TOPLINE:

Several triggers, such as consultations for malignancy and heart failure, noted in electronic health records (EHRs) of older adults were associated with mortality. The initiation of advance care planning often occurred close to or even earlier than the optimal timing windows.

METHODOLOGY:

• Researchers conducted a nested case-control study using data from EHRs from primary care in a province in Netherlands to identify triggers for initiating advance care planning.
• They analysed 17,098 records of individuals aged 65 years or older, of which 4139 were from deceased individuals (mean age, 81 years; 49.7% women) who were propensity score matched with 12,959 individuals who were alive (mean age, 79 years; 57.7% women) after the follow-up from January 2017 to January 2020.
• Triggers for initiating advance care planning were identified using routine EHRs and national data.
• The "optimal time window" to start advance care planning, expressed as the median number of days, was determined by presenting anonymised routine EHRs of patients who died of cancer, organ failure, or multimorbidity to GPs, and the best time to initiate advance care planning was identified.
• The study focused on the timing of triggers relative to an optimal time window for advance care planning, and the association of triggers with death was assessed.

TAKEAWAY:

• Triggers such as consultations for malignancy (odds ratio [OR], 8.35; 95% CI, 7.42-9.41), heart failure (OR, 5.25; 95% CI, 4.59-5.99), dementia (OR, 4.75; 95% CI, 3.99-6.56), general decline (OR, 4.15; 95% CI, 3.72-4.64), and skin ulcers (OR, 4.04; 95% CI, 3.55-4.61) were associated with mortality.
• The median timing of triggers, including consultations for dyspnoea, general decline, and fever, closely aligned with the median of the optimal time window for advance care planning.
• Prescriptions of opioids were associated with mortality (OR, 4.58; 95% CI, 4.25-4.93), and consultations for these had a median timing closest to the median of the optimal time window for advance care planning; however, the timing for prescriptions of oral corticosteroids, oral diuretics, and insulin was earlier.
• Emergency department referrals (OR, 7.11; 95% CI, 6.52-7.75), a home visit (OR, 5.97; 95% CI, 5.51-6.47), and hospital admissions (OR, 7.32; 95% CI, 6.75-7.94) were also significant triggers, with a median timing closest to the median of the optimal time window for advance care planning.

IN PRACTICE:

"GPs can use the triggers identified in the EHR in an automated computer search to prioritise patients for ACP [advance care planning]. They may prioritise ACP in patients with multiple triggers present in their EHR, particularly those more present in deceased patients and with closest proximity to the optimal ACP timing window," the authors wrote.

SOURCE:

This study was led by Willemijn Tros, Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands. It was published online on November 29, 2025, in BMJ Open.

LIMITATIONS:

The end-of-life communication was used as a reference for advance care planning and may not have fully captured its broader scope. The reliance on routine EHRs may have resulted in underreporting or missing data. The mean age of the cohort was around 80 years, and its urban-rural composition may have limited generalisability to other older populations.

DISCLOSURES:

This study was supported by a European Research Council Consolidator grant and Leiden University Medical Center. No relevant conflicts of interest were disclosed by the authors.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.