Advance care planning documentation in older adults undergoing evaluation at a preoperative medicine clinic: A single-center retrospective chart review

Background: A preoperative evaluation is an opportunity to engage in advance care planning (ACP) with older adults. The objective of this study was to identify the frequency and characteristics associated with ACP documentation in older adults evaluated at a preoperative medicine clinic (PMC) prior to elective surgery. Methods: We performed a retrospective chart review of preoperative medicine clinic (PMC) visits with patients aged 65 and older from April to July 2020 at our tertiary academic medical center. A patient-level analysis was done to identify patient characteristics associated with ACP documentation. Odds ratios were estimated from logistic regression. Results: 1409 patients presented over 1456 visits. 28% of visits documented a surrogate decision maker (SDM), 11% an advance directive (AD), and 17% a POLST (of which 36% ordered Do Not Resuscitate (DNR) and 44% Limited Treatment or Comfort Measures Only). Increasing age, ASA 3–4, and cognitive impairment increased the odds of any ACP documentation (OR 1.08, 2.76, 3.28; all P<0.001) and preoperative POLST completion (OR 1.09, 1.81, 3.96; all P<0.001). Visits for high-risk (HR) procedures were more likely to have any ACP documentation (OR 1.80, P<0.001), though patients with treatment-limiting POLST orders were less likely to be seen at PMC in preparation for a HR procedure compared to those ordering Full Treatment (OR 0.49, P = 0.045). Conclusions: ACP documentation is more frequently completed for higher risk patients undergoing PMC evaluation, however overall rates are low. Systematizing ACP documentation may be facilitated using a centralized ACP repository with the medical record.