Year of Publication


Degree Name

Doctor of Nursing Practice

Committee Chair

Dr. Elizabeth Tovar

Clinical Mentor

Dr. Jacqueline Gibson

Committee Member

Dr. Mollie Aleshire


Background: Advance directives (ADs) are a proactive, patient-centered tool to facilitate communication about end-of-life wishes between patients, family members, and healthcare providers. Increased importance on ADs is now emphasized in primary care settings; however, findings from recent studies indicate poor documentation of AD discussions or decisions in primary care.

Purpose: To assess current AD documentation practices in an internal medicine primary care department and to explore provider perceptions of facilitators and barriers for discussion and documentation of end-of-life preferences.

Methods: This descriptive study was conducted in three phases: 1) assessment of current state of AD documentation by retrospective chart review of 150 random charts of patients who presented for routine visits from June 1, 2014 to September 30, 2015; 2) anonymous electronic provider survey assessing provider’s facilitators and barriers to discussion and documentation of ADs; and 3) provider focus group exploring facilitators and barriers of AD discussion and documentation and potential solutions to increase AD documentation in clinic.

Results: Only two out of 150 charts had AD documentation and both visits were Annual Wellness Visits. Providers’ perceived barriers to AD discussion and documentation included time, lack of urgency and difficulty finding a place to document AD discussion. The key facilitator included the option of Annual Wellness Visits for patients 65 years and older.

Recommendations: Recommendations to improve AD documentation include three strategies: increase awareness of ADs among providers, utilize a standardized AD patient education tool, and encourage patient participation in Annual Wellness Visits.