Innovations in Advance Care Planning Documentation: A Pragmatic Study Reveals Promising Interventions

The GeriPal Podcast, a leading platform for discussions on geriatrics and palliative care, recently featured a comprehensive exploration of advancements in advance care planning (ACP) documentation. Hosted by Eric Widera and Alex Smith, the episode spotlighted a pragmatic cluster randomized control trial published in the Journal of General Internal Medicine in December 2025. The study, titled "Interventions to Improve Advanced Care Planning Documentation in the EHR, a Cluster Randomized Control Trial," aimed to identify and implement effective strategies for integrating ACP into routine healthcare. The discussion featured prominent researchers in the field: Anne Walling, a palliative care physician researcher at UCLA; Neil Wenger, a general internist and researcher at UCLA; and Rebecca Sudore, a geriatrician, palliative care physician, and researcher at UCSF.

The core motivation behind the study, as articulated by Dr. Anne Walling, stemmed from personal experience and a deep-seated passion for improving patient care communication. Dr. Walling shared a poignant anecdote about her mother’s severe brain injury after a horseback riding accident, highlighting how enhanced communication could have significantly improved their family’s experience. This personal drive fueled her commitment to making the world a better place, particularly by refining how healthcare systems approach advance care planning.

Dr. Neil Wenger echoed this sentiment, framing quality healthcare as intrinsically linked to love and a genuine commitment to the patient’s well-being. He emphasized that true quality measurement and care provision originate from a clinician’s passion for improving the patient’s immediate and future care. For Dr. Wenger, advance care planning is the embodiment of this principle, focusing on understanding and prioritizing a patient’s wishes, both now and for times when they may no longer be able to communicate for themselves, ensuring these preferences guide their care trajectory.

The Imperative of Advance Care Planning

Advance care planning (ACP) is a critical process that helps individuals articulate their values, preferences, and goals for future medical care, particularly in situations where they may lose the capacity to make decisions. This process is crucial for ensuring that healthcare aligns with a patient’s wishes, especially for those with serious or life-limiting illnesses.

Historically, the effectiveness of ACP has been a subject of ongoing research and debate. While some studies have indicated positive outcomes, others, particularly older ones, have yielded mixed results. Dr. Rebecca Sudore pointed out the importance of methodological rigor when examining ACP literature. She highlighted a significant study conducted at the Veterans Affairs (VA) healthcare system, which utilized their integrated system of Life Sustaining Treatment Orders. This research demonstrated that when ACP is conducted and a patient’s stated wishes are known, there is a direct correlation between those wishes and the care received. Patients who desired comfort care, for instance, received it, leading to decreased utilization of aggressive treatments and improved bereaved family survey scores.

Furthermore, Dr. Sudore underscored a consistent finding across various ACP studies: a reduction in post-traumatic stress disorder (PTSD) and complicated grief for both patients and their families. This suggests that ACP offers profound emotional and psychological benefits, irrespective of the specific methodological approach.

Challenges in Implementation and the EHR’s Role

Despite the evident benefits, implementing ACP effectively within the complex landscape of healthcare systems presents numerous challenges. Dr. Neil Wenger, as a primary care provider, articulated the difficulty in evaluating ACP’s impact, especially regarding utilization metrics. He noted that while palliative care specialists often see patients further along in their illness trajectory, for general internists, conversations about goals and future medical care can span a decade and guide subsequent treatment decisions. The challenge lies in ensuring these crucial conversations are documented and accessible to all involved clinicians, including hospitalists and oncologists, particularly when electronic health records (EHRs) may not seamlessly share information.

This challenge of documentation and accessibility was a primary driver for the study led by Dr. Walling. The research, published in Annals of Internal Medicine, focused on developing and testing interventions to improve ACP documentation within the EHR. The study’s authors recognized that even the most effective conversations could be lost if not properly recorded and retrievable.

The Study Design: A Pragmatic Approach to ACP

The cluster randomized control trial, published in JAMA Internal Medicine, was designed as a pragmatic study, meaning it aimed to assess the effectiveness of interventions in real-world clinical settings. The study involved three University of California healthcare systems and included approximately 50 different primary care clinics, encompassing a diverse range of providers.

The central aim was to create an infrastructure within the healthcare system to support ACP. This involved identifying eligible patients, determining the optimal timing for interventions, and implementing subtle "nudges" to encourage both clinicians and patients to engage in ACP discussions. The study focused specifically on patients with serious illnesses, a group that often experiences high healthcare utilization and benefits significantly from aligned care.

Defining Serious Illness: An Innovative EHR-Based Approach

A key innovation of the study was the development of an electronic health record (EHR) phenotype to consistently and accurately identify patients with serious illness across different healthcare systems. This approach moved beyond relying solely on ICD codes, which can be inconsistent or fail to capture the nuances of serious illness.

Dr. Anne Walling explained the iterative process of creating this phenotype. It began with established ICD codes for conditions such as advanced cancer, COPD, renal disease, liver disease, ALS, and heart failure. However, to ensure accuracy, the researchers developed a reference standard of patients meeting their criteria for serious illness. They then analyzed structured data elements within the EHR—data that is readily accessible and quantifiable—to identify patterns and indicators associated with these conditions. This included elements like pulmonary function test results, even if specific tests were not available across all sites. The final algorithm achieved a remarkable 98% positive predictive value for identifying the target population.

Dr. Neil Wenger clarified the definition of serious illness used in the study. It encompassed individuals with life-limiting conditions, functional or cognitive limitations, or those experiencing significant symptoms driving increased healthcare utilization. The goal was not to predict imminent death but to identify patients who could benefit from ACP discussions to guide their care over the coming years and prevent potential loss of decision-making capacity. This focus on "serious illness" rather than strict prognosis allowed for a broader application of ACP interventions within primary care.

The Three-Arm Intervention Strategy

The study randomized clinics into three arms, each receiving different interventions designed to prompt ACP discussions prior to primary care visits:

• Arm 1: Advance Directive Information: Patients received messages, delivered via the patient portal and mail, containing information about advance directives. The messaging was carefully crafted with input from various stakeholders, including clinicians and patients, to ensure it was positive and patient-centered, emphasizing the importance of having a voice in one’s care.
• Arm 2: Prepare for Your Care Integration: This arm included all the information from Arm 1, plus resources from the "Prepare for Your Care" program. Prepare for Your Care offers user-friendly advance directives focused on values and goals, along with online modules. Participants received URLs and pamphlets directing them to these resources.
• Arm 3: Navigator Intervention: This arm involved a non-clinician healthcare navigator who conducted outreach to both patients and clinicians. The navigator’s role was to stimulate patient engagement with the intervention, encourage the opening of messages, and facilitate the completion and submission of advance directives. Crucially, the navigator also assessed patient readiness for an ACP discussion and provided a pre-visit note to the clinician, indicating whether the patient was resistant, receptive, or already prepared to discuss their wishes. Clinicians also received training on ACP prior to the intervention launch.

Study Findings: Evidence of Intervention Effectiveness

The study tracked outcomes over a two-year period, focusing on patients who initially had no documented advance directive or POLST (Physician Orders for Life-Sustaining Treatment).

• Advance Directive and POLST Completion: In Arms 1 and 2, approximately 13-14% of patients in this cohort eventually had an advance directive or POLST documented in the EHR. This represents a significant achievement, as it implies not only completion but also proper witnessing, notarization, and uploading into the system.
• Navigator Impact: The navigator intervention in Arm 3 demonstrated a higher completion rate, with 20% of patients having an advance directive or POLST documented in the EHR. This suggests that personalized outreach and support can significantly enhance the uptake of these crucial documents.
• Goals of Care Conversations: Beyond document completion, the study also measured the occurrence of documented goals of care conversations. Using natural language processing (NLP) software developed by Charlotte Linville, the researchers found that Arms 1 and 2 showed approximately 35% of patients having documented conversations. The navigator group (Arm 3) saw an additional 4-5% absolute difference in documented conversations, indicating that the navigator’s role not only facilitated documentation but also stimulated more meaningful discussions. It’s important to note that navigator-specific documentation of ACP discussions was excluded from this calculation, suggesting the actual number of conversations in that group was even higher.

Addressing Skepticism and Broader Implications

During the podcast discussion, Alex Smith raised a valid skeptical perspective, questioning the metrics of form completion and the relatively low overall rates, especially considering the "heavy lift" involved in implementing such a program. Dr. Rebecca Sudore addressed these concerns by highlighting that the study is ongoing and that future survey data will provide deeper insights into patient-reported outcomes beyond just form completion. She emphasized that the true value lies not just in the forms but in the increased frequency of goals of care conversations.

The researchers acknowledged that while the direct impact on healthcare utilization might not have been immediately apparent within the study’s timeframe, the long-term benefits are substantial. The implemented systems are designed to run in the background, requiring minimal ongoing clinician time once established. This "infrastructure" approach allows for continuous improvement and adaptation, similar to how public health messages for flu shots are delivered over time.

The navigator role, while an additional cost, was deemed a worthwhile investment due to its significant impact on ACP completion and conversation rates. At UCLA, the navigator position has become an integral part of a larger program, demonstrating its sustainability and value within the healthcare system. The development of a standardized, scalable navigator protocol further enhances its replicability.

The Future of Advance Care Planning

The study’s success in developing a replicable EHR phenotype for identifying seriously ill patients is a significant contribution. The shared code and willingness of the researchers to collaborate with other health systems signal a commitment to advancing the field collectively.

The discussion concluded with a strong emphasis on the "love" aspect of quality care – ensuring that patient wishes and values guide their medical journey. The study’s interventions, particularly the navigator’s role and the use of values-focused advance directives, are designed to empower patients and facilitate these crucial conversations. The positive shift observed in how clinicians utilize the "goals of care" section of EHRs, now a go-to place for information rather than a blank space, signifies a cultural change driven by these pragmatic interventions.

Ultimately, the GeriPal podcast episode underscored that improving advance care planning is not merely about ticking boxes but about fostering a system where patient voices are heard, values are respected, and care is truly aligned with individual needs and preferences. The research presented offers a tangible pathway for healthcare systems to achieve this vital goal, reinforcing the idea that love, in the form of dedicated, patient-centered care, is indeed all you need.