End-of-life care planning: improving documentation of advance directives in the outpatient clinic using electronic medical records

Salim Hayek, Ria Nieva, Frank Corrigan, Amy Zhou, Uma Mudaliar, David Mays, Michael Massoomi, Nurcan Ilksoy

Research output: Contribution to journalArticlepeer-review

24 Scopus citations


BACKGROUND: The right to self-determination is fundamental in clinical ethics. End-of-life conversations and advance directives (ADs), in addition to preserving this right, have been shown to decrease the likelihood of in-hospital death, improve the quality of care, and lower health costs in the final week of life. Despite these benefits, the rates of AD documentation are poor.

OBJECTIVE: Our aim was to assess the effectiveness of an electronic medical record (EMR)-based reminder in improving AD documentation rates.

METHODS: We conducted a prospective quality improvement study in outpatients at the Grady Memorial Hospital Purple Pod Clinic in Atlanta, GA. Using the EMR system EPIC we set to implement a reminder system consisting of the addition of "Advanced Directives Counseling" to the problem list (ADPL) of 50% of outpatients meeting one of the following criteria: age >65 years, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), acquired immune deficiency syndrome (AIDS), malignancy, cirrhosis, end-stage renal disease (ESRD), or stroke. Primary care physicians were encouraged to document ADs for all patients. The number of patients with documented ADs was assessed at 6 months post-test of change.

RESULTS: A total of 588 patient charts were screened by seven providers, with 157 patients meeting the predefined criteria for AD documentation. During a 6-month period, 64 patients were seen in the clinic; 38 had AD on their problem list, and 26 did not. Seventy-six percent of charts with ADPL had documentation of an AD. Only 11.5% of those without ADPL had an AD documented.

CONCLUSIONS: EMR-based reminders are effective in improving documentation rates of ADs. Further research is needed to establish whether improved documentation impacts inpatient management and costs of care.

Original languageEnglish (US)
Pages (from-to)1348-1352
Number of pages5
JournalJournal of Palliative Medicine
Issue number12
StatePublished - Dec 1 2014
Externally publishedYes

ASJC Scopus subject areas

  • General Nursing
  • Anesthesiology and Pain Medicine


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