Advance Care Planning in Primary Care. A Retrospective Medical Record Study Among Patients With Different Illness Trajectories.

Background: Advance Care Planning (ACP) enables physicians to align healthcare with patients wishes, reduces burdensome life-prolonging medical interventions, and potentially improves the quality of life of patients in the last phase of life. However, little objective information is available about the extent to which structured ACP conversations are held in general practice. Our aim was to examine the documentation of ACP for patients with cancer, organ failure and multimorbidity in medical records (as a proxy for ACP application) in Dutch general practice. Methods: We chose a retrospective medical record study design in seven primary care facilities. Medical records of 119 patients who died non-suddenly (55 cancer, 28 organ failure and 36 multimorbidity) were analysed. Other variables were: general characteristics, data on ACP documentation, correspondence between medical specialist and GP, and healthcare utilization in the last two years of life. Results: In 65% of the records, one or more ACP items was registered. Most often documented were aspects regarding euthanasia (35%), the preferred place of care and death (29%) and concerns and hopes towards the future (29%). Median timing of the first ACP conversation was 126 days before death. ACP was more often documented in patients with cancer (84%) than in those with organ failure (57%) or multimorbidity (42%) (p = 0,000). Patients with cancer had the most frequent (median 3 times, inter-quartile range (IQR) 2-5), and extensive (median 5 items, IQR 2-7) ACP consultations. Conclusion: Documentation of ACP items in medical records by GPs is present, but incomplete, especially in patients with multimorbidity or organ failure. We recommend more attention for, and documentation of ACP in daily practice in order to start anticipatory conversations in time, and to address the needs of all people living with advanced conditions in primary care.