Document Type



Doctor of Nursing Practice



Date of Defense


Graduate Advisor

Dr. Nancy Magnuson, Nursing


Nancy Magnuson, DSN, APRN, PCNS, FNP-BC

Vanessa Loyd, DNP, PhD, RN

Linda Cornejo, BSN, RN, MBA



Problem: Palliative care (PC) services are widely underutilized for patients with cancer, partly due to the shortage of PC specialists. Additionally, many Americans have not filled out advance directive (AD) paperwork which is commonly addressed in PC. In the absence of an AD, cancer patients are at risk of receiving undesired aggressive treatments in the event they are unable to make decisions independently.

Methods: This quality improvement pilot initiative utilized a descriptive observational design to evaluate the number of ADs documented in the electronic health record (EHR) on an inpatient oncology unit. A retrospective EHR review was used to collect baseline comparison data. A prospective EHR review was performed after the implementation of visual aids, daily reminders, and audit tools for nurses.

Results: Chart review of 70 patients before implementation showed 21 patients (30%) had ADs documented. After implementation, a chart review of 80 patients showed 33 patients (41.3%) had ADs documented. Pre-implementation, 42 patients (60%) were screened for ADs at the time of admission. The number of patients screened increased to 73 patients (91.3%) in the post-implementation group. A Chi-square test of independence between screening for AD and documentation of AD was statistically significant (p < .001).

Implications for Practice: Implementation of visual aids, daily reminders, and audits improved nurses’ awareness of patients without AD paperwork. The findings of this study suggest several approaches could be implemented by nurses regarding PC services and the importance of ADs.