Documentation of code status and discussion of goals of care in gravely ill hospitalized patients

2009 ◽  
Vol 24 (2) ◽  
pp. 288-292 ◽  
Author(s):  
Abigail Holley ◽  
Steven J. Kravet ◽  
Grace Cordts
Keyword(s):  
Hospitalized Patients ◽  
Goals Of Care ◽  
Code Status

scholarly journals Process Mapping to Examine How Goals of Care Discussions and Decisions about Life-Sustaining Treatments Occur On Medical Wards: A Multi-Center Observational Study

2020 ◽  
Vol 15 (1) ◽  
pp. 12-25
Author(s):  
Dev Jayaraman ◽  
Nishan Sharma ◽  
Alannah Smrke ◽  
Jessica Simon ◽  
Peter Dodek ◽  
...  
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Nous Avons ◽  
Healthcare Workers ◽  
Hospital Setting ◽  
Hospitalized Patients ◽  
Communication Process ◽  
Prise De Décision ◽  
Goals Of Care ◽  
Travailleurs De La Santé

BackgroundPoor quality communication about goals of care with seriously ill, hospitalized patients is associated with substantial discordance between prescribed medical orders for life-sustaining treatment and patients’ stated preferences. Designing tailored solutions to this discordance requires a better understanding of this communication process. ObjectiveTo acquire a detailed understanding of the process of communication about goals of care and decision making about life-sustaining treatments for hospitalized patients, and to seek opportunities for improvement. SettingMedical wards of three university-affiliated teaching hospitals in Canada. MethodAt each site, we used drop-in sessions and one-on-one interviews to consult with health care workers on eligible wards to create cross-functional (swim lane) maps of the process of communication about goals of care and decision making about life-sustaining treatments. Healthcare workers were also asked about barriers to this process to enable the identification of opportunities for improvement. ResultsA total of 112 healthcare workers provided input into the creation of process maps across the three sites. Common elements across sites were that: (1) physicians play a central role, (2) the full process for a given patient involves several interactions amongst members of the inter-professional team, and (3) the process is iterative. We also noted between-site variations in the location of GoC discussions and the extent to which trainees and multi-disciplinary team members were involved. Finally, we identified several key barriers that may serve as targets for future quality improvement efforts: suboptimal location of conversations, insufficient support of physician learners in goals-of-care conversations, and incomplete engagement of the inter-professional team. ConclusionEfforts to improve the quality of goals-of-care discussions and decision making about life-sustaining treatments in the hospital setting need to account for the central role played by physicians in the process but can be enhanced if they can more fully engage the inter-professional health care team.Resume Contexte Une communication de mauvaise qualité sur les objectifs des soins aux patients gravementmalades et hospitalisés est associée à une discordance importante entre les ordonnances médicales prescrites pour un traitement de survie et les préférences déclarées des patients. La conception de solutions adaptées à cette discordance nécessite une meilleure compréhension de ce processus de communication. ObjectifAcquérir une compréhension détaillée du processus de communication sur les objectifs des soins et la prise de décision sur les traitements de maintien de la vie pour les patients hospitalisés, et rechercher des possibilités d’amélioration. ParamètresLes services médicaux de trois hôpitaux universitaires canadiens affiliés à l’université. MéthodeSur chaque site, nous avons eu recours à des séances d’information et à des entretiens individuels pour consulter les travailleurs de la santé dans les services éligibles afin de créer des cartes interfonctionnelles (couloir de nage) du processus de communication sur les objectifs des soins et la prise de décision sur les traitements de maintien des fonctions vitales. Les travailleurs de la santé ont également été interrogés sur les obstacles à ce processus afin de permettre l’identification des possibilités d’amélioration. RésultatsAu total, 112 travailleurs de la santé ont participé à la création de cartes de processus sur les trois sites. Les éléments communs à tous les sites étaient les suivants : (1) les médecins jouent un rôle central, (2) le processus complet pour un patient donné implique plusieurs interactions entre les membres de l’équipe interprofessionnelle, et (3) le processus est itératif. Nous avons également noté des variations entre les sites en ce qui concerne le lieu des discussions du gouvernement et le degré d’implication des stagiaires et des membres de l’équipe pluridisciplinaire. Enfin, nous avons identifié plusieurs obstacles clés qui pourraient servir de cibles aux futurs efforts d’amélioration de la qualité : le lieu sous-optimal des conversations, le soutien insuffisant des apprenants médecins dans les conversations sur les objectifs de soins et l’engagement incomplet de l’équipe interprofessionnelle. ConclusionLes efforts visant à améliorer la qualité des discussions sur les objectifs des soins et la prise de décision concernant les traitements vitaux en milieu hospitalier doivent tenir compte du rôle central joué par les médecins dans le processus, mais peuvent être renforcés s’ils peuvent faire participer davantage l’équipe interprofessionnelle de soins de santé.

The pyramid of treatment levels: A tool to convey goal-based treatment options.

2018 ◽  
Vol 36 (34_suppl) ◽  
pp. 147-147
Author(s):  
Heather Leeper ◽  
Andrew Kamell
Keyword(s):  
Decision Making ◽  
Medical Care ◽  
End Of Life ◽  
Symptom Management ◽  
End Of Life Care ◽  
Life Care ◽  
Care Providers ◽  
Goals Of Care ◽  
Code Status ◽  
Wide Range

147 Background: 60% of Americans die in acute care hospitals and under 40% of advanced cancer patients have end-of-life care discussions with their health care providers. Didactic methods and tools to teach about symptom management, navigation of treatment decisions, code status, and end-of-life care decisions within an inpatient setting are a necessity to meet this high demand. Methods: A model of medical care systematically dividing clinical management decisions into escalating levels of medical care relative to illness severity, treatment goals, and code status was created. The model is illustrated as a pyramid with a base of symptom management as the initial level of medical care. The second level represents disease-focused medical care including antibiotics, disease-modifying drugs, and chemotherapy administration. Hospitalization with increasingly complex and invasive interventions represents the third level followed by critical illness care including ICU admission and vasopressors as the fourth level. Intubation comprises the fifth level and CPR forms the top of the pyramid. Results: This model has been used extensively at our institution in educating medical students, residents, fellows, and faculty. All groups reported it was helpful in understanding POLST forms, code status, and collaboratively developing appropriate goal-based care plans with their patients. Symptom management remaining as a non-negotiable foundation of care emphasizes its importance. This depiction of medical care may facilitate goals of care and code status discussions and is particularly helpful for determining appropriate care goals or options when considering de-escalation of medical therapies. Used implicitly or explicitly in patient and family discussions, it has facilitated decision-making and discerning the appropriateness of the overall treatment plan relative to patient goals of care. Conclusions: This model of care with its companion pyramid accommodate a wide range of clinical scenarios, is an effective, high yield didactic device for patients, families, and healthcare providers alike, and has applications as supportive tool to optimize goal-based clinical decision making in the context of serious illness.

scholarly journals The value of history and goals of care with code status; even in an emergency setting

2013 ◽  
Vol 2013 (jan25 1) ◽  
pp. bcr2012006962-bcr2012006962
Author(s):  
A. Irfan ◽  
S. Hublikar ◽  
J. H. Cho ◽  
J. Hill
Keyword(s):  
Emergency Setting ◽  
Goals Of Care ◽  
Code Status

Is there a shift in use of subacute rehabilitation (SAR) instead of hospice referral since immunotherapy became available?

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. 11530-11530
Author(s):  
Jonathan Yeh ◽  
Louise Knight ◽  
Joyce M. Kane ◽  
Danielle Doberman ◽  
Arjun Gupta ◽  
...  
Keyword(s):  
Cancer Therapy ◽  
Discharge Planning ◽  
Drug Approval ◽  
Do Not Resuscitate ◽  
Post Discharge ◽  
Goals Of Care ◽  
Code Status ◽  
Hospice Referral ◽  
Electronic Chart ◽  
Time Of Admission

11530 Background: Immunotherapy has rapidly become mainstream treatment. Since the first drug approval in 2011, we have noted a decline in referrals from inpatient oncology to hospice, and an increase in referrals to sub-acute rehabilitation (SAR) facilities, possibly with the aim of “getting strong enough” for immunotherapy and other promising drugs. This study explores outcomes after discharge to SAR, including rates of cancer-directed therapy after SAR, overall survival, and hospice utilization. Methods: Electronic chart review of patients discharged from oncology units to SAR facilities from 2009-2017. Demographics, admission statistics, and post-discharge outcomes were gathered from discharge summaries and targeted chart searches. Results: SAR referrals increased from 28 in 2012 to 82 in 2016. Age 66, males 52%, solid tumors 58%. 358 patients were referred to SAR 413 times. 174 patients (49%) returned to the oncology clinic prior to re-admission or death, and only 117 (33%) ever received further cancer-directed treatment (chemotherapy, radiation, or immunotherapy). 219 of 358 (61%) died within 6 months. Only 3 individuals who were not on immunotherapy at time of admission went on to receive immunotherapy after discharge to SAR. Among all discharges, 28% led to readmissions within 30 days. 74 patients (21%) were deceased within 30 days, of whom only 31% were referred to hospice. Palliative care involvement resulted in more frequent do not resuscitate (DNR) code status (33 v 22%), documented goals of care (GOC) discussions (81 v 23%), and electronic advance directives (42 v 28%).(All p<0.05). Conclusions: A growing number of oncology inpatients are being discharged to SAR, but two-thirds do not receive further cancer therapy at any point, including a substantial fraction that are re-admitted or deceased within 1 month. Many patients lose the opportunity to use hospice for optimal end of life care, as few SAR facilities offer this. These data can help guide decision-making and discharge planning that aligns with patients’ goals of care. More clinical data are needed to predict who is most likely to benefit from SAR and proceed to further cancer therapy.

Physician perceptions about goals of care of hospitalized patients with malignancies.

2020 ◽  
Vol 38 (15_suppl) ◽  
pp. e19234-e19234
Author(s):  
Nino Balanchivadze ◽  
Alexander Antoni Slota ◽  
Andrew Mangano ◽  
Adam Kudirka ◽  
Yaser Alkhatib
Keyword(s):  
Hospice Care ◽  
Hospital Setting ◽  
Hospitalized Patients ◽  
Actual Condition ◽  
Real Patient ◽  
Goals Of Care ◽  
Primary Care Residency ◽  
Cancer Management ◽  
Patient Goals ◽  
Hospice Referral

e19234 Background: More sophisticated treatment techniques in cancer management have led to increased complexity in patient care. The perception of cancer outcomes is different between physicians and may result in premature hospice referral in hospitalized patients with or without cancer-related acute illness. We created a clinical scenario-based survey to assess perceptions of goals of care choices of inpatient primary providers while caring for patients with malignancies. Methods: A survey was developed and sent to all internal medicine and primary care residency programs nationwide via “Survey Monkey” online platform. Cases were adapted from real patient encounters. A total of 8 cases were presented and physicians were asked to determine level of care. Two cases represented potentially curable disease, three described patients with treatable but incurable malignancies, and the remainder described patients with advanced malignancies appropriate for hospice care. Physicians were also questioned about patterns of consulting hematology/oncology (HO) and their opinions regarding barriers in providing care to patients with malignancies. Results: Of 269 physicians who took the survey, 184 physicians (68%) fully completed it. 37% reported consulting HO for every patient with underlying malignancy, while 2% of the providers do not have access to HO consultants. In curable cancers, 65% of physicians would request inpatient oncology consultation while 11% would initiate hospice referral. There was a significant variation in choices for care in treatable cancer cases. In case 1, 13% of surveyed physicians thought that patients were hospice appropriate, while a higher percentage felt the same for the 2nd and 3rd cases with 18% and 52%, respectively. For hospice-appropriate patients, 25% of providers felt that further cancer treatment should be performed in younger patients, while the majority agreed on hospice referral (91%) for older patients. The most reported barrier to providing care to hospitalized patients with malignancies was a disconnect between the perception of goals of care of the primary treating oncologist/hematologist and patient’s actual condition. Conclusions: Perceptions about goals of care in hospitalized patients with malignancies varies and is affected by patient age and perceived severity of disease, which doesn’t necessarily translate into outcome statistics reported in literature. A multidisciplinary approach and treating oncologist involvement might be warranted when patient goals of care change is planned in hospital setting.

scholarly journals Processes of code status transitions in hospitalized patients with advanced cancer

Cancer ◽  
2017 ◽  
Vol 123 (24) ◽  
pp. 4895-4902 ◽  
Author(s):  
Areej El‐Jawahri ◽  
Kelsey Lau‐Min ◽  
Ryan D. Nipp ◽  
Joseph A Greer ◽  
Lara N. Traeger ◽  
...  
Keyword(s):  
Advanced Cancer ◽  
Hospitalized Patients ◽  
Code Status
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