1
|
Sanders JJ, Benotti E, Jaramillo C, Sihlongonyane B, Downey N, Mitchell S, Sterba KR, Carey EC, Meier D, Mohta NS, Fromme E, Paladino J. Implementing the Serious Illness Care Program in Safety Net Health Systems: a qualitative study. J Pain Symptom Manage 2024:S0885-3924(24)00787-5. [PMID: 38815729 DOI: 10.1016/j.jpainsymman.2024.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 05/03/2024] [Accepted: 05/14/2024] [Indexed: 06/01/2024]
Abstract
CONTEXT Interventions to improve the quality of care for people affected by serious illness commonly fail to reach patients from marginalized and underserved communities, which include those characterized by racialized or indigenous identity, sexual and gender minority status, and rural living. Interventions to improve care through serious illness conversations have demonstrated benefit, but little is known about their implementation in health systems that predominantly serve these patient groups. OBJECTIVES The study aimed to understand factors influencing implementation of a serious illness communication-focused intervention - the Serious Illness Care Program - in health systems who primarily provide care to marginalized and underserved communities. METHODS Qualitative interviews (16) and focus groups (3) were conducted with 19 interdisciplinary team members from six geographically diverse U.S. healthcare systems. Using a template analysis approach, investigators coded data inductively and deductively to identify themes. RESULTS Three themes emerged: patient factors, intervention elements, and health system contextual factors. Participants highlighted mission-driven efforts, creativity, interprofessional practice, and trainees as enablers of success. They identified weaknesses in the intervention's communication tool - the Serious Illness Conversation Guide guide, - as barriers to implementation of conversations. Resource constraints, socio-economic vulnerability, and mistrust in the health system were seen as additional barriers. CONCLUSIONS Health systems that provide care to underserved and marginalized communities face unique challenges implementing the Serious Illness Care Program. They also possess assets, some unique to these settings, that support program adoption. Findings suggest that implementation of similar programs in low-resource healthcare settings may help address unmet needs among marginalized populations.
Collapse
Affiliation(s)
- Justin J Sanders
- Ariadne Labs, Boston, MA; McGill University, Montreal, QC, Canada.
| | | | | | | | | | | | | | | | | | - Namita S Mohta
- Ariadne Labs, Boston, MA; Harvard Medical School; Brigham and Women's Hospital, Boston, MA
| | - Erik Fromme
- Ariadne Labs, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; Harvard Medical School
| | - Joanna Paladino
- Ariadne Labs, Boston, MA; Harvard Medical School; Massachusetts General Hospital, Boston, MA
| |
Collapse
|
2
|
Pusa S, Baxter R, Andersson S, Fromme EK, Paladino J, Sandgren A. Core Competencies for Serious Illness Conversations: An Integrative Systematic Review. J Palliat Care 2024:8258597241245022. [PMID: 38557369 DOI: 10.1177/08258597241245022] [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: 04/04/2024]
Abstract
Objective: The Serious Illness Care Program was developed to support goals and values discussions between seriously ill patients and their clinicians. The core competencies, that is, the essential clinical conversation skills that are described as requisite for effective serious illness conversations (SICs) in practice, have not yet been explicated. This integrative systematic review aimed to identify core competencies for SICs in the context of the Serious Illness Care Program. Methods: Articles published between January 2014 and March 2023 were identified in MEDLINE, PsycINFO, CINAHL, and PubMed databases. In total, 313 records underwent title and abstract screening, and 96 full-text articles were assessed for eligibility. The articles were critically appraised using the Joanna Briggs Institute Critical Appraisal Guidelines, and data were analyzed using thematic synthesis. Results: In total, 53 articles were included. Clinicians' core competencies for SICs were described in 3 themes: conversation resources, intrapersonal capabilities, and interpersonal capabilities. Conversation resources included using the conversation guide as a tool, together with applying appropriate communication skills to support better communication. Intrapersonal capabilities included calibrating one's own attitudes and mindset as well as confidence and self-assurance to engage in SICs. Interpersonal capabilities focused on the clinician's ability to interact with patients and family members to foster a mutually trusting relationship, including empathetic communication with attention and adherence to patient and family members views, goals, needs, and preferences. Conclusions: Clinicians need to efficiently combine conversation resources with intrapersonal and interpersonal skills to successfully conduct and interact in SICs.
Collapse
Affiliation(s)
- Susanna Pusa
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
- Department of Nursing, Umeå University, Umeå, Sweden
| | - Rebecca Baxter
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
- Department of Nursing, Umeå University, Umeå, Sweden
| | - Sofia Andersson
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
- Department of Nursing, Umeå University, Umeå, Sweden
| | - Erik K Fromme
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Joanna Paladino
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Anna Sandgren
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
| |
Collapse
|
3
|
Baxter R, Pusa S, Andersson S, Fromme EK, Paladino J, Sandgren A. Core elements of serious illness conversations: an integrative systematic review. BMJ Support Palliat Care 2024:spcare-2023-004163. [PMID: 37369576 DOI: 10.1136/spcare-2023-004163] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Ariadne Labs' Serious Illness Care Program (SICP), inclusive of the Serious Illness Conversation Guide (SICG), has been adapted for use in a variety of settings and among diverse population groups. Explicating the core elements of serious illness conversations could support the inclusion or exclusion of certain components in future iterations of the programme and the guide. AIM This integrative systematic review aimed to identify and describe core elements of serious illness conversations in relation to the SICP and/or SICG. DESIGN Literature published between 1 January 2014 and 20 March 2023 was searched in MEDLINE, PsycINFO, CINAHL and PubMed. All articles were evaluated using the Joanna Briggs Institute Critical Appraisal Guidelines. Data were analysed with thematic synthesis. RESULTS A total of 64 articles met the inclusion criteria. Three themes were revealed: (1) serious illness conversations serve different functions that are reflected in how they are conveyed; (2) serious illness conversations endeavour to discover what matters to patients and (3) serious illness conversations seek to align what patients want in their life and care. CONCLUSIONS Core elements of serious illness conversations included explicating the intention, framing, expectations and directions for the conversation. This encompassed discussing current and possible trajectories with a view towards uncovering matters of importance to the patient as a person. Preferences and priorities could be used to inform future preparation and recommendations. Serious illness conversation elements could be adapted and altered depending on the intended purpose of the conversation.
Collapse
Affiliation(s)
- Rebecca Baxter
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University-Vaxjo Campus, Vaxjo, Sweden
| | - Susanna Pusa
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University-Vaxjo Campus, Vaxjo, Sweden
| | - Sofia Andersson
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University-Vaxjo Campus, Vaxjo, Sweden
| | - Erik K Fromme
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Joanna Paladino
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Anna Sandgren
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University-Vaxjo Campus, Vaxjo, Sweden
| |
Collapse
|
4
|
Pusa S, Baxter R, Sandgren A. Physicians' perceptions of the implementation of the serious illness care program: a qualitative study. BMC Health Serv Res 2023; 23:1401. [PMID: 38087357 PMCID: PMC10717999 DOI: 10.1186/s12913-023-10419-5] [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: 07/09/2023] [Accepted: 12/01/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Conversations about goals, values and priorities with patients that are seriously ill are associated with improved palliative healthcare. The Serious Illness Care Program is a multi-component program that can facilitate more, better, and earlier conversations between clinicians and seriously ill patients. For successful and sustainable implementation of the Serious Illness Care Program, it is important to consider how stakeholders perceive it. The aim of our study was to explore physicians' perceptions and experiences of implementing the Serious Illness Care Program. METHODS Data were collected through four focus group discussions with physicians (n = 14) working at a hospital where the Serious Illness Care program was in the process of being implemented. Data were analyzed with inductive thematic analysis. RESULTS Physicians' perceptions of the implementation encompassed three thematic areas: hovering between preparedness and unpreparedness, being impacted and being impactful, and picking pieces or embracing it at all. CONCLUSIONS This study identified key aspects related to the individual physician, the care team, the impact on the patient, and the organizational support that were perceived to influence the implementation and sustainable integration of the Serious Illness Care Program. Describing these aspects provides insight into how the Serious Illness Care Program is implemented in practice and indicates areas for future training and development. TRIAL REGISTRATION Not applicable.
Collapse
Affiliation(s)
- Susanna Pusa
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden.
| | - Rebecca Baxter
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
| | - Anna Sandgren
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
| |
Collapse
|
5
|
Yang L, Zhu N, Wang X, Tan J, Chen L, Su C, Dong T, Long B, Qiu Y, Deng R. Experiences and perspectives of healthcare professionals, patients and caregivers toward the serious illness conversation guide: protocol for a qualitative meta-synthesis. BMJ Open 2023; 13:e073171. [PMID: 38011974 PMCID: PMC10685960 DOI: 10.1136/bmjopen-2023-073171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 11/03/2023] [Indexed: 11/29/2023] Open
Abstract
INTRODUCTION Exploring the experiences and perspectives of healthcare professionals, patients and caregivers toward serious illness conversations based on the Serious Illness Care Program is vital for improving communication with patients who are seriously ill, as has been shown in previous studies. However, few studies have carried out a systematic review to examine common themes, strengthen conclusions and identify gaps in the literature, the findings of which could help steer further research, policies and practice to improve more timely and person-centred conversations about the values and priorities of patients with serious illnesses. The objective of this qualitative meta-synthesis is to explore how healthcare professionals, patients and caregivers described their own experiences of the processes of serious illness communication through a secondary analysis of published qualitative data. METHODS AND ANALYSIS Meta-aggregation will be used to conduct a systematic review of qualitative studies. We conducted an initial search on 10 October 2023; papers published in English will be searched using electronic databases, including PubMed (MEDLINE), Web of Science, Embase, Ovid and CINAHL. Studies that satisfy the eligibility criteria will be evaluated for methodological quality using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research. The meta-aggregative review will consist of the following: (1) extraction of findings of all included studies; (2) categorisation of the findings, with at least two findings per category; and (3) synthesis of one or more findings from at least two categories. Study eligibility screening, data extraction, analysis and JBI Critical Appraisal Checklist and Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research assessments will be undertaken independently by two authors. ETHICS AND DISSEMINATION Secondary data analysis of published literature does not require ethical approval. The results will be disseminated in peer-reviewed journals and presented in conference papers and elsewhere. PROSPERO REGISTRATION NUMBER CRD42022330859.
Collapse
Affiliation(s)
- Liu Yang
- Department of Emergency, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Nanxi Zhu
- Department of Emergency, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Department of Neonatal Medicine Center, Xiamen Children's Hospital, Xiamen, China
| | - Xianlin Wang
- Department of Nursing, Zunyi Medical University, Zunyi, China
| | - Jin Tan
- Department of Nursing, Zunyi Medical University, Zunyi, China
| | - Liuliu Chen
- School of Health, Zhuhai College of Science and Technology, Zhuhai, China
| | - Cui Su
- Department of Nursing, Zunyi Medical University, Zunyi, China
| | - Tiaoxia Dong
- Department of Nursing, Zunyi Medical University, Zunyi, China
| | - Bingjie Long
- Department of Neonatal Medicine Center, Xiamen Children's Hospital, Xiamen, China
| | - Yeyin Qiu
- Fifth Affiliated Hospital of Zunyi Medical University, Zhuhai, China
| | - Renli Deng
- Department of Emergency, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Department of Nursing, Zunyi Medical University, Zunyi, China
| |
Collapse
|
6
|
Sullivan SS, Mann CM, Wittenberg E. Communication Openings: A Novel Approach for Serious Illness Communication in Homecare. J Gerontol Nurs 2023; 49:33-41. [PMID: 37906048 DOI: 10.3928/00989134-20231011-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Serious illness communication in homecare about hospice and/or palliative care transitions is lacking due to clinical culture. The purpose of the current study was to understand communication openings using COMFORT™, a palliative care communication model used to train nurses. Qualitative, focus group interviews with 31 homecare nurses were conducted. Data were transcribed verbatim and thematically analyzed using NVivo software, followed by hand-sorting. Four themes for communication openings for initiating discussions about potential hospice and/or palliative care transitions were identified: Organizational Openings (homecare appropriateness, eligibility requirements, and staffing); Patient Openings (patient physical decline, psychosocial changes, safety concerns, and denying/stopping care); Caregiver Openings (caregiver physical changes and patient readiness); and Nurse Openings (need for hospice, checking for prognosis understanding, increasing interprofessional care needs, and providing end-of-life care). This study extends the concept of communication openings in the COMFORT model. Further development of communication openings as part of COMFORT communication is needed in educational and intervention research. [Journal of Gerontological Nursing, 49(11), 33-41.].
Collapse
|
7
|
Paladino J, Fromme EK, Kilpatrick L, Dingfield L, Teuteberg W, Bernacki R, Jackson V, Sanders JJ, Jacobsen J, Ritchie C, Mitchell S. Lessons Learned About System-Level Improvement in Serious Illness Communication: A Qualitative Study of Serious Illness Care Program Implementation in Five Health Systems. Jt Comm J Qual Patient Saf 2023; 49:620-633. [PMID: 37537096 DOI: 10.1016/j.jcjq.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 06/26/2023] [Accepted: 06/26/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Serious illness communication is a key element of high-quality care, but it is difficult to implement in practice. The Serious Illness Care Program (SICP) is a multifaceted intervention that contributes to more, earlier, and better serious illness conversations and improved patient outcomes. This qualitative study examined the organizational and implementation factors that influenced improvement in real-world contexts. METHODS The authors performed semistructured interviews of 30 health professionals at five health systems that adopted SICP as quality improvement initiatives to investigate the organizational and implementation factors that appeared to influence improvement. RESULTS After SICP implementation across the organizations studied, approximately 4,661 clinicians have been trained in serious illness communication and 56,712 patients had had an electronic health record (EHR)-documented serious illness conversation. Facilitators included (1) visible support from leaders, who financially invested in an implementation team and champions, expressed the importance of serious illness communication as an institutional priority, and created incentives for training and documenting serious illness conversations; (2) EHR and data infrastructure to foster performance improvement and accountability, including an accessible documentation template, a reporting system, and customized data feedback for clinicians; and (3) communication skills training and sustained support for clinicians to problem-solve communication challenges, reflect on communication experiences, and adapt the intervention. Inhibitors included leadership inaction, competing priorities and incentives, variable clinician acceptance of EHR and data tools, and inadequate support for clinicians after training. CONCLUSION Successful implementation appeared to rely on multilevel organizational strategies to prioritize, reward, and reinforce serious illness communication. The insights derived from this research may function as an organizational road map to guide implementation of SICP or related quality initiatives.
Collapse
|
8
|
Carter C, Mohammed S, Upshur R, Kontos P. "I don't see the whole picture of their health": a critical ethnography of constraints to interprofessional collaboration in end-of-life conversations in primary care. BMC PRIMARY CARE 2023; 24:225. [PMID: 37898764 PMCID: PMC10612350 DOI: 10.1186/s12875-023-02171-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 10/04/2023] [Indexed: 10/30/2023]
Abstract
CONTEXT Interprofessional collaboration is recommended in caring for frail older adults in primary care, yet little is known about how interprofessional teams approach end-of-life (EOL) conversations with these patients. OBJECTIVE To understand the factors shaping nurses' and allied health clinicians' involvement, or lack of involvement in EOL conversations in the primary care of frail older adults. METHODS/SETTING A critical ethnography of a large interprofessional urban Family Health Team in Ontario, Canada. Data production included observations of clinicians in their day-to-day activities excluding direct patient care; one-to-one semi-structured interviews with clinicians; and document review. Analysis involved coding data using an interprofessional collaboration framework as well as an analysis of the normative logics influencing practice. PARTICIPANTS Interprofessional clinicians (n = 20) who cared for mildly to severely frail patients (Clinical Frailty Scale) at the Family Health Team. RESULTS Findings suggest primary care nurses and allied health clinicians have the knowledge, skills, and inclination to engage frail older adults in EOL conversations. However, the culture of the clinic prioritizes biomedical care, and normalizes nurses and allied health clinicians providing episodic task-based care, which limits the possibility for these clinicians' engagement in EOL conversations. The barriers to nurses' and allied health clinicians' involvement in EOL conversations are rooted in neoliberal-biomedical ideologies that shapes the way primary care is governed and practiced. CONCLUSIONS Our findings help to explain why taking an individual-level approach to addressing the challenge of delayed or avoided EOL conversations, is unlikely to result in practice change. Instead, primary care teams can work to critique and redevelop quality indicators and funding models in ways that promote meaningful interprofessional practice that recognize the expertise of nursing and allied health clinicians in providing high quality primary care to frail older patients, including EOL conversations.
Collapse
Affiliation(s)
- Celina Carter
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
| | - Shan Mohammed
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Ross Upshur
- Department of Family and Community Medicine and Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Pia Kontos
- KITE Research Institute, Toronto Rehabilitation Institute - University Health Network, Toronto, Canada
| |
Collapse
|
9
|
Izumi SS, Caron D, Guay-Bélanger S, Archambault P, Michaels L, Heinlein J, Dorr DA, Totten A, Légaré F. Development and Evaluation of Serious Illness Conversation Training for Interprofessional Primary Care Teams. J Palliat Med 2023; 26:1198-1206. [PMID: 37040304 DOI: 10.1089/jpm.2022.0268] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023] Open
Abstract
Background: Early advance care planning (ACP) conversations are essential to deliver patient-centered care. While primary care is an ideal setting to initiate ACP, such as Serious Illness Conversations (SICs), many barriers exist to implement such conversations in routine practice. An interprofessional team approach holds promises to address barriers. Objective: To develop and evaluate SIC training for interprofessional primary care teams (IP-SIC). Design: An existing SIC training was adapted for IP-SIC and then implemented and evaluated for acceptability and effectiveness. Setting/Context: Interprofessional teams in 15 primary care clinics in five US states. Measures: Acceptability of the IP-SIC training and participants' self-reported likelihood to engage in ACP after the training. Results: The 156 participants were a mix of physicians and advanced practice providers (APPs) (44%), nurses and social workers (31%), and others (25%). More than 90% of all participants rated the IP-SIC training positively. While nurse/social worker and other groups were less likely than physician and APP group to engage in ACP before training (4.4, 3.7, and 6.4 on a 1-10 scale, respectively), all groups showed significant increase in likelihood to engage in ACP after the IP-SIC training (8.5, 7.7, and 9.2, respectively). Both physician/APP and nurse/social worker groups showed significant increase in likelihood to use the SIC Guide after the IP-SIC training, whereas an increase in likelihood to use SIC Guide among other groups was not statistically significant. Conclusion: The new IP-SIC training was well accepted by interprofessional team members and effective to improve their likelihood to engage in ACP. Further research exploring how to facilitate collaboration among interprofessional team members to maximize opportunities for more and better ACP is warranted. ClinicalTrials.gov ID: NCT03577002.
Collapse
Affiliation(s)
- Shigeko Seiko Izumi
- School of Nursing, Oregon Health and Science University, Portland, Oregon, USA
| | - Danielle Caron
- VITAM-Centre de Recherche en Santé Durable, Centre Intégré Universitaire de Santé et Services Sociaux de la Capitale-Nationale, Quebec City, Quebec, Canada
| | - Sabrina Guay-Bélanger
- VITAM-Centre de Recherche en Santé Durable, Centre Intégré Universitaire de Santé et Services Sociaux de la Capitale-Nationale, Quebec City, Quebec, Canada
| | - Patrick Archambault
- VITAM-Centre de Recherche en Santé Durable, Centre Intégré Universitaire de Santé et Services Sociaux de la Capitale-Nationale, Quebec City, Quebec, Canada
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
- Centre de Recherche, Centre Intégré en Santé et Services Sociaux de Chaudière-Appalaches, Lévis, Quebec, Canada
| | - LeAnn Michaels
- Oregon Rural Practice-Based Research Network, Oregon Health and Science University, Portland, Oregon, USA
| | - Julia Heinlein
- Oregon Rural Practice-Based Research Network, Oregon Health and Science University, Portland, Oregon, USA
| | - David A Dorr
- Oregon Rural Practice-Based Research Network, Oregon Health and Science University, Portland, Oregon, USA
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, USA
| | - Annette Totten
- Oregon Rural Practice-Based Research Network, Oregon Health and Science University, Portland, Oregon, USA
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, USA
| | - France Légaré
- VITAM-Centre de Recherche en Santé Durable, Centre Intégré Universitaire de Santé et Services Sociaux de la Capitale-Nationale, Quebec City, Quebec, Canada
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
| |
Collapse
|
10
|
Paladino J, Sanders JJ, Fromme EK, Block S, Jacobsen JC, Jackson VA, Ritchie CS, Mitchell S. Improving serious illness communication: a qualitative study of clinical culture. BMC Palliat Care 2023; 22:104. [PMID: 37481530 PMCID: PMC10362669 DOI: 10.1186/s12904-023-01229-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 07/17/2023] [Indexed: 07/24/2023] Open
Abstract
OBJECTIVE Communication about patients' values, goals, and prognosis in serious illness (serious illness communication) is a cornerstone of person-centered care yet difficult to implement in practice. As part of Serious Illness Care Program implementation in five health systems, we studied the clinical culture-related factors that supported or impeded improvement in serious illness conversations. METHODS Qualitative analysis of semi-structured interviews of clinical leaders, implementation teams, and frontline champions. RESULTS We completed 30 interviews across palliative care, oncology, primary care, and hospital medicine. Participants identified four culture-related domains that influenced serious illness communication improvement: (1) clinical paradigms; (2) interprofessional empowerment; (3) perceived conversation impact; (4) practice norms. Changes in clinicians' beliefs, attitudes, and behaviors in these domains supported values and goals conversations, including: shifting paradigms about serious illness communication from 'end-of-life planning' to 'knowing and honoring what matters most to patients;' improvements in psychological safety that empowered advanced practice clinicians, nurses and social workers to take expanded roles; experiencing benefits of earlier values and goals conversations; shifting from avoidant norms to integration norms in which earlier serious illness discussions became part of routine processes. Culture-related inhibitors included: beliefs that conversations are about dying or withdrawing care; attitudes that serious illness communication is the physician's job; discomfort managing emotions; lack of reliable processes. CONCLUSIONS Aspects of clinical culture, such as paradigms about serious illness communication and inter-professional empowerment, are linked to successful adoption of serious illness communication. Further research is warranted to identify effective strategies to enhance clinical culture and drive clinician practice change.
Collapse
Affiliation(s)
- Joanna Paladino
- Massachusetts General Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- Ariadne Labs, Joint Innovation Center at Brigham & Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, MA, USA.
- Mongan Institute Center for Aging and Serious Illness, Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, USA.
| | | | - Erik K Fromme
- Harvard Medical School, Boston, MA, USA
- Ariadne Labs, Joint Innovation Center at Brigham & Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Dana Farber Cancer Institute, Boston, MA, USA
| | - Susan Block
- Harvard Medical School, Boston, MA, USA
- Dana Farber Cancer Institute, Boston, MA, USA
| | - Juliet C Jacobsen
- Massachusetts General Hospital, Boston, MA, USA
- Lund University, Lund, Sweden
| | - Vicki A Jackson
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Christine S Ritchie
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Mongan Institute Center for Aging and Serious Illness, Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, USA
| | | |
Collapse
|
11
|
Myrhøj CB, Viftrup DT, Jarden M, Clemmensen SN. Interdisciplinary collaboration in serious illness conversations in patients with multiple myeloma and caregivers - a qualitative study. BMC Palliat Care 2023; 22:93. [PMID: 37438765 DOI: 10.1186/s12904-023-01221-5] [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: 03/31/2023] [Accepted: 07/04/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND There is growing evidence that conversations between healthcare professionals and patients with serious illness can improve the quality of end-of-life cancer care. Yet, there is lack of insight into how different healthcare professions collaborate to deliver serious illness communication, as well as patients' and caregivers' perceptions of this collaboration between the nurse and physician. This study explores the interdisciplinary collaboration between nurses and physicians in serious illness conversations with patients diagnosed with multiple myeloma and their caregivers. METHODS Eleven dyadic interviews were conducted with 22 patients and caregivers, and two focus group interviews involving four nurses and the other with four physicians. Data analysis and reporting were conducted using reflexive thematic analysis within phenomenological epistemology. RESULTS The interdisciplinary collaboration was characterized by three main themes: (1) Importance of relationships, (2) Complementary perspectives, and (3) The common goal. CONCLUSION This study highlights the importance of interdisciplinarity in serious illness conversations as it enhances the use of existential and descriptive language when addressing medical, holistic, and existential issues. The use of broader language also reflects that interdisciplinary interaction strengthens the expertise of each professional involved in patient care. Through interdisciplinary collaboration, the preferences, hopes, and values of the patient and caregiver can be integrated into the treatment plan, which is key in providing the delivery of optimal care. To promote cohesive and coordinated collaboration, organizational changes are recommended such as supporting continuity in patient-healthcare professional relationships, providing interdisciplinary training, and allocating time for pre-conversation preparation and post-conversation debriefing.
Collapse
Affiliation(s)
- Cæcilie Borregaard Myrhøj
- Department of Hematology, Copenhagen University Hospital, Blegdamsvej 9, Rigshospitalet, Copenhagen, 2100, Denmark.
- Cancer Survivorship and Treatment Late Effects (CASTLE), Department of Oncology, Copenhagen University, Blegdamsvej 58, Rigshospitalet, Copenhagen, 2100, Denmark.
| | - Dorte Toudal Viftrup
- Department of Public Health, Research Unit of General Practice, University of Southern Denmark, Odense C, 5000, Denmark
| | - Mary Jarden
- Department of Hematology, Copenhagen University Hospital, Blegdamsvej 9, Rigshospitalet, Copenhagen, 2100, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, Copenhagen, 2200, Denmark
| | - Stine Novrup Clemmensen
- Department of Hematology, Copenhagen University Hospital, Blegdamsvej 9, Rigshospitalet, Copenhagen, 2100, Denmark
| |
Collapse
|
12
|
Mochizuki T, Yamashita D, Miura C, Nakamura M, Izumi S(S. Feasibility and acceptability of advance care planning facilitated by nonphysician clinicians in Japanese primary care: Implementation pilot study. J Gen Fam Med 2022; 24:30-37. [PMID: 36605916 PMCID: PMC9808147 DOI: 10.1002/jgf2.586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/21/2022] [Accepted: 08/21/2022] [Indexed: 01/04/2023] Open
Abstract
Background Implementation of advance care planning (ACP) is urgently needed in Japan, which is one of the most aging countries. This study tested the feasibility and acceptability of ACP facilitated by nonphysician clinicians, and identified barriers and enablers to implementing ACP into Japanese primary care. Methods We trained 10 nonphysician clinicians (seven registered nurses, two medical social workers, and one care manager) in four primary care clinics as ACP facilitators. From April to June 2019, the trained facilitators had 19 ACP conversations with their patients. We conducted semistructured interviews and surveys regarding satisfaction and appropriateness of the ACP with patients, family members, ACP facilitators, and primary care physicians (PCPs) regarding their perceptions about ACP facilitated by nonphysician clinicians. Survey data were analyzed using descriptive statistics, and interviews were analyzed using a qualitative content analysis approach. Results Majority of patients (75%) and family members (71%) were satisfied with ACP facilitated by nonphysician clinicians. In 71%, ACP facilitators and PCPs thought their ACP facilitation was appropriate and acceptable. Patients stated that they felt comfortable having ACP conversations with nonphysician clinicians. Identified barriers and enablers for ACP included: time restraints, size and organization of the clinics, settings for ACP conversations (ACP at the patient's home), team collaboration, and use of existing system to trigger ACP. Conclusions Advance care planning facilitated by nonphysician clinicians was feasible and acceptable in Japanese primary care. Further studies are needed to explore strategies to overcome the barriers and enhance the enablers identified in this study.
Collapse
Affiliation(s)
- Takahiro Mochizuki
- Japan Association for Development of Community Medicine Practice‐Based Research NetworkTokyoJapan
| | - Daisuke Yamashita
- Department of Family MedicineOregon Health & Science UniversityPortlandOregonUSA
| | - Chikako Miura
- Japan Association for Development of Community Medicine Practice‐Based Research NetworkTokyoJapan
| | - Masakazu Nakamura
- Japan Association for Development of Community Medicine Practice‐Based Research NetworkTokyoJapan
| | | |
Collapse
|
13
|
Lakin JR, Zupanc SN, Lindvall C, Moseley ET, Das S, Sciacca K, Cabral HJ, Burns EA, Carney MT, Itty J, Lopez S, Emmert K, Martin NJ, Lambert S, Polo J, Sanghani S, Dugas JN, Gomez M, Winter MR, Wang N, Gabry-Kalikow S, Dobie A, Amshoff M, Cucinotta T, Joel M, Caruso LB, Ramirez AM, Salerno K, Ogunneye Q, Henault L, Davis AD, Volandes A, Paasche-Orlow MK. Study protocol for Video Images about Decisions to Improve Ethical Outcomes with Palliative Care Educators (VIDEO-PCE): a pragmatic stepped wedge cluster randomised trial of older patients admitted to the hospital. BMJ Open 2022; 12:e065236. [PMID: 35879001 PMCID: PMC9328081 DOI: 10.1136/bmjopen-2022-065236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Despite the known benefit to patients and families, discussions about goals, values and preferences for medical care in advancing serious illness often do not occur. Many system and clinician factors, such as patient and clinician reticence and shortage of specialty palliative care teams, contribute to this lack of communication. To address this gap, we designed an intervention to promote goals-of-care conversations and palliative care referrals in the hospital setting by using trained palliative care educators and video decision aids. This paper presents the rationale, design and methods for a trial aimed at addressing barriers to goals-of-care conversations for hospitalised adults aged 65 and older and those with Alzheimer's disease and related Dementias, regardless of age. METHODS AND ANALYSIS The Video Image about Decisions to Improve Ethical Outcomes with Palliative Care Educators is a pragmatic stepped wedge, cluster randomised controlled trial, which aims to improve and extend goals-of-care conversations in the hospital setting with palliative care educators trained in serious illness communication and video decision aids. The primary outcome is the proportion of patients with goals-of-care documentation in the electronic health record. We estimate that over 9000 patients will be included. ETHICS AND DISSEMINATION The Institutional Review Board (IRB) at Boston Medical Center will serve as the single IRB of record for all regulatory and ethical aspects of this trial. BMC Protocol Number: H-41482. Findings will be presented at national meetings and in publications. This trial is registered at ClinicalTrials.gov. TRIAL REGISTRATION NUMBER NCT04857060; ClinicalTrials.gov.
Collapse
Affiliation(s)
- Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Sophia N Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Edward T Moseley
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Sophiya Das
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Kate Sciacca
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Howard J Cabral
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Edith A Burns
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Maria T Carney
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Jennifer Itty
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Santiago Lopez
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Kaitlin Emmert
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Narda J Martin
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Sherene Lambert
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Jennifer Polo
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Shreya Sanghani
- Institute of Health System Science, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Julianne N Dugas
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Michele Gomez
- Commonwealth Care Alliance, Boston, Massachusetts, USA
| | - Michael R Winter
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Na Wang
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts, USA
| | | | - Alexandra Dobie
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
- Palliative Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Meredith Amshoff
- Palliative Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Traci Cucinotta
- Palliative Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Milton Joel
- Palliative Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Lisa B Caruso
- Boston University School of Medicine, Department of Medicine, Section of Geriatrics, Boston Medical Center, Boston, Massachusetts, USA
| | - Ana Maria Ramirez
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Kathleen Salerno
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Qausarat Ogunneye
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Lori Henault
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | | | - Angelo Volandes
- Harvard Medical School, Boston, Massachusetts, USA
- ACP Decisions, Waban, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael K Paasche-Orlow
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| |
Collapse
|
14
|
Morberg Jämterud S, Sandgren A. Health care professionals' perceptions of factors influencing the process of identifying patients for serious illness conversations: A qualitative study. Palliat Med 2022; 36:1072-1079. [PMID: 35729752 PMCID: PMC9247430 DOI: 10.1177/02692163221102266] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Serious Illness Care Programme enables patients to receive care that is in accordance with their priorities. However, despite clarity about palliative care needs, many barriers to and difficulties in identifying patients for serious illness conversations remain. AIM To explore healthcare professionals' perceptions about factors influencing the process of identifying patients for serious illness conversations. DESIGN Qualitative design. A thematic analysis of observations and semi-structured interviews was used. SETTING/PARTICIPANTS Twelve observations at team meetings in which physicians and nurses discussed the process of identifying the patients for serious illness conversations were conducted at eight different clinics in two hospitals. Semi-structured interviews were conducted with three physicians and two nurses from five clinics. RESULTS Identifying the right patient and doing so at the right time were key to identifying patients for serious illness conversations. The continuity of relations and continuity over time could facilitate the identification process, while attitudes towards death and its relation to hope could hinder the process. CONCLUSIONS The process of identifying patients for serious illness conversations is complex and may not be captured only by generic tools such as the surprise question. It is crucial to address existential and ethical obstacles that can hinder the identification of patients for serious illness conversations.
Collapse
Affiliation(s)
- Sofia Morberg Jämterud
- Department of Thematic Studies, Linköping University, Linköping, Sweden.,Center for Collaborative Palliative Care, Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
| | - Anna Sandgren
- Center for Collaborative Palliative Care, Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
| |
Collapse
|
15
|
Is This ACP? A Focus Group Study of Patient Experiences of Advance Care Planning. J Gen Intern Med 2022; 37:1484-1493. [PMID: 35018570 PMCID: PMC9086090 DOI: 10.1007/s11606-021-07208-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 10/08/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND To date, most research on patients' experiences with advance care planning (ACP) focuses on motivations to engage in discussions and how patients prepare. Gaps remain in understanding how non-critically ill Medicare patients perceive ACP encounters, including how they characterize positive and negative experiences with ACP. OBJECTIVES Understanding these patients' perceptions is imperative as Medicare has sought to incentivize provision of ACP services via two billing codes in 2016. DESIGN Qualitative focus group study. Thematic analysis was performed to assess participants ACP experience. PARTICIPANTS Medicare beneficiaries who had engaged in or were billed for ACP. KEY RESULTS Seven focus groups were conducted with 34 Medicare beneficiaries who had engaged in ACP across 5 US health systems. Participants described a spectrum of perceptions regarding ACP, and a range of delivery approaches, including group ACP, discussions with specialists during serious illness, and ACP in primary care settings during wellness visits. Despite being billed for ACP or having ACP services noted in their medical record, many did not recognize that they had engaged in ACP, expressed lack of clarity over the term "ACP," and were unaware of the Medicare billing codes. Among participants who described quality patient-centered ACP experiences, three additional themes were identified: trusted and established patient/clinician relationships, transparent communication and documentation, and an understanding that ACP is revisable. Participants offered recommendations for clinicians and health systems to improve the patient ACP experience. CONCLUSIONS Findings include actionable steps to promote patient-centered ACP experiences, including clinician training to support improved communication and facilitating shared decision-making, allocating sufficient clinical time for discussions, and ensuring that documentation of preferences is clear and accessible. Other approaches such as group ACP and ACP navigators may help to support patient interests within clinical constraints and need to be further explored.
Collapse
|
16
|
Andersson S, Sandgren A. Organizational readiness to implement the Serious Illness Care Program in hospital settings in Sweden. BMC Health Serv Res 2022; 22:539. [PMID: 35459204 PMCID: PMC9026003 DOI: 10.1186/s12913-022-07923-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 04/08/2022] [Indexed: 11/29/2022] Open
Abstract
Background The Serious Illness Care Program (SICP) is a model developed for structured communication, identifying patients, and training physicians to use a structured guide for conversations with patients and family members. However, there is a lack of knowledge regarding the sustainable implementation of this conversation model. Therefore, the aim of this study was to identify barriers and enablers during the implementation of the SICP in hospital settings. Methods The SICP was implemented at 20 units in two hospitals in Sweden. During the implementation process, seven individual interviews and two group interviews were conducted with seven facilitators (five physicians, one behavioral therapist, and one administrator). Data were analyzed using qualitative content analysis, first inductively, and then deductively using the organizational readiness for change as a theoretical framework. Result The analysis resulted in three factors acting as enablers and eight factors acting as enablers and/or barriers during the implementation of the SICP. The three factors considered as enablers were preliminaries, identifying patients, and facilitator’s role. The eight factors considered as enablers and/or barriers were broad implementation, leadership, time, confidence, building foundation, motivation to work change, motivation for training in serious illness conversations, and attitudes. Conclusion This study indicates limited readiness to implement the SICP in hospital settings due to considerable variation in organizational contextual factors, change efficacy, and change commitment. The identified enablers and barriers for implementation of the SICP could guide and support future implementations to be sustainable over time. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07923-5.
Collapse
Affiliation(s)
- Sofia Andersson
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden.
| | - Anna Sandgren
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
| |
Collapse
|
17
|
Patient Identification for Serious Illness Conversations: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19074162. [PMID: 35409844 PMCID: PMC8998898 DOI: 10.3390/ijerph19074162] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/24/2022] [Accepted: 03/29/2022] [Indexed: 02/04/2023]
Abstract
Serious illness conversations aim to align medical care and treatment with patients’ values, goals, priorities, and preferences. Timely and accurate identification of patients for serious illness conversations is essential; however, existent methods for patient identification in different settings and population groups have not been compared and contrasted. This study aimed to examine the current literature regarding patient identification for serious illness conversations within the context of the Serious Illness Care Program and/or the Serious Illness Conversation Guide. A scoping review was conducted using the Joanna Briggs Institute guidelines. A comprehensive search was undertaken in four databases for literature published between January 2014 and September 2021. In total, 39 articles met the criteria for inclusion. This review found that patients were primarily identified for serious illness conversations using clinical/diagnostic triggers, the ’surprise question’, or a combination of methods. A diverse assortment of clinicians and non-clinical resources were described in the identification process, including physicians, nurses, allied health staff, administrative staff, and automated algorithms. Facilitators and barriers to patient identification are elucidated. Future research should test the efficacy of adapted identification methods and explore how clinicians inform judgements surrounding patient identification.
Collapse
|
18
|
Karim S, Levine O, Simon J. The Serious Illness Care Program in Oncology: Evidence, Real-World Implementation and Ongoing Barriers. Curr Oncol 2022; 29:1527-1536. [PMID: 35323328 PMCID: PMC8947515 DOI: 10.3390/curroncol29030128] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 02/22/2022] [Indexed: 11/16/2022] Open
Abstract
The Serious Illness Care Program (SICP), designed by Ariadne Labs, is a multicomponent intervention to improve conversations about values and goals for patients with a life-limiting illness. In oncology, implementation of the SICP achieved more, earlier, and better-quality conversations and reduced anxiety and depression among patients with advanced cancer. In this commentary, we describe the SICP, including results from the cluster-randomized trial, provide examples of real-world implementation of this program, and highlight ongoing challenges and barriers that are preventing widespread adoption of this intervention into routine practice. For the SICP to be successfully embedded into routine patient care, it will require significant effort, including ongoing leadership support and training opportunities, champions from all sectors of the interdisciplinary team, and adaptation of the program to a wider range of patients. Future research should also investigate how early conversations can be translated into personalized care plans for patients.
Collapse
Affiliation(s)
- Safiya Karim
- Department of Oncology, Faculty of Medicine, University of Calgary, Calgary, AB T2N 4N2, Canada;
- Correspondence: ; Tel.: +1-403-521-3166; Fax: +1-402-283-1651
| | - Oren Levine
- Department of Oncology, Faculty of Health Sciences, McMaster University, Hamilton, ON L8V 5C2, Canada;
| | - Jessica Simon
- Department of Oncology, Faculty of Medicine, University of Calgary, Calgary, AB T2N 4N2, Canada;
- Department of Community Health Services, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N2, Canada
| |
Collapse
|
19
|
Jacobsen J, Jackson V, Asfaw S, Greenwald JL, Slavin P. One Hospital's Response to the Institute of Medicine Report, "Dying in America". J Pain Symptom Manage 2022; 63:e182-e187. [PMID: 34756956 DOI: 10.1016/j.jpainsymman.2021.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/05/2021] [Accepted: 10/22/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND In response to the Institute of Medicine (IOM) report, Dying in America, we undertook an institution wide effort to improve the experience of patients and families facing serious illness by engaging leadership and developing a program to promote the practice of generalist palliative care. MEASURES The impact of the program was measured with process measures related to its' three parts. INTERVENTION We developed a three-part generalist palliative care program that focuses on 1) instructional design, 2) advance care planning, and 3) engagement. OUTCOMES Over four years, the program trained 51 interprofessional clinicians in a two-week intensive palliative care course and 1,541 interprofessional clinicians in a 90-150 min skills-based training. Clinicians documented 15,791 serious illness conversations. Zoom community engagement sessions were attended by 411 live viewers, and subsequently, 1918 YouTube views. Additionally, we report on the impact of the COIVD-19 crisis on our efforts. Early in the pandemic, over two months, 464 interprofessional clinicians documented 5,168 conversations with patients. CONCLUSION/LESSONS LEARNED A broad based strategy resulted wide institutional engagement with serious illness care.
Collapse
Affiliation(s)
- Juliet Jacobsen
- Harvard Medical School (J.J., V.J., J.L.G.), Massachusetts General Hospital, Boston, Massachusetts, USA.
| | - Vicki Jackson
- Harvard Medical School (J.J., V.J., J.L.G.), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shae Asfaw
- Massachusetts General Hospital (S.A.), Boston, Massachusetts, USA
| | - Jeffrey L Greenwald
- Harvard Medical School (J.J., V.J., J.L.G.), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Peter Slavin
- Department of Health Care Policy (P.S.), Harvard Medical School; President, Massachusetts General Hospital, Boston, Massachusetts, USA
| |
Collapse
|
20
|
Portz JD, Graney BA, Bekelman DB. " Made Me Realize That Life Is Worth Living": A Qualitative Study of Patient Perceptions of a Primary Palliative Care Intervention. J Palliat Med 2022; 25:28-38. [PMID: 34264752 PMCID: PMC8721497 DOI: 10.1089/jpm.2021.0015] [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: 01/03/2023] Open
Abstract
Background: Primary palliative care is needed to meet the complex needs of patients with serious illness and their families. However, patient perceptions of primary palliative care are not well understood and can inform subsequent primary palliative care interventions and implementation. Objective: Elicit the patient perspective on a primary palliative care intervention, Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA), from patient perspectives. Design: Qualitative study using patient interviews and two methods of triangulation. Setting/Subjects: Between July 2014 and September 2015, we interviewed 45 patients who participated in the intervention in a Veterans Affairs (VA) (primary site), academic, and urban safety-net health system in the United States. Main Measures: Participants were asked about what was most and least helpful, how the intervention affected participants' lives, and what should be changed about the intervention. Data were analyzed using a general inductive approach. To enhance validity of the results, we triangulated the findings from patient interviews, reviews of care coordinator documentation, and interprofessional palliative care providers. Results: The six themes identified that primary care intervention: (1) Cared for My Psychosocial Needs, (2) Encouraged Self-Management, (3) Medication Recommendations Worked, (4) Facilitated Goal Attainment, (5) Team was Beneficial, and (6) Good Visit Timing. Conclusions: Participants experienced benefits from the primary palliative care intervention and attributed these benefits to individualized assessment and support, facilitation of skill building and self-management, and oversight from an interprofessional care team. Future primary palliative care interventions may benefit from targeting these specific patient-valued processes.
Collapse
Affiliation(s)
- Jennifer Dickman Portz
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA.,Address correspondence to: Jennifer Dickman Portz, PhD, MSW, Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Mailstop B180, 12631 East 17th Avenue, Aurora, CO 80045, USA
| | - Bridget A. Graney
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - David B. Bekelman
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Medicine, Department of Veterans Affairs, Eastern Colorado Health Care System, Aurora, Colorado, USA
| |
Collapse
|
21
|
Taels B, Hermans K, Van Audenhove C, Boesten N, Cohen J, Hermans K, Declercq A. How can social workers be meaningfully involved in palliative care? A scoping review on the prerequisites and how they can be realised in practice. Palliat Care Soc Pract 2021; 15:26323524211058895. [PMID: 34870204 PMCID: PMC8637690 DOI: 10.1177/26323524211058895] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/14/2021] [Indexed: 11/20/2022] Open
Abstract
Palliative care is a holistic practice using a multidisciplinary approach in
addressing multidimensional needs. Although the social aspects surrounding the
end-of-life phase suggest a place for social work in it, the profession is often
inadequately involved in daily practice. This contrasts strongly with the
potential meaningful contributions of social workers in this field. To date, no
comprehensive list of prerequisites for meaningful social work involvement in
palliative care exists. This review aims to gain more insight on the
prerequisites for meaningful social work involvement in palliative care and how
to realise them in practice. It could therefore provide pathways for future
intervention development in enhancing the involvement of social workers and
maximising their contributions in palliative care. A scoping review methodology
was used. A systematic selection of peer-reviewed articles ranged from 2000 to
April 2021 – out of the electronic databases Web of Science, Scopus and Pubmed –
was conducted. The 170 articles that met the eligibility criteria were analysed
for relevant content using open and axial coding processes. The findings are
reported according to the PRISMA-ScR checklist. The nine prerequisites listed in
this review concern the level of individual social work capacities and the level
of contextual factors structuring social work practices. A majority of articles
have, however, focused on the level of individual social work capacities in a
rather specialist view on palliative care. Future research should further
address the contextual level of social work involvement in the broader practice
of death, dying and bereavement.
Collapse
Affiliation(s)
- Brent Taels
- LUCAS - Centre for Care Research and Consultancy, Department of Public Health and Primary Care, KU Leuven, 3000 Leuven, Belgium
| | - Kirsten Hermans
- LUCAS - Centre for Care Research and Consultancy, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Chantal Van Audenhove
- LUCAS - Centre for Care Research and Consultancy, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Nadine Boesten
- LUCAS - Centre for Care Research and Consultancy, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group, Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussel, Belgium
| | - Koen Hermans
- LUCAS - Centre for Care Research and Consultancy, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Anja Declercq
- LUCAS - Centre for Care Research and Consultancy, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| |
Collapse
|
22
|
Whitehead PB, Gamaluddin S, DeWitt S, Stewart C, Kim KY. Caring for Patients With Dementia at End of Life. Am J Hosp Palliat Care 2021; 39:716-724. [PMID: 34519251 DOI: 10.1177/10499091211046247] [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: 11/16/2022] Open
Abstract
Care of the dementia patient continues to be challenging. It is a terminal condition that many times goes undiagnosed leading to improper evidence-based interventions. Healthcare professionals (HCPs) should initiate goals of care conversations early with patients and their families in order to align treatment preferences. Early integration of palliative medicine is an important intervention that can lead to better manage symptoms and lessen the strain on loved ones. Additionally, early enrollment into hospice should be encouraged with loved ones to promote quality of life as defined by the patient.
Collapse
Affiliation(s)
- Phyllis B Whitehead
- Carilion Roanoke Memorial Hospital Palliative Care Service, Roanoke, VA, USA.,Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | | | - Sarah DeWitt
- Carilion Roanoke Memorial Hospital Palliative Care Service, Roanoke, VA, USA.,Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Christi Stewart
- Carilion Roanoke Memorial Hospital Palliative Care Service, Roanoke, VA, USA.,Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,Carilion Center for Healthy Aging, Roanoke, VA, USA
| | - Kye Y Kim
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,Carilion Center for Healthy Aging, Roanoke, VA, USA
| |
Collapse
|
23
|
Lagrotteria A, Swinton M, Simon J, King S, Boryski G, Ma IWY, Dunne F, Singh J, Bernacki RE, You JJ. Clinicians' Perspectives After Implementation of the Serious Illness Care Program: A Qualitative Study. JAMA Netw Open 2021; 4:e2121517. [PMID: 34406399 PMCID: PMC8374609 DOI: 10.1001/jamanetworkopen.2021.21517] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Discussions about goals of care with patients who are seriously ill typically occur infrequently and late in the illness trajectory, are of low quality, and focus narrowly on the patient's resuscitation preferences (ie, code status), risking provision of care that is inconsistent with patients' values. The Serious Illness Care Program (SICP) is a multifaceted communication intervention that builds capacity for clinicians to have earlier, more frequent, and more person-centered conversations. OBJECTIVE To explore clinicians' experiences with the SICP 1 year after implementation. DESIGN, SETTING, AND PARTICIPANTS This qualitative study was conducted at 2 tertiary care hospitals in Canada. The SICP was implemented at Hamilton General Hospital (Hamilton, Ontario) from March 1, 2017, to January 19, 2018, and at Foothills Medical Centre (Calgary, Alberta) from March 1, 2018, to December 31, 2020. A total of 45 clinicians were invited to participate in the study, and 23 clinicians (51.1%) were enrolled and interviewed. Semistructured interviews of clinicians were conducted between August 2018 and May 2019. Content analysis was used to evaluate information obtained from these interviews between May 2019 and May 2020. EXPOSURES The SICP includes clinician training, communication tools, and processes for system change. MAIN OUTCOMES AND MEASURES Clinicians' experiences with and perceptions of the SICP. RESULTS Among 23 clinicians interviewed, 15 (65.2%) were women. The mean (SD) number of years in practice was 14.6 (9.1) at the Hamilton site and 12.0 (6.9) at the Calgary site. Participants included 19 general internists, 3 nurse practitioners, and 1 social worker. The 3 main themes were the ways in which the SICP (1) supported changes in clinician behavior, (2) shifted the focus of goals-of-care conversations beyond discussion of code status, and (3) influenced clinicians personally and professionally. Changes in clinician behavior were supported by having a unit champion, interprofessional engagement, access to copies of the Serious Illness Conversation Guide, and documentation in the electronic medical record. Elements of the program, especially the Serious Illness Conversation Guide, shifted the focus of goals-of-care conversations beyond discussion of code status and influenced clinicians on personal and professional levels. Concerns with the program included finding time to have conversations, building transient relationships, and limiting conversation fluidity. CONCLUSIONS AND RELEVANCE In this qualitative study, hospital clinicians described components of the SICP as supporting changes in their behavior and facilitating meaningful patient interactions that shifted the focus of goals-of-care conversations beyond discussion of code status. The perceived benefits of SICP implementation stimulated uptake within the medical units. These findings suggest that the SICP may prompt hospital culture changes in goals-of-care dialogue with patients and the care of hospitalized patients with serious illness.
Collapse
Affiliation(s)
- Andrew Lagrotteria
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marilyn Swinton
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jessica Simon
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Seema King
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Irene Wai Yan Ma
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Fiona Dunne
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Japteg Singh
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Rachelle E. Bernacki
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - John J. You
- Division of General Internal and Hospitalist Medicine, Department of Medicine, Trillium Health Partners, Credit Valley Hospital, Mississauga, Ontario, Canada
| |
Collapse
|
24
|
Brown-Johnson C, Haverfield MC, Giannitrapani KF, Lo N, Lowery JS, Foglia MB, Walling AM, Bekelman DB, Shreve ST, Lehmann LS, Lorenz KA. Implementing Goals-of-Care Conversations: Lessons From High- and Low-Performing Sites From a VA National Initiative. J Pain Symptom Manage 2021; 61:262-269. [PMID: 32781166 DOI: 10.1016/j.jpainsymman.2020.07.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 07/31/2020] [Accepted: 07/31/2020] [Indexed: 11/29/2022]
Abstract
CONTEXT The Veterans Health Administration (VA) National Center for Ethics in Healthcare implemented the Life-Sustaining Treatment Decisions Initiative, including policy and practice standards, clinician communication training, a documentation template, and central implementation support to foster advance care planning via goals-of-care conversations for seriously ill veterans in 2014, spreading nationally to other Veterans Health Affairs (VA) sites in 2017. OBJECTIVES Our goal was to describe the range of early implementation experiences among the pilot sites, and compare them with spread sites that implemented LSTDI about two years later, identifying cross-site best practices and pitfalls. METHODS We conducted semistructured interviews with 32 key stakeholders from 12 sites to identify cross-site best practices and pitfalls related to implementation. RESULTS Three primary implementation themes emerged: organizational readiness for transformation, importance of champions, and time and resources needed to achieve implementation. Each theme's barriers and facilitators highlighted variability in success based on complexity in terms of vertical hierarchy and horizontal cross-role/cross-clinic relationships. CONCLUSION Learning health care systems need multilevel interdisciplinary implementation approaches to support communication about serious illness, from broad-based system-level training and education to build communication skills, to focusing on characteristics of successful individual champions who listen to critics and are tenacious in addressing concerns.
Collapse
Affiliation(s)
- Cati Brown-Johnson
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA.
| | - Marie C Haverfield
- Department of Communication Studies, San Jose State University, San Jose, California, USA
| | - Karleen F Giannitrapani
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, USA; Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - Natalie Lo
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, USA
| | - Jill S Lowery
- National Center for Ethics in Health Care, Department of Veterans Affairs, Washington, DC, USA; Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Mary Beth Foglia
- National Center for Ethics in Health Care, Department of Veterans Affairs, Washington, DC, USA; University of Washington School of Medicine, Seattle, Washington, USA
| | - Anne M Walling
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, West Los Angeles, California, USA; Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, Los Angeles, California, USA
| | - David B Bekelman
- Center of Innovation for Veteran-Centered and Value Driven Care, Rocky Mountain Regional VA Medical Center, Colorado, USA; University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, Colorado, USA
| | - Scott T Shreve
- Palliative and Hospice Care Program, Department of Veteran Affairs, Washington, DC, USA
| | - Lisa Soleymani Lehmann
- VA New England Healthcare System, Bedford, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Karl A Lorenz
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, USA; Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA
| |
Collapse
|
25
|
Beddard-Huber E, Strachan P, Brown S, Kennedy V, Marles MM, Park S, Roberts D. Supporting Interprofessional Engagement in Serious Illness Conversations: An Adapted Resource. J Hosp Palliat Nurs 2021; 23:38-45. [PMID: 33136801 DOI: 10.1097/njh.0000000000000712] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Communication is vital to quality palliative care nursing particularly when caring for someone with a chronic life-limiting illness and their family. Conversations about future decline and preferred care are considered challenging and difficult and are often avoided, resulting in missed opportunities for improving care. To support more, earlier, better conversations, health care organizations in British Columbia, Canada, adopted the Serious Illness Care Program inclusive of the Serious Illness Conversation Guide developed by Ariadne Labs. Workshops for interprofessional team members have been held throughout the province. Nurses and allied health identified the need for more guidance in using the guide in the contexts of their clinical practice. Specifically challenging has been prognosis communication that falls within the scope of practice for each profession. Informed by workshop feedback, an expert team of nurse clinicians and educators tailored an interprofessional clinician reference guide to optimize the guide's use across health care settings. In this article, we present the adaptations focusing on (1) the role of nurses and allied health in serious illness communication, (2) prognosis communication, and (3) a range of role-play scenarios specific to nonphysician practice for serious illness conversations that may arise within the process of care.
Collapse
|
26
|
Paladino J, Brannen E, Benotti E, Henrich N, Ritchie C, Sanders J, Lakin JR. Implementing Serious Illness Communication Processes in Primary Care: A Qualitative Study. Am J Hosp Palliat Care 2020; 38:459-466. [PMID: 32794412 DOI: 10.1177/1049909120951095] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Primary care clinicians face barriers to engaging patients in conversations about prognosis, values, and goals ("serious illness conversations"). We introduced a structured, multi-component intervention, the Serious Illness Care Program (SICP), to facilitate conversations in the primary care setting. We present findings of a qualitative study to explore practical aspects of program implementation. METHODS We conducted semi-structured interviews of participating primary care physicians, nurse care coordinators, and social workers and coded transcripts to assess the activities used to integrate SICP into the workflow. RESULTS We conducted interviews with 14 of 46 clinicians from 6 primary care clinics, stopping with thematic saturation. Qualitative analysis revealed major themes around activities in the timing of the conversation (before, during, and after) and overarching insights about the program. Clinicians used a variety of strategies to adapt program components while preserving key program goals, including processes to generate accountability to ensure that conversations happen in busy clinical workflows. The interviews revealed changes to clinicians' mindset and norms, such as the recognition of the need to start conversations earlier in the illness course and the use of more expansive models of prognostic communication that address function and quality of life. Data also revealed indicators of sustainable behavior change and the spread of communication practices to patients outside the intended program scope. CONCLUSION SICP served as a framework for primary care clinicians to integrate serious illness communication into routine care. The shifts in processes employed by inter-professional clinicians revealed comprehensive models for prognostic communication and creative workflows to ensure that patients with complex illnesses had proactive, longitudinal, and patient-centered serious illness conversations and care planning.
Collapse
Affiliation(s)
- Joanna Paladino
- 480938Ariadne Labs, Brigham and Women's Hospital & Harvard Chan School of Public Health, Boston, MA, USA.,Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Elise Brannen
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Emily Benotti
- 480938Ariadne Labs, Brigham and Women's Hospital & Harvard Chan School of Public Health, Boston, MA, USA
| | - Natalie Henrich
- 480938Ariadne Labs, Brigham and Women's Hospital & Harvard Chan School of Public Health, Boston, MA, USA
| | - Christine Ritchie
- Harvard Medical School, Boston, MA, USA.,Division of Palliative Medicine, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Justin Sanders
- 480938Ariadne Labs, Brigham and Women's Hospital & Harvard Chan School of Public Health, Boston, MA, USA.,Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Psychosocial Oncology and Palliative Care, 1855Dana-Farber Cancer Institute, Boston, MA, USA
| | - Joshua R Lakin
- 480938Ariadne Labs, Brigham and Women's Hospital & Harvard Chan School of Public Health, Boston, MA, USA.,Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Psychosocial Oncology and Palliative Care, 1855Dana-Farber Cancer Institute, Boston, MA, USA
| |
Collapse
|
27
|
Integration of Advance Care Planning Into Clinical Practice: A Quality Improvement Project for Leaders. J Nurs Adm 2020; 50:426-432. [PMID: 32694441 DOI: 10.1097/nna.0000000000000911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This quality improvement initiative sought to develop a proactive integrated system approach to advance care planning (ACP) through leadership and colleague engagement. BACKGROUND Nurse leaders have the capacity to influence the professional competencies of care teams in ACP. Nurse leaders were educated on the importance of ACP, national quality metrics, resources for staff education, and ways to integrate ACP into workflows based on a population management model. METHODS The project design is a prospective, mixed method design. RESULTS Nurse leader participants demonstrated a significant increase in knowledge of the importance of ACP and evidence-based models to increase staff engagement and competency. CONCLUSIONS Study supports nurse leader interventions, promoted engagement of proactive ACP to honor patient choice, and aligns with the mission and vision of one of the largest national Catholic healthcare organizations of being a trusted partner for life.
Collapse
|
28
|
Portz JD, Lum HD, Bull S, Boxer RS, Bekelman DB, Ford KL, Gleason K, Casillas A, Bayliss EA. Perceptions of Patient Portal Use for Advance Directive Documentation among Older Adults with Multiple Chronic Conditions. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2020; 16:238-249. [PMID: 32482160 PMCID: PMC9205613 DOI: 10.1080/15524256.2020.1771806] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Patient portals can play an innovative role in facilitating advanced care planning (ACP) and documenting advance directives (ADs) among older adults with multiple chronic conditions. The objective of this qualitative sub-study was to (1) understand older adults' use of an ACP patient portal section and (2) obtain user-design input on AD documentation features. Although some older adults may be reluctant, participants reported likely to use a portal for ADs with proper portal design and support.
Collapse
Affiliation(s)
- Jennifer Dickman Portz
- Division of General Internal Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, Colorado
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Hillary D. Lum
- Division of Geriatric Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, Colorado
- VA Eastern Colorado Health Care System, Denver, Colorado
| | - Sheana Bull
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Rebecca S. Boxer
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
| | - David B. Bekelman
- Division of General Internal Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, Colorado
- VA Eastern Colorado Health Care System, Denver, Colorado
| | - Kelsey L. Ford
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kathy Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
| | - Alejandra Casillas
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Elizabeth A. Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
- Department of Family Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, Colorado
| |
Collapse
|
29
|
Lakin JR, Neal BJ, Maloney FL, Paladino J, Vogeli C, Tumblin J, Vienneau M, Fromme E, Cunningham R, Block SD, Bernacki RE. A systematic intervention to improve serious illness communication in primary care: Effect on expenses at the end of life. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2020; 8:100431. [PMID: 32553522 DOI: 10.1016/j.hjdsi.2020.100431] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 04/26/2020] [Accepted: 04/29/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND At a population level, conversations between clinicians and seriously ill patients exploring patients' goals and values can drive high-value healthcare, improving patient outcomes and reducing spending. METHODS We examined the impact of a quality improvement intervention to drive better communication on total medical expenses in a high-risk care management program. We present our analysis of secondary expense outcomes from a prospective implementation trial of the Serious Illness Care Program, which includes clinician training, coaching, tools, and system interventions. We included patients who died between January 2014 and September 2016 who were selected for serious illness conversations, using the "Surprise Question," as part of implementation of the program in fourteen primary care clinics. RESULTS We evaluated 124 patients and observed no differences in total medical expenses between intervention and comparison clinic patients. When comparing patients in intervention clinics who did and did not have conversations, we observed lower average monthly expenses over the last 6 ($6297 vs. $8,876, p = 0.0363) and 3 months ($7263 vs. $11,406, p = 0.0237) of life for patients who had conversations. CONCLUSIONS Possible savings observed in this study are similar in magnitude to previous studies in advance care planning and specialty palliative care but occur earlier in the disease course and in the context of documented conversations and a comprehensive, interprofessional case management program. IMPLICATIONS Programs designed to drive more, earlier, and better serious illness communication hold the potential to reduce costs. LEVEL OF EVIDENCE Prospectively designed trial, non-randomized sample, analysis of secondary outcomes.
Collapse
Affiliation(s)
- Joshua R Lakin
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Department of Medicine, Brigham & Women's Hospital, Boston, MA, USA.
| | - Brandon J Neal
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Francine L Maloney
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Joanna Paladino
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Christine Vogeli
- Harvard Medical School, Boston, MA, USA; Partners Healthcare, Boston, MA, USA; Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Erik Fromme
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Rebecca Cunningham
- Harvard Medical School, Boston, MA, USA; Department of Medicine, Brigham & Women's Hospital, Boston, MA, USA
| | - Susan D Block
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Department of Medicine, Brigham & Women's Hospital, Boston, MA, USA; Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
| | - Rachelle E Bernacki
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Department of Medicine, Brigham & Women's Hospital, Boston, MA, USA
| |
Collapse
|
30
|
Turner S, Torabi S, Stilos K. Quality dying: An approach to ICD deactivation in the hospital setting. Am J Hosp Palliat Care 2020; 37:664-668. [PMID: 32126793 DOI: 10.1177/1049909120905254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In Canada, cardiovascular disease is the second most common cause of death. A subset of these patients will require a cardiovascular implantable electronic device (CIED). An estimated 200 000 Canadians are living with a CIED. CIEDs can improve life and prevent premature death. However, when patients reach the end of their lives, they can pose a challenge. An example of which is a painful shock delivered from an implantable cardioverter defibrillator (ICD) for an arrhythmia in a dying patient. Receiving a shock at the end of life (EOL) is unacceptable in an age when we aim to ease the suffering of the dying and allow for a comfortable death. METHODS As a quality standard of practice, all clinicians are expected to engage in EOL conversations in patients requiring CIED deactivation. Due to the potential discomfort of an ICD shock, specific conversations about deactivation of an ICD are encouraged. A process improvement approach was developed by our hospital that included an advance care planning simulation lab, electronic documentation and a standardized comfort measures order set that includes addressing the need for ICD deactivation at EOL. RESULTS EOL conversations are complex. Health care providers have been equally challenged to have conversations about ICD deactivation. Standardization of the process of ICD deactivation ensures an approach to EOL which respects the individuality of patients and promotes quality dying. CONCLUSION Our hospital is committed to assisting clinicians to provide quality care by improving conversations about EOL care. On the basis of a synthesis of existing literature, we describe the importance of and the ideal process for having EOL conversations in patients about ICD deactivation at the EOL.
Collapse
Affiliation(s)
- Suzette Turner
- Schulich Heart Program, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada.,Lawrence Bloomberg Faculty of Nursing, Toronto, Ontario, Canada
| | - Sarah Torabi
- Division of Palliative Care, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada.,Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kalli Stilos
- Lawrence Bloomberg Faculty of Nursing, Toronto, Ontario, Canada.,Division of Palliative Care, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
31
|
Paladino J, Koritsanszky L, Neal BJ, Lakin JR, Kavanagh J, Lipsitz S, Fromme EK, Sanders J, Benjamin E, Block S, Bernacki R. Effect of the Serious Illness Care Program on Health Care Utilization at the End of Life for Patients with Cancer. J Palliat Med 2020; 23:1365-1369. [PMID: 31904304 DOI: 10.1089/jpm.2019.0437] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Objectives: To determine the effect of the Serious Illness Care Program on health care utilization at the end of life in oncology. Design: Analysis of the secondary outcome of health care utilization as part of a cluster-randomized clinical trial that ran from 2012 to 2016. Clinicians in the intervention group received training, coaching, and system supports to have discussions with patients using a Serious Illness Conversation Guide (SICG); clinicians in the control arm followed usual care. Setting/Subject: Patients with advanced cancer who died within two years of enrollment at the Dana-Farber Cancer Institute. Measurement: Health care utilization was abstracted from the electronic medical record using the National Quality Forum (NQF)-endorsed indicators of aggressive cancer care at the end of life and scored from 0 to 6 (one point for each aggressive indicator); t tests and chi-square tests were used to determine differences between intervention and control patients. Results: The charts of 159 patients who died were reviewed. Neither the main outcome of mean number of aggressive indicators (0.9 vs. 0.9, p = 0.84) nor the proportion of patients with any aggressive care (49% intervention [95% CI: 40-57] vs. 54% control [95% CI: 42-67]) differed between patients in the intervention and control groups. Conclusion: In this analysis of a secondary outcome from a randomized clinical trial of the Serious Illness Care Program, intervention and control patients had similar end-of-life health care utilization as measured by the mean number of NQF-endorsed indicators. Future research efforts should focus on studying the strategies by which communication about patients' prognosis, values, and goals leads to personalized care plans.
Collapse
Affiliation(s)
- Joanna Paladino
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Luca Koritsanszky
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Brandon J Neal
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Joshua R Lakin
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jane Kavanagh
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Stu Lipsitz
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Erik K Fromme
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Justin Sanders
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Evan Benjamin
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Susan Block
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Rachelle Bernacki
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| |
Collapse
|
32
|
Nelson-Brantley H, Buller C, Befort C, Ellerbeck E, Shifter A, Ellis S. Using Implementation Science to Further the Adoption and Implementation of Advance Care Planning in Rural Primary Care. J Nurs Scholarsh 2019; 52:55-64. [PMID: 31545557 DOI: 10.1111/jnu.12513] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2019] [Indexed: 01/15/2023]
Abstract
PURPOSE To analyze the literature on advance care planning (ACP) in primary care through the lens of implementation science, with a focus on implications for rural settings. DESIGN Scoping review of the literature. METHODS The Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline, PsycINFO, and the Psychology and Behavioral Sciences Collection databases were searched for studies related to ACP adoption and implementation in primary care. The Theoretical Domains Framework was used to map the literature to 14 determinants that serve as barriers or facilitators to ACP. The Conceptual Model of Evidence-Based Practice Implementation in Public Service Sectors was used to analyze the stage of implementation for each of the included studies. FINDINGS Four steps to ACP were specified: identification, conversation, documentation, and follow-up. Determinants were identified for each step, but studies largely focused on the conversation step. Professional role and identity, environmental context and resources, and emotion were the most frequently cited determinants in initiating conversations. The identification step was largely determined by behavioral regulation. For documenting ACP, environmental context and resource determinants were most prevalent. In the few studies that addressed follow-up, providers expressed a desire for electronic reminders as a behavioral regulator to follow-up. CONCLUSIONS While ACP has been shown to have patient, family, and societal benefits, its uptake in primary care has been minimal. Because ACP is a complex process that is highly context dependent, implementation science is critical to inform its successful adoption and implementation. Smaller healthcare networks, adaptable professional roles, trusted relationships, and tight-knit community might be important facilitators of ACP in rural primary care. CLINICAL RELEVANCE Findings from this study can be used to accelerate ACP implementation in rural primary care.
Collapse
Affiliation(s)
| | - Carol Buller
- Delta, Clinical Assistant Professor, University of Kansas School of Nursing, Kansas City, KS, USA
| | - Christie Befort
- Associate Professor and Associate Director for Cancer Prevention and Control, Department of Preventative Medicine and Public Health, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Edward Ellerbeck
- Professor and Chair of the Department of Preventative Medicine and Public Health, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Ariel Shifter
- Graduate Research Assistant, Department of Health Policy & Management, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Shellie Ellis
- Assistant Professor, Department of Health Policy & Management, University of Kansas School of Medicine, Kansas City, KS, USA
| |
Collapse
|
33
|
Paladino J, Kilpatrick L, O'Connor N, Prabhakar R, Kennedy A, Neal BJ, Kavanagh J, Sanders J, Block S, Fromme E. Training Clinicians in Serious Illness Communication Using a Structured Guide: Evaluation of a Training Program in Three Health Systems. J Palliat Med 2019; 23:337-345. [PMID: 31503520 DOI: 10.1089/jpm.2019.0334] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Failure to initiate discussions about patients' values and goals in serious illness remains a common problem. Many clinicians are inadequately trained for these discussions. Objective: Evaluate whether a novel train-the-trainer model results in high-quality training that improves clinicians' self-reported competencies in serious illness communication. Design: Multimethod evaluation of an educational program. Setting/Context: In 2016, three faculty at Ariadne Labs (AL) conducted three train-the-trainer courses to equip faculty trainers at each of the three institutions to teach serious illness communication to clinicians. Measures: As collected by a post-training questionnaire, primary evaluation measure is clinicians' self-reported change in skills after the training compared with before. Secondary measures include a course evaluation and qualitative learnings. Results: From 2016 to 2018, AL trained 22 trainers (19/22 were palliative care specialists) in three systems, who trained 297 clinicians (49% physicians; 35% advanced practice clinicians; 12% registered nurses, social workers, or chaplain; 4.0% Other) spanning subspecialties (48%); primary care (28%); palliative care (17%); and other (7.1%). Clinicians reported statistically significant improvement in all skills for two of the systems, with a third system demonstrating improvement in all skills with two reaching statistical significance (p < 0.0001). Participants rated the quality of the training highly (95% mostly/extremely effective) and shared a diverse array of takeaways that reflect positive shifts in knowledge, attitudes, and skills. Conclusion: Serious illness communication training, delivered through a train-the-trainer model, was highly acceptable and resulted in significant self-reported improvements in competencies of clinicians. This may be a viable method for health systems seeking to train their clinical workforce.
Collapse
Affiliation(s)
- Joanna Paladino
- Ariadne Labs, Brigham and Women's Hospital, Harvard TH Chan School of Public Health, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Laurel Kilpatrick
- Baylor Scott & White Health, Texas A&M University College of Medicine, Bryan, Texas
| | - Nina O'Connor
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Anna Kennedy
- Ariadne Labs, Brigham and Women's Hospital, Harvard TH Chan School of Public Health, Boston, Massachusetts
| | - Brandon J Neal
- Ariadne Labs, Brigham and Women's Hospital, Harvard TH Chan School of Public Health, Boston, Massachusetts
| | - Jane Kavanagh
- Ariadne Labs, Brigham and Women's Hospital, Harvard TH Chan School of Public Health, Boston, Massachusetts
| | - Justin Sanders
- Ariadne Labs, Brigham and Women's Hospital, Harvard TH Chan School of Public Health, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Susan Block
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Erik Fromme
- Ariadne Labs, Brigham and Women's Hospital, Harvard TH Chan School of Public Health, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| |
Collapse
|
34
|
Totten AM, Fagnan LJ, Dorr D, Michaels LC, Izumi S(S, Combe A, Légaré F. Protocol for a Cluster Randomized Trial Comparing Team-Based to Clinician-Focused Implementation of Advance Care Planning in Primary Care. J Palliat Med 2019; 22:82-89. [PMID: 31486729 PMCID: PMC7366267 DOI: 10.1089/jpm.2019.0117] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2019] [Indexed: 12/18/2022] Open
Abstract
Introduction: For many patients, primary care is an appropriate setting for advance care planning (ACP). ACP focuses on what matters most to patients and ensuring health care supports patient-defined goals. ACP may involve interactions between a clinician and a patient, but for seriously ill patients ACP could be managed by a team. Methods: We are conducting a cluster randomized trial comparing team-based to clinician-focused ACP using the Serious Illness Care Program (SICP) in 42 practices recruited from 7 practice-based research networks (PBRNs). Practices were randomized to one of the two models. Patients are referred to the study after engaging in ACP in primary care. Our target enrollment is 1260 subjects. Patient data are collected at enrollment, six months and one year. Primary outcomes are patient-reported goal-concordant care and days at home. Secondary outcomes include additional patient measures, clinician/team experience, and practice-level measures of SICP implementation. Study Implementation: This trial was designed and is conducted by the Meta-network Learning and Research Center (Meta-LARC), a consortium of PBRNs focused on integrating engagement with patients, families, and other stakeholders into primary care research and practice. The trial pairs a comparative effectiveness study with implementation of a new program and is designed to balance fidelity to the assigned model with flexibility to allow each practice to adapt implementation to their environment and priorities. Our dissemination will report the results of comparing the two models and the implementation experience of the practices to create guidance for the spread of ACP in primary care.
Collapse
Affiliation(s)
- Annette M. Totten
- Department of Medical Informatics and Clinical Epidemiology, Oregon Rural Practice-Based Research Network, Oregon Health and Science University, Portland, Oregon
| | - Lyle J. Fagnan
- Oregon Rural Practice-Based Research Network, Oregon Health and Science University, Portland, Oregon
| | - David Dorr
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon
| | - LeAnn C. Michaels
- Oregon Rural Practice-Based Research Network, Oregon Health and Science University, Portland, Oregon
| | | | - Angela Combe
- Oregon Rural Practice-Based Research Network, Oregon Health and Science University, Portland, Oregon
| | - France Légaré
- Centre de Recherche Sur Les Soins et Les Services de Première Ligne de l'Université Laval, Quebec, Canada
| |
Collapse
|