Background Mortality predictions as the COVID-19 pandemic began highlighted a need to prepare adults for possible severe illness, encouraging engagement with Advance Care Planning (ACP).

Aim To explore ACP activity and engagement during the COVID-19 pandemic.

Methods A retrospective cohort study, comparing the creation, content and use of Coordinate My Care (CMC) records, the Electronic Palliative Care Co-ordination System in London, during and prior to the onset of COVID-19. Records for patients aged 18+, created and published in the pre-pandemic period (2018–2019) and ‘wave 1’ (W1) of COVID-19 (20/03/20–04/07/20) were included. Demographics, the ACP-related content, and the use of CMC records created were compared using descriptive statistics.

Results 56,343 records were included (35,108 pre-pandemic period and 21,235 W1). During W1, the mean records created each week increased by 296.9% (P<0.005). More people creating records at this time were aged below 80 (39.9% vs 35.1% pre-pandemic, P<0.005) and had WHO performance status 0–1 (17.7% vs 11.63% pre pandemic, P<0.005). Less people who created records during W1 had an estimated prognosis of days - weeks (9.0% vs 16.7% pre-pandemic, P<0.005), were ‘Not For Resuscitation’ (61.8% vs 70.3% pre-pandemic, P<0.005) and had a Ceiling of Treatment of ‘Symptomatic Treatment Only’ (8.1% vs 14.0%, P<0.005). More patients in W1 listed hospital as their preferred place of care (PPC) and preferred place of death (PPD) (PPC: 13.3% vs 5.8% pre-pandemic, P<0.005. PPD: 14.0% vs 7.9%, P<0.005). Average monthly non-urgent and urgent record views rose by 320.3% (P=0.02) and 154.3% (P=0.01) in W1.

Conclusion A marked increase in ACP activity is shown during wave 1 of the pandemic. Amplified engagement, provision and awareness at this time is suggested by increased use among younger, more independent patients with longer prognoses and a higher preference for hospital care creating records in W1 compared to before the pandemic.