Just ask: discussing goals of care with patients in hospital with serious illness

39 Background: Patients with serious illness routinely receive treatments that are not aligned with their goals. Earlier clinical conversations about patients’ values and priorities lead to more goal-concordant care and improved quality of life, but these conversations often happen too late or not at all. The Serious Illness Care Program has designed a systematic approach to train and support clinicians in conducting more, earlier, and better conversations about goals of care with their patients. Objectives: Evaluate clinician adoption and acceptability of the training program and the Serious Illness Conversation Guide; determine the frequency, timing, and quality of goals of care documentation before death. Methods: Cluster-randomized trial including oncology clinicians and their patients. Intervention: clinician identification of high risk patients; 2½ hour clinician training on the Serious Illness Conversation Guide; email trigger/reminder; EMR documentation. Preliminary chart review to extract goals-of-care conversations for deceased patients in intervention and control. Results: 90 oncology clinicians: 47 intervention; 43 control. Of 47 intervention clinicians, 46 are trained and rate the training as effective (4.3/5). 97% of trained clinicians who have been triggered have adopted the Conversation Guide and find it acceptable (4.2/5). 342 patients enrolled: 176 intervention; 166 control; 38% have died (n = 131). A preliminary chart review revealed more goals-of-care conversations occurred before death in intervention compared to control (92% versus 70%, p = 0.0037); intervention conversations took place four months earlier than control (median 143 days versus 63 days, p = 0.0008). In addition, conversations were more patient centered (95% versus 45%, p < 0.001) and more readily retrievable in the EMR (68% versus 28%, p < 0.001). Conclusions: Preliminary data about the Serious Illness Care systematic approach demonstrate strong clinician adoption and acceptability. The intervention results in more, earlier, and better conversations about patient values and priorities, in addition to more patient-centered and retrievable documentation of goals of care in the medical record. Clinical trial information: NCT01786811.

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Serious illness communication among patients with head and neck cancer.

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.31_suppl.2 ◽

2019 ◽

Vol 37 (31_suppl) ◽

pp. 2-2

Author(s):

Floyd Buen ◽

Emily J Martin ◽

Neil Wenger ◽

Kirsten Buen ◽

Anne M. Walling

Keyword(s):

Head And Neck Cancer ◽

Head And Neck ◽

Retrospective Analysis ◽

Neck Cancer ◽

Medical Records ◽

Primary Care Providers ◽

Treatment Preferences ◽

Care Providers ◽

Goals Of Care ◽

Serious Illness

2 Background: Head and neck cancer is associated with significant morbidity and mortality, yet little is known about the frequency and content of discussions addressing patients’ values, goals of care, and treatment preferences. Methods: Using an institutional cancer registry, we conducted a retrospective analysis of 70 decedents who underwent surgical treatment for squamous cell carcinoma of the head and neck. We abstracted patients’ medical records using a standardized template. An independent reviewer re-abstracted 20% of the records. For abstracted data pertaining to documented values, goals of care, and/or treatment preferences our inter-rater reliability was greater than 93%. Results: The mean age at diagnosis was 66 years and 69% were male. An enduring advance directive, a completed Physician Order for Life Sustaining Treatment form, and a serious illness conversation documented in the medical record were noted in 27%, 4%, and 49% of the medical records, respectively. Half of the documented goals of care discussions were held in the inpatient setting, over 50% were held in the last month of life, and 25% were held in the last week of life. These conversations involved specialist palliative care providers (47%), hematologist/oncologists (41%), hospitalists (32%), head and neck surgeons (21%), radiation oncologists (19%), and intensivists (18%). None of these discussions involved patients’ primary care providers. Of those with a known location of death, 58% died in the hospital and 4 out of 5 of these patients died during attempted cardiopulmonary resuscitation. Conclusions: In this retrospective analysis, serious illness communication was documented in the minority of patients who died of head and neck cancer. These discussions occurred late in the trajectory of illness. The continuity relationships of teams treating head and neck cancer patients (e.g., head and neck surgeon, radiation/oncologist and hematologist/oncologist) situate these clinicians in the best position to enact serious illness conversations. These data suggest that opportunities to have these discussions upstream are often missed.

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Serious Illness Conversations in advanced kidney disease: a mixed-methods implementation study

BMJ Supportive & Palliative Care ◽

10.1136/bmjspcare-2020-002830 ◽

2021 ◽

pp. bmjspcare-2020-002830

Author(s):

Natanong Thamcharoen ◽

Pitchaphon Nissaisorakarn ◽

Robert A Cohen ◽

Mara A Schonberg

Keyword(s):

Mixed Methods ◽

Pilot Study ◽

Kidney Disease ◽

Advance Care Planning ◽

Disease Stage ◽

Treatment Preferences ◽

Care Planning ◽

Goals Of Care ◽

Serious Illness ◽

Advance Care

ObjectiveAdvanced kidney disease is associated with a high risk of morbidity and mortality. Consequently, invasive treatments such as dialysis may not yield survival benefits. Advance care planning has been encouraged. However, whether such discussions are acceptable when done earlier, before end-stage kidney treatment decision-making occurs, is unclear. This pilot study aimed to explore whether use of the Serious Illness Conversation Guide to aid early advance care planning is acceptable, and to evaluate the information gained from these conversations.MethodsPatients with advanced kidney disease (stage 3B and above) and high mortality risk at 2 years were enrolled in this mixed-methods study from an academic nephrology clinic. Semi-structured interviews were conducted using the adapted Serious Illness Conversation Guide. Thematic analysis was used to assess patients’ perceptions of the conversation. Participants completed a questionnaire assessing conversation acceptability.ResultsTwenty-six patients participated, 50% were female. Participants felt that the conversation guide helped them reflect on their prognosis, goals of care and treatment preferences. Most did not feel that the conversation provoked anxiety (23/26, 88%) nor that it decreased hopefulness (24/26, 92%). Some challenges were elicited; patients expressed cognitive dissonance with the kidney disease severity due to lack of symptoms; had difficulty conceptualising their goals of care; and vocalised fear of personal failure without attempting dialysis.ConclusionsPatients in this pilot study found the adapted Serious Illness Conversation Guide acceptable. This guide may be used with patients early in the course of advanced kidney disease to gather information for future advanced care planning.

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Coaches Activating Reaching and Engaging Patients (CAREPlan): A randomized controlled trial combining two evidence-based interventions to improve goals of care documentation.

Journal of Clinical Oncology ◽

10.1200/jco.2020.39.28_suppl.2 ◽

2021 ◽

Vol 39 (28_suppl) ◽

pp. 2-2

Author(s):

Divya Ahuja Parikh ◽

Mary Khay Asuncion ◽

Jennifer Hansen ◽

Briththa Seevaratnam ◽

Sana Indravadan Khateeb ◽

...

Keyword(s):

Randomized Controlled Trial ◽

End Of Life ◽

Primary Outcome ◽

Controlled Trial ◽

Control Group ◽

Clinical Factors ◽

Goals Of Care ◽

Serious Illness ◽

Randomized Controlled ◽

Intent To Treat

2 Background: In our prior work, community or lay health worker-led goals of care interventions improved goals of care documentation by clinicians and decreased health care use at the end of life. Other studies have demonstrated improvements in provider-patient communication and goals of care documentation using the Serious Illness Care Program. The objective of this study was to determine whether the combination of these two interventions could improve goals of care documentation among patients with advanced stages of genitourinary cancers at an academic center. Methods: A randomized controlled trial was conducted from April 3, 2019, through October 30, 2019, among patients with metastatic or recurrent cancer on at least second line therapy in the urologic oncology clinics at Stanford Cancer Center. Patients were randomized to usual care or the intervention with a lay navigator trained to assist patients with establishing end-of-life care preferences using the Serious Illness Conversation Guide. The primary outcome was goals of care documentation by the primary oncologist. We used intent to treat analyses, descriptive statistics to compare demographic and clinical factors, and a logistic regression adjusting for imbalance to determine the effect on the primary outcome. Results: Two-hundred participants were randomized and included in the intent to treat analysis. Median age was 72 years, majority were male (n=175, 87.5%) and self-identified as non-Hispanic white (n=123, 61.5%). The majority had prostate cancer (n=110, 53.5%), followed by kidney cancer (n=51, 25.5%), and urothelial cancer (n=29, 14.5%) and most had stage IV disease at diagnosis (n=186, 93%). There were no significant differences in demographic or clinical factors except for gender; there were more females on the control arm (n=8 vs n=17, p=0.01) thus analysis of the primary outcome was adjusted for gender. The adjusted analysis showed that at 12 months post-enrollment, the intervention significantly increased goals of care documentation by the primary oncologist as compared to the control group (53.7% vs 32.6%, p=0.002). Conclusions: The CAREPlan program increased goals of care documentation by the primary oncologist at this single academic medical center. Clinical trial information: NCT03856463.

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Goals-of-Care Consultations Are Associated with Lower Costs and Less Acute Care Use among Propensity-Matched Cohorts of African Americans and Whites with Serious Illness

Journal of Palliative Medicine ◽

10.1089/jpm.2019.0522 ◽

2020 ◽

Vol 23 (9) ◽

pp. 1204-1213 ◽

Cited By ~ 1

Author(s):

Lauren T. Starr ◽

Connie M. Ulrich ◽

Scott M. Appel ◽

Paul Junker ◽

Nina R. O'Connor ◽

...

Keyword(s):

African Americans ◽

Acute Care ◽

Goals Of Care ◽

Serious Illness

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Changing Culture Around Serious Illness: The VA Life-Sustaining Treatment Decisions Initiative

Innovation in Aging ◽

10.1093/geroni/igaa057.2708 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

pp. 751-752

Author(s):

Joan Carpenter ◽

Robert Burke

Keyword(s):

Treatment Decisions ◽

Treatment Preferences ◽

Veterans Health ◽

Health Administration ◽

Comfort Care ◽

Goals Of Care ◽

Serious Illness ◽

Wide Range ◽

Life Sustaining Treatment ◽

Seriously Ill

Abstract Discussing and documenting goals of care and life-sustaining treatment decisions with seriously ill patients is a widely endorsed practice by healthcare and professional organizations. In 2018, The Veterans Health Administration (VA) initiated a new national policy to standardize such practices, the Life Sustaining Treatment Decisions Initiative (LSTDI), which included a coordinated set of evidence-based strategies and practice standards for conducting, documenting, and supporting high-quality goals of care conversations (GoCCs); staff training to enhance skills in conducting, documenting, and supporting GoCCs; standardized, durable electronic health record tools for documenting patients’ goals and preferences; and monitoring and information technology tools to support implementation and improvement. In this symposium, we will describe the first 20 months of implementing the LSTDI across the VA, the largest integrated healthcare system in the US. The first paper will focus on the factors associated with documentation of a GoCC and treatment preferences. The second paper will present findings describing facilitators and barriers to implementing the LSTDI and identifying factors that promote high rates of LSTDI documentation. The third paper examines patient level outcomes associated with a documented goal of comfort care, specifically the odds of receipt of hospice/palliative care, hospitalization, or ICU admission. This symposium will provide attendees with important information regarding a wide range of individual and system strategies to enhance the care of seriously ill older adults by engaging patients with serious illness in GoCCs and documenting their preferences for treatment in durable, easily accessible notes and orders.

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