure versus
comfort
conversatio
ns

Measurement/
Instrumentation
(focus group,
1:1, open-ended
survey)

Data
Analysis

Findings/
Themes

facilitate
development
and
implementation
of policies and
guidelines
safeguarding
the interest of
patients and
Level/Quality
of Evidence;
Decision for
practice/
application to
practice/
Generalization
healthcare
organizations;
improve and
ease EOL
journey
PICOT utility
to study: need
for guidelines
and policies in
ambulatory
clinics

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

BEING PROACTIVE IN GERIATRIC ADVANCE CARE PLANNING

33
technological
advancements
have the
capability to
prolong life
rather than
allowing
natural dying
process
V5: Cost
involvement –
expenditure on
healthcare
V6:Ethical
theories – work
against the
egoistic theory
by working for
the good of the
patient

Citation

Conceptual
Framework

Design/
Method/

Sample/Setting
(describe)

Major
Variables

Measurement/
Instrumentation

Data
Analysis

Findings/
Themes

Level/Quality
of Evidence;

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

BEING PROACTIVE IN GERIATRIC ADVANCE CARE PLANNING

Lum et al. (2016).
Advance
care
planning
meets
group
medical
visits: the
feasibilit
y of
promotin
g
conversat
ions.
Annals of
Family
Medicine
.
Country: USA
Bias: Sponsors
had no role in
design, method,
and manuscript
Citation

Inferred –
Geriatric wellbeing

Conceptual
Framework

Sampling
(Grounded
Theory,
phenomenolo
gy,
Narrative…)
Qualitative
GMV
Conversation
Project
(Primary carebased group
visit model)met in 2
sessions of 2
hours each
facilitated by
geriatrician
and social
Design/
Method/
Sampling
(Grounded
Theory,
phenomenolo
gy,
Narrative…)
worker
RE-AIM
Framework

11 physicians
who selected
participants
80 patients
approached, 32
participated in 5
group visits and
27 participated
in both sessions
Group sizes-4-9
Sample/Setting
(describe)
Average age 83,
63% females,
69% white, 13%
black
Other
demographics
consideredrelationship
status, self-

34
Studied and
Their
Definitions

(focus group,
1:1, open-ended
survey)

Conversation
Group Visit
Structuresessions,
patients,
practice
setting,
location,
optional
resource,
facilitator
considerations,
group visit
Major
Variables
Studied and
Their
Definitions

Conversation
Starter Kit –
main tool, audio
recorded and
transcribed

session format,
documentation,
billing (table 1)

Communication
Guide

Facilitators’
communication
guide-

Clinic based
flyers
Initial telephone
conversation
Facilitator
Measurement/
Instrumentation
(focus group,
1:1, open-ended
survey)

Group versus
clinic visits

Decision for
practice/
application to
practice/
Generalization
R-40%
participation
rate, mean
age 79
years, 59%
women,
72% white
E-Clinic
versus
group visit
result 1941%,
p=0.02
Data
Analysis

Qualitative
Analysisp=0.02

A-median
number of
referrals 5
per
physician
I-84%
retention
rate, n=29
measured
patient

Theme 2:
Patients
initiated
group
discussions
of a broad
range of
ACP topics
(table 4)

Theme 1:
Patients
shared
personal
values and
challenges
related to
ACP (table
4)
Findings/T
hemes

LOE: IV
(cohort group)
Weakness:
financial
support for
facilitator and
staff training
Strength:
conversation
project tool
used, CMS
incentive
Level/Quality
of Evidence;
Decision for
practice/
application to
practice/
Generalization
Utility to
PICOT: May be
an effective

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

BEING PROACTIVE IN GERIATRIC ADVANCE CARE PLANNING
R- reach
Eeffectiveness
A-adoption
Iimplementatio
n
Mmaintenance
was not
evaluated

Funding:
Colorado
Health
Foundati
on,
Universit
y of
Colorado
Hospital,
Universit
y
Physician
s,
NPCRC,
CCTSI,
DISC,
NIH/NC
RR (pg
131)

Conceptual
Framework

Inclusion -65
years or older,
spoke
English,
received
primary at
Senior Clinic
Design/
Method/
Sampling
(Grounded
Theory,
phenomenolo
gy,
Narrative…)
Exclusioncognitive,
hearing,

reported health
status, caregiver
for another
person, attended
with partner,
type of
insurance,
education, living
situation,
referral source,
reason for not
participating
Senior Clinic at
University of
Colorado
Hospital
(Aurora,
Colorado)
Sample/Setting
(describe)

35
introduction,
share ACP
experiences,
consider
personal
values, choose
a surrogate
decision maker
(session 1),
review
individual
ACP goals,
consider
flexibility,
consider future
healthcare
choices, plan
for
conversations
with healthcare
Major
Variables
Studied and
Their
Definitions

GMV 5-point
Likert scale
Researchersgeriatric
palliative
medicine
specialist, nurse
qualitative
researcher, group
visit specialist,
implementation
scientist, and
academic leaders

Measurement/
Instrumentation
(focus group,
1:1, open-ended
survey)

experience
of
conversation
group visit
M- not
evaluated

model for
integrating
high-quality,
patient centered
ACP into
primary care

40%
participation
rate, 84%
retention
rate, 16%
attrition rate
Data
Analysis

Findings/T
hemes

Level/Quality
of Evidence;
Decision for
practice/
application to
practice/
Generalization

professionals,
and goal
setting (session
2)

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

BEING PROACTIVE IN GERIATRIC ADVANCE CARE PLANNING

36

mental health
impairments
Reasons for
not
participatingexisting ACP,
lack of
interest,
illness, lack of
transportation,
and unknown

Citation

PurposeDetermining
new models
to facilitate
ACP
conversations

Citation

Myers et al.
(2018). Clinic
staff tools for

Conceptual
Framework

Adult Learning
Theory

Design/
Method/
Sampling
(Grounded
Theory,
phenomenolo
gy,
Narrative…)
Systematic
Review

Sample/Setting
(describe)

Setting: varies
per study and
not mentioned

Major
Variables
Studied and
Their
Definitions

Respecting
individual

Measurement/
Instrumentation
(focus group,
1:1, open-ended
survey)
Tools used to
select searches

Data
Analysis

Adultfacilitating

Findings/
Themes

No
consensus
on tools or

Level/Quality
of Evidence;
Decision for
practice/
application to
practice/
Generalization
LOE: I
(systematic
review)

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

BEING PROACTIVE IN GERIATRIC ADVANCE CARE PLANNING
advance care
planning and goals
of care
discussions: a
systematic review.
American Journal
of Hospice &
Palliative
Medicine.

Educational
design
Search for
existing
guidelines and
systematic
review, and
search for
primary
literature

Country: Ontario,
Canada
Bias: potential
conflict
of
interest
of
OMHLT
C funded
$50,000
research,
education
, and
ACP
resources
Funding: CCO &
OMHLT
C

Conceptual
Framework

Guidelines,
randomized
trials,
comparative
studies, and
noncomparati
ve studies that
included
MEDLINE,
EMBASE,
Design/
Method/
Sampling
(Grounded
Theory,
phenomenolo
gy,
Narrative…)

Guideline
search=1701
documents (82
papers full
review)
Adult-73
Pediatric-9
Systematic
review=824
documents (55
papers full
review)
Adult-47
Pediatric-8
Primary
Literature31,105
Sample/Setting
(describe)
documents (353
papers full
review)
Adult-313
Pediatric-40

37
EOL care
choices
Type of
intervention
used- POLST,
ACA tool,
MYWK, and
pediatric ACP
tool (FACE)

11-item
Assessment of
Multiple
Systematic
Reviews
(AMSTAR)
Cochrane Risk of
Bias tool for
RCT
Risk of bias for
nonRCT

Major
Variables
Studied and
Their
Definitions

Measurement/
Instrumentation
(focus group,
1:1, open-ended
survey)

Respecting
individual
EOL care
choices – no
P value
POLSThigh
consistency
between
code status
and
treatment
received

processes
for
ACP/GOC
discussions
Only
consensus
is the
definition,
critical
elements,
and desired
outcomes

ACA toolno
significant
difference
between
control and
experimenta
l group

Tool
developme
nt should
focus on
enabling
clinic staffs
to facilitate
value-based
discussions

Data
Analysis

Findings/T
hemes

Weakness: no
standardized on
ACP/GOC tool
Strength: shift
focus on
desired/valuebased care
Utility to
PICOT: focus
to establish
pilot study
about ACP
discussion
system-wide
approach
Level/Quality
of Evidence;
Decision for
practice/
application to
practice/
Generalization

MYWKresulted in
positive
patient and

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

BEING PROACTIVE IN GERIATRIC ADVANCE CARE PLANNING
Citation

International
Advance Care
Planning
Conference
and the
American
Society of
Clinical
Oncology
Palliative
Care
Symposium

Conceptual
Framework

Design/
Method/
Sampling
(Grounded
Theory,
phenomenolo
gy,
Narrative…)
InclusionEnglish
language,
patients living
w/chronic
illnesses,
health-care

38

RCT-11 used

clinic staff
outcomes

NonRCT-33
used

Pediatricfacilitating

Guidelines- no
suitable
guidelines
identified
No specific
demographic
data provided
*Figure 1
illustrates all
info
Sample/Setting
(describe)

Major
Variables
Studied and
Their
Definitions

Measurement/
Instrumentation
(focus group,
1:1, open-ended
survey)

FACEadolescent
better
informed
about EOL
than control
group
(p=.007),
experimenta
l
adolescents
less
depression
(p=.0268)
Documenta
tion

Findings/T
hemes

Level/Quality
of Evidence;
Decision for
practice/
application to
practice/
Generalization

Data
Analysis
Adult94.4%
stored at
agency,
48.8%

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

BEING PROACTIVE IN GERIATRIC ADVANCE CARE PLANNING
Citation

clinic staff
tools, includes
at least one
outcome of
interest,
comparative
data,
noncomparati
ve data,
minimum
study size of
30 patients

39
stored at
residence,3.
3% special
AD file
Pediatric-no
studies

Exclusioncase studies,
commentaries
, editorials
Purposeprovide
evidence for
tools/practices
available for
use by clinic
staffs to
effectively
facilitate ACP
conversations
and GOC
Focused
questionswhat tools

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

BEING PROACTIVE IN GERIATRIC ADVANCE CARE PLANNING

40

enable clinic
staffs to
introduce
ACP/GOC
discussions
(1), what tools
enable clinic
staffs to
facilitate
ACP/GOC
discussions
(2), what tools
are best suited
for
documentati
on of
ACP/GOC
discussions
(3)

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

BEING PROACTIVE IN GERIATRIC ADVANCE CARE PLANNING

41

Appendix B

Table 9
Evaluation Table of Quantitative Studies
Citation
Conceptual
Design/ Method/
Framework
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Booth, A.T., &
Lehna, C.
(2016).
Advanced
directives and
advance care
planning for
healthcare
professionals.
Accent on
Research.
Country: USA
Bias: unstated

Conceptual
dimension
related to AD
and ACP (i.e.
perceived
knowledge,
capability to
communicate,
and awareness
of the
patient’s level
of illness).

Quantitative
Design: Needs
Assessment (3 site visits
at 3 different times)
Inclusion: ICU staff
(inferred)
Exclusion: unstated
Purpose: assess HPS
need for information on
ACP/implement/evaluat
e educational plan for
change in
knowledge/behaviors

Sample/Settin
g (describe)

Trauma/Stroke
ICU in
Kentucky

Major
Variables
Studied and
Their
Definitions

AD & ACP
conceptual
dimension
definitions:

Total n =23
N=11, 73%,
nurses n=10,
67%
nurse
technicians
n=2, 13%

1)perceived
personal
knowledge
2)capability to
communicate
3)awareness of
the patient’s
level of illness

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)
Need
Assessment
Survey (11item) used to
assess ICU
healthcare
professionals
perceived
knowledge,
capability to
communicate
with patients
and their
families, and
barriers to EOL
discussion
concerning

Data Analysis
(stats used)

Pre/post-test
self-report
Mean score and
standard
deviation
calculated for
knowledge and
comfort scales
Frequencies
and percentages
for yes/no
questions

Findings/
Themes

Education
Interventioninformation
about how to
complete AD,
link to Agency
for Healthcare
Research and
Quality
PowerPoint on
patient codes,
code status,
clinic staffs
effect on
treatment plans

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization
LOE: IV
Weakness: one
facility, lack of
time by ICU staff
to perform
completion of AD
and provide
education
Strength:
revealing the need
for supplemental
educational
intervention

1) 83% no AD,
average

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

BEING PROACTIVE IN GERIATRIC ADVANCE CARE PLANNING

42

Table 9
Evaluation Table of Quantitative Studies
Citation
Conceptual
Design/ Method/
Framework
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Funding:
Agency for
Healthcare
Citation
Research and
Quality
Improvement

Conceptual
Framework

Design/ Method/
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Sample/Settin
g (describe)

respiratory
therapist n=2,
13%
secretary n=1,
7%
Sample/Settin
g (describe)
average age
36.9 years of
age (SD=
13.0)
range= 24-61

worked
average of 8.7
years in
healthcare
(SD=9.1;

Major
Variables
Studied and
Their
Definitions

Major
Variables
Studied and
Their
Definitions

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)
topics of ACP
and AD.
Quiz for
healthcare AD
– pre/post test
scores
Measurement/
Instrumentatio
n
(focus group,
1:1,
researcher(s)
1)perceived
persona
knowledge:
number of own
AD
2)capability to
communicate:
inquired about

Data Analysis
(stats used)

Findings/
Themes

percentage
increase by
13%

Results:
Majority of
participants did

Data Analysis

Findings/Theme
s

2) 73% pre and
80% post
3) increased 6%
*no statistically
significance

not have AD,
moderately
comfortable
communicating,
and time/access
barriers concerns
shared.

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization
Utility to PICOT:
ruled out ICU
setting and
enforces the need
for staff education
Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization

All SD on table
1 range = 3.4 –
6.0

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

BEING PROACTIVE IN GERIATRIC ADVANCE CARE PLANNING

43

Table 9
Evaluation Table of Quantitative Studies
Citation
Conceptual
Design/ Method/
Framework
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Sample/Settin
g (describe)

range =1.9-35
years)
worked 8.4
years in ICUS
(SD=
9.3;range = 4
m to 35 yrs

Major
Variables
Studied and
Their
Definitions

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)

Data Analysis
(stats used)

Findings/
Themes

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization

ACP (yes/no
format)
3)awareness of
patient’s level
of illness:
chronicity vs
comorbidities
(yes/no format)
Knowledge
scalemeasured level
of comfort in
communicating
Level of
comfort in
discussion
**all measured
on a 1-5 Likert
scale

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

BEING PROACTIVE IN GERIATRIC ADVANCE CARE PLANNING

44

Table 9
Evaluation Table of Quantitative Studies
Citation
Conceptual
Design/ Method/
Framework
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Citation

Arnett et al.
(2017).
Advance care
planning:
understanding
clinical routines
and experiences
of
interprofessional
team members
in diverse health
care settings.
American

Conceptual
Framework

Improving
quality and
honoring
individual
preferences
near end of
life –inferred

Design/ Method/
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Quantitative
Design: cross sectional
online survey
Sampling:118 healthcare
team members from
community basedclinics, long-term care,
academic clinics,
federally qualified
agencies, and hospitals

Sample/Settin
g (describe)

Major
Variables
Studied and
Their
Definitions

Sample/Settin
g (describe)

Major
Variables
Studied and
Their
Definitions

Setting:
primary care
in urban, rural,
and highly
rural

Survey
variables (3
questions):
role of
healthcare
member (1),
description of
clinical
routines (2),
workflow,
ACP policies,
and
perspective

Sample:
physicians,
social workers,
nurses,
advance nurse
practitioners,
physician

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)
(minimum to
maximum)
Measurement/
Instrumentatio
n
(focus group,
1:1,
researcher(s)
Chi-squared
test
N=118

Data Analysis
(stats used)

Findings/
Themes

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization

Data Analysis

Findings/
Themes

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization
LOE: IV

Quantitative
Roles:
physicians,
social workers,
nurses, advance
nurse
practitioners,
physician
assistants,
chaplains,
medical
assistants, and

Though
healthcare team
members
strongly believe
ACP and EOL
discussions are
important, there
is a gap in
policies;
documenting,
reviewing, and
transferring
documents

Weakness:
conducted in
primary care
setting in
Colorado only
Strength:
illustrating that
ACP/EOL
discussions should
not solely be the

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

BEING PROACTIVE IN GERIATRIC ADVANCE CARE PLANNING

45

Table 9
Evaluation Table of Quantitative Studies
Citation
Conceptual
Design/ Method/
Framework
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Journal of
Hospice &
Palliative
Medicine.
Country: USA
Bias: to surgical,
private practices,
Citation
veterans’
administration,
elderly acute
care settings
Funding:
Colorado Health
Foundation,
National
Palliative Care
Research Center

Inclusion: not mentioned
Exclusion: not
mentioned
Conceptual
Framework

***interprofessional
team primary care
settings utilized for the
cross sectional survey
(inferred)
Design/ Method/
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Sample/Settin
g (describe)

Major
Variables
Studied and
Their
Definitions

assistants,
chaplains,
medical
assistants, and
health coaches
Sample/Settin
g (describe)

and
experiences
with ACP (3)

Major
Variables
Studied and
Their
Definitions

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)

Data Analysis
(stats used)

health coaches
(1)

Measurement/
Instrumentatio
n
(focus group,
1:1,
researcher(s)

71% believe
ACP
discussions
should be
performed by
physicians, and
85% believe it
Data Analysis
can be a
nonphysician
responsibility
(1)
Clinical
routines,
systems
processes, ACP
policies:

Findings/
Themes

Lack of
education about
ACP and EOL
billing and
coding
Findings/
Themes

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization
responsibility of
clinic staffs but
should be a team
approach
Utility to PICOT:
primary setting
ACP and
appropriately
coding and billing
Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization
Medicare for
reimbursement

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

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Table 9
Evaluation Table of Quantitative Studies
Citation
Conceptual
Design/ Method/
Framework
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Junior Faculty
Career
Development
Grant

Sample/Settin
g (describe)

Major
Variables
Studied and
Their
Definitions

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)

Data Analysis
(stats used)

Findings/
Themes

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization

electronically
stored (64%),
systematically
available
(45%),
guidelines and
policies (37%),
outreach and
communication
programs
(14%) (2)
ACP
discussions,
time spent,
patient/family
member
initiating
discussion,
billing practice,
rating of ACP

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

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Table 9
Evaluation Table of Quantitative Studies
Citation
Conceptual
Design/ Method/
Framework
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Sample/Settin
g (describe)

Major
Variables
Studied and
Their
Definitions

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)

Data Analysis
(stats used)

Findings/
Themes

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization

and EOL
discussions (3)
Family
medicine vs
geriatric
medicine length
of ACP
conversation
(longer in
geriatric);
p=.056
Advanced care
practitioners
had longer
conversation
than
physicians;
p=.068

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

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Table 9
Evaluation Table of Quantitative Studies
Citation
Conceptual
Design/ Method/
Framework
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Sample/Settin
g (describe)

Major
Variables
Studied and
Their
Definitions

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)

Data Analysis
(stats used)

Findings/
Themes

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

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Table 9
Evaluation Table of Quantitative Studies
Citation
Conceptual
Design/ Method/
Framework
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Citation

Bestvina.
(2017).
Implementation
of advance care
planning in
oncology; a
review of
literature.
American
society of

Conceptual
Framework

Design/ Method/
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Improving
quality and
honoring
individual
preferences
near end of
life -inferred
(Institute of
Medicine
drivers)

A literature review of
PubMed

Inclusion: ACP,
oncology, palliative,
terminal care, quality of
life, and electronic
health records articles

Sample/Settin
g (describe)

Major
Variables
Studied and
Their
Definitions

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)

Data Analysis
(stats used)

Findings/
Themes

Sample/Settin
g (describe)

Major
Variables
Studied and
Their
Definitions

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)

Data Analysis

Findings/
Themes

Variable 1:
Who needs
ACP and at
what point in
the cancer care
continuum?

Downs and
Black Criteria
(used to assess
quality of
articles)

Sample
Start; N = 476
articles
Final; N =26
Setting:
University of
Chicago

Variable 2:
Who should

Measurement/

Quantitative
Chi-squared
test
Downs and
Black Criteria
(used to assess
quality of
articles) = 11
very good

ACP and EOL
discussions are
now expected in
oncology
settings within
the first 3 initial
visits based on
the Oncology
Care
Model/National

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization
Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization

LOE:I
Strength: patient
rapport between
client and clinic
staff, more ease
with delivery of
prognostic
information, video
aids helped in

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

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Table 9
Evaluation Table of Quantitative Studies
Citation
Conceptual
Design/ Method/
Framework
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

clinical
oncology.
Country: United
States of
America
Bias: not
mentioned
Funding: Merck
Citation

Conceptual
Framework

Exclusion: no exclusion
criteria mentioned in
detail

Design/ Method/
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Sample/Settin
g (describe)

Major
Variables
Studied and
Their
Definitions

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)

Data Analysis
(stats used)

Sample/Settin
g (describe)

conduct ACP
sessions?

Instrumentatio
n
(focus group,
1:1, openended survey)

articles, 7 good
articles, 3 fair
articles, and 2
poor articles,
and 3 unrated
articles

Variable
3:What is the
best tool to
educate
patients?
Variable 4:
What is the
best way to
engage health
care clinic
staffs?
Major
Variables
Studied and
Their
Definitions

V1: stage IIIIV (metastatic
disease,
advanced
malignancy,
less than 12
months to live,
if grouped with
palliative team
patient had a
better idea of
prognosis and
less likely to

Findings/
Themes

comprehensive
cancer network
guidelines.
Institute of
Medicine
recommends that
ACP should be
revisited based
on the Dying in
America
movement.
Findings/
Themes

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization
making a better
decision
Weakness:
discouraging hope
to fight cancer
Utility to PICOT:
potentially using
video aids and the
question prompt
list to allow
patients to ask
focused questions
to help guide them
in their decision
making
Level/Quality of
Evidence;
Decision for
practice/

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

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Table 9
Evaluation Table of Quantitative Studies
Citation
Conceptual
Design/ Method/
Framework
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Sample/Settin
g (describe)

Major
Variables
Studied and
Their
Definitions

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)

Data Analysis
(stats used)

get chemo;
p=.02

Findings/
Themes

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization
application to
practice/
Generalization

Data Analysis
V2: Nurses to
start note,
physicians to
complete note
(69%
documented
ACP, and 46%
code status
orders)
V3: Question
prompt list:
used to improve
patient/clinic
staff EOL care
communication

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

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Table 9
Evaluation Table of Quantitative Studies
Citation
Conceptual
Design/ Method/
Framework
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Sample/Settin
g (describe)

Major
Variables
Studied and
Their
Definitions

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)

Data Analysis
(stats used)

Findings/
Themes

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization

; p<.001 (more
prognostics
Data Analysis
questions asked
by patient
p=.004, and
discussed EOL
more frequently
p=.001,
consultation
were longer
p=.002) when
QPL was used
Code status
change (no
CPR) p=.023,
chi squared =
5.1
Knowledge
scores increase

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

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Table 9
Evaluation Table of Quantitative Studies
Citation
Conceptual
Design/ Method/
Framework
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Sample/Settin
g (describe)

Major
Variables
Studied and
Their
Definitions

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)

Data Analysis
(stats used)

Findings/
Themes

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization

after video
presentation
about ACP
95%
confidence
interval, p=.746
V4: Serious
Illness Care
program
training helped
guide
physicians with
suggested
prompts for
conversation
which
increased
documentation
to 33.7%

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

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Table 9
Evaluation Table of Quantitative Studies
Citation
Conceptual
Design/ Method/
Framework
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Auriemman et
al. (2016).
Public opinion
regarding
financial
incentives to
engage in
advance care
planning and
complete
advance care.
American
Journal of
Hospice and
Palliative
Medicine

Conceptual
Framework
Concept/US
Congressmen
bipartisan bill:
Personalize
Your Care
Act of 2013,
Medicare
Choices
Empowermen
t and
Protection
Act, and Care
Planning Act

Design/ Method/
Sampling
(Grounded Theory,
phenomenology,
Narrative…)
Design: Cross-sectional
online and in-person
surveys
Inclusion: none noted
(See demo)
Exclusion: none noted
(See demo)
Demographics:

Country: United
States of
America

Age: 18-34 (42.9), 35-54
(53.4), 55-older (21.6)

Sample/Settin
g (describe)

Sample/Settin
g (describe)
Participants:
English
Speaking
adults
N= 883 total
Online=503
In-person=380
Setting: public
park in
Philadelphia
Pennsylvania

Major
Variables
Studied and
Their
Definitions

Major
Variables
Studied and
Their
Definitions
All
demographics
analyzed but
the 4 variables
were the main
focus
V1: political
ideology
V2:religion
V3:education
V4: income

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)

Data Analysis
(stats used)

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)

Data Analysis

In-person
versus online
surveys

Logistic
Regression

Measurement:
5-point Likert
scale
Amount of
dollars used for
incentivizing
ACP
completion = $

Findings/
Themes

Findings/
Themes

Quantitative
Wilcoxon signrank test

Wilcoxon ranksum test
In-person
versus online
surveys: 380
(68.7%
complete) vs
503(64.4%
complete)

Financial
incentives can
increase ACP
rates

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization
Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization

Accept or
decline ACP
with health
insurance
agencies could
be a new policy

LOE:VII

Financial
incentives for
ACP are less
likely favorable
than smoking
and cancer
screenings;

Weakness:
understanding the
underlying reason
why is not stated
in the study

Strength:Financial
incentives do not
necessarily
increase ACP rates

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

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Table 9
Evaluation Table of Quantitative Studies
Citation
Conceptual
Design/ Method/
Framework
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Bias: none
mentioned

Gender: Male 50.7,
Female 49.3

Funding: Doris
Duke Charitable
Citation

Race: White (61.7),
Black (24.9), Asian
(6.7), Other (7)

Foundation,
University of
Pennsylvania
Center for
Health
Incentives and
Behavioral
Economics
Patient
Engagement and
Community
Outreach pilot
grant, and Otto
Haas Charitable
Trust

Design/ Method/
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Sample/Settin
g (describe)

Sample/Settin
g (describe)

Major
Variables
Studied and
Their
Definitions

Major
Variables
Studied and
Their
Definitions

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)

Data Analysis
(stats used)

Findings/
Themes

Method: 13
questions, 10
minute survey

In person:
younger, higher
incomes, highly
educated, nonwhite, full-time
employed (p
<.05)

perhaps this is a
limitation of the
study.

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)

Data Analysis

Employment: full time
(50.5)

Online:
Christian,
active smokers,
chronic
conditions,
family o/friend
colon cancer, (p
<.05)

Household income:
$60,000 or less (47.6),

Online patients
would prefer

Education: high school
or less (24.9), college
(53.2), graduate (21.9)

Findings/
Themes
Need more
research to
determine
underlying
reason.

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization
Utility to PICOT:
Formulates the
question will CMS
incentive be
enough to help
primary care
settings increase
ACP rates

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

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Table 9
Evaluation Table of Quantitative Studies
Citation
Conceptual
Design/ Method/
Framework
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

more than $60,000
(52.4)
Political ideology:
liberal (34.5), moderate
(44.1), conservative
(21.5)
Religion: catholic
(23.5), protestant (14.6),
other Christian (28.5),
Jewish (4.6)
Design/ Method/
Sampling
(Grounded Theory,
phenomenology,
Narrative…)
Importance of religion in
daily life: unimportant

Sample/Settin
g (describe)

Major
Variables
Studied and
Their
Definitions

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)

Data Analysis
(stats used)

Findings/
Themes

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization

patient payment
for ACP
completion
(p<.002)
Data Analysis
Measurement:
5-point Likert
scale: measures
status
quo(p<.001),
pay patient to
complete ACP
(p<.001),
Insurance
active choice,
insurance
requirement,
pay clinic staffs
if patients
complete ACP

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

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Table 9
Evaluation Table of Quantitative Studies
Citation
Conceptual
Design/ Method/
Framework
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

(28.5), neutral (19.4),
important (52.1)
Experience with ACP:
yes (59.6), no (40.4)
Chronic condition: yes
(21.8), no (78.2)
Smoker: yes (23.9), no
(76.1)

Sample/Settin
g (describe)

Major
Variables
Studied and
Their
Definitions

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)

Data Analysis
(stats used)

Findings/
Themes

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization

(p<.001), Pay
clinic staffs to
discuss
(p<.001),
Median
proposed
payment: $100,
minimal
amount was $5

Friends/family with lung
cancer: yes(34.1), no
(65.9)
Friends/family with
colon cancer: yes (25.4),
no 74.6)
Purpose of study: paying
clinic staffs versus

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

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Table 9
Evaluation Table of Quantitative Studies
Citation
Conceptual
Design/ Method/
Framework
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Sample/Settin
g (describe)

Major
Variables
Studied and
Their
Definitions

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)

Data Analysis
(stats used)

Findings/
Themes

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization

paying patients to help
incentivize completion
of ACP

Courtright et al.
(2016). A
randomized trial
of expanding
choices sets to
motivate
advance
directive
completion.
Medical

Conceptual
Framework
Primary focus
Patient SelfDetermination
Act

Design/ Method/
Sampling
(Grounded Theory,
phenomenology,
Narrative…)
Design: different types
of ACP to choose from
Method:

Sample/Settin
g (describe)
Sample: n=
1,266
outpatient
hemodialysis
patients

Major
Variables
Studied and
Their
Definitions
V1: brief
V2: expanded
V3:
comprehensive

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)
Department of
Veterans
Affairs and

Data Analysis

Findings/
Themes

Quantitative
RCT -321
Chi-square –
intention to
treat analysis

ESRD patients
thought that
filling out an
expanded ACP
version would
motivate them to
complete ACP,

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization
LOE:I

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

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Table 9
Evaluation Table of Quantitative Studies
Citation
Conceptual
Design/ Method/
Framework
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Decision
Making.
Country: United
States of
America
Bias: funding
agreement
ensured the
authors’
independence in
designing the
study,
interpreting the
data, and writing
and publishing
the report
Funding:
National Heart,
Lung, and Blood

Improving
Quality and
Honoring
Individual
Preferences
near end of
life: Institute
of Medicine
motive
Inferred
Conceptual
Framework

Sampling
Inclusion: outpatient
hemodialysis patients
Design/ Method/
Sampling
(Grounded Theory,
phenomenology,
Narrative…)
Exclusion: receiving
dialysis <90 days, nonEnglish speaking, blind,
cognitive impairment
(287 excluded 1st
round), have ACP with
living will, declined
participation, unable to
approach (658 excluded
2nd round)

Sample/Settin
g (describe)

Setting: 15
dialysis
centers in
Philadelphia
and New
Jersey region
Sample/Settin
g (describe)

Major
Variables
Studied and
Their
Definitions

All types were
only
mentioned not
explained in
detail, each
type of ACP
allowed free
text writing
Major
Variables
Studied and
Their
Definitions

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)

Data Analysis
(stats used)

Five Wishes
documents

Fisher exact
test

McGill Quality
of –life
Questionnaire
– assessed
demographics,
previous endof-life
discussions,
quality of life
at baseline
(p=.002)

2-tailed t test

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)

Wilcoxon ranksum test
Logistic
Regression

Findings/
Themes

however it did
not affect the
ACP rates.
Patients who did
complete ACPs
may have
forgotten to
return the
completed
documents
Findings/
Themes

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization

Patient needs for
notarization,
time, emotional
costs required to
contemplate
one’s mortality

Weakness: though
length of
document in this
study was not
significant, it
could still be a

Data Analysis
Primary
outcome =
completed and
returned ACP,
there were no
difference in
completion
rates;
13.1%;95%

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization
Strength:
generating new
evidence that
EMR may be the
new platform for
ACP completion

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

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Table 9
Evaluation Table of Quantitative Studies
Citation
Conceptual
Design/ Method/
Framework
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Institute,
National
Institute of
Diabetes and
Digestive, and
Kidney Disease,
The Center for
Health
Incentives and
Behavioral
Economics,
University of
Pennsylvania,
and Otto Haas
Charitable Trust

Standard Choice Set = n
162, 127 completed 3mo f/u assessments, 2
died, 1 incapacitated, 6
withdrew, 6 declined, 18
unreachable
Expanded Choice Set =
n159, 129 completed 3mo f/u, 2 died, 2
incapacitated, 6
withdrew, 5 declined, 12
unreachable

Design/ Method/
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Sample/Settin
g (describe)

Major
Variables
Studied and
Their
Definitions

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)

Data Analysis
(stats used)

Findings/
Themes

12-item shortform Health
survey –
assessed the
same factors
above (p=.002)

confidence
interval versus
12.2%;95%
confidence
interval; p=0.80

and complete the
documents

Chart review
and transplant
status were
reviewed

Completion
rates did not
differ between
completing at
practice and
completing at
home
18.3%;95%
confidence
interval versus
14.3%;95%
confidence
interval; p=0.40

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization
barrier in other
studies
Utility to PICOT:
choosing the
correct ACP
documentation for
ambulatory clinics

Secondary
outcome =

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

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Table 9
Evaluation Table of Quantitative Studies
Citation
Conceptual
Design/ Method/
Framework
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Sample/Settin
g (describe)

Major
Variables
Studied and
Their
Definitions

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)

Data Analysis
(stats used)

Findings/
Themes

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization

Data Analysis
Purpose of study: testing
the influence of
increasing the number of
options (types) for
completing ACP among
seriously ill patients

change in
quality of life =
highly satisfied
with decision
process,
satisfaction
score of 4.28,
s=0.78, and no
difference
between
standard and
expanded ACP
forms
Results
between
standard and
expanded ACP
use: wanted to
complete an

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

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Table 9
Evaluation Table of Quantitative Studies
Citation
Conceptual
Design/ Method/
Framework
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Sample/Settin
g (describe)

Major
Variables
Studied and
Their
Definitions

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)

Data Analysis
(stats used)

Findings/
Themes

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization

ACP (standard
71.9%, and
expanded
85.3% with
p=.004)
Completed an
advance
directive
(standard
13.1%, and
expanded
12.2% with
p=0.80
Satisfaction
with decision
score: p=0.65

Silvia et al.
(2019). The
SHARE

Conceptual
Framework

Design/ Method/
Sampling

Sample/Settin
g (describe)

Major
Variables
Studied and

Measurement/
Instrumentatio
n

Data Analysis
Quantitative

Findings/
Themes

Level/Quality of
Evidence;
Decision for

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

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Table 9
Evaluation Table of Quantitative Studies
Citation
Conceptual
Design/ Method/
Framework
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Program for
dementia:
Implementation
of an early-stage
dyadic careplanning
intervention.
Dementia.
Country: United
States of
America
Bias: none noted
Funding: Grant
numbers
90AI004-01 and
90AI040 from
U.S.
Administration
for Community
Living,

SHARE care
values:
Support,
Health,
Activities,
Resources,
and Education
based from
Gerontology
Society of
America.
“Working
together” the
best case
scenario when
there is shared
and early
recognition of
the symptoms
and help is
sought jointly.

(Grounded Theory,
phenomenology,
Narrative…)
Inclusion: community
dwelling, English
Speaking, able to read
printed material,
symptoms of
progressive memory
loss, dementia diagnosis,
and MMSE between 2127, cognitive
impairment diagnosis,
and primary caregivers

Sample/Settin
g (describe)

N= 49 dyads
Demographics
: female
(61.3%),
Relationships:
wife (37.5%),
husband
(12.5%),
daughter
(30%), son
(1%), other
(7%)

Exclusion:

Ethnicity:
white (80%)

Design/ Method/
Sampling

Sample/Settin
g (describe)

Major
Variables
Studied and
Their
Definitions

Their
Definitions
Values and
Preference
Scalemeasured
independence,
who helps out,
activities with
family and
friends, not
being a
burden, and
safety (care
values)
Major
Variables
Studied and
Their
Definitions

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)
(focus group,
1:1, openended survey)
Resources:
family, friends,
service clinic
staffs, this
helps to build a
balanced and
realistic plan of
care for future.
SHARE’s
counselors:
ALL one
Master’s
degree earned,
and four
earning Master
Degree

Data Analysis
(stats used)

Paired sample
t-test =
caregivers to
perform less
care tasks T2
(M=6.9) than at
T1 (M=12.3),
t(39)=5.40, p
<.001
Acceptability
and Feasibility:
40 dyads, 6.4
sessions, SD =
1.01, time spent
average of 82
minutes SD =
12.75 in each
session,
average total

Findings/
Themes

Early
discussions help
create a
balanced,
realistic, and
based on the
patients with
dementia care
values.
These
discussions
introduced the
concept of
caregiver burden
and addressing
how to reduce
burden in a
meaningful and
understandable
manner.

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization
practice/
application to
practice/
Generalization
LOE:III
Strength:
caregivers are
called to make
difficult decisions
are crucial times
and are
unprepared when
discussions do not
happen early in
the disease
process, trained
counselors
facilitate a positive
and productive

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

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Table 9
Evaluation Table of Quantitative Studies
Citation
Conceptual
Design/ Method/
Framework
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Department of
Health and
Human Services

Conceptual
Framework
Empowermen
t and SelfEfficacy for
everyone
Emphasis on
strong, open,
and trusting
relationship is
the
foundation,
ensuring the
goals of the
program are
achieved.

(Grounded Theory,
phenomenology,
Narrative…)
Purpose of study: built
on assessing and
documenting the person
living with dementia’s
care values and
preferences for future
care. Care givers are
given a chance to
achieve understanding
of their loved one’s
desires before the onset
of disease progression
when the demand for
making care decisions is
high.

Sample/Settin
g (describe)

Percentage of
patient and
caregiver
living together
(67.5%)
College
graduate
(67.5%)
Caregiver
employment
(45%)
Patient
employment
(17.5%)
Alzheimer’s
Diagnosis
(12%)

Major
Variables
Studied and
Their
Definitions

Values and
Preference
Scalemeasured
personal
activities of
daily living,
instrumental
activities of
daily living,
and
socioemotional
care tasks
(care
preferences)
selection of
care giver for
future planning
(clinic staffs)

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)

Data Analysis
(stats used)

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)

9.44 hours SD
= 2.35
Data Analysis

SHARE
Counselor
Manual
Counselor’s
Guide
Magnetic
Boards used to
facilitate care
values and
preferences
discussions
5-point Likert
scale

SHARE
Counselors’
level of skill,
helpfulness,
friendliness,
usefulness
using 5-point
Likert scale
ranged between
3.03-3.77 per
caregivers and
2.83-3.76 per
patients with
dementia
Satisfactions
scores using 5point Likert

Findings/
Themes

Findings/Theme
s

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization
EOL
conversations,
Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization
Weakness:
sessions too long,
time constraints,
stress related to
topic, patient with
dementia
impairment, some
participants were
not ready to have
EOL discussions,
participants were
not followed over

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

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Table 9
Evaluation Table of Quantitative Studies
Citation
Conceptual
Design/ Method/
Framework
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Sample/Settin
g (describe)

Dementia
(10%)
Undiagnosed
(18%)
Sample:
Patients with
early dementia
and their
family
members,
recruited over
a 20 month
period,

SHARE
Counselors
N=5

Major
Variables
Studied and
Their
Definitions

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)

Data Analysis
(stats used)

Dyads meet
jointly,
separately,
then jointly for
final session
with the
counselor

scale mean 3.46
and SD = .76
per caregiver,
and mean 3.65
and SD = .60
per patient with
dementia

SHARE care
circle: building
rapport,
establishing
buy-in, and
effective
communicatio
n

SHARE
strategies=
100% per care
givers, and
97% per
patients with
dementia

Findings/
Themes

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization
a period of time
(longevity of the
study)
Utility to PICOT:
early discussions
before crucial
events occur help
the caregiver and
patient be on the
same page and
less
miscommunicatio
n and feeling of
guilt will occur

SHARE
protocol:
understanding
memory loss
(meet jointly

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

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Table 9
Evaluation Table of Quantitative Studies
Citation
Conceptual
Design/ Method/
Framework
Sampling
(Grounded Theory,
phenomenology,
Narrative…)

Sample/Settin
g (describe)

Major
Variables
Studied and
Their
Definitions

Setting:
various social
service
agencies in
North east
Ohio

1), care values
(separately 2),
car preferences
(jointly 3),
taking care of
self/taking care
of others
(jointly 4),
family and
friends (jointly
5), community
resources
(jointly 6), and
looking to the
future (jointly
7)

Measurement/
Instrumentatio
n
(focus group,
1:1, openended survey)

Data Analysis
(stats used)

Findings/
Themes

Level/Quality of
Evidence;
Decision for
practice/
application to
practice/
Generalization

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

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Appendix C
Significant Basics
LOE

VII

Authors

Cain, 2016

Common Conceptual Frameworks
Outpatient Setting
Clinic staff and Staff Involvement
Major Common Variables/Themes
Clinic staff lack of ACP & EOL
Education
Staff members ACP Training
Time Constraints
Legal Consequences
ACP Public Education
MPOA & Health Proxy
Autonomous Decision Making
Future Disability and Aggressive
Treatment
Advocacy for Imitating ACP
Conversations
ACP documentation
ACP rates
Participants Criteria
Cognitively Intact & Literate
Chronic Conditions
Terminal Illnesses
Data Analysis/Outcomes
ACP documentation & Rate
Effect

VI
Karnik &
Kanekar ,
2016

IV

I

IV

IV

I

VII

I

III

Lum et al,
2016

Myers et al,
2018

Booth &
Lehna, 2016

Arnett et al,
2017

Bestivina,
2017

Auriemann et
al, 2016

Courtright et
al, 2016

Silvia et al,
2019

Death with
Dignity Act

Egoisti and
Virtue Theory

Geriatric wellbeing

Adult Leering
Theory

Conceptual
Dimension

Improving
Quality of life

X
X

X
X

X
X

X
X

X

X
X

Quality of life
in Oncology
Patients
X
X

Empowerment
and Protection
Act
X
X

Patient SelfDetermination
Act
X
X

Empowerment
and SelfEfficacy
X
X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X
X

X
X

X

X
X

X
X
X
X

X
X
X
X

X
X
X
X
X

X

X
X
X
X

X
X

X

X

X

X

X

X

X

X

X

X

X
X

X
X

X
X

X
X

X
X

X

X

X

X

X

X

X

X

NM

X
X
X

X
X

X
X
X

NM

D&↑R

D&↑R

X

NM

NM

D & NRR

D&↑R

D&↑R

D&↑R

Key: AD – advance directives, ACP – advance care planning, ACA TOOL = availability, current issues, and anticipation tool, AMSTAR = assessment of multiple
systematic reviews, CCTSI = Colorado Clinic & Translational Sciences Institute, DISC = Development and Informatics Service Center, D= documented, FACE = familycentered advance care planning, GMV= group medical visits, GOC = goals of care, HPS – healthcare professionals, ICU = intensive care unit, LOE= level of evidence,
m –months, MYWK = making your wishes known, n – sample size, NIH/NCRR = National Institute of Health, NONRCT = non-randomized controlled trial, NM = not
mentioned, NRR = no reported rate, NPCRS = National Palliative Care Research Center, POLST = physician order for life sustaining treatment, R = rate, RCT =
randomized controlled trial, SD = standard deviation, yrs = years, ↑= increase

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Appendix D

Table 1
Average Age of Clinic Staff
Variable
M
SD
Age
37
12.93

n
7

Min
22.00

Max
52.00
(Intellectus Statistics, 2020)

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Appendix E
Table 2
Frequency Table of Demographic Characteristics
Variable
Race
Asian/Pacific
Caucasian
Gender
F
M
Level of Education
Some College
College Degree
Graduate Degree
Post Graduate
Role
Healthcare Provider
Medical Assistant
Medical Assistant/Medical Scribe
Medical Scribe
Office Manager
Training
Yes
No
Comfort
Yes
No
Meaningful
Yes
No

n

%

1
6

14%
86%

6
1

86%
14%

1
3
1
2

14%
43%
14%
29%

2
2
1
1
1

29%
29%
14%
14%
14%

0
7

0%
100%

4
3

57%
43%

7
0

100%
0%

(Intellectus Statistics, 2020)

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Appendix F
Table 3
Summary Statistics Table for Interval and Ratio Variables
Variable
M
SD
Pre_Attitude to Change_Total Score
7.43 1.40
Pre_Communication_Total Score
13.71 2.63
Pre_Leadership and Management_Total Score 14.43 2.70
Pre_Need for Change_Total Score
17.14 3.13
Pre_Preparation for Change_Total Score
14.00 3.27
Pre_Total Score
66.71 12.20

n
7
7
7
7
7
7

Min
6.00
10.00
12.00
11.00
10.00
51.00

Max
10.00
18.00
19.00
20.00
20.00
87.00

(Intellectus Statistics, 2020)

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Appendix G

Table 4
Summary Statistics Table for Interval and Ratio Variables
Variable
M SD
Post_Attitude to Change_Total Score
8.71 1.11
Post_Communication_Total Score
16.71 2.50
Post_Leadership and Management_Total Score 15.86 2.41
Post_Need for Change_Total Score
21.29 2.29
Post_Preparation for Change_Total Score
16.14 2.34
Post_Total Score
78.71 9.59

n
7
7
7
7
7
7

Min
7.00
14.00
13.00
18.00
13.00
70.00

Max
10.00
20.00
20.00
25.00
20.00
95.00

(Intellectus Statistics, 2020)

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Appendix H
Table 5
Summary Statistics Table for Interval and Ratio Variables
Variable
M
SD
Pre_Attitude to Change_Total Score
7.43 1.40
Post_Attitude to Change_Total Score
8.71 1.11

n
7
7

Min
6.00
7.00

Max
10.00
10.00

(Intellectus Statistics, 2020)

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73
Appendix I

Figure 1

Figure 1. Boxplot pre and post total ranked scores.

(Intellectus Statistics, 2020)

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74

Appendix J

Table 6
Two-Tailed Mann-Whitney Test for Electronic Medical Record by BILLING_CODES
Mean Rank
Variable
Electronic Medical Record

0
47.74

1
22.50

U
512.00

z
-3.01

p
.003

(Intellectus Statistics, 2020)

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75

Appendix K
Table 7
Frequency Table for Nominal Variables
Variable
Race
Caucasian
Asian
Billing Codes
Not Billed
99497
Advance Care Planning Type
Short Form
Long Form
Electronic Medical Record
Documented/Scanned
Not Documented/Scanned
Gender
Female
Male

Annual Wellness Visit

Follow Up

57 (100%)
0 (0%)

32 (97%)
1 (3%)

52 (91%)
5 (9%)

30 (91%)
3 (9%)

57 (100%)
0(0%)

33 (100%)
0(0%)

31 (54%)
26 (46%)

13 (39%)
20 (61%)

33 (58%)
24 (42%)

17 (52%)
16 (48%)

(Intellectus Statistics, 2020)

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76
Appendix L

Figure 2
Health Action Process Approach Model

(Schwarzer, 2008)

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Appendix M
Figure 3
PDSA Cycle

(Malnutrition Quality Improvement Initiative, 2016)