Seriously Ill Patients' Prioritized Goals and Their Clinicians' Perceptions of Those Goals

Human-Centered Design Development and Acceptability Testing of a Goal Concordant Prescribing Program in Hospice

Introduction: Home hospice medication management ideally addresses symptoms, reduces unnecessary medication use, and optimizes quality of life. Grounding decisions in goals of care is critical. How to ascertain and align patients', families', and clinicians' goals for medication management remains challenging. Objectives: To describe the iterative development and acceptability testing of a structured, interdisciplinary approach to goal concordant prescribing (GCP). Methods/Approach: We started with a previously developed deprescribing curriculum that followed a three-step process: review, align, and simplify. We utilized human-centered design and adult learning experts to translate the existing curriculum into tools and training that addressed gaps identified in an environmental scan (see Supplementary Data for a review of existing tools). Weekly multidisciplinary design team meetings revealed the need for tools to facilitate medication-focused and goal-oriented communication. The revised GCP program includes three clinician-facing tools: (1) GCP Person-Centered Medication Reconciliation worksheet, (2) Goal Assessment and Priorities (GAP) Tool, and (3) GCP Conversation Guide. Acceptability was tested with nursing and social work staff at a not-for-profit hospice who completed two 2-hour GCP training sessions. We used a content analytic approach to evaluate written and verbal feedback that was collected after each session. Results: Participants felt that framing deprescribing in positivist language that connected medication changes to goals was innovative and a useful conversation skill. Participants also felt that GCP training was acceptable, the GAP tool and skill practice were useful, the GCP Program added value to clinical practice, and medication review in relation to prioritized goals was innovative and useful without adding to clinician workload. Conclusion: GCP supports alignment of patient and family priorities with medication management. This nurse-delivered intervention involves the interdisciplinary team and employs novel tools. Pilot testing indicates GCP tool and training acceptability to facilitate medication management conversations.

Leveraging the electronic health record to identify delivery of goal-concordant care

Background

Goal-concordant care (GCC) is recognized as the highest quality of care and most important outcome measure for serious illness research, yet there is no agreed-upon or validated method to measure it.

Objective

Assess feasibility of measuring GCC using clinical documentation in the electronic health record (EHR).

Design

Retrospective chart review study.

Participants

Adults with ≥50% predicted six-month mortality risk admitted to three urban hospitals in a single health system. All participants had goals-of-care (GOC) discussions documented in the EHR 6 months before and 6 months after admission manually classified into one of four categories of goals: (1) comfort-focused, (2) maintain or improve function, (3) life-extension, or (4) unclear.

Main Measures

Pairs of physician-coders independently reviewed EHR notes from 6 months before through 6 months after admission to identify and classify care received between each documented GOC discussion into one of the four goals categories. Epochs between GOC discussions were then coded as goal-concordant if GOC and care received classifications were aligned, goal-discordant if they were misaligned, or uncertain if either classification was unclear or not documented. Coder inter-rater reliability was assessed using kappa statistics.

Key Results

Inter-rater reliability for classifying care received was almost perfect (95% interrater agreement; Cohen's kappa=0.92; 95% CI, 0.86-0.99). Of 398 total epochs across 109 unique patients, 198 (50%) were goal-concordant, 112 (28%) were of uncertain concordance, and 88 (22%) were goal-discordant. Eighty (73%) patients received care of uncertain concordance during at least one epoch. Forty-eight (44%) patients received goal-discordant care during at least one epoch.

Conclusions

Clinician chart review was a feasible method for measuring GCC and can inform natural language processing and machine learning methods to improve the clinical and research utility of this method. More work is needed to understand the driving factors underlying the high rate of uncertain concordance and goal-discordant care identified among this seriously ill cohort.

Understanding the provision of goal-concordant care in the intensive care unit: A sequential two-phase qualitative descriptive study

BACKGROUND

Goal-concordant care in intensive care is care that aligns with the patient's expressed goals, values, preferences and beliefs. Communication and shared decision-making are key to ensuring goal-concordant care.

AIMS

The aims of his study were to explore (i) critical care clinicians' perspectives on how patient goals of care were communicated between clinicians, patients, and family in the intensive care unit; (ii) critical care nurses' role in this process; and (iii) how goals of care were used to guide care.

METHOD

Sequential two-phase qualitative descriptive design. Data were collected from February to June 2022 in a level-3 intensive care unit in a private hospital in Melbourne, Australia. In Phase One, individual interviews were conducted with critical care nurse participants (n = 11). In Phase Two, the findings were presented to senior clinical leaders (n = 2) to build a more comprehensive understanding. Data were analysed using Braun and Clarke's six step reflexive thematic analysis.

FINDINGS

There was poor consensus on the term 'goals of care', with some participants referring to daily treatment goals or treatment limitations and others to patients' wishes and expectations beyond the ICU. Critical care nurses perceived themselves as information brokers and patient advocates responsible for ensuring patient goals of care were respected, but engaging in goals-of-care conversations was challenging. A lack of role clarity, poor team communication, and inadequate processes to communicate patient goals impeded goal-concordant care. Senior clinical leaders affirmed these views, emphasising the need to utilise critical care nurses' insight for practical solutions to improve patient care.

CONCLUSIONS

Clarity in both, the term 'goals of care' and the critical care nurses' role in these conversations, are the essential first steps to ensuring patients' values, preferences, and beliefs to guide shared-decision-making and goal-concordant care. Improved verbal and written communication that is inclusive of all members of the treating team is key to addressing these issues.

Do goals of care documentation reflect the conversation?: Evaluating conversation-documentation accuracy

BACKGROUND

Documenting goals of care in the electronic health record is meant to relay patient preferences to other clinicians. Evaluating the content and documentation of nurse and social worker led goals of care conversations can inform future goals of care initiative efforts.

METHODS

As part of the ADvancing symptom Alleviation with Palliative Treatment trial, this study analyzed goals of care conversations led by nurses and social workers and documented in the electronic health record. Informed by a goals of care communication guide, we identified five goals of care components: illness understanding, goals and values, end of life planning, surrogate, and advance directives. Forty conversation transcripts underwent content analysis. Through an iterative team process, we defined documentation accuracy as four categories: (1) Complete-comprehensive accurate documentation of the conversation, (2) Incomplete-partial documentation of the conversation, (3) Missing-discussed and not documented, and (4) Incorrect-misrepresented in documentation. We also defined-Not Discussed-for communication guide questions that were not discussed nor documented. A constant comparative approach was used to determine the presence or absence of conversation content in the documentation.

RESULTS

All five goals of care components were discussed in 67% (27/40) of conversation transcripts. Compared to the transcripts, surrogate (37/40, 93%) and advance directives (36/40, 90%) were often documented completely. Almost 40% of goals and values (15/40, 38%) and half of end of life planning (19/40, 48%) were incomplete. Illness understanding was missing (13/40, 33%), not discussed (13/40, 33%), or incorrect (2/40, 5%).

CONCLUSION

Nurse and social worker led goals of care conversations discussed and documented most components of the goals of care communication guide. Further research may guide how best to determine the relative importance of accuracy, especially in the broad setting of incomplete, missing, and incorrect EHR documentation.

Beyond translation: Transcreation of a clinicians' guide to structure discussions about health-related values with Latinx patients throughout cancer

OBJECTIVE

This study aimed to ensure accurate translation and cultural appropriateness of a guide designed to help oncology clinicians provide person-centered care to Spanish-speaking Latinx patients with cancer.

METHODS

Initial translation of a clinician-patient values discussion guide in open-ended question format ("Guide") was pretested in interviews with 27 Spanish-speaking individuals, followed by national expert panel review. At three sites, semi-structured, in-depth, audio-recorded interviews in the participant's preferred language (Spanish/English) were then conducted with Latinx patients receiving systemic treatment for a solid tumor malignancy and family joining them at clinic.

RESULTS

Interviews of 43 patient/family participants representing diverse Latinx communities addressed the Guide's understandability, acceptability, relevance and responsiveness. Rapid analysis of interviews contributed to cultural adaptation/transcreation of the Guide for a pilot interventional trial.

CONCLUSION

Moving beyond translation to transcreation can help promote inclusion, equity, and cultural sensitivity in oncologic care/communication.

PRACTICE IMPLICATIONS

Clinicians now have a linguistically- and culturally-adapted guide including questions and prompts to help structure discussions in Spanish or English of health-related values with Latinx patients receiving oncologic care.

Patient and Clinician Stakeholder Perspectives on a Patient Portal Questionnaire Eliciting Illness and Treatment Understanding and Core Health-Related Values

Introduction

Person-centered communication is foundational to cancer care. In pilot research, a questionnaire eliciting patients' illness and treatment understanding (ITU) and core health-related values (HRV) through the electronic patient portal demonstrated feasibility, acceptability, and efficacy. The aim of this study was to elicit stakeholder feedback to refine the design of the portal-based intervention, remain end-user centered, and optimize future system-wide integration.

Methods

Between April and June 2023, we purposively sampled patients and clinicians from a previous pilot study to participate in a 20-30-minute semistructured interview about their opinions of and experiences with the portal questionnaire on ITU and HRV. An interdisciplinary coding team used a two-phase rapid analysis to identify themes, subthemes, and illustrative participant quotations.

Results

Fourteen patients (mean age = 68 years) and 12 clinicians participated (total n = 26). Colorectal cancer was the commonest malignancy (64%) among patients. Clinicians were mostly physicians (50%), nurse practitioners (33%), and registered nurses (17%), with two-thirds having >15 years of experience in their specialty. Analysis generated four themes: (1) clinical utility of questionnaire, (2) barriers to questionnaire implementation, (3) considerations and strategies for modifying the questionnaire, and (4) considerations and strategies for questionnaire implementation. Themes captured key information about incorporating this questionnaire into clinical practice.

Conclusion

Patients with cancer and their clinicians found a portal-based ITU and HRV questionnaire clinically useful to improve multiple aspects of person-centered communication. Participant recommendations about questionnaire timing and sharing of questionnaire responses with the clinical team will inform future questionnaire implementation and scaling in clinical settings.

Pulmonologists' Perspectives on and Access to Palliative Care for Patients With Idiopathic Pulmonary Fibrosis in South Carolina

Background

Idiopathic pulmonary fibrosis (IPF) is a serious illness with an unpredictable disease course and survival rates comparable with some cancers. Patients with IPF suffer considerable symptom burden, declining quality of life, and high health care resource utilization. Patients and caregivers report many unmet needs, including a desire for more education regarding diagnosis and assistance with navigating disease trajectory. Compelling evidence suggests that palliative care (PC) provides an extra layer of support for patients with serious illness.

Research Question

The purpose of this survey was to gain perspectives regarding PC for patients with IPF by board-certified pulmonologists in South Carolina (SC).

Study Design and Methods

A 24-item survey was adapted (with permission) from the Pulmonary Fibrosis Foundation PC Survey instrument. Data were analyzed and results are presented.

Results

Pulmonologists (n = 32, 44%) completed the survey; 97% practice in urbanized settings. The majority agreed that PC and hospice do not provide the same service. There were varying views about comfort in discussing prognosis, disease trajectory, and addressing advance directives. Options for ambulatory and inpatient PC are limited and early PC referral does not occur. None reported initiating a PC referral at time of initial IPF diagnosis.

Interpretation

Pulmonologists in SC who participated in this survey are aware of the principles of PC in providing comprehensive care to patients with IPF and have limited options for PC referral. PC educational materials provided early in the diagnosis can help facilitate and guide end-of-life planning and discussions. Minimal resources exist for patients in underserved communities.

Patient Portals to Elicit Essential Patient-Reported Elements of Communication Supporting Person-Centered Oncologic Care: A Pilot Study of the PERSON Approach

PURPOSE

Patient portal technology offers important new opportunities to support person-centered clinician-patient communication.

METHODS

Questionnaires relating to understanding of illness and treatment intent were sent quarterly via portal to all patients scheduled for follow-up in GI medical oncology clinics. For patients in selected clinics, items eliciting health-related values were added. Patient responses were available to all oncology team members in the electronic health record. Workflow and content of clinician-patient discussions about illness, treatment, and care goals stayed within clinicians' discretion. Feasibility (patient response rate), patient understanding, acceptability (three-item patient questionnaire), and efficacy (quality of clinician communication) were evaluated.

RESULTS

From May 2021 through December 2022, a total of 12,233 questionnaires about illness/treatment understanding were sent to 6,325 patients (one to six per patient), with 97% response, including 9,358 with both open- and closed-ended responses. Fewer than 0.1% of patients indicated distress related to the questionnaire/process. Open-ended responses complemented closed-ended answers by revealing prognostic awareness and illness concerns. Of 48 patients approached to complete the full questionnaire including values items via portal, 15 first received and completed them in clinic (5 on iPad, 10 on paper), while 33 received and 27 (82%) completed the portal questionnaire. Patients found the portal process acceptable, and ratings of clinician communication were higher after clinic visits informed by patients' questionnaire responses (average prescore 6.8 v 5.9 post; P = .03).

CONCLUSION

Almost all patients in this large GI cancer cohort responded via the portal about their understanding of illness and treatment goals. Eliciting their personal values by portal was also feasible, accepted by patients, and improved patient ratings of clinicians' communication. Portals represent a promising tool for scaling assessment of essential patient-reported elements of person-centered communication.