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Am J Hosp Palliat Care. 2019 Sep 2:1049909119872757. doi: 10.1177/1049909119872757. [Epub ahead of print]

Improving Advance Care Planning in a Resident Primary Care Clinic.

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1 Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA.
2 Lifespan Biostatistics Core, Rhode Island Hospital, Providence, RI, USA.
3 Department of Medicine, Warren Alpert Medical School, Providence, RI, USA.



Two-thirds of chronically ill patients do not have an advance directive. The primary aim of this study was to develop an intervention to increase the documentation of advance directives in elderly adults in an internal medicine resident primary care clinic. The secondary aims were to improve resident confidence in discussing advance care planning and increase the number of discussions.


The study was a pre- and postintervention study. The study intervention was a 30-minute educational session on advance care planning. Study participants were patients aged 65 years and older who were seen in an internal medicine residency primary care clinic over a 6-month period and internal medicine residents. Clinic encounters were reviewed for the presence of advance care planning discussions before and after the intervention. Resident confidence was measured on a Likert scale.


Two hundred ninety-five eligible patients were seen in the clinic from January 1, 2017, to June 30, 2017, and included in the analysis performed between 2017 and 2018. The mean number of documented advance care planning discussions increased from 2.24 (95% confidence interval [CI]: 1.0-4.9) during the preintervention period to 8.94 (95% CI: 5.94-13.24]) during the postintervention period (P = .0011). Following the intervention, residents overall reported increased confidence in discussing advance care planning.


A relatively modest intervention to increase advance care planning discussions is feasible in an internal medicine primary care clinic and can improve the confidence of residents with end-of-life discussion.


advance care planning; advance directive; electronic medical record; primary care; resident education


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