Risk of 12-month mortality among hospital inpatients using the surprise question and SPICT criteria: a prospective study

ObjectivesPeople with serious life-limiting disease benefit from advance care planning, but require active identification. This study applied the Gold Standards Framework Proactive Identification Guidance (GSF-PIG) to a general hospital population to describe high-risk patients and explore prognostic performance for 12-month mortality.MethodsProspective cohort study conducted in a metropolitan teaching hospital in Australia. Hospital inpatients on a single day aged 18 years and older were eligible, excluding maternity and neonatal, mental health and day treatment patients. Data sources included medical record and structured questions for medical and nursing staff. High-risk was predefined as positive response to the surprise question (SQ) plus two or more SPICT indicators of general deterioration. Descriptive variables included demographics, frailty and functional measures, treating team, advance care planning documentation and hospital utilisation. Primary outcome for prognostic performance was 12-month mortality.ResultsWe identified 540 eligible inpatients on the study day and 513 had complete data (mean age 60, 54% male, 30% living alone, 19% elective admissions). Of these, 191 (37%) were high-risk; they were older, frailer, more dependent and had been in hospital longer than low-risk participants. Within 12 months, 92 participants (18%) died (72/191(38%) high-risk versus 20/322(6%) low-risk, P<0.001), providing sensitivity 78%, specificity 72%, positive predictive value 38% and negative predictive value 94%. SQ alone provided higher sensitivity, adding advanced disease indicators improved specificity.ConclusionsThe GSF-PIG approach identified a large minority of hospital inpatients who might benefit from advance care planning. Future studies are needed to investigate the feasibility, cost and impact of screening in hospitals.

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Improving advance care planning in high‐risk hospitalised patients: a knowledge translation pilot study

Internal Medicine Journal ◽

10.1111/imj.15276 ◽

2021 ◽

Vol 51 (4) ◽

pp. 623-624

Author(s):

Arvind Rajamani ◽

Karen Fernandez ◽

Hailey Carpen ◽

Upul Liyanage ◽

Jeffery Zijian Wang ◽

...

Keyword(s):

Pilot Study ◽

High Risk ◽

Knowledge Translation ◽

Advance Care Planning ◽

Care Planning ◽

Hospitalised Patients ◽

Advance Care

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Introducing Advance Care Planning Prior to High-Risk Operations: A Pilot Project in the Cardiovascular Surgery Department

Canadian Journal of Cardiology ◽

10.1016/j.cjca.2016.07.579 ◽

2016 ◽

Vol 32 (10) ◽

pp. S329

Author(s):

T. Killackey ◽

J. MacIver ◽

P. Murphy ◽

H. Storey ◽

M. Eason ◽

...

Keyword(s):

High Risk ◽

Advance Care Planning ◽

Cardiovascular Surgery ◽

Pilot Project ◽

Care Planning ◽

Advance Care ◽

Surgery Department

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Advance care planning and terminal intensive care unit admissions for cancer patients: We can do better.

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.15_suppl.e23000 ◽

2019 ◽

Vol 37 (15_suppl) ◽

pp. e23000-e23000

Author(s):

Joseph Heng ◽

Ramy Sedhom ◽

Thomas J. Smith

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

High Risk ◽

Advance Care Planning ◽

Hematologic Malignancies ◽

Cancer Center ◽

Care Planning ◽

Code Status ◽

Risk Of Death ◽

Advance Care

e23000 Background: Terminal oncology intensive care unit (ICU) admissions are associated with high healthcare costs and decreased quality of life. Chemotherapy can be given in non-curative settings to optimize symptom control, but use of it at the end of life does not improve longevity. In addition, goals of care are too often not addressed for patients at high risk of death. Methods: We carried out a retrospective review identifying patients of a large academic cancer center who were admitted to and expired in an ICU between January 1, 2017 to December 31, 2018. Results: 120 patients met inclusion criteria. Median age was 58 years. Only 15.0% (n = 18) of all patients had advance directives. The majority of patients (94.1%, n = 113) were FULL CODE on admission. Median duration of admission was 10 days. Median time to death from ICU admission was 7.5 days. 65.0% (n = 78) of all patients were intubated, while 15.0% (n = 15) received CPR. 58.3% (n = 70) of the study population had solid malignancies; of note, 97.1% (n = 68) of these patients were metastatic at presentation and had a median ECOG performance status of 2. Patients with metastatic solid tumors typically have a more indolent course of progression compared to patients with hematologic malignancies. However, only 23.5% (n = 16) had discussed goals of care or code status with their outpatient oncologists, despite many seeing them within the last month prior to admission (83.8%, n = 57). Similarly, only 4.0% (n = 2) of patients with hematologic malignancies had advance care planning discussions with their oncologists prior to their terminal ICU admission. 27.5% (n = 33) of all patients had an inpatient palliative care consult. The inpatient pulmonary/critical care team had a high rate of inpatient code status transitions, with 85.6% (n = 97) of FULL CODE admissions transitioning to DNR/DNI. Conclusions: These findings reflect contemporary practice at a major academic cancer center. Despite most patients having regular contact with their outpatient oncologists, the intensity of health care utilization noted highlights a need to optimize recognition of patients at high risk of death and to engage patients in advance care planning discussions to avoid terminal ICU admissions.

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Creating an advance-care-planning decision aid for high-risk surgery: a qualitative study

BMC Palliative Care ◽

10.1186/1472-684x-13-32 ◽

2014 ◽

Vol 13 (1) ◽

Cited By ~ 9

Author(s):

Anne LR Schuster ◽

Rebecca A Aslakson ◽

John FP Bridges

Keyword(s):

High Risk ◽

Qualitative Study ◽

Advance Care Planning ◽

Decision Aid ◽

Care Planning ◽

Planning Decision ◽

Advance Care

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P-16 Simple, accurate identification of appropriate hospital inpatients for advance care planning by COTE

10.1136/bmjspcare-2018-hospiceabs.41 ◽

2018 ◽

Author(s):

Jean Potter ◽

Roberta Jordan ◽

Catherine Pye ◽

Yolande Saunders

Keyword(s):

Advance Care Planning ◽

Care Planning ◽

Accurate Identification ◽

P 16 ◽

Advance Care ◽

Hospital Inpatients

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The Surprise Question Is Not Correlated with Increases in Advance Care Planning Documentation (QI713)

Journal of Pain and Symptom Management ◽

10.1016/j.jpainsymman.2021.01.048 ◽

2021 ◽

Vol 61 (3) ◽

pp. 660-661

Author(s):

Teresa Letellier ◽

Christina Holt ◽

Amy Haskins ◽

Rebecca Hutchinson

Keyword(s):

Advance Care Planning ◽

Care Planning ◽

Advance Care ◽

Surprise Question

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Crucial Conversations for High-Risk Populations before Surgery: Advance Care Planning in a Preoperative Setting

Palliative Medicine Reports ◽

10.1089/pmr.2021.0015 ◽

2021 ◽

Vol 2 (1) ◽

pp. 260-264

Author(s):

Roma Patel ◽

Alexia Torke ◽

Barb Nation ◽

Ann Cottingham ◽

Jennifer Hur ◽

...

Keyword(s):

High Risk ◽

Advance Care Planning ◽

Care Planning ◽

High Risk Populations ◽

Advance Care

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Crucial Conversations for High Risk Populations Before Surgery: Advance Care Planning in a Preoperative Setting

10.21203/rs.3.rs-100950/v1 ◽

2020 ◽

Author(s):

Roma Gautam Patel ◽

Alexia Torke ◽

Barb Nation ◽

Ann Cottingham ◽

Jennifer Hur ◽

...

Keyword(s):

High Risk ◽

Advance Directives ◽

Advance Care Planning ◽

Elective Surgery ◽

Total Mortality ◽

Major Surgery ◽

Care Planning ◽

Advance Care ◽

One Year

Abstract Background: High-risk patients undergoing elective surgery may experience life-threatening complications. Preoperative assessment clinics provide an opportunity to conduct Advance Care Planning but it is unknown how often this is accomplished or subsequently needed for goals of care discussions. Objective: 1) assess the relationship between advance directives with readmissions and mortality at one year 2) qualitatively examine clinical events that occurred for patients who died during follow-up.Design: This was an observational cohort study conducted via chart review. Patients were followed for one year.Participants: Four hundred patients who were undergoing preoperative evaluation for elective surgery at two academic hospitals. Main measures: The prevalence of advance directives at the time of surgery, prevalence of advance directives in the electronic medical record during the one year follow-up period, readmissions and mortality at one year. Key Results: Three hundred and ninety patients were included. There were 102 (26.4%) patients were readmitted, which was not associated with having an AD on file. Seventeen (4.4%) filed an AD during follow-up. Twelve of 19 (63%) patients who died had an AD on file at the time of death. There was a significant association between having an AD at any time with mortality (chi-square p-value <0.001). Total mortality for the cohort was 4.9%. Of the 19 patients who died, seven (37%) underwent resuscitation, four of whom had an AD on file. Conclusions: A minority of patients who die within a year after major surgery have an AD, highlighting the missed opportunity to conduct advance care planning in a preoperative clinic.

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