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Table 2 Measured Metrics of Palliative and Therapeutic Harmonization (PATH) Advance Care Planning Implementation

From: Evaluation of an initiative to improve advance care planning for a home-based primary care service

Documentation of key element on EMR

Description

 Frailty stage documenteda

Documentation on EMR of assigned frailty stage using the Clinical Frailty Scale (8) informed by Collaborative Comprehensive Geriatric Assessment.

 Substitute decision-maker documenteda

Documentation on EMR of the patient’s substitute decision-makerb or formal representative, if available.

 Resuscitation decision documenteda

Documentation on EMR of patient decision with regards to resuscitation in the event of a cardiopulmonary arrest.

 Hospitalization decision documenteda

Documentation on EMR of patient decision with regards to hospitalization in the event of a health crisis.

Expressed preferences

Description

 Expressed preference for do-not-resuscitate

The resuscitation decision expresses a preference for do-not-resuscitate (versus resuscitate).

 Expressed preference for do-not-hospitalize

The hospitalization decision expresses a preference for do-not-hospitalize (versus hospitalize) in the event of an acute care crisis.

  1. EMR electronic medical record
  2. aDocumented – refers to the presence of documentation on key advance care planning decisions; these preferences are noted on the EMR face sheet, which is the front page of the EMR that contains crucial patient information such as patient identification and personal information, clinical information, and identification of family/substitute decision-maker
  3. bThe substitute decision-maker is the person responsible to make health decisions on the patient’s behalf when there is impaired capacity. This person is designated in the absence of a formal representation agreement