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advance care planning, end of life, heart failure, Seattle heart failure model



  1. Crosby, Erin M. DNP, APRN, CNP
  2. Gutierrez, Karen M. PhD, RN, AHN-BC


This quality improvement project utilized a risk stratification process and an advance care planning (ACP) tool to identify patients at high risk of death and prompt ACP discussions and documentation of health care preferences in the electronic health record. Inherent uncertainty in heart failure (HF) prognostication and provider time constraints impede initiation of timely ACP discussions. In an effort to mitigate these obstacles, the Seattle Heart Failure Model was utilized to calculate mortality risk for 195 patients in an ambulatory HF clinic. Next, a HF-specific ACP tool, developed for this project, was used to prompt and guide ACP discussions with patients determined to have a prognosis of life expectancy of 3 years or less. The project yielded a 35% completion of ACP tools over 3 months, with 100% of these entered into the electronic health record. Postimplementation surveys suggest clinic staff believe a comprehensive and systematic approach to ACP services facilitates timely ACP discussions and decision making in the outpatient setting.