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Advance care planning (ACP) intends to support person-centered medical decision-making by eliciting patient preferences. Research has not identified significant associations between ACP and goal-concordant end-of-life care, leading to justified scientific debate regarding ACP utility.To delineate ACP's potential benefits and missed opportunities and identify an evidence-informed, clinically relevant path ahead for ACP in serious illness.We conducted a narrative review merging the best available ACP empirical data, grey literature, and emergent scholarly discourse using a snowball search of PubMed, Medline, and Google Scholar (2000-2022). Findings were informed by our team's interprofessional clinical and research expertise in serious illness care.Early ACP practices were largely tied to mandated document completion, potentially failing to capture the holistic preferences of patients and surrogates. ACP models focused on serious illness communication rather than documentation show promising patient and clinician results. Ideally, ACP would lead to goal-concordant care even amid the unpredictability of serious illness trajectories. But ACP might also provide a false sense of security that patients' wishes will be honored and revisited at end-of-life. An iterative, 'building block' framework to integrate ACP throughout serious illness is provided alongside clinical practice, research, and policy recommendations.We advocate a balanced approach to ACP, recognizing empirical deficits while acknowledging potential benefits and ethical imperatives (e.g., fostering clinician-patient trust and shared decision-making). We support prioritizing patient/surrogate-centered outcomes with more robust measures to account for interpersonal clinician-patient variables that likely inform ACP efficacy and may better evaluate information gleaned during serious illness encounters.

INTRODUCTION: Medicare Advantage (MA) cares for an increasing proportion of traditional Medicare (TM) patients although, the association of MA on low-value care among hospitalized patients is uncertain. We sought to determine whether invasive mechanical ventilation (IMV) use or mortality differs among hospitalized patients with advanced dementia (AD) enrolled in MA vs TM and the influence of hospital MA concentration. METHODS: Retrospective cohort of hospitalized Medicare patients from 2016-17 who were ≥66 years old with AD (n=147,153) and had a hospitalization with an assessment completed during a nursing home stay ≤120 days prior to that hospitalization indicating AD and severe cognitive/functional impairment. MA enrollment was ascertained at hospitalization; IMV use and 30- and 365-day mortality were determined via Medicare data. Multivariable logistic regression models clustered by hospital were used. RESULTS: Among hospitalized Medicare patients with AD, 27,253 (19%) were enrolled in MA, mean age was 84 (95%CI:83.9-84.0) and 92,736 (63%) were female. Enrollment in MA was associated with increased IMV use (Adjusted Odds Ratio(AOR)=1.11,95%CI: 1.04-1.18), 30-(AOR=1.09,95%CI:1.05-1.12) and 365-day mortality (AOR=1.12,95%CI:1.08-1.16) compared to TM. Use of IMV was not different based on concentration of MA at the hospital level. CONCLUSIONS: MA may reduce hospitalizations, however, once hospitalized, patients with AD enrolled in MA experience higher rates of IMV use and worse 30- and 365-day mortality compared to TM patients. Higher hospital concentration of MA did not reduce use of IMV. MA may not offer significant benefits in reducing low-value care among patients hospitalized with serious illness, questioning the benefits of this care model.

to 11/30/2014 was obtained. Undocumented status was indicated on the initial intake form. Diagnoses, reason for consult, length of stay, PCCS interventions and discharge disposition were analyzed. Results. 428 patients were referred to the PCCS. 40.2% were 18-65 years old, and 59.8% were >65 years old. 49.8% were female. Approximately 11% of these patients died within 2 days of completion of their PCCS consultation. 14% of patients were identified as UAU. More than 1/3 of these patients returned home with no palliative care services due to undocumented status and returned frequently to ED for symptom exacerbations. The most common reason for consult for these patients was discharge planning/placement, and for four of these patients, the ultimate disposition was remaining in the city hospital until their death due to their lack of insurance and their undocumented status. Conclusion. To date, very little data on the experience of undocumented and uninsured patients exists outside of anecdote and case report. Characterizing the end-of-life care in the uninsured and undocumented patients provides much needed data to help hospital systems provide palliation and discharge to appropriate care systems for this vulnerable population. Implications for Research, Policy or Practice. Characterization of care for this vulnerable population allows for identification of policy and system changes that may allow palliative care to reach this vulnerable patient population.