Background: We discovered four out of five Medical Oncology patients admitted to the hospital December 2019 and January 2020 were discharged to hospice and died within a week. None of those patients had advance directives. In November and December 2019, all oncology patient charts were reviewed and only 7% (12/174) had advance directives. We believe an established advance directive could have helped avoid unnecessary hospitalization, improved end of life care and reduced wasteful health care costs. This led to the question: Would process changes in a rural cancer center lead to an increase in completion and documentation of Advance Directives, thereby providing more patient goal congruent care?Methods: Data collection and process mapping was performed revealing current processes and overall barriers. This was analyzed and countermeasures were developed leading to process changes and interventions. The interventions included assigning dedicated staff to “own” the advance directives education, follow up and completion, training and certification of staff, and education of the entire Cancer Center on the new process and interventions. The new process included a standardized order set to cue a referral to the dedicated staff, standardized patient education and follow up and documentation consistencies. Results: The initial data collection revealed an advance directive completion rate of 7% in new oncology patients. Process inconsistencies and communication deficiencies, with redundant screening and no follow up, created significant barriers to advance directives. Repeat data collection after creating a position for dedicated staff to educate patients and help with advance directive completion revealed a completion and documentation rate of 6% and thus, was insufficient to lead to change. When a consistent process with formal communication to the dedicated staff was implemented, improvements were noted. Our most recent data collection revealed a 36% completion and documentation rate in advance directives. Conclusions: Lack of effective advance directive programs potentially lead to end of life care incongruent with patients’ wishes and wasteful of health care resources. An advance directive ensures that if a patient is unable to clearly communicate their wishes, these wishes are still honored. In addition, the advance directive can help avoid unnecessary hospitalizations, improve end of life care and reduce wasteful health care costs. As a rural cancer center with a limited service area, we are challenged with a small sample size. Practice will be needed to ensure consistency and efficacy of the current interventions in order to support continued improvement in completion and documentation rates of advance directives. This project will be expanded to address advance directives for all patients.