Pragmatic Trial to Increase Advance Care Planning: Anne Walling, Neil Wenger, & Rebecca Sudore

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GeriPal - A Geriatrics and Palliative Medicine Podcast 50 min 2 speakers 8 chapters transcribed 10 hours ago

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What is the purpose of the pragmatic trial on advance care planning?

Eric Widera 0:00

This episode of the Jerry Powell Podcast is sponsored by the UCSF Division of Palliative Medicine, an amazing group of palliative care clinicians doing amazing care.

Alex Smith 0:10

UCSF Division of Pallid Medicine is dedicated to doing interdisciplinary work. They're dedicated to making a broad and inclusive environment for working. And we've had many of the members of the Division of Palliative Medicine on the Jerry Powell podcast, including Naomi Sachs, Danny Shamas, Kara Bischoff, Carly Zapata, Steve Pantalat, and Mike Raybo, among others. This is a terrific group of people, and I think you'd love to work with them.

Eric Widera 0:41

And if you're interested in learning more about the business and please check out our show notes and click on the link. And best of all, if you take the job, you can hang out with me and Alex. What's better than that, Alex? Nothing. This podcast is CME eligible. To learn more about CME, Alex, what do they do?

Alex Smith 0:57

They can either go to the CME tab associated with this episode, or they can go to jerrypal dot org backslash CME.

Eric Widera 1:06

And on to the show. Welcome to the JerryPal podcast. This is Eric Wadera. This is Alex Smith. And Alex, we're going to be talking about one of our favorite subjects on JerryPal, advanced care planning, how to improve it. Who do we have as our guest?

Alex Smith 1:23

We are delighted to welcome Annie Walling, who is a palliative care physician researcher at UCLA. Annie, welcome to the Jerry Powell podcast.

Anne Walling 1:32

Thank you.

Alex Smith 1:33

And we're delighted to welcome a giant researcher in the field, Neil Wenger, who's a general internist and researcher at UCLA. Neil, welcome to the JerryPal podcast. Glad to be here. And we're delighted to welcome back frequent guests about these advanced care planning topics, Rebecca Sidore, who's a geriatrician, palliative care doc, and researcher at UCSF. Rebecca, welcome back to JerichoPal.

Rebecca Sudore 1:56

Good to be back. Thank you.

Eric Widera 1:58

So uh I'm excited to talk about this. Again, one of our favorite subjects, advanced care planning. Think about ways we can increase advanced care planning. But before we jump into this topic, Annie, do you have a song request for Alex?

Anne Walling 2:10

I do. And I have a reason behind it. So my favorite quote by Donna Bedian, who's known as the father of healthcare quality, is the secret of quality is love. And so we chose um All You Need is Love by the Beatles.

Alex Smith 2:24

Okay, good choice. I'm shocked we haven't done this one before. I played this one for Diane at some meeting, but Diane Meyer, but I guess we hadn't done it on JerryPell. So delighted that you requested it. Thank you. There's nothing you can do that can't be done. Nothing you can sing that can't be sung. Nothing you can say but you can learn how to play the game. It's easy

2:57

Yeah.

Alex Smith 2:59

There's nothing you can make that can't be made. No one you can save that can't be saved. Nothing you can do but you can learn how to be you in time. It's easy

Unknown 3:16

All you need is love. All you need is love. All you need is love, love. Love is all you need.

Eric Widera 3:32

That was wonderful. Annie, what did he mean by that quote?

Anne Walling 3:36

Well, I think that if you really care and you can look back and improve things, and I think that that's sort of like what I based my whole career on is like really wanting to make the world a better place.

Eric Widera 3:48

And why why did you focus on one of those improvements, improving advanced care planning documentation?

Anne Walling 3:54

Well, I think that I mean, honestly, my personal passion about this comes from personal experience. So before I entered medical school, my mom had had a severe brain injury after a horseback riding accident. And I feel like the if the communication had been improved, like our experience would have been a lot better. And so coming into this as a clinician um and interacting with families all the time, I just really am passionate about improving. the way that we communicate with people. And I think advanced care planning is a key piece of that.

Eric Widera 4:25

Yeah. Rebecca, we've had you on the podcast. We've asked you this Neil, I've never asked you this question w Like

How did the guests’ personal experiences shape their interest in advance care planning?

Eric Widera 4:32

Why is this important to you? What's the love aspect here for you about this?

Neil Wenger 4:37

Uh you know, I think when Donamedian talks about love being the basis of quality measurement and the provision of high quality medical care.

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Chapters

8 chapters

1 What is the purpose of the pragmatic trial on advance care planning? 0:00–4:32 2 How did the guests’ personal experiences shape their interest in advance care planning? 4:32–11:26 3 How were seriously‑ill primary‑care patients identified using structured EHR data? 11:26–18:00 4 What were the three intervention arms and how did each nudge work? 18:00–26:19 5 What were the key outcomes—documented directives, POLST forms, and care‑plan conversations? 26:19–32:42 6 Why do some critics question the choice of primary outcomes and lack of a control group? 32:42–39:44 7 Can the EHR‑based algorithm and navigator model be scaled to other health systems? 39:44–46:00 8 What are the take‑away lessons for clinicians and health‑system leaders from this study? 46:00–50:05

Speakers

2 identified

Eric Widera 8 min Alex Smith 6 min

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Topics in this episode

Alex 1 Alex Smith 1 UCLA 3 UCSF 2 Yale 1 The Beatles 1 Eric Widera 1 VA 1 Hartford Foundation 1 Rebecca Sudore 3 living will 1 advanced directive 1

Source

Recorded02 Apr 2026

Publisherrss.libsyn.com ↗

Transcriptspeaker-named · 100+ languages

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Show notes

Today we're delighted to talk with Anne Walling, Neil Wenger, and Rebecca Sudore about a pragmatic implementation trial aimed at increasing advance care planning for primary care patients with serious illness in University of California clinics, published in Annals of Internal Medicine. Seriously ill primary care patients were identified using structured data fields (meaning routinely captured without needing to read the chart or use natural language processing). This study focused on patients without a completed advance directive or POLST form. This was a 3 arm trial that tested a nudge in the patient portal and a mailed advanced directive vs. the nudge plus a link to PrepareForYourCare vs. the nudge plus PrepareForYourCare plus a navigator reminding patients to talk with their doctor and bring any completed advance directives or POLST forms to the PCP visit. In brief, the study found that at 2 years there were higher rates of advance directive or POLST in the electronic health record (about 20%) in the arm with the nudge plus PrepareForYourCare plus the navigator compared to the other 2 arms (around 13%). Rates of advance care planning discussions with primary care providers were similarly higher in the 3rd arm. Health care utilization, however, did not differ between arms. Please see links to articles describing the intervention in detail and incorporation of stakeholder perspectives. I'm going to cut to the pushback to this article right up front: The study's primary outcomes were advanced directives or completion of POLST forms - haven't we moved beyond thinking completion of forms should be the primary outcome of advance care planning research? There was no control condition. Observed increases in advance directive or POLST in the electronic health record may have occurred without any intervention. People with serious illness get sicker with time and the sicker they are the more likely they are to engage in advance care planning, without any intervention. This is particularly true as the study occurred during the hight of the Covid pandemic, when there was a global effort to increase advance care planning. How much did these interventions contribute on top of that rise that might have occurred without intervention? Observed documentation - 13-20% - was low. Is it worth the effort of getting buy-in to automate these EHR nudges and spend FTE to hire a navigator? Particularly as health systems, who pushed for focusing on seriously ill patients because they are the most expensive/highest utilizers, did not get what they wanted, i.e. no difference in utilization of acute healthcare services between arms? Our guests provide a strong defense and additional context, which you can and should listen to on the podcast. And I have to point out, setting aside the advance care planning aspect, the method of identifying upstream primary care patients with serious illness is a major contribution to the field in and of itself. Pioneers in the field, led by Amy Kelley, have been working to identify the seriously ill population for over a decade. And a fun fact about All You Need is Love - the verses are in 7/4 time! -Alex Smith

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