Background The creation of an Advance Care Plan (ACP) with patients under the care of a specialist palliative medicine team is a crucial part of their role. It is important that such discussions are documented effectively, to accurately reflect the patient’s wishes and protect their autonomy. The appropriate dissemination of an ACP to key professionals involved in the care of such patients is equally important; to ensure continuity of care across the multidisciplinary team.
Methods We set out to assess the prevalence and subsequent communication of clearly documented ACP’s in the electronic and Palliative Care-held notes in patients admitted to a hospice for any reason. Through analysis of paper and electronic patient records, it was possible to assess whether ACP’s were a) being created and documented clearly, b) being communicated back to the patient’s General Practitioner and c) if the ACP was being transferred onto the patient’s Summary Care Record (SCR).
Results On admission to the hospice, 14 out of 26 patients (54%) had no documented ACP in their notes. Of patients with no ACP, 71% were known to Community Palliative Care teams. In patients with documented ACPs, 75% of these plans had been appropriately been communicated to the patient’s GP, however 78% of patients with communication to the GP had no Advance Care Planning details on their SCR.
Conclusions These findings demonstrate the imperative for improved documentation of ACPs in Secondary and Community care and for Summary Care Records to be updated to reflect discussions with patients. Further work will focus on introduction of escalation plans to improve documentation and communication with GP’s as well as communication of results, education of professionals involved with Advance Care Planning and re-audit.