Background: Ensuring that hospitalized patients have a clearly documented Advance Care Plan (ACP) is important to provide them with goal-concordant care. Our institution undertook an inpatient Quality Improvement (QI) initiative to improve accessible ACP documentation. Though this work significantly improved ACP documentation rates, ACP rates for Latinx patients were significantly lower than those of the general population. Analysis revealed a possible causal role of religion and spirituality for some Latinx patients. To our knowledge, there has been no prior published utilization of Spiritual Care services to improve ACP documentation; thus we aimed to improve this for Latinx patients through involvement of Spiritual Care teams. We targeted improvement on the Malignant Hematology (MH) service, which cares for patients with hematologic malignancy and bone marrow transplant and is staffed by hospitalists.

Purpose: (1) To conduct a pilot intervention to increase ACP documentation for Latinx Malignant Hematology patients through an interdisciplinary and collaborative approach involving Spiritual Care, Hospital Medicine and Hematology Oncology teams. (2) To enhance communication between medical providers via utilization of resources that support patients’ spiritual needs and advance care planning.

Description: We convened representatives from Spiritual Care, MH service Hospitalists and Malignant Hematologists to develop an innovative approach to increase ACP documentation for MH unit Latinx patients. Twice-weekly, over 5 weeks from May-June 2021, Spiritual Care chaplains were provided with a list of patients on the MH service (by the hospitalist or malignant hematologist) who self-identified as Latinx. Chaplains consulted with these patients during the week and had conversations around spirituality and goals of care if patients were receptive. A templated script with question prompts for the Chaplains guided their conversations. If new information was gleaned from these conversations regarding ACP, Chaplains would document this in an ACP note. If the Chaplains discovered information that needed further discussion, hospitalists on service were informed. During this pilot, the weekday daily percentage of Latinx patients on the MH service with ACP notes was measured. In total, the Spiritual Care team met with 28 patients. This intervention led to an overall increase in ACP documentation among Latinx patients from 48% to 70% during the pilot period (Graphs 1 and 2). Qualitative feedback from MH providers showed a high perceived value of these ACP notes, especially how patients’ cultural backgrounds and religious beliefs impacted their views on medical care and ACP goals.

Conclusions: This novel intervention of including Spiritual Care chaplains to initiate and document ACP conversations in Malignant Hematology Latinx patients led to a substantial increase of 22% in ACP documentation rates for hospitalized Latinx patients. This collaboration highlights the impact and importance of this unique multidisciplinary approach involving Spiritual Care providers. They are valuable adjuncts as they are particularly adept at discussing goals of care with specific patient populations who have strong religious beliefs. The success of this pilot suggests a potential for this intervention to be expanded in scope. Hospitalists should involve Spiritual Care providers early for ACP discussions and documentation, especially for patients who indicate receptivity to speaking with chaplains.

IMAGE 1: Graph 1:Monthly ACP Documentation, All patients and Latinx Patients

IMAGE 2: Graph 2: Daily Data from Intervention