Palliative Care Clinicians’ Perceptions of Clinician Bias and Bias Management in Goals of Care Discussions at the End of Life (S709)

Purpose Palliative care is a philosophy of care that encompasses holistic, patient-centric care involving patients and their family members and loved ones. Palliative care patients often have complex needs. A common challenge in managing patients near their end of life is the complexity of navigating clinical decisions and finding achievable and realistic goals of care that are in line with the values and wishes of patients. This often results in differing opinions and conflicts within the multidisciplinary team. Conclusion This article describes a tool derived from the biopsychosocial model and the 4-quadrant ethical model. The authors describe the use of this tool in managing a patient who wishes to have fried chicken despite aspiration risk and how this tool was used to encourage discussions and reduce conflict and distress within the multidisciplinary team.

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Quality Improvement Initiatives to Reduce Mortality: An Opportunity to Engage Palliative Care and Improve Advance Care Planning

American Journal of Hospice and Palliative Medicine® ◽

10.1177/1049909118794149 ◽

2018 ◽

Vol 36 (2) ◽

pp. 97-104 ◽

Cited By ~ 3

Author(s):

Signe Peterson Flieger ◽

Erica Spatz ◽

Emily J. Cherlin ◽

Leslie A. Curry

Keyword(s):

Palliative Care ◽

Quality Improvement ◽

End Of Life ◽

Advance Care Planning ◽

Secondary Analysis ◽

Care Quality ◽

Care Planning ◽

Goals Of Care ◽

Patient Goals ◽

Advance Care

Background: Despite substantial efforts to integrate palliative care and improve advance care planning, both are underutilized. Quality improvement initiatives focused on reducing mortality may offer an opportunity for facilitating engagement with palliative care and advance care planning. Objective: In the context of an initiative to reduce acute myocardial infarction (AMI) mortality, we examined challenges and opportunities for engaging palliative care and improving advance care planning. Methods: We performed a secondary analysis of qualitative data collected through the Leadership Saves Lives initiative between 2014 and 2016. Data included in-depth interviews with hospital executives, clinicians, administrators, and quality improvement staff (n = 28) from 5 hospitals participating in the Mayo Clinic Care Network. Focused analysis examined emergent themes related to end-of-life experiences, including palliative care and advance care planning. Results: Participants described challenges related to palliative care and advance care planning in the AMI context, including intervention decisions during an acute event, delivering care aligned with patient and family preferences, and the culture around palliative care and hospice. Participants proposed strategies for addressing such challenges in the context of improving AMI quality outcomes. Conclusions: Clinicians who participated in an initiative to reduce AMI mortality highlighted the challenges associated with decision-making regarding interventions, systems for documenting patient goals of care, and broader engagement with palliative care. Quality improvement initiatives focused on mortality may offer a meaningful and feasible opportunity for engaging palliative care. Primary palliative care training is needed to improve discussions about patient and family goals of care near the end of life.

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OP456 Encouraging Shared Decision-Making Of Goals Of Care Discussions In Lung Cancer Patients Using A Smartphone Application

International Journal of Technology Assessment in Health Care ◽

10.1017/s0266462321001070 ◽

2021 ◽

Vol 37 (S1) ◽

pp. 17-17

Author(s):

Amanda Lovato ◽

Nisha Almeida

Keyword(s):

Lung Cancer ◽

Palliative Care ◽

Focus Groups ◽

End Of Life ◽

Cancer Patients ◽

Smartphone Application ◽

Quality Improvement Initiative ◽

Care Hospital ◽

Goals Of Care ◽

Lung Cancer Patients

IntroductionAn important reason for receiving non-beneficial treatment at end-of life is the lack of timely discussions on goals of care and end-of-life preferences. A recent randomized clinical trial demonstrated that patients primed with a questionnaire on their end-of-life preferences were more likely to initiate such conversations with their doctors. Our objective is to integrate the questionnaire into a smartphone application to facilitate early goals of care discussions. To achieve this goal, we first plan to undertake a feasibility study to understand stakeholder preferences.MethodsAs part of a quality improvement initiative at our Canadian quaternary-care hospital, we conducted focus groups with oncology and palliative care physicians and patients to understand barriers to early conversations on end-of-life preferences, and to assess feasibility of using smartphone technology in facilitating these conversations. The app would integrate a questionnaire to patients and send prompts to physicians on patient readiness and timing of conversations.ResultsWe conducted separate focus groups with lung cancer patients (n = 6) and clinicians in oncology (n = 6) and palliative care (n = 6). Clinical teams expressed enthusiasm about early conversations but raised several barriers including system (lack of electronic documentation and access to data; multiple physicians), clinician (lack of time) and patient (stigma associated with end-of-life) barriers. Clinicians agreed that an app could overcome some of these barriers such as access to patient and electronic data by making patients the repository of all their data and empowering them to initiate discussions. However, they raised concerns about universal accessibility of such technology, especially among the elderly. Patient focus groups will take place in March 2021 and inform us on feasibility in this population.ConclusionsThere is a consensus among physicians at our hospital that early end-of-life conversations have the potential to mitigate adverse events and that use of a smart phone app could facilitate such conversations.

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Aggressive care at the end of life: A study of practice based factors in patients with stage IV cancer.

Journal of Clinical Oncology ◽

10.1200/jco.2017.35.8_suppl.80 ◽

2017 ◽

Vol 35 (8_suppl) ◽

pp. 80-80

Author(s):

Mohammad Omar Atiq ◽

Rahul Ravilla ◽

Ajay Kumar ◽

Sajjad Haider ◽

Ji-Ling Tang ◽

...

Keyword(s):

Palliative Care ◽

Length Of Stay ◽

End Of Life ◽

Cancer Patients ◽

Stage Iv ◽

Goals Of Care ◽

Significant Difference ◽

Aggressive Care ◽

Stage Iv Cancer ◽

End Stage

80 Background: Numerous studies established that early utilization of palliative care-hospice services are beneficial to cancer patients. To reduce the incidence of aggressive care in terminal cancer patients, we conducted a quality improvement study to identify pertinent risk factors and develop interventions. Methods: Through chart review, we retrospectively identified patients with stage IV cancer that were followed by oncology clinic and were admitted to the University Hospital between 8/1/2015-10/31/15. For those patients who died during the last hospitalization or were discharged to hospice care, we obtained demographic, cancer related and practice related variables listed in Table. We used Mann Whitney U test and multivariable regression to find effects of factors related to length of stay (LOS) and cost of stay (COS). Results: Length of stay was significantly prolonged in those receiving chemotherapy within the past month (6 vs 3 p=0.035). Multivariate analyses found that patients with goals of care documented in the clinic had lower COS by 36.7% and LOS by 46.7%. On average, an ICU stay resulted in COS 2.2 times higher. No significant difference was seen in LOS based on a documented palliative care clinic visit or presence of an advanced directive. Conclusions: We identified practice based factors that need improvement including earlier goals of care conversations and less chemotherapy at the end of life. Identifying end stage patients in earlier admissions, collaborating with palliative care, and adding goals of care documentation to clinic note templates, are all interventions we are studying to improve care for end stage cancer patients. [Table: see text]

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Managing Bias in Palliative Care: Professional Hazards in Goals of Care Discussions at the End of Life

American Journal of Hospice and Palliative Medicine® ◽

10.1177/1049909117707486 ◽

2017 ◽

Vol 35 (2) ◽

pp. 355-363 ◽

Cited By ~ 1

Author(s):

Katharine A. Callaghan ◽

Joseph B. Fanning

Keyword(s):

Palliative Care ◽

End Of Life ◽

Management Strategies ◽

Life Goals ◽

Semistructured Interview ◽

Patient Centered ◽

Perfect Agreement ◽

Goals Of Care ◽

Self Recognition ◽

Centered Care

Background: In the setting of end-of-life care, biases can interfere with patient articulation of goals and hinder provision of patient-centered care. No studies have addressed clinician bias or bias management specific to goals of care discussions at the end of life. Objectives: To identify and determine the prevalence of palliative care clinician biases and bias management strategies in end-of-life goals of care discussions. Design: A semistructured interview guide with relevant domains was developed to facilitate data collection. Participants were asked directly to identify biases and bias management strategies applicable to this setting. Two researchers developed a codebook to identify themes using a 25% transcript sample through an iterative process based on grounded theory. Inter-rater reliability was evaluated using Cohen κ. It was 0.83, indicating near perfect agreement between coders. The data approach saturation. Setting/Participants: A purposive sampling of 20 palliative care clinicians in Middle Tennessee participated in interviews. Results: The 20 clinicians interviewed identified 16 biases and 11 bias management strategies. The most frequently mentioned bias was a bias against aggressive treatment (n = 9), described as a clinician’s assumption that most interventions at the end of life are not beneficial. The most frequently mentioned bias management strategy was self-recognition of bias (n = 17), described as acknowledging that bias is present. Conclusion: This is the first study identifying palliative care clinicians’ biases and bias management strategies in end-of-life goals of care discussions.

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Transitions between care settings until death

Oxford Textbook of Geriatric Medicine ◽

10.1093/med/9780198701590.003.0039 ◽

2017 ◽

pp. 287-294

Author(s):

Elizabeth C. Gundersen ◽

Benjamin A. Bensadon ◽

Joseph G. Ouslander

Keyword(s):

Palliative Care ◽

End Of Life ◽

Geriatric Patients ◽

Care Transitions ◽

Healthcare Systems ◽

Goals Of Care ◽

Vulnerable Patients ◽

Treatment Plans ◽

Multifaceted Interventions ◽

Poor Care

The problem of poor care transitions in geriatric patients is complex and challenging, and one which has become a priority across healthcare systems. Various interventions have shown success in improving transitions in care, but there is no one solution and more progress must yet be made, especially in the care of our most vulnerable patients, including those with dementia or at the end of life. Perhaps the most commonly recurring themes, however, are the need for multifaceted interventions and increased patient- and family-centred care. It is essential to discuss goals of care with patients and families, and then form treatment plans—including discharge plans—which respect those goals. Geriatric and palliative care clinicians are uniquely suited to contribute their skills in this area to improve care transitions.

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Clinical ethics consultation in oncology.

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.15_suppl.9121 ◽

2012 ◽

Vol 30 (15_suppl) ◽

pp. 9121-9121

Author(s):

Andrew G Shuman ◽

Sacha M Montas ◽

Andrew R Barnosky ◽

Lauren B Smith ◽

David W Kissane ◽

...

Keyword(s):

Palliative Care ◽

End Of Life ◽

Advance Directives ◽

Professional Education ◽

Clinical Ethics ◽

Interpersonal Conflict ◽

Ethics Consultation ◽

Clinical Ethics Consultation ◽

Goals Of Care ◽

Code Status

9121 Background: There is limited empirical research exploring the nature of clinical ethical consultations within the oncology population. Our objective is to review, describe and compare clinical ethics consultations at two NCI-designated comprehensive cancer centers, in order to identify opportunities for systems improvement in clinical care. Methods: This case series is derived from prospectively-maintained clinical ethics consultation databases at each institution. All adult oncology patients receiving ethics consultation from 2007 through 2011 were included as eligible cases. Both qualitative and quantitative analyses were undertaken. Demographic and clinical information were obtained from the databases for all patients, and verified via chart abstraction. Additional variables studied included the reason for and context of the ethical consultation, the patient’s code status before and after consultation, and involvement of palliative care or other adjuvant services. Opportunities for systems-level improvements and/or educational initiatives were identified. Results: A total of 207 eligible cases were identified. The most common primary issues leading to ethics consultation were code status and advance directives (25%), surrogate decision-making (17%), and medical futility (13%). Communication lapses were identified in 41%, and interpersonal conflict arose in 51%. Prior to ethics consultation, 26% of patients were DNR; 60% were DNR after ethics consultation. Palliative care consultation occurred in 41% of cases. Opportunities for systems improvement and professional education related to goals of care at the end of life, the role of palliative care involvement, and improved communication. Conclusions: Ethics consultations among cancer patients reflect the realities inherent to their clinical management. Appropriately addressing advance directives within the context of overall goals of care is crucial. Thoughtful consideration of communication barriers, sources of interpersonal conflict, symptom control, and end-of-life care are paramount to optimal management strategies in this patient population.

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Early introduction of palliative care for children with solid tumors.

Journal of Clinical Oncology ◽

10.1200/jco.2014.32.31_suppl.23 ◽

2014 ◽

Vol 32 (31_suppl) ◽

pp. 23-23

Author(s):

Karen S. Fernandez ◽

Rober J. Lucia ◽

Rachel Buchheit ◽

Michele J. Holman ◽

Penelope Sandiford ◽

...

Keyword(s):

Palliative Care ◽

High Risk ◽

Physical Function ◽

End Of Life ◽

Solid Tumors ◽

Professional Relationship ◽

Goals Of Care ◽

Early Introduction ◽

Palliative Care Consultation ◽

The Impact

23 Background: Patients with solid tumors (ST) have the highest rate of relapse and mortality among pediatric oncology. Many patients suffer from acute and chronic therapy-related toxicity that have major implications in the patients’ lives. An early introduction of palliative care consultation (PCC) for patients with ST was implemented in 2012. Objectives: To assess the impact of the early introduction of PCC for children with ST on 1) Facilitation of interdisciplinary meetings (IDM) and goals of care 2) Counseling support including coping, advocacy, self-care, 3) Grieving, 4) End-of-life decision making/planning, and 5) Bereavement. Methods: An audit of all PCC from November/2012 to May/2014 was performed. Newly diagnosed patients with high risk ST (metastatic disease, need for HSCT or risk for relapse of > 30%) were eligible for early PCC (36/44). Patients with brain tumors were excluded (19). Counselors were introduced to the patient/family at diagnosis. The perception of the intervention was explored among physicians and counselors. Results: 29/35 patients (72%) were offered early PCC, 1 declined the intervention. 17/29 developed disease relapse or progression (58%), 11/17 died. 9/29 had high risk ST without relapse (31%), 6/29 had loss of physical function (21%), 5/29 had other chronic diseases (17%). 20 had IDM for re-direction of goals of care. 25 (86%) received at least 1 of 3 counseling aspects. 20 received grieving support during treatment (6 due to loss of physical function, 4 during relapse and 11 during the dying process). 11 received end-of-life and bereavement support. Median number of visits/patient was 14. Pediatric oncologists felt early PCC favored effective communication between patients/families and medical teams, counselors felt early PCC was critical for rapport and trust building for an effective and productive professional relationship that strengthen the continuity of care. Conclusions: Early PCC for children with ST is feasible, and well-accepted by patients/families and physicians. It facilitates the comprehensive care of patients with ST throughout the disease trajectory.

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Process measures of palliative and end-of-life care among young adults who died from cancer.

Journal of Clinical Oncology ◽

10.1200/jco.2018.36.34_suppl.54 ◽

2018 ◽

Vol 36 (34_suppl) ◽

pp. 54-54

Author(s):

Hanneke Poort ◽

Sophia Zupanc ◽

Alexi A. Wright ◽

Charlotta Lindvall

Keyword(s):

Palliative Care ◽

End Of Life ◽

End Of Life Care ◽

Cancer Center ◽

Life Care ◽

Process Measures ◽

Goals Of Care ◽

Code Status ◽

Essential Components ◽

Eol Care

54 Background: Timely delivery of palliative and end-of-life care (EOL) are essential components of high-quality cancer care. To date, however, few studies have examined process measures for EOL care in young adult (YA; ages 18-35 years) cancer decedents. Methods: We conducted a retrospective study using medical records of YA decedents who received cancer treatment at an academic cancer center between Jan. 1, 2012 and June 13, 2018. We used natural language processing (NLP) with validated key words to identify documentation of four process measures – palliative care involvement, and discussions of goals of care, code status, and hospice – from documented clinical encounters in the medical record within 6 months of death. Results: During this period 146/2,878 (5.1%) YA patients had a recorded death date and a first note at least 31 days prior to death. In this decedent cohort, the mean age was 28.2 years (SD=4.4) and 58.9% were men. The most common diagnoses were brain cancer (33.6%), sarcoma (19.9%), and breast cancer (12.3%). The 146 patients accrued 26,441 clinical notes during the last 6 months of life (median=116.5 notes, IQR 37.0-222.0). Using NLP, we identified that 68.5% of the 146 YAs had at least one process measure documented in the last 6 months of life, including: 54.1% palliative care involvement; 56.8% discussions of goals of care; 47.3% discussions of code status; and 51.4% discussions of hospice. On average, palliative care was documented 7.5 times (range 0-75); goals of care 6.1 times (range 0-43), code status 1.9 times (range 0-12), and hospice 8.1 times (range 0-67). Late documentation of process measures (defined as first recorded within 30 days of death) included: hospice (45.3%), code status (30.3%), palliative care (20.8%), and goals of care (9.6%). Notably, in 31.5% of YAs, we did not detect documentation of any process measures prior to death. Conclusions: In this cohort of YA cancer decedents, nearly one-third of YAs did not have documentation of any process measures, highlighting the importance of efforts to improve EOL care communication with this young population.

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Interpreting in palliative care: A systematic review of the impact of interpreters on the delivery of palliative care services to cancer patients with limited English proficiency.

Journal of Clinical Oncology ◽

10.1200/jco.2014.32.31_suppl.123 ◽

2014 ◽

Vol 32 (31_suppl) ◽

pp. 123-123 ◽

Cited By ~ 2

Author(s):

Milagros Silva ◽

Margaux Genoff ◽

Alexandra Zaballa ◽

Stacy Marie Stabler ◽

Francesca Gany ◽

...

Keyword(s):

Systematic Review ◽

Palliative Care ◽

Quality Of Care ◽

End Of Life ◽

Limited English Proficiency ◽

Goals Of Care ◽

Care Services ◽

Palliative Care Services ◽

The Impact

123 Background: According to the 2011 U.S. Census 60% of people living in the U.S. speak a language other than English at home, and of these approximately 40% have limited English proficiency (LEP). Language barriers can affect the health outcomes of LEP patients and the use of trained interpreters can improve patient-physician communication. Since effective communication is the cornerstone of delivering adequate palliative care, a systematic review was conducted to determine the impact of interpreters on the delivery of palliative care services to LEP patients with cancer. Methods: We conducted a systematic review of the literature search in all available languages of 6 databases from 1966 and 2013. Studies evaluated interpreter interventions for LEP patients receiving palliative care services. Of 38 references, 11 articles were found by multiple reviewers to meet inclusion criteria. Data were collected on the study design, size, comparison groups, outcomes, and interpreter characteristics. Results: A total of 6 qualitative and 5 quantitative studies assessed the use of interpreters. All studies found that the quality of care provided to LEP patients receiving palliative services is affected by communication. Most studies showed that when no trained interpreters were used, LEP patients and families had inadequate understanding about their diagnosis or prognosis during goals of care conversations, and worse symptom management at end of life including pain and anxiety. Half of the studies concluded that trained interpreters are not utilized adequately and several suggested that pre-meetings between clinicians and interpreters are important to discuss topics and terminology to be used during goals of care conversations. Conclusions: Published studies show worse outcomes during end of life care and goals of care discussions when trained interpreters are not used. Moreover, trained interpreters are not being used appropriately in the field. More clinically relevant studies are needed to improve the quality of care provided to LEP patients and families receiving palliative services.

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