Oral Presentations

O-7: The Best Laid Plans: A simple intervention for initiating advance care planning in primary care

Will Caron (KW),
Julianne Rastin
Natalie Munn

McMaster University
Centre for Family Medicine


Key Words: Advance Care Planning, Primary Care, EMR Tools

Advance care planning (ACP) is an important process. Despite the evidence supporting ACP, there are many barriers to its implementation. Evidence suggests that using patient information resources and electronic medical record (EMR) tools are effective strategies for initiating ACP. Our project aimed to evaluate whether the combined intervention of a patient handout and EMR tool had an effect on documenting substitute decision makers (SDM) in a family medicine setting.

Over a one week period at three family medicine clinics in Waterloo Region, patients ≥65 who attended for a regular visit were given a handout on ACP and SDM by the clinic nurse. If the patient shared their SDM, or any other information regarding ACP, this was recorded in the chart using an EMR tool. Data from this intervention was collected 3 months post-intervention.


Fifty-four patients received a handout with 38 patients (70%) having an SDM recorded in the EMR tool. There were 5 documented ACP discussions and 3 documented ACPs. Of the 38 patients who had an SDM recorded, there were 19 females (79% of female participants) and 19 males (63% of male participants). 63% of those who responded were aged 75 or older, while 37% were between the ages of 65-74.

Our study shows that combining patient education with EMR documentation can be beneficial as a catalyst for discussion of ACP and documentation of SDM. We hope that this study serves as a springboard for further studies regarding advanced care planning in primary care.