Mary Kiely

Mary Kiely

New York University Langone Health, USA

Title: Advanced care planning in an outpatient infusion center


Mary Kiely holds a DNP from the University of Alabama at Birmingham and a Master of Science in Nursing from Hunter College in New York. She practices full-time as a level III Adult Nurse Practitioner and is ANCC certified in Rheumatology. Her specialty is in Infusion Therapy. She has published and presented posters on her area of expertise at the Rheumatology Nurses Society’s annual national conferences and within NYU Langone Health. She is also on the Faculty of the New York University Rory Meyers College of Nursing with the adult-gerontology primary care nurse practitioner program.


Statement of the Problem: The national framework and preferred practices for palliative and hospice care quality recommends advance care planning (ACP) as an ongoing discussion throughout an adult’s lifetime. A health care proxy (HCP) is a written advanced directive enabling anyone 18+ years of age to appoint another person(s) to make medical decisions if temporary or permanent incapacity occurs. Less than 35% of Americans, however, have ACP directives. Patients with chronic immune-mediated inflammatory diseases (CIID) including systemic connective tissue disorders, rheumatoid arthritis, and inflammatory bowel diseases have increased morbidity and mortality risk due to cardiovascular events. The quality improvement goal is to implement a plan that encourages these patients to engage in ACP discussions to make early decisions about their future care.

Supporting Evidence: The most common patient barrier to ACP is a lack of awareness regarding advanced directives.  A recent study revealed 79% of advanced practice nurses (APNs) identified an educational need to increase knowledge and ease of discussion about ACP.   

Methodology: Patients with CIID treated in a non-oncology infusion center present an opportunity to discuss this issue. As an intervention the APN meets with infusion patients prior to initial infusion to introduce ACP, educate them about a HCP and facilitate document completion.

Measure: A retrospective review of the medical record for evidence of HCP education and document completion.

Results: N=320 patients with an increase from 12.9% to 30% of patients with designated HCP on record post counseling.

Conclusion:  Initiating a conversation about designating a HCP increased the number of patients with HCPs.

Recommendations:  Educational initiatives for patients and APNs in outpatient departments will increase the likelihood of incorporating ACP into patient care.  Respecting Choices Last Steps® is an established program in 287 U.S. medical centers focused on developing skills for early ACP discussions.