预先指示 (AD) 指定是预先护理计划 (ACP) 的重要组成部分，有助于使护理与患者目标保持一致。然而，它在高风险手术癌症患者中并未得到充分利用，并且多种障碍导致该人群的 AD 指定率较低。旨在评估早期姑息治疗整合与接受手术的癌症患者中 AD 指定变化的关联。这项队列研究是对 2016 年 6 月至 2022 年 5 月期间在具有区域治疗专业知识的综合癌症中心的肿瘤外科诊所接受晚期腹部和软组织恶性肿瘤择期手术的成年患者的前瞻性登记的回顾性分析，其中中位 (IQR) 术后随访时间为 27 (15-43) 个月。数据分析于 2022 年 12 月至 2023 年 4 月进行。使用电子健康记录 (EHR)、术前检查表和住院医师教育，将 ACP 建议和早期姑息治疗咨询整合到 2020 年手术工作流程中。主要结果是 AD 指定和记录。进行多变量逻辑回归来评估与 AD 指定和记录相关的因素。 在 326 名患者中（中位 [IQR] 年龄 59 [51-67] 岁；189 名女性患者 [58.0%]；243 名非西班牙裔白人患者 [77.9%] ]）接受手术的 254 名患者（77.9%）被指定为 AD。指定率从工作流程集成前的 72.0%（182 名患者中的 131 名）增加到 2020 年工作流程集成后的 85.4%（144 名患者中的 123 名）（P = .004）。 2020 年工作流程集成后，AD 记录率并没有显着增加（记录了 48.9% [182 个 AD 中的 89 个]，而记录了 56.3% [144 个 AD 中的 81 个；P = .19）。 AD 认定与姑息治疗咨询（比值比 [OR]，41.48；95% CI，9.59-179.43；P < .001）、姑息治疗（OR，5.12；95% CI，1.32-19.89；P = .02）、最高年龄四分位数（OR，3.79；95% CI，1.32-10.89；P = .01）和工作流程集成（OR，2.05；95% CI，1.01-4.18；P = .048）。自我认定为非西班牙裔白人以外的种族或族裔的患者患指定 AD 的可能性较小（OR，0.36；95% CI，0.17-0.76；P = .008）。 AD 记录与姑息治疗咨询（OR，4.17；95% CI，2.57-6.77；P < .001）和最高年龄四分位数（OR，2.41；95% CI，1.21-4.79；P = .01）相关。综合 ACP 计划与接受手术的晚期癌症患者的 AD 指定率增加相关。这些发现证明了修改临床路径、整合基于 EHR 的干预措施以及在高级护理患者的手术流程中与姑息治疗医生同居的可行性和重要性。

Advance directive (AD) designation is an important component of advance care planning (ACP) that helps align care with patient goals. However, it is underutilized in high-risk surgical patients with cancer, and multiple barriers contribute to the low AD designation rates in this population.To assess the association of early palliative care integration with changes in AD designation among patients with cancer who underwent surgery.This cohort study was a retrospective analysis of a prospectively maintained registry of adult patients who underwent elective surgery for advanced abdominal and soft tissue malignant tumors at a surgical oncology clinic in a comprehensive cancer center with expertise in regional therapeutics between June 2016 and May 2022, with a median (IQR) postoperative follow-up duration of 27 (15-43) months. Data analysis was conducted from December 2022 to April 2023.Integration of ACP recommendations and early palliative care consultations into the surgical workflow in 2020 using electronic health records (EHR), preoperative checklists, and resident education.The primary outcomes were AD designation and documentation. Multivariable logistic regression was performed to assess factors associated with AD designation and documentation.Among the 326 patients (median [IQR] age 59 [51-67] years; 189 female patients [58.0%]; 243 non-Hispanic White patients [77.9%]) who underwent surgery, 254 patients (77.9%) designated ADs. The designation rate increased from 72.0% (131 of 182 patients) before workflow integration to 85.4% (123 of 144 patients) after workflow integration in 2020 (P = .004). The AD documentation rate did not increase significantly after workflow integration in 2020 (48.9% [89 of 182] ADs documented vs 56.3% [81 of 144] ADs documented; P = .19). AD designation was associated with palliative care consultation (odds ratio [OR], 41.48; 95% CI, 9.59-179.43; P < .001), palliative-intent treatment (OR, 5.12; 95% CI, 1.32-19.89; P = .02), highest age quartile (OR, 3.79; 95% CI, 1.32-10.89; P = .01), and workflow integration (OR, 2.05; 95% CI, 1.01-4.18; P = .048). Patients who self-identified as a race or ethnicity other than non-Hispanic White were less likely to have designated ADs (OR, 0.36; 95% CI, 0.17-0.76; P = .008). AD documentation was associated with palliative care consulation (OR, 4.17; 95% CI, 2.57- 6.77; P < .001) and the highest age quartile (OR, 2.41; 95% CI, 1.21-4.79; P = .01).An integrated ACP initiative was associated with increased AD designation rates among patients with advanced cancer who underwent surgery. These findings demonstrate the feasibility and importance of modifying clinical pathways, integrating EHR-based interventions, and cohabiting palliative care physicians in the surgical workflow for patients with advanced care.