101 Background: ICU admissions in the last 30 days of life is a quality measure endorsed by the National Quality Forum. Our prior research has demonstrated that nearly half of terminal oncology ICU hospitalizations are potentially avoidable. Methods: This was a retrospective care series of patients cared for in an academic medical center’s ambulatory oncology practice who died in an ICU during July 1, 2012 to June 30, 2013. Using a standardized assessment tool, an oncologist, intensivist, and hospitalist reviewed each patient’s electronic health record from 3 months prior to hospitalization until death and made a clinical determination of avoidability. Two investigators, blinded to the specialty of the reviewer, used a grounded theory approach to extract clinical themes associated with avoidability from the reviewers’ assessments. Results: The primary themes for avoidability identified and percent by specialty were as follows: failure to initiate appropriate advance care planning in the outpatient setting (68% oncologists, 55% intensivists, 65% hospitalists), failure to integrate understanding of limited prognosis from underlying cancer within the context of acute hospitalization (23% oncologists, 24% intensivists, 26% hospitalists), failure of clinical management (6% oncologists, 21% intensivists, 6% hospitalists), failure to recognize futility of outside hospital transfer (3% oncologists, 0% intensivists, 0% hospitalists), and failure of care coordination (0% oncologists, 0% intensivists, 3% hospitalists). A failure to educate and integrate surrogates into timely medical decision making was a prominent secondary theme for oncologists (22%), intensivists (18%), and hospitalists (29%). Conclusions: The themes identified suggest potential interventions to prevent avoidable terminal oncology ICU hospitalizations, including improved advance care planning in the outpatient setting, inpatient multidisciplinary communication to gain a better understanding of the patient’s underlying malignancy within the context of the acute hospitalization and prevent failures in clinical management, and better education and integration of surrogates in medical decision making.
Power Dynamics in a Triad Relationship: Advance Care Planning for Older Adults with Dementia in China
