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Wittenberg E, Goldsmith JV, Chen C(K, Prince-Paul M. A conceptual model of the nurse's role as primary palliative care provider in goals of care communication. PEC INNOVATION 2024; 4:100254. [PMID: 38298557 PMCID: PMC10828588 DOI: 10.1016/j.pecinn.2024.100254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/10/2023] [Accepted: 01/10/2024] [Indexed: 02/02/2024]
Abstract
Objective Nurses have opportunities to engage in goals of care conversations that can promote palliative care communication. The purpose of this study was to describe nurses' experiences in goals of care communication as summarized in the literature and to present a conceptual model of communication pathways for nurses. Methods An integrative review of the literature (2016-2022) addressing nurses' experiences in goals of care communication was conducted using PubMed, CINAHL, and PsychInfo databases. A total of 92 articles were retrieved. A total of 12 articles were included for this review after applying the inclusion and exclusion criteria. Results Of the 12 articles, the majority were qualitative studies (n = 8). Qualitative analysis of findings from all articles revealed three dominant themes: nurses' ambiguous role responsibilities, goals of care as end-of-life communication, and the need for nurse communication training. Conclusion This article suggests an innovative conceptual model for advancing nurse communication about goals of care to facilitate primary palliative care. Innovation The framework characterizes two communication pathways for Advanced Practice Nurses who direct goals of care discussions and Registered Nurses who support goals of care communication. The model informs future communication training aimed at supporting primary palliative care.
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Affiliation(s)
- Elaine Wittenberg
- From California State University Los Angeles, Department of Communication Studies, Los Angeles, CA, USA
| | - Joy V. Goldsmith
- From University of Memphis, Department of Communication and Film, Memphis, TN, USA
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Hasegawa T, Okuyama T, Akechi T. The trajectory of prognostic cognition in patients with advanced cancer: is the traditional advance care planning approach desirable for patients? Jpn J Clin Oncol 2024; 54:507-515. [PMID: 38336476 PMCID: PMC11075734 DOI: 10.1093/jjco/hyae006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 01/15/2024] [Indexed: 02/12/2024] Open
Abstract
Most patients with advanced cancer initially express a desire to be informed of their prognosis, and prognostic discussions between patients and their oncologists can trigger the subsequent trajectory of prognostic cognitions. On the continuum of prognostic cognition, including inaccurate/accurate prognostic awareness (awareness of incurability of cancer, terminal nature of illness or life expectancy) and prognostic acceptance (accepting one's prognosis), patients' perceptions of being informed of their prognosis by oncologists and patients' coping strategy for serious medical conditions regulate prognostic cognitions. However, nearly half of the patients with advanced cancer have poor prognostic awareness, and few patients achieve prognostic acceptance. These phenomena partly act as barriers to participation in advance care planning. When oncologists engage in advance care planning conversations, they must assess the patient's prognostic cognition and readiness for advance care planning. Considering the inaccurate prognostic awareness in a non-negligible proportion of patients and that astatic patients' preferences for future treatment and care are influenced by prognostic cognition, more research on decision-making support processes for high-quality and goal-concordant end-of-life care is needed along with research of advance care planning. In addition to making decisions regarding future medical treatment and care, oncologists must engage in continuous and dynamic goal-of-care conversations with empathic communication skills and compassion from diagnosis to end-of-life care.
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Affiliation(s)
- Takaaki Hasegawa
- Center for Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
| | - Toru Okuyama
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
- Department of Psychiatry/Palliative Care Center, Nagoya City University West Medical Center, Nagoya, Japan
| | - Tatsuo Akechi
- Center for Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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3
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Auriemma CL, Song A, Walsh L, Han JJ, Yapalater SR, Bain A, Haines L, Scott S, Whitman C, Taylor SP, Halpern SD, Courtright KR. Classification of Documented Goals of Care Among Hospitalized Patients with High Mortality Risk: a Mixed-Methods Feasibility Study. J Gen Intern Med 2024:10.1007/s11606-024-08773-z. [PMID: 38710861 DOI: 10.1007/s11606-024-08773-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 04/17/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND The ability to classify patients' goals of care (GOC) from clinical documentation would facilitate serious illness communication quality improvement efforts and pragmatic measurement of goal-concordant care. Feasibility of this approach remains unknown. OBJECTIVE To evaluate the feasibility of classifying patients' GOC from clinical documentation in the electronic health record (EHR), describe the frequency and patterns of changes in patients' goals over time, and identify barriers to reliable goal classification. DESIGN Retrospective, mixed-methods chart review study. PARTICIPANTS Adults with high (50-74%) and very high (≥ 75%) 6-month mortality risk admitted to three urban hospitals. MAIN MEASURES Two physician coders independently reviewed EHR notes from 6 months before through 6 months after admission to identify documented GOC discussions and classify GOC. GOC were classified into one of four prespecified categories: (1) comfort-focused, (2) maintain or improve function, (3) life extension, or (4) unclear. Coder interrater reliability was assessed using kappa statistics. Barriers to classifying GOC were assessed using qualitative content analysis. KEY RESULTS Among 85 of 109 (78%) patients, 338 GOC discussions were documented. Inter-rater reliability was substantial (75% interrater agreement; Cohen's kappa = 0.67; 95% CI, 0.60-0.73). Patients' initial documented goal was most frequently "life extension" (N = 37, 44%), followed by "maintain or improve function" (N = 28, 33%), "unclear" (N = 17, 20%), and "comfort-focused" (N = 3, 4%). Among the 66 patients whose goals' classification changed over time, most changed to "comfort-focused" goals (N = 49, 74%). Primary reasons for unclear goals were the observation of concurrently held or conditional goals, patient and family uncertainty, and limited documentation. CONCLUSIONS Clinical notes in the EHR can be used to reliably classify patients' GOC into discrete, clinically germane categories. This work motivates future research to use natural language models to promote scalability of the approach in clinical care and serious illness research.
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Affiliation(s)
- Catherine L Auriemma
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Anne Song
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lake Walsh
- Division of Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Jason J Han
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Sophia R Yapalater
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alexander Bain
- Division of Pulmonary and Critical Care, New York University-Langone, New York, NY, USA
| | - Lindsay Haines
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Stefania Scott
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Casey Whitman
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Stephanie P Taylor
- Division of Hospital Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Scott D Halpern
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Katherine R Courtright
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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Aller A, Shirazi A, Pedell L, Altschuler A, Hauser K, Cheslock M, Wei J, Duffens A, Whitehead H, Lim P, Katzel J, Martinez F, Lin A, Aller S, Aller C, Jones T, Yen SM, Liu R. What Matters Most: The Documented Goals, Values and Motivators of Advanced Cancer Patients. Am J Hosp Palliat Care 2023:10499091231223144. [PMID: 38112439 DOI: 10.1177/10499091231223144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Goals of care conversations are essential to delivery of goal concordant care. Infrequent and inconsistent goals of care documentation potentially limit delivery of goal concordant care. METHODS At Kaiser Permanente San Francisco Cancer Center, a standardized documentation template was designed and implemented to increase goals of care documentation by oncologists. The centralized, prompt-based template included value clarification of the goals and values of advanced cancer patients beyond treatment preferences. Documented conversations using the template during the initial pilot period were reviewed to characterization the clinical context in which conversations were recorded. Common goals and motivators were also identified. RESULTS A total of 178 advanced cancer patients had at least 1 documented conversation by a medical oncologist using the goals of care template. Oncologists consistently documented within the template goals of therapy and motivating factors in decision making. The most frequently documented goals of care were "Avoiding Pain and Suffering," "Physical Independence," and "Living as Long as Possible." The least recorded goal was "Comfort Focused Treatment Only." CONCLUSIONS Review of oncologist documented goals of care conversations using a prompt-based template allowed for characterization of the clinical context, therapy goals and motivators of advanced cancer patients. Communication of goals of care conversations by oncologists using a standardized prompt-based template within a centralized location has the potential to improve delivery of goal concordant care.
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Affiliation(s)
- Ashley Aller
- Department of Hematology and Oncology, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Aida Shirazi
- Department of Graduate Medical Education, Kaiser Permanente Northern California, San Francisco, CA, USA
| | | | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Karen Hauser
- Department of Internal Medicine, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Megan Cheslock
- Department of Geriatrics Medicine, Edith Nourse Rogers Memorial Veterans' Hospital, Bedford, MA, USA
| | - Jenny Wei
- Department of Internal Medicine, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Ali Duffens
- Department of Internal Medicine, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Hannah Whitehead
- The Permanente Medical Group Consulting Services, Kaiser Permanente, Oakland, CA, USA
| | - Peggy Lim
- The Permanente Medical Group Consulting Services, Kaiser Permanente, Oakland, CA, USA
| | - Jed Katzel
- Department of Hematology and Oncology, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Francisco Martinez
- Department of Hematology and Oncology, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Amy Lin
- Department of Hematology and Oncology, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Steve Aller
- Department of Hematology-Oncology, Seattle Children's Hospital, Seattle, WA, USA
| | - Cynthia Aller
- Department of Hematology, Providence Regional Cancer System Lacey Cancer Clinic, Lacey, WA, USA
| | - Tyler Jones
- The Permanente Medical Group Consulting Services, Kaiser Permanente, Oakland, CA, USA
| | - Sue May Yen
- The Permanente Medical Group Consulting Services, Kaiser Permanente, Oakland, CA, USA
| | - Raymond Liu
- Department of Hematology and Oncology, Kaiser Permanente Northern California, San Francisco, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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Gelfman LP, Barnes DE, Goldstein N, Volow AM, Shi Y, Li B, Sudore RL. Quality and Satisfaction With Advance Care Planning Conversations Among English- and Spanish-Speaking Older Adults. J Palliat Med 2023; 26:1380-1385. [PMID: 37335910 PMCID: PMC10551762 DOI: 10.1089/jpm.2022.0565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2023] [Indexed: 06/21/2023] Open
Abstract
Background: Little is known about the patient-reported quality of and satisfaction with advance care planning (ACP) conversations with surrogates and clinicians among English- and Spanish-speaking older adults, or the potential disparities associated with ACP communication satisfaction. Objectives: To determine patients' perceived quality of and satisfaction with ACP surrogate/clinician conversations and associated patient characteristics. Design: Cross-sectional baseline data were used from two ACP trials, 2013-2017. Outcomes included self-reported ACP conversation quality ("general" vs. "detailed") and communication satisfaction (5-point Likert scale). Associations were determined by chi-squared and t-tests. Setting/Subjects: Subjects were primary care patients ≥55 years with chronic/serious illness in the United States. Results: Of 1398 patients, mean age was 65.6 years (±7.7), 46% women, 32% Spanish speaking, 34% had limited health literacy, and 589 (42%) reported conversations with surrogates and 216 (15%) with clinicians. Of these, less than half rated the conversations as detailed high quality (clinician: 43%; surrogate: 37%). Five-point communication satisfaction scores were higher with detailed versus general conversations (e.g., surrogates: 4.4 vs. 4.1, p = 0.001; clinicians: 4.4 vs. 4.2, p = 0.18) and more often reported by men versus women [(4.4 (0.8) vs. 4.0 (1.0), p = 0.003]; those with adequate versus limited health literacy [4.4 (0.8) vs. 4.0 (0.9), p = 0.002]; and English versus Spanish speakers [4.5 (0.7) vs. 3.5 (0.9), p < 0.001]. Conclusions: Among English- and Spanish-speaking older adults, ACP conversations were infrequent and most were general in quality. Higher quality detailed conversations resulted in greater communication satisfaction. Interventions are needed to improve conversation quality, particularly for Spanish-speaking patients and those with limited health literacy. Trial Registrations: ClinicalTrials.gov identifiers: "Improving Advance Care Planning by Preparing Diverse Seniors for Decision Making (PREPARE)" NCT01990235 and "Preparing Spanish-Speaking Older Adults for Advance Care Planning and Medical Decision Making (PREPARE)" NCT02072941.
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Affiliation(s)
- Laura P. Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Deborah E. Barnes
- Department of Psychiatry and University of California, San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
- Innovation and Implementation Center for Aging and Palliative Care, Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Nathan Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Aiesha M. Volow
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Ying Shi
- San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Brookelle Li
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Rebecca L. Sudore
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
- Innovation and Implementation Center for Aging and Palliative Care, Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
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6
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Gonella S, Dimonte V, Arnone Y, Albanesi B, Berchialla P, Di Giulio P, van der Steen JT. Interventions to Promote End-of-Life Conversations: A Systematic Review and Meta-Analysis. J Pain Symptom Manage 2023; 66:e365-e398. [PMID: 37164151 DOI: 10.1016/j.jpainsymman.2023.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/26/2023] [Accepted: 05/02/2023] [Indexed: 05/12/2023]
Abstract
CONTEXT Although several interventions aimed to promote end-of-life conversations are available, it is unclear whether and how these affect delivery of end-of-life conversations. Measuring the processes associated with high-quality end-of-life care may trigger improvement. OBJECTIVES To estimate the effect of interventions aimed to promote end-of-life conversations in clinical encounters with patients with advanced chronic or terminal illness or their family, on process indicators of end-of-life conversations. METHODS Systematic review with meta-analysis (PROSPERO no. CRD42021289471). Four databases (PubMed, CINAHL, PsycINFO, and Scopus) were searched up to September 30, 2021. The primary outcomes were any process indicators of end-of-life conversations. Results of pairwise meta-analyses were presented as Risk Ratio (RR) for occurrence, standardized mean difference (SMD) for quality and ratio of means (ROM) for duration. Meta-analysis was not performed when fewer than four studies were available. RESULTS A total of 4,663 articles were scanned. Eighteen studies were included in the systematic review and 16 entered at least one meta-analysis: documented occurrence (n = 8), patient-reported occurrence (n = 4), patient-reported-quality (n = 4), duration (n = 4). There was significant variability in settings, patients' clinical conditions, and professionals. No significant effect of interventions on documented occurrence (RR 1.54, 95% CI 0.84-2.84; I2 91%), patient-reported occurrence (RR 1.52, 95% CI 0.80-2.91; I2 95%), patient-reported quality (SMD 0.83, 95% CI -1.06 to 2.71; I2 99%), or duration (ROM 1.20, 95% CI 0.95-1.51; I2 65%) of end-of-life conversations was found. Data on frequency were conflicting. Interventions targeting multiple stakeholders promoted earlier and more comprehensive conversations. CONCLUSION Heterogeneity was considerable, but findings suggest no significant effect of interventions on occurrence, patient-reported quality and duration of end-of-life conversations. Nevertheless, we found indications for interventions targeting multiple stakeholders to promote earlier and more comprehensive conversations.
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Affiliation(s)
- Silvia Gonella
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino (S.G.), Torino, Italy.
| | - Valerio Dimonte
- Department of Public Health and Pediatrics (B.A., P.DG., V.D., Y.A.), University of Torino, Torino, Italy
| | - Ylenia Arnone
- Department of Public Health and Pediatrics (B.A., P.DG., V.D., Y.A.), University of Torino, Torino, Italy
| | - Beatrice Albanesi
- Department of Public Health and Pediatrics (B.A., P.DG., V.D., Y.A.), University of Torino, Torino, Italy
| | - Paola Berchialla
- Department of Clinical and Biological Sciences (P.B.), University of Torino, Torino, Italy
| | - Paola Di Giulio
- Department of Public Health and Pediatrics (B.A., P.DG., V.D., Y.A.), University of Torino, Torino, Italy
| | - J T van der Steen
- Department of Public Health and Primary Care (J.T.S.), Leiden University Medical Center, Leiden, The Netherlands; Department of Primary and Community Care (J.T.S.), Radboud University Medical Center, Radboudumc Alzheimer Center, Nijmegen. The Netherlands
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7
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Kazi BS, Duberstein PR, Kluger BM, Epstein RM, Fiscella KA, Kazi ZS, Dahl SK, Allen RJ, Saeed F. Prevalence and Correlates of Preference-Concordant Care Among Hospitalized People Receiving Maintenance Dialysis. KIDNEY360 2023; 4:e751-e758. [PMID: 37143194 PMCID: PMC10371368 DOI: 10.34067/kid.0000000000000131] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 03/30/2023] [Indexed: 05/06/2023]
Abstract
Key Points A large proportion of hospitalized patients receiving dialysis report not receiving preference-concordant care. Hospitalized patients on dialysis desiring a comfort-oriented medical plan were likely to report receiving preference-concordant care. Background Preference-concordant care is a cornerstone of high-quality medical decision-making, yet the prevalence and correlates of preference-concordant care have not been well-studied in patients receiving dialysis. We surveyed hospitalized people receiving maintenance dialysis to estimate the prevalence and correlates of preference-concordant care among this population. Methods We assessed preference concordance by asking participants (223/380, 59% response rate), “How strongly do you agree or disagree that your current treatment plan meets your preference?” We assessed treatment plan preference by asking whether patients preferred a plan that focused on (1 ) extending life or (2 ) relieving pain and discomfort. We assessed shared dialysis decision-making using the 9-item Shared Decision-Making Questionnaire. We examined the differences between those reporting lack of preference-concordant care and those reporting receipt of preference-concordant care using chi-squared analyses. We also studied whether patients' treatment plan preferences or shared dialysis decision-making scores were correlated with their likelihood of receiving preference-concordant care. Results Of the 213 respondents who provided data on preference concordance, 90 (42.3%) reported that they were not receiving preference-concordant care. Patients who preferred pain and discomfort relief over life extension were less likely (odds ratio, 0.15 [95% confidence interval, 0.08 to 0.28] P = <0.0001) to report receiving preference-concordant care; patients with higher shared decision-making scores were more likely (odds ratio, 1.02 [95% confidence interval, 1.01 to 1.03], P = 0.02) to report preference-concordant care. Conclusions A substantial proportion of this sample of hospitalized people receiving maintenance dialysis reported not receiving preference-concordant care. Efforts to improve symptom management and enhance patient engagement in dialysis decision-making may improve the patients' perceptions of receiving preference-concordant care.
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Affiliation(s)
- Basil S Kazi
- Department of Internal Medicine, University of Illinois at Chicago, Chicago, Illinois
- School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | - Paul R Duberstein
- Department of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, New Jersey
| | - Benzi M Kluger
- Department of Palliative Care, University of Rochester Medical Center, Rochester, New York
- Department of Neurology, University of Rochester Medical Center, Rochester, New York
| | - Ronald M Epstein
- Department of Palliative Care, University of Rochester Medical Center, Rochester, New York
- Department of Family Medicine, University of Rochester Medical Center, Rochester, New York
| | - Kevin A Fiscella
- Department of Family Medicine, University of Rochester Medical Center, Rochester, New York
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York
| | - Zain S Kazi
- Institute of Advanced Analytics, North Carolina State University, Raleigh, North Carolina
| | - Spencer K Dahl
- School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | - Rebecca J Allen
- School of Behavioral and Natural Sciences, Mount St. Joseph University, Cincinnati, Ohio
| | - Fahad Saeed
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York
- Department of Nephrology, University of Rochester Medical Center, Rochester, New York
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8
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Hickman SE, Sudore RL, Torke AM, Tang Q, Bakoyannis G, Heim Smith N, Myers AL, Hammes BJ. POLST recall, concordance, and decision quality outcomes among nursing home residents and surrogate decision-makers. J Am Geriatr Soc 2023. [PMID: 36929327 DOI: 10.1111/jgs.18330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 02/09/2023] [Accepted: 02/17/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND POLST orders are actionable in an emergency, so it is important that the decisions be of high quality and concordant with current preferences. The goal of this study is to determine the relationship between concordance and decision quality outcomes, including decision satisfaction and decisional conflict, among nursing facility residents and surrogates who recall POLST. METHODS We completed structured interviews in 29 nursing facilities with 275 participants who had previously signed a POLST form. This included residents who were still making their own medical decisions (n = 123) and surrogate decision-makers for residents without decisional capacity (n = 152). POLST recall was defined as remembering talking about and/or completing the POLST form previously signed by the participant. Concordance was determined by comparing preferences elicited during a standardized interview with the POLST form on file. Decisional conflict, decision satisfaction, and conversation quality were assessed with standardized tools. RESULTS Half of participants (50%) remembered talking about or completing the POLST form, but recall was not associated with the length of time since POLST completion or concordance with existing preferences. In multivariable analyses, there was no association between POLST recall, concordance, and decision quality outcomes, though satisfaction was associated with conversation quality. CONCLUSIONS Half of the residents and surrogates in this study recalled the POLST they previously signed. Neither the age of the form nor the ability to recall the POLST conversation should be considered indicators of whether existing POLST orders match current preferences. Findings confirm a relationship between POLST conversation quality and satisfaction, underscoring the importance of POLST completion as a communication process.
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Affiliation(s)
- Susan E Hickman
- Department of Community & Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, USA.,Research in Palliative and End-of-Life Communication & Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, Indiana, USA.,Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Rebecca L Sudore
- Division of Geriatrics, School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Alexia M Torke
- Research in Palliative and End-of-Life Communication & Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, Indiana, USA.,Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Qing Tang
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA
| | - Giorgos Bakoyannis
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA
| | - Nicholette Heim Smith
- Department of Community & Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, USA
| | - Anne L Myers
- Department of Community & Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, USA
| | - Bernard J Hammes
- Respecting Choices, A Division of C-TAC Innovations, La Crosse, Wisconsin, USA
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9
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Uyeda AM, Lee RY, Pollack LR, Paul SR, Downey L, Brumback LC, Engelberg RA, Sibley J, Lober WB, Cohen T, Torrence J, Kross EK, Curtis JR. Predictors of Documented Goals-of-Care Discussion for Hospitalized Patients With Chronic Illness. J Pain Symptom Manage 2023; 65:233-241. [PMID: 36423800 PMCID: PMC9928787 DOI: 10.1016/j.jpainsymman.2022.11.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 11/04/2022] [Accepted: 11/13/2022] [Indexed: 11/23/2022]
Abstract
CONTEXT Goals-of-care discussions are important for patient-centered care among hospitalized patients with serious illness. However, there are little data on the occurrence, predictors, and timing of these discussions. OBJECTIVES To examine the occurrence, predictors, and timing of electronic health record (EHR)-documented goals-of-care discussions for hospitalized patients. METHODS This retrospective cohort study used natural language processing (NLP) to examine EHR-documented goals-of-care discussions for adults with chronic life-limiting illness or age ≥80 hospitalized 2015-2019. The primary outcome was NLP-identified documentation of a goals-of-care discussion during the index hospitalization. We used multivariable logistic regression to evaluate associations with baseline characteristics. RESULTS Of 16,262 consecutive, eligible patients without missing data, 5,918 (36.4%) had a documented goals-of-care discussion during hospitalization; approximately 57% of these discussions occurred within 24 hours of admission. In multivariable analysis, documented goals-of-care discussions were more common for women (OR=1.26, 95%CI 1.18-1.36), older patients (OR=1.04 per year, 95%CI 1.03-1.04), and patients with more comorbidities (OR=1.11 per Deyo-Charlson point, 95%CI 1.10-1.13), cancer (OR=1.88, 95%CI 1.72-2.06), dementia (OR=2.60, 95%CI 2.29-2.94), higher acute illness severity (OR=1.12 per National Early Warning Score point, 95%CI 1.11-1.14), or prior advance care planning documents (OR=1.18, 95%CI 1.08-1.30). Documentation of these discussions was less common for racially or ethnically minoritized patients (OR=0.823, 95%CI 0.75-0.90). CONCLUSION Among hospitalized patients with serious illness, documented goals-of-care discussions identified by NLP were more common among patients with older age and increased burden of acute or chronic illness, and less common among racially or ethnically minoritized patients. This suggests important disparities in goals-of-care discussions.
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Affiliation(s)
- Alison M Uyeda
- Department of Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E, J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E., J.T., E.K.K., J.R.C.), Seattle, Washington, USA
| | - Robert Y Lee
- Department of Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E, J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E., J.T., E.K.K., J.R.C.), Seattle, Washington, USA
| | - Lauren R Pollack
- Department of Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E, J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E., J.T., E.K.K., J.R.C.), Seattle, Washington, USA
| | - Sudiptho R Paul
- Department of Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E, J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E., J.T., E.K.K., J.R.C.), Seattle, Washington, USA
| | - Lois Downey
- Department of Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E, J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E., J.T., E.K.K., J.R.C.), Seattle, Washington, USA
| | - Lyndia C Brumback
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Department of Biostatistics, University of Washington (L.C.B.), Seattle, Washington, USA
| | - Ruth A Engelberg
- Department of Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E, J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E., J.T., E.K.K., J.R.C.), Seattle, Washington, USA
| | - James Sibley
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Department of Biomedical Informatics and Medical Education, University of Washington (J.S., W.B.L., T.C.), Seattle, Washington, USA
| | - William B Lober
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Department of Biomedical Informatics and Medical Education, University of Washington (J.S., W.B.L., T.C.), Seattle, Washington, USA; Department of Biobehavioral Nursing and Health Informatics, University of Washington (W.B.L.), Seattle, Washington, USA
| | - Trevor Cohen
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Department of Biomedical Informatics and Medical Education, University of Washington (J.S., W.B.L., T.C.), Seattle, Washington, USA
| | - Janaki Torrence
- Department of Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E, J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E., J.T., E.K.K., J.R.C.), Seattle, Washington, USA
| | - Erin K Kross
- Department of Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E, J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E., J.T., E.K.K., J.R.C.), Seattle, Washington, USA
| | - J Randall Curtis
- Department of Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E, J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., L.C.B., R.A.E., J.S., W.B.L., T.C., J.T., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington (A.M.U., R.Y.L., L.R.P., S.R.P., L.D., R.A.E., J.T., E.K.K., J.R.C.), Seattle, Washington, USA.
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10
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De Panfilis L, Veronese S, Perin M, Cascioli M, Farinotti M, Kruger P, Zagarella RM, Curtis JR, Sudore RL, Nielsen EL, Engelberg RA, Giordano A, Solari A. Italian cross-cultural adaptation of the Quality of Communication questionnaire and the 4-item advance care planning engagement questionnaire. PLoS One 2023; 18:e0282960. [PMID: 36952509 PMCID: PMC10035811 DOI: 10.1371/journal.pone.0282960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 02/28/2023] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND Advance care planning (ACP) is influenced by several factors (e.g., patient's readiness to engage, clinician's skills, and the cultural environment). Availability of reliable and valid self-reported measures of the ACP domains is crucial, including cross-cultural equivalence. AIM To culturally adapt into Italian the 19-item Quality of Communication (QOC) and the 4-item ACP Engagement (4-item ACP-E) questionnaires. METHODS We translated and culturally adapted the two questionnaires and produced a significant other (SO) version of the QOC (QOC-SO). Each questionnaire was field tested via cognitive interviews with users: nine patients (QOC, 4-item ACP-E) and three SOs (QOC-SO) enrolled at three palliative care services. RESULTS We made minor changes to 5/19 QOC items, to improve clarity and internal consistency; we changed the response option 'didn't do' into 'not applicable'. Finally, we slightly revised the QOC to adapt it to the paper/electronic format. QOC debriefing revealed that the section on end of life was emotionally challenging for both patients and SOs. We simplified the 4-item ACP-E layout, added a sentence in the introduction, and revised the wording of one item, to improve coherence with the Italian ACP legislation. ACP-E debriefing did not reveal any major issue. CONCLUSIONS Results were satisfactory in terms of semantic, conceptual and normative equivalence of both questionnaires. Acceptability was satisfactory for the 4-item ACP-E, while findings of the QOC cognitive debriefing informed a major amendment of a pilot trial protocol on ACP in multiple sclerosis (ConCure-SM): use of the interviewer version only, in an adaptive form. Psychometric testing of both questionnaires on a large, independent sample will follow.
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Affiliation(s)
| | | | - Marta Perin
- Bioethics Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Marta Cascioli
- Hospice 'La Torre sul Colle', Azienda USL Umbria 2, Spoleto, Italy
| | - Mariangela Farinotti
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Paola Kruger
- EUPATI Fellow (European Patients Academy for Therapeutic Innovation) Italy, Rome, Italy
| | - Roberta M Zagarella
- Bioethics Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
- National Research Council (CNR), Interdepartmental Center for Research Ethics and Integrity (CID Ethics), Rome, Italy
| | - J R Curtis
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, Washington, United States of America
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Rebecca L Sudore
- Division of Geriatrics, School of Medicine, University of California San Francisco, San Francisco, San Francisco, California, United States of America
- San Francisco Veterans Affairs Health Care System, San Francisco, California, United States of America
| | - Elizabeth L Nielsen
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, Washington, United States of America
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, Washington, United States of America
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Andrea Giordano
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Alessandra Solari
- Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
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11
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Clarke J, Momeyer MA, Rosselet R, Sinnott L, Overcash J. Serious Illness Conversation Training for Inpatient Medical Oncology Advanced Practice Providers: A Quality Improvement Project. J Adv Pract Oncol 2023; 14:37-48. [PMID: 36741212 PMCID: PMC9894205 DOI: 10.6004/jadpro.2023.14.1.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background Hospitalized advanced cancer patients and their families are inadequately informed about their cancer diagnosis and prognosis, which limits educated and reasonable decision-making for their care and end-of-life planning. Objectives The primary objective of this evidence-based project was to enhance serious illness conversations (SICs) with advanced cancer patients by providing advanced practice providers (APP) training and to increase the frequency of SIC documentation in the electronic medical record (EMR). Methods SIC training included a 45-minute Zoom video recording and 30-minute discussion groups. Advanced practice providers' beliefs and self-efficacy were measured pre- and post-training via a survey. Prior training was queried in the pre-survey. Data from APP discussion groups were summarized and themes identified. Serious illness conversation documentation frequency was measured. Pre- and post-survey differences were assessed using Wilcoxon rank sum tests. Findings 19 inpatient medical oncology nurse practitioners and 6 physician assistants participated. Many reported little formal training yet are engaging in SICs regularly. Scores on both the belief and self-efficacy survey sections were high prior to training and did not significantly change following training. Despite the high pre-survey scores, many of the APPs verbalized the need for more training to improve their confidence and to learn SIC communication skills. Training significantly improved the APP's ability to manage their own emotions and be present. This indicates a trend toward improved APP comfort with SICs. Accessible documentation in the EMR increased with training.
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Affiliation(s)
- Jo Clarke
- From The Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | - Robin Rosselet
- From The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Loraine Sinnott
- From The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Janine Overcash
- From The Ohio State University Wexner Medical Center, Columbus, Ohio
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12
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Modes ME, Engelberg RA, Nielsen EL, Brumback LC, Neville TH, Walling AM, Curtis JR, Kross EK. Seriously Ill Patients' Prioritized Goals and Their Clinicians' Perceptions of Those Goals. J Pain Symptom Manage 2022; 64:410-418. [PMID: 35700932 PMCID: PMC9482939 DOI: 10.1016/j.jpainsymman.2022.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 05/25/2022] [Accepted: 06/07/2022] [Indexed: 12/27/2022]
Abstract
CONTEXT Seriously ill patients whose prioritized healthcare goals are understood by their clinicians are likely better positioned to receive goal-concordant care. OBJECTIVES To examine the proportion of seriously ill patients whose prioritized healthcare goal is accurately perceived by their clinician and identify factors associated with accurate perception. METHODS Secondary analysis of a multicenter cluster-randomized trial of outpatients with serious illness and their clinicians. Approximately two weeks after a clinic visit, patients reported their current prioritized healthcare goal- extending life over relief of pain and discomfort, or relief of pain and discomfort over extending life - and clinicians reported their perception of their patients' current prioritized healthcare goal; matching these items defined accurate perception. RESULTS Of 252 patients with a prioritized healthcare goal, 60% had their goal accurately perceived by their clinician, 27% were cared for by clinicians who perceived prioritization of the alternative goal, and 13% had their clinician answer unsure. Patients who were older (OR 1.03 per year; 95%CI 1.01, 1.05), had stable goals (OR 2.52; 95%CI 1.26, 5.05), and had a recent goals-of-care discussion (OR 1.78, 95%CI 1.00, 3.16) were more likely to have their goals accurately perceived. CONCLUSION A majority of seriously ill outpatients are cared for by clinicians who accurately perceive their patients' prioritized healthcare goals. However, a substantial portion are not and may be at higher risk for goal-discordant care. Interventions that facilitate goals-of-care discussions may help align care with goals, as recent discussions were associated with accurate perceptions of patients' prioritized goals.
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Affiliation(s)
- Matthew E Modes
- Division of Pulmonary and Critical Care Medicine (M.E.M), Cedars-Sinai Medical Center, Los Angeles, California, USA.
| | - Ruth A Engelberg
- Division of Pulmonary (R.A.E., E.L.N., J.R.C., E.K.K.), Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (R.A.E., E.L.N., L.C.B., J.R.C., E.K.K.), University of Washington, Seattle, Washington, USA
| | - Elizabeth L Nielsen
- Division of Pulmonary (R.A.E., E.L.N., J.R.C., E.K.K.), Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (R.A.E., E.L.N., L.C.B., J.R.C., E.K.K.), University of Washington, Seattle, Washington, USA
| | - Lyndia C Brumback
- Cambia Palliative Care Center of Excellence (R.A.E., E.L.N., L.C.B., J.R.C., E.K.K.), University of Washington, Seattle, Washington, USA; Department of Biostatistics (L.C.B.), University of Washington, Seattle, Washington, USA
| | - Thanh H Neville
- Division of Pulmonary (T.H.N.), Critical Care, and Sleep Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Anne M Walling
- Division of General Internal Medicine and Health Services Research (A.M.W.), University of California Los Angeles, Los Angeles, California, USA; Center for the Study of Healthcare Innovation (A.M.W.), Implementation and Policy, Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, California, USA
| | - J Randall Curtis
- Division of Pulmonary (R.A.E., E.L.N., J.R.C., E.K.K.), Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (R.A.E., E.L.N., L.C.B., J.R.C., E.K.K.), University of Washington, Seattle, Washington, USA; Department of Bioethics and Humanities (J.R.C.), University of Washington, Seattle, Washington, USA
| | - Erin K Kross
- Division of Pulmonary (R.A.E., E.L.N., J.R.C., E.K.K.), Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (R.A.E., E.L.N., L.C.B., J.R.C., E.K.K.), University of Washington, Seattle, Washington, USA
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13
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Uyeda AM, Curtis JR, Engelberg RA, Brumback LC, Guo Y, Sibley J, Lober WB, Cohen T, Torrence J, Heywood J, Paul SR, Kross EK, Lee RY. Mixed-methods evaluation of three natural language processing modeling approaches for measuring documented goals-of-care discussions in the electronic health record. J Pain Symptom Manage 2022; 63:e713-e723. [PMID: 35182715 PMCID: PMC9124686 DOI: 10.1016/j.jpainsymman.2022.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 01/05/2022] [Accepted: 02/07/2022] [Indexed: 01/02/2023]
Abstract
CONTEXT Documented goals-of-care discussions are an important quality metric for patients with serious illness. Natural language processing (NLP) is a promising approach for identifying goals-of-care discussions in the electronic health record (EHR). OBJECTIVES To compare three NLP modeling approaches for identifying EHR documentation of goals-of-care discussions and generate hypotheses about differences in performance. METHODS We conducted a mixed-methods study to evaluate performance and misclassification for three NLP featurization approaches modeled with regularized logistic regression: bag-of-words (BOW), rule-based, and a hybrid approach. From a prospective cohort of 150 patients hospitalized with serious illness over 2018 to 2020, we collected 4391 inpatient EHR notes; 99 (2.3%) contained documented goals-of-care discussions. We used leave-one-out cross-validation to estimate performance by comparing pooled NLP predictions to human abstractors with receiver-operating-characteristic (ROC) and precision-recall (PR) analyses. We qualitatively examined a purposive sample of 70 NLP-misclassified notes using content analysis to identify linguistic features that allowed us to generate hypotheses underpinning misclassification. RESULTS All three modeling approaches discriminated between notes with and without goals-of-care discussions (AUCROC: BOW, 0.907; rule-based, 0.948; hybrid, 0.965). Precision and recall were only moderate (precision at 70% recall: BOW, 16.2%; rule-based, 50.4%; hybrid, 49.3%; AUCPR: BOW, 0.505; rule-based, 0.579; hybrid, 0.599). Qualitative analysis revealed patterns underlying performance differences between BOW and rule-based approaches. CONCLUSION NLP holds promise for identifying EHR-documented goals-of-care discussions. However, the rarity of goals-of-care content in EHR data limits performance. Our findings highlight opportunities to optimize NLP modeling approaches, and support further exploration of different NLP approaches to identify goals-of-care discussions.
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Affiliation(s)
- Alison M Uyeda
- Department of Medicine (A.M.U., J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA
| | - J Randall Curtis
- Department of Medicine (A.M.U., J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Division of Pulmonary, Critical Care, and Sleep Medicine (J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA; Department of Biobehavioral Nursing and Health Informatics (J.R.C., J.S., W.B.L.), University of Washington, Seattle, WA.
| | - Ruth A Engelberg
- Department of Medicine (A.M.U., J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Division of Pulmonary, Critical Care, and Sleep Medicine (J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Lyndia C Brumback
- Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Department of Biostatistics (L.C.B.), University of Washington, Seattle, WA
| | - Yue Guo
- Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Department of Biomedical Informatics and Medical Education (Y.G., W.B.L., T.C.), University of Washington, Seattle, WA
| | - James Sibley
- Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Department of Biobehavioral Nursing and Health Informatics (J.R.C., J.S., W.B.L.), University of Washington, Seattle, WA
| | - William B Lober
- Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Department of Biomedical Informatics and Medical Education (Y.G., W.B.L., T.C.), University of Washington, Seattle, WA; Department of Biobehavioral Nursing and Health Informatics (J.R.C., J.S., W.B.L.), University of Washington, Seattle, WA
| | - Trevor Cohen
- Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Department of Biomedical Informatics and Medical Education (Y.G., W.B.L., T.C.), University of Washington, Seattle, WA
| | - Janaki Torrence
- Department of Medicine (A.M.U., J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Division of Pulmonary, Critical Care, and Sleep Medicine (J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Joanna Heywood
- Department of Medicine (A.M.U., J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Division of Pulmonary, Critical Care, and Sleep Medicine (J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Sudiptho R Paul
- Department of Medicine (A.M.U., J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Division of Pulmonary, Critical Care, and Sleep Medicine (J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Erin K Kross
- Department of Medicine (A.M.U., J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Division of Pulmonary, Critical Care, and Sleep Medicine (J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Robert Y Lee
- Department of Medicine (A.M.U., J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Division of Pulmonary, Critical Care, and Sleep Medicine (J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
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14
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Lee RY, Kross EK, Downey L, Paul SR, Heywood J, Nielsen EL, Okimoto K, Brumback LC, Merel SE, Engelberg RA, Curtis JR. Efficacy of a Communication-Priming Intervention on Documented Goals-of-Care Discussions in Hospitalized Patients With Serious Illness: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e225088. [PMID: 35363271 PMCID: PMC8976242 DOI: 10.1001/jamanetworkopen.2022.5088] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE High-quality goals-of-care communication is critical to delivering goal-concordant, patient-centered care to hospitalized patients with chronic life-limiting illness. However, implementation and documentation of goals-of-care discussions remain important shortcomings in many health systems. OBJECTIVE To evaluate the efficacy, feasibility, and acceptability of a patient-facing and clinician-facing communication-priming intervention to promote goals-of-care communication for patients hospitalized with serious illness. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial enrolled patients from November 6, 2018, to February 18, 2020. The setting was 2 hospitals in an academic health care system in Seattle, Washington. Participants included hospitalized adults with chronic life-limiting illness, aged 65 years or older and with markers of frailty, or aged 80 years or older. Data analysis was performed from August 2020 to August 2021. INTERVENTION Patients were randomized to usual care with baseline questionnaires (control) vs the Jumpstart communication-priming intervention. Patients or surrogates in the intervention group and their clinicians received patient-specific Jumpstart Guides populated with data from questionnaires and the electronic health records (EHRs) that were designed to prompt and guide a goals-of-care discussion. MAIN OUTCOMES AND MEASURES The primary outcome was EHR documentation of a goals-of-care discussion between randomization and hospital discharge. Additional outcomes included patient-reported or surrogate-reported goals-of-care discussions, patient-reported or surrogate-reported quality of communication, and intervention feasibility and acceptability. RESULTS Of 428 eligible patients, this study enrolled 150 patients (35% enrollment rate; mean [SD] age, 59.2 [13.6] years; 66 women [44%]; 132 [88%] by patient consent and 18 [12%] by surrogate consent). Seventy-five patients each were randomized to the intervention and control groups. Compared with the control group, the cumulative incidence of EHR-documented goals-of-care discussions between randomization and hospital discharge was higher in the intervention group (16 of 75 patients [21%] vs 6 of 75 patients [8%]; risk difference, 13% [95% CI, 2%-24%]; risk ratio, 2.67 [95% CI, 1.10-6.44]; P = .04). Patient-reported or surrogate-reported goals-of-care discussions did not differ significantly between groups (30 of 66 patients [45%] vs 36 of 66 patients [55%]), although the intrarater consistency of patient and surrogate reports was poor. Patient-rated or surrogate-rated quality of communication did not differ significantly between groups. The intervention was feasible and acceptable to patients, surrogates, and clinicians. CONCLUSIONS AND RELEVANCE In this randomized clinical trial, a patient-facing and clinician-facing communication priming intervention for seriously ill, hospitalized patients promoted EHR-documented goals-of-care discussions before discharge with good feasibility and acceptability. Communication-priming interventions should be reexamined in a larger randomized clinical trial to better understand their effectiveness in the inpatient setting. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03746392.
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Affiliation(s)
- Robert Y. Lee
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Erin K. Kross
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Lois Downey
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Sudiptho R. Paul
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
- University of Washington School of Medicine, Seattle
| | - Joanna Heywood
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Elizabeth L. Nielsen
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Kelson Okimoto
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
- Department of Family Medicine, University of Washington, Seattle
| | - Lyndia C. Brumback
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Department of Biostatistics, University of Washington, Seattle
| | - Susan E. Merel
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle
| | - Ruth A. Engelberg
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - J. Randall Curtis
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
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15
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Daly J, Schmidt M, Thoma K, Xu Y, Levy B. How Well are Serious Illness Conversations Documented and What are Patient and Physician Perceptions of These Conversations? J Palliat Care 2022; 37:332-340. [PMID: 35341365 DOI: 10.1177/08258597221090387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The Serious Illness Care Program (SICP), developed in 2011 by Ariadne Labs, restructures care so that knowing and then honoring patients' wishes becomes part of routine care. OBJECTIVES 1) summarize patient perceptions of use of the Serious Illness Conversation Guide (SICG) components, 2) assess whether a serious illness conversation was documented in the electronic health record (EHR) and identify the SICG components that were included, 3) summarize clinician perceptions of use of the SICG components, and 4) assess the association of documented SICG components with the patient's perception of the SICG discussion. METHODS Clinicians at three family medicine offices were trained in serious illness conversations using the SICG. They documented their serious illness conversations in the medical record. Retrospective chart review for SICG components was conducted for patients. Patients and clinicians completed questionnaires about their experience with the SICG. Statistical analysis included the Pearson chi-square test for categorical variables and Cohen's kappa to determine agreement between clinician documentation and patient perception. RESULTS Eighty-nine patients consented and completed their baseline questionnaire. Mean age of the 89 patients was 72 years and 65 (73%) were female. Thirty (34%) medical records had one or more SICG components documented. Seventy-nine (89%) patients reported at least one individual component of the SICG being discussed. Clinicians reported they engaged in asking patients what is important to them at a mean of 5.9, with 7 being "all the time". There was slight agreement (kappa = .19) for patient perception and clinician documentation of discussing patient goals, but no agreement for any of the other SICG components. CONCLUSION Even among trained clinicians, only one-third of patients had documentation of at least one SICG component. Only slight agreement was found between clinician documentation of SICG in the medical record and patient perception of SICG discussion.
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Affiliation(s)
- Jeanette Daly
- Family Medicine, The University of Iowa, 200 Hawkins Drive, Iowa, USA
| | - Megan Schmidt
- Family Medicine, The University of Iowa, 200 Hawkins Drive, Iowa, USA
| | - Kate Thoma
- Family Medicine, The University of Iowa, 200 Hawkins Drive, Iowa, USA
| | - Yinghui Xu
- Family Medicine, The University of Iowa, 200 Hawkins Drive, Iowa, USA
| | - Barcey Levy
- Family Medicine, The University of Iowa, 200 Hawkins Drive, Iowa, USA
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16
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Lai C, Aceto P, Pellicano GR, Servidei G, Gambardella A, Lombardo L. Will I or my loved one die? Concordant awareness between terminal cancer patients and their caregivers is associated with lower patient anxiety and caregiver burden. Eur J Cancer Care (Engl) 2021; 31:e13546. [PMID: 34931734 DOI: 10.1111/ecc.13546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 11/22/2021] [Accepted: 12/02/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The aims of this study were to investigate the association between patients' awareness of their terminal illness and the levels of anxiety and depression, whether the concordance between the patients' and caregivers' belief about the patient's terminal illness was associated with patient's anxiety and depression, and with the caregiver burden. METHOD The study recruited 31 terminally ill patients with cancer along with their caregivers from a Palliative Care Unit. All data about patients and caregivers' awareness of the illness, patients' depression and anxiety, and caregiver burden were collected. RESULTS Patients aware of their short-term prognosis of death showed lower levels of anxiety than the unaware ones, especially women. Aware patients with concordant caregivers showed lower levels of anxiety but not of depression. Caregivers concordant with the patients' awareness presented lower levels of strain and burden. Finally, terminal patients who had an adult child caregiver were less likely to be aware of their terminal condition. CONCLUSIONS It appears that illness awareness and the caregiver's concordance with the patient's belief on the terminal condition are associated with lower anxiety, especially in women, and a reduced burden for caregivers.
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Affiliation(s)
- Carlo Lai
- Dynamic and Clinical Psychology, and Health Department, Sapienza University of Rome, Rome, Italy
| | - Paola Aceto
- Department of Anaesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anaesthesiology and Intensive Care, Catholic University of Sacred Heart, Rome, Italy
| | - Gaia Romana Pellicano
- Dynamic and Clinical Psychology, and Health Department, Sapienza University of Rome, Rome, Italy
| | - Giulia Servidei
- Dynamic and Clinical Psychology, and Health Department, Sapienza University of Rome, Rome, Italy
| | - Aldo Gambardella
- Dynamic and Clinical Psychology, and Health Department, Sapienza University of Rome, Rome, Italy
| | - Luigi Lombardo
- Centro di Cure Palliative, Fondazione Sanità e Ricerca, Rome, Italy
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17
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MacMartin MA, Barnato AE. Development of an Abstraction Tool to Assess Palliative Care Components. Am J Hosp Palliat Care 2021; 39:1418-1427. [PMID: 34894773 DOI: 10.1177/10499091211061724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Little is known regarding the fidelity of delivery of guideline-recommended components of palliative care in "real world" encounters. Objective: To develop a qualitative coding framework to identify components of clinical palliative care in clinical documentation across care settings. Design: Retrospective review of palliative care clinical documentation from medical providers, with directed qualitative content analysis to identify components of clinical care documented. Setting/Subjects: Purposively sampled deceased patients seen by palliative care at a US academic medical center between 7/1/2011-7/1/2018. Main Outcomes and Measures: The outcome of this work is a coding framework for use in future research. We assessed the robustness of the framework using Cohen's kappa. Results: We reviewed sixty-two encounters from twenty-six patients. We identified 7 major themes in documentation: (1) addressing physical symptoms, (2) addressing psychological symptoms, (3) establishing illness understanding, (4) supporting decision making, (5) end-of-life planning, (6) understanding psychosocial context, and (7) care coordination. Interrater reliability varied widely between components, with Cohen's kappa ranging from -.51 to 1. Conclusions: This pilot study provides a coding framework to measure documentation of clinical palliative care components. Several components could not be reliably identified using this framework, suggesting the need for additional measurement strategies.
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Affiliation(s)
- Meredith A MacMartin
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,22916Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Amber E Barnato
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,22916Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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18
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Harris E, Eng D, Ang Q, Clarke E, Sinha A. Goals of care discussions in acute hospital admissions - Qualitative description of perspectives from patients, family and their doctors. PATIENT EDUCATION AND COUNSELING 2021; 104:2877-2887. [PMID: 34598803 DOI: 10.1016/j.pec.2021.09.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 08/03/2021] [Accepted: 09/06/2021] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Goals of care discussions guide care for hospital inpatients at risk of deterioration. We aimed to explore patient and family experience of goals of care during the first 72 h of admission along with their doctor's perspective. METHODS A qualitative descriptive study. Patients, family and doctors who participated in a goals of care discussion during an acute hospital admission at an Australian tertiary teaching hospital were interviewed in 2019. RESULTS Many participants found goals of care discussions appropriate and reported understanding. However, communication was commonly procedure-focused, with questioning about preferences for cardiopulmonary resuscitation and intubation. Some considered the discussion as inapplicable to their state of health, and occasionally surprising. Participants commonly related goals of care with death, and without context, this led to fear of abandonment. Previous experience with end of life care influenced decision-making. Preference for family presence was clear. CONCLUSIONS This study identifies deficiencies in goals of care communication in the acute hospital setting. Discussions are life-saving-procedure focused, leading to poor understanding and potentially distress, and jeopardising patient-centred care. PRACTICE IMPLICATIONS Assessment of patient values and clear communication on the aims of goals of care discussions is essential to optimise patient and institutional outcomes. Clinicians should consider environment and invite family participation.
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Affiliation(s)
| | - Derek Eng
- Royal Perth Hospital, Perth, Australia; School of Medicine, Division of Internal Medicine, University of Western Australia, Crawley, Australia; St John of God Subiaco Hospital, Subiaco, Australia; School of Medicine, University of Notre Dame, Fremantle, Australia.
| | - QiKai Ang
- Royal Perth Hospital, Perth, Australia.
| | | | - Atul Sinha
- Royal Perth Hospital, Perth, Australia; School of Medicine, Division of Internal Medicine, University of Western Australia, Crawley, Australia; Fiona Stanley Hospital, Murdoch, Australia.
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19
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Edsall A, Howard S, Dewey EN, Siegel T, Zonies D, Brasel K, Cook MR, Nagengast AK. Critical decisions in the trauma intensive care unit: Are we practicing primary palliative care? J Trauma Acute Care Surg 2021; 91:886-890. [PMID: 34695065 DOI: 10.1097/ta.0000000000003324] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Devastating injuries require both urgent assessment by a trauma service and early attention to patients' goals of care (GOC). American College of Surgeons Trauma Quality Improvement Program (TQIP) guidelines recommend an initial palliative assessment within 24 hours of admission and family meeting, if needed, within 72 hours. We hypothesize that a primary palliative care-based practice improves adherence to TQIP guidelines in trauma patients. METHODS All adult trauma patients who died while inpatient from January 2014 to December 2018 were reviewed. Timing of GOC discussions, transition to comfort measures only (CMO), and the utilization of specialty palliative services were analyzed with univariate analysis. RESULTS During the study period, 415 inpatients died. Median Injury Severity Score was 26 (interquartile range [IQR], 17-34), median age was 67 years (IQR, 51-81 years), and 72% (n = 299) transitioned to CMO before death. Documented GOC discussions increased from 77% of patients in 2014 to 95% of patients in 2018 (p < 0.001), and in 2018, the median time to the first GOC discussion was 15 hours (IQR, 7- 24 hours). Specialty palliative care was consulted in 7% of all patients. Of patients who had at least one GOC discussion, 98% were led by the trauma intensive care unit (TICU) team. Median time from admission to first GOC discussion was 27 hours (IQR, 6-91 hours). Median number of GOC discussions was 1 (IQR, 1-2). Median time to CMO after the final GOC discussion was 0 hours (IQR, 0-3). Median time to death after transition to CMO was 4 hours (IQR, 1-18 hours). CONCLUSION Of those who died during index admission, we demonstrated significant improvement in adherence to American College of Surgeons TQIP palliative guidelines across the 5-year study period, with the TICU team guiding the majority of GOC discussions. Our TICU team has developed an effective primary palliative care approach, selectively consulting specialty palliative care only when needed. LEVEL OF EVIDENCE Therapeutic/care management, level III.
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Affiliation(s)
- Andrew Edsall
- From the Department of Surgery (A.E., S.H., E.N.D., T.S., D.Z., K.B., M.R.C., A.K.N.), Oregon Health and Science University; and Operative Care Division (A.K.N.), VA Portland Medical Center, Portland, Oregon
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20
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Molloy MJ, Ruhnke GW. Goal-Concordant Care After Hospitalization for Serious Acute Illness: A Key Opportunity for Hospitalists in Patient-Centered Outcomes. J Hosp Med 2021; 16:703. [PMID: 34752215 DOI: 10.12788/jhm.3723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 10/15/2021] [Indexed: 11/20/2022]
Affiliation(s)
- Matthew J Molloy
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Gregory W Ruhnke
- Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
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21
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Rutz Voumard R, Dugger KM, Kiker WA, Barber J, Borasio GD, Curtis JR, Jox RJ, Creutzfeldt CJ. Goal-Concordant Care After Severe Acute Brain Injury. Front Neurol 2021; 12:710783. [PMID: 34603183 PMCID: PMC8485029 DOI: 10.3389/fneur.2021.710783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 08/13/2021] [Indexed: 12/23/2022] Open
Abstract
Background: Patients with severe acute brain injury (SABI) lack decision-making capacity, calling on families and clinicians to make goal-concordant decisions, aligning treatment with patient's presumed goals-of-care. Using the family perspective, this study aimed to (1) compare patient's goals-of-care with the care they were receiving in the acute setting, (2) identify patient and family characteristics associated with goal-concordant care, and (3) assess goals-of-care 6 months after SABI. Methods: Our cohort included patients with SABI in our Neuro-ICU and a Glasgow Coma Scale Score <12 after day 2. Socio-demographic and clinical characteristics were collected through surveys and chart review. At enrollment and again at 6 months, each family was asked if the patient would prefer medical care focused on extending life vs. care focused on comfort and quality of life, and what care the patient is currently receiving. We used multivariate regression to examine the characteristics associated with (a) prioritized goals (comfort/extending life/unsure) and (b) goal concordance. Results: Among 214 patients, families reported patients' goals-of-care to be extending life in 118 cases (55%), comfort in 71 (33%), and unsure for 25 (12%), while care received focused on extending life in 165 cases (77%), on comfort in 23 (11%) and families were unsure in 16 (7%). In a nominal regression model, prioritizing comfort over extending life was significantly associated with being non-Hispanic White and having worse clinical severity. Most patients who prioritized extending life were receiving family-reported goal-concordant care (88%, 104/118), while most of those who prioritized comfort were receiving goal-discordant care (73%, 52/71). The only independent association for goal concordance was having a presumed goal of extending life at enrollment (OR 23.62, 95% CI 10.19–54.77). Among survivors at 6 months, 1 in 4 family members were unsure about the patient's goals-of-care. Conclusion: A substantial proportion of patients are receiving unwanted aggressive care in the acute setting after SABI. In the first days, such aggressive care might be justified by prognostic uncertainty. The high rate of families unsure of patient's goals-of-care at 6 months suggests an important need for periodic re-evaluation of prognosis and goals-of-care in the post-acute setting.
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Affiliation(s)
- Rachel Rutz Voumard
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA, United States.,Department of Palliative and Supportive Care, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Kaley M Dugger
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA, United States
| | - Whitney A Kiker
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, United States.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, United States
| | - Jason Barber
- Department of Neurosurgery, Harborview Medical Center, University of Washington, Seattle, WA, United States
| | - Gian Domenico Borasio
- Department of Palliative and Supportive Care, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - J Randall Curtis
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, United States.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, United States
| | - Ralf J Jox
- Department of Palliative and Supportive Care, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland.,Institute of Humanities in Medicine, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Claire J Creutzfeldt
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA, United States.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, United States
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Modes ME, Heckbert SR, Engelberg RA, Nielsen EL, Curtis JR, Kross EK. Patient-Reported Receipt of Goal-Concordant Care Among Seriously Ill Outpatients-Prevalence and Associated Factors. J Pain Symptom Manage 2020; 60:765-773. [PMID: 32389606 PMCID: PMC7508896 DOI: 10.1016/j.jpainsymman.2020.04.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/22/2020] [Accepted: 04/27/2020] [Indexed: 11/18/2022]
Abstract
CONTEXT Goal-concordant care is an important indicator of high-quality care in serious illness. OBJECTIVES To estimate the prevalence of patient-reported receipt of goal-concordant care among seriously ill outpatients and identify factors associated with the absence of patient-reported goal concordance. METHODS Analysis of enrollment surveys from a multicenter cluster-randomized trial of outpatients with serious illness. Patients reported their prioritized health care goal and the focus of their current medical care; these items were matched to define receipt of goal-concordant care. RESULTS Of 405 patients with a prioritized health care goal, 58% reported receipt of goal-concordant care, 17% goal-discordant care, and 25% were uncertain of the focus of their care. Patient-reported receipt of goal concordance differed by patient goal. For patients who prioritized extending life, 86% reported goal-concordant care, 2% goal-discordant care, and 12% were uncertain of the focus of their care. For patients who prioritized relief of pain and discomfort, 51% reported goal-concordant care, 21% goal-discordant care, and 28% were uncertain of the focus of their care. Patients who prioritized a goal of relief of pain and discomfort were more likely to report goal-discordant care than patients who prioritized a goal of extending life (relative risk ratio 22.20; 95% CI 4.59, 107.38). CONCLUSION Seriously ill outpatients who prioritize a goal of relief of pain and discomfort are less likely to report receipt of goal-concordant care than patients who prioritize extending life. Future interventions designed to improve receipt of goal-concordant care should focus on identifying patients who prioritize relief of pain and discomfort and promoting care aligned with that goal.
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Affiliation(s)
- Matthew E Modes
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.
| | - Susan R Heckbert
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Ruth A Engelberg
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Elizabeth L Nielsen
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Bioethics and Humanities, University of Washington, Seattle, Washington, USA
| | - Erin K Kross
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
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Modes ME, Engelberg RA, Downey L, Nielsen EL, Lee RY, Curtis JR, Kross EK. Toward Understanding the Relationship Between Prioritized Values and Preferences for Cardiopulmonary Resuscitation Among Seriously Ill Adults. J Pain Symptom Manage 2019; 58:567-577.e1. [PMID: 31228534 PMCID: PMC6754772 DOI: 10.1016/j.jpainsymman.2019.06.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 06/10/2019] [Accepted: 06/11/2019] [Indexed: 10/26/2022]
Abstract
CONTEXT Prioritizing among potentially conflicting end-of-life values may help patients discriminate among treatments and allow clinicians to align treatments with values. OBJECTIVES To investigate end-of-life values that patients prioritize when facing explicit trade-offs and identify predictors of patients whose values and treatment preferences seem inconsistent. METHODS Analysis of surveys from a multi-center cluster-randomized trial of patients with serious illness. Respondents prioritized end-of-life values and identified cardiopulmonary resuscitation (CPR) preferences in two health states. RESULTS Of 535 patients, 60% prioritized relief of discomfort over extending life, 17% prioritized extending life over relief of discomfort, and 23% were unsure. Patients prioritizing extending life were most likely to prefer CPR, with 93% preferring CPR in current health and 67% preferring CPR if dependent on others, compared with 69% and 21%, respectively, for patients prioritizing relief of discomfort, and 78% and 33%, respectively, for patients unsure of their prioritized value (P < 0.001 for all comparisons). Among patients prioritizing relief of discomfort, preference for CPR in current health was less likely among older patients (odds ratio 0.958 per year; 95% CI 0.935, 0.981) and more likely with better self-perceived health (odds ratio 1.402 per level of health; 95% CI 1.090, 1.804). CONCLUSION Clinicians face challenges as they clarify patient values and align treatments with values. Patients' values predicted CPR preferences, but a substantial proportion of patients expressed CPR preferences that appeared potentially inconsistent with their primary value. Clinicians should question assumptions about relationships between values and CPR preferences. Further research is needed to identify ways to use values to guide treatment decisions.
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Affiliation(s)
- Matthew E Modes
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.
| | - Ruth A Engelberg
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Lois Downey
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Elizabeth L Nielsen
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Robert Y Lee
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Bioethics and Humanities, University of Washington, Seattle, Washington, USA
| | - Erin K Kross
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
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Udelsman BV, Lilley EJ, Qadan M, Chang DC, Lillemoe KD, Lindvall C, Cooper Z. Deficits in the Palliative Care Process Measures in Patients with Advanced Pancreatic Cancer Undergoing Operative and Invasive Nonoperative Palliative Procedures. Ann Surg Oncol 2019; 26:4204-4212. [DOI: 10.1245/s10434-019-07757-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Indexed: 01/19/2023]
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Dalal AK, Dykes P, Samal L, McNally K, Mlaver E, Yoon CS, Lipsitz SR, Bates DW. Potential of an Electronic Health Record-Integrated Patient Portal for Improving Care Plan Concordance during Acute Care. Appl Clin Inform 2019; 10:358-366. [PMID: 31141830 DOI: 10.1055/s-0039-1688831] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Care plan concordance among patients and clinicians during hospitalization is suboptimal. OBJECTIVE This article determines whether an electronic health record (EHR)-integrated patient portal was associated with increased understanding of the care plan, including the key recovery goal, among patients and clinicians in acute care setting. METHODS The intervention included (1) a patient portal configured to solicit a single patient-designated recovery goal and display the care plan from the EHR for participating patients; and (2) an electronic care plan for all unit-based nurses that displays patient-inputted information, accessible to all clinicians via the EHR. Patients admitted to an oncology unit, including their nurses and physicians, were enrolled before and after implementation. Main outcomes included mean concordance scores for the overall care plan and individual care plan elements. RESULTS Of 457 and 283 eligible patients approached during pre- and postintervention periods, 55 and 46 participated in interviews, respectively, including their clinicians. Of 46 postintervention patients, 27 (58.7%) enrolled in the patient portal. The intention-to-treat analysis demonstrated a nonsignificant increase in the mean concordance score for the overall care plan (62.0-67.1, adjusted p = 0.13), and significant increases in mean concordance scores for the recovery goal (30.3-57.7, adjusted p < 0.01) and main reason for hospitalization (58.6-79.2, adjusted p < 0.01). The on-treatment analysis of patient portal enrollees demonstrated significant increases in mean concordance scores for the overall care plan (61.9-70.0, adjusted p < 0.01), the recovery goal (30.4-66.8, adjusted p < 0.01), and main reason for hospitalization (58.3-81.7, adjusted p < 0.01), comparable to the intention-to-treat analysis. CONCLUSION Implementation of an EHR-integrated patient portal was associated with increased concordance for key care plan components. Future efforts should be directed at improving concordance for other care plan components and conducting larger, randomized studies to evaluate the impact on key outcomes during transitions of care. CLINICAL TRIALS IDENTIFIER NCT02258594.
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Affiliation(s)
- Anuj K Dalal
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, United States.,Harvard Medical School, Harvard University, Boston, Massachusetts, United States
| | - Patricia Dykes
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, United States.,Harvard Medical School, Harvard University, Boston, Massachusetts, United States
| | - Lipika Samal
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, United States.,Harvard Medical School, Harvard University, Boston, Massachusetts, United States
| | - Kelly McNally
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Eli Mlaver
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Cathy S Yoon
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Stuart R Lipsitz
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, United States.,Harvard Medical School, Harvard University, Boston, Massachusetts, United States
| | - David W Bates
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, United States.,Harvard Medical School, Harvard University, Boston, Massachusetts, United States
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