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Serna MK, Yoon C, Fiskio J, Lakin JR, Schnipper JL, Dalal AK. The Association of Standardized Documentation of Serious Illness Conversations With Healthcare Utilization in Hospitalized Patients: A Propensity Score Matched Cohort Analysis. Am J Hosp Palliat Care 2024; 41:479-485. [PMID: 37385609 PMCID: PMC10983774 DOI: 10.1177/10499091231186818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023] Open
Abstract
Background: Serious Illness Conversations (SICs) conducted during hospitalization can lead to meaningful patient participation in the decision-making process affecting medical management. The aim of this study is to determine if standardized documentation of a SIC within an institutionally approved EHR module during hospitalization is associated with palliative care consultation, change in code status, hospice enrollment prior to discharge, and 90-day readmissions. Methods: We conducted retrospective analyses of hospital encounters of general medicine patients at a community teaching hospital affiliated with an academic medical center from October 2018 to August 2019. Encounters with standardized documentation of a SIC were identified and matched by propensity score to control encounters without a SIC in a ratio of 1:3. We used multivariable, paired logistic regression and Cox proportional-hazards modeling to assess key outcomes. Results: Of 6853 encounters (5143 patients), 59 (.86%) encounters (59 patients) had standardized documentation of a SIC, and 58 (.85%) were matched to 167 control encounters (167 patients). Encounters with standardized documentation of a SIC had greater odds of palliative care consultation (odds ratio [OR] 60.10, 95% confidence interval [CI] 12.45-290.08, P < .01), a documented code status change (OR 8.04, 95% CI 1.54-42.05, P = .01), and discharge with hospice services (OR 35.07, 95% CI 5.80-212.08, P < .01) compared to matched controls. There was no significant association with 90-day readmissions (adjusted hazard ratio [HR] .88, standard error [SE] .37, P = .73). Conclusions: Standardized documentation of a SIC during hospitalization is associated with palliative care consultation, change in code status, and hospice enrollment.
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Affiliation(s)
- Myrna K. Serna
- Division of General Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Catherine Yoon
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA, USA
| | - Julie Fiskio
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA, USA
| | - Joshua R. Lakin
- Harvard Medical School, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, USA
| | - Jeffrey L. Schnipper
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Anuj K. Dalal
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Mack JW, Cernik C, Xu L, Laurent CA, Fisher L, Cannizzaro N, Munneke J, Cooper RM, Lakin JR, Schwartz CM, Casperson M, Altschuler A, Wiener L, Kushi LH, Chao CR, Uno H. Use of Cancer-Directed therapy at the end of life among adolescents and young adults. J Natl Cancer Inst 2024:djae038. [PMID: 38377408 DOI: 10.1093/jnci/djae038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 12/06/2023] [Accepted: 02/15/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Adolescents and young adults (AYAs) frequently receive chemotherapy near death. We know less about use of targeted agents and immunotherapy or trends over time. METHODS We conducted a retrospective cohort study of 1,836 AYAs with cancer who died between 2009-2019 after receiving care at one of three sites (Dana-Farber Cancer Institute, Kaiser Permanente Northern California, and Kaiser Permanente Southern California). We reviewed electronic health data and medical records to examine use of cancer-directed therapy in the last 90 days of life, including chemotherapy, targeted therapy, immunotherapy, and investigational drugs. RESULTS Over the study period, 35% of AYAs received chemotherapy in the last 90 days of life; 24% received targeted therapy, 7% immunotherapy, and 5% investigational drugs. Fifty-six percent received at least one form of systemic cancer-directed therapy in the last 90 days of life. After adjustment for patient sex, race, ethnicity, age, site of care, diagnosis, and years from diagnosis to death, the proportion of AYAs receiving targeted therapy (odds ratio (OR) 1.05 per year of death, 95% confidence interval (CI) 1.02-1.10, P = .006), immunotherapy (OR 1.27, 95%CI 1.18-1.38, P<.0001), and any cancer-directed therapy (OR1.04, 95%CI 1.01-1.08, P=.01) in the last 90 days of life increased over time. CONCLUSIONS More than half of AYAs receive cancer therapy in the last 90 days of life, and use of novel agents such as targeted therapy and immunotherapy are increasing over time. While some AYAs may wish to continue cancer therapy while living with advanced disease, efforts are needed to ensure that use of cancer-directed therapy meets preferences of AYAs approaching death.
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Affiliation(s)
- Jennifer W Mack
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Colin Cernik
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Lanfang Xu
- MedHealth Statistical Consulting Inc. Solon, OH, USA
| | - Cecile A Laurent
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Lauren Fisher
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Nancy Cannizzaro
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Julie Munneke
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Robert M Cooper
- Department of Pediatric Oncology, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Corey M Schwartz
- Division of Medical Oncology, Kaiser Permanente Northern California, Oakland, California, USA
| | | | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Lori Wiener
- Psychosocial Support and Research Program, National Cancer Institute, Bethesda, Maryland, USA
| | - Lawrence H Kushi
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Chun R Chao
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Hajime Uno
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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Mack JW, Cernik C, Uno H, Laurent CA, Fisher L, Xu L, Munneke J, Cannizzaro N, Casperson M, Schwartz CM, Lakin JR, Cooper RM, Altschuler A, Wiener L, Chao CR, Kushi L. Quality of End-of-Life Care Among Adolescents and Young Adults With Cancer. J Clin Oncol 2024; 42:621-629. [PMID: 37890132 DOI: 10.1200/jco.23.01272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/21/2023] [Accepted: 08/24/2023] [Indexed: 10/29/2023] Open
Abstract
Adolescents, young adults with cancer receive limited psychosocial and spiritual support near death.
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Affiliation(s)
- Jennifer W Mack
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Colin Cernik
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
| | - Hajime Uno
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
| | | | - Lauren Fisher
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
| | | | | | - Nancy Cannizzaro
- Medical Oncology, Kaiser Permanente Northern California, Oakland, CA
| | - Mallory Casperson
- Pediatric Oncology, Kaiser Permanente Southern California, Pasadena, CA
| | - Corey M Schwartz
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Joshua R Lakin
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Robert M Cooper
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
| | | | - Lori Wiener
- Psychosocial Support and Research Program, National Cancer Institute, Bethesda, MD
| | - Chun R Chao
- Medical Oncology, Kaiser Permanente Northern California, Oakland, CA
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Serna MK, Yoon C, Fiskio J, Lakin JR, Schnipper JL, Dalal AK. A Mixed Methods Analysis of Standardized Documentation of Serious Illness Conversations Within an Electronic Health Record Module During Hospitalization. Am J Hosp Palliat Care 2024:10499091241228269. [PMID: 38334010 DOI: 10.1177/10499091241228269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Analysis of documented Serious Illness Conversations (SICs) in the inpatient setting can help clinicians align management to address patient and caregiver needs. METHODS We conducted a mixed methods analysis of the first instance of standardized documentation of a SIC within a structured module among hospitalized general medicine patients from 2018 to 2019. Percentage of documentations that included a description of patient or family understanding of the patient's medical condition and use of radio buttons to answer the "prognostic information shared," "hopes," and "worries" modules are reported. Using grounded theory approach, physicians analyzed free text entries to: "What is important to the patient/family?" and "Recommendations or next steps planned." RESULTS Out of 5142 patients, 59 patients had a documented SIC. Patient or family understanding of the medical condition(s) was reported in 56 (95%). For "prognostic information shared," the most frequently selected radio buttons were: 49 (83%) incurable disease and 28 (48%) prognosis of weeks to months while those for "hopes" were: 52 (88%) be comfortable and 27 (46%) be at home and for "worries" were: 49 (83%) other physical suffering and 36 (61%) pain. Themes generated from entries to "What's important to patient/family?" included being with loved ones; comfort; mentally and physically present; and reliable care while those for "Recommendations" were coordinating support services; symptom management; and support and communication. CONCLUSIONS SIC content indicated concern about pain and reliable care suggesting the complex, intensive nature of caring for seriously ill patients and the need to consider SICs earlier in the life course of patients.
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Affiliation(s)
- Myrna Katalina Serna
- Division of General Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Catherine Yoon
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Julie Fiskio
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Joshua R Lakin
- Harvard Medical School, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jeffrey L Schnipper
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Anuj K Dalal
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Murakami N, Reich AJ, He K, Gelfand SL, Leiter RE, Sciacca K, Adler JT, Lu E, Ong SC, Concepcion BP, Singh N, Murad H, Anand P, Ramer SJ, Dadhania DM, Lentine KL, Lakin JR, Alhamad T. Kidney Transplant Clinicians' Perceptions of Palliative Care for Patients With Failing Allografts in the US: A Mixed Methods Study. Am J Kidney Dis 2024; 83:173-182.e1. [PMID: 37726050 DOI: 10.1053/j.ajkd.2023.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/03/2023] [Accepted: 07/09/2023] [Indexed: 09/21/2023]
Abstract
RATIONALE & OBJECTIVE Kidney transplant patients with failing allografts have a physical and psychological symptom burden as well as high morbidity and mortality. Palliative care is underutilized in this vulnerable population. We described kidney transplant clinicians' perceptions of palliative care to delineate their perceived barriers to and facilitators of providing palliative care to this population. STUDY DESIGN National explanatory sequential mixed methods study including an online survey and semistructured interviews. SETTING & PARTICIPANTS Kidney transplant clinicians in the United States surveyed and interviewed from October 2021 to March 2022. ANALYTICAL APPROACH Descriptive summary of survey responses, thematic analysis of qualitative interviews, and mixed methods integration of data. RESULTS A total of 149 clinicians completed the survey, and 19 completed the subsequent interviews. Over 90% of respondents agreed that palliative care can be helpful for patients with a failing kidney allograft. However, 46% of respondents disagreed that all patients with failing allografts benefit from palliative care, and two-thirds thought that patients would not want serious illness conversations. More than 90% of clinicians expressed concern that transplant patients and caregivers would feel scared or anxious if offered palliative care. The interviews identified three main themes: (1) transplant clinicians' unique sense of personal and professional responsibility was a barrier to palliative care engagement, (2) clinicians' uncertainty regarding the timing of palliative care collaboration would lead to delayed referral, and (3) clinicians felt challenged by factors related to patients' cultural backgrounds and identities, such as language differences. Many comments reflected an unfamiliarity with the broad scope of palliative care beyond end-of-life care. LIMITATIONS Potential selection bias. CONCLUSIONS Our study suggests that multiple barriers related to patients, clinicians, health systems, and health policies may pose challenges to the delivery of palliative care for patients with failing kidney transplants. This study illustrates the urgent need for ongoing efforts to optimize palliative care delivery models dedicated to kidney transplant patients, their families, and the clinicians who serve them. PLAIN-LANGUAGE SUMMARY Kidney transplant patients experience physical and psychological suffering in the context of their illnesses that may be amenable to palliative care. However, palliative care is often underutilized in this population. In this mixed-methods study, we surveyed 149 clinicians across the United States, and 19 of them completed semistructured interviews. Our study results demonstrate that several patient, clinician, system, and policy factors need to be addressed to improve palliative care delivery to this vulnerable population.
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Affiliation(s)
- Naoka Murakami
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Amanda J Reich
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Katherine He
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Samantha L Gelfand
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Richard E Leiter
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kate Sciacca
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joel T Adler
- Department of Surgery, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - Emily Lu
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Song C Ong
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Beatrice P Concepcion
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Neeraj Singh
- Willis Knighton Health System, Shreveport, Louisiana
| | - Haris Murad
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Prince Anand
- Medical University of South Carolina, Greenville, South Carolina
| | | | | | - Krista L Lentine
- Saint Louis University Transplant Center, SSM-Saint Louis University Hospital, St Louis, Missouri
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.
| | - Tarek Alhamad
- Division of Nephrology, Washington University in St. Louis, St. Louis, Missouri.
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Ouchi K, Prachanukool T, Aaronson EL, Lakin JR, Higuchi M, Liu SW, Kennedy M, Revette AC, Chary AN, Kaithamattam J, Lee B, Neville TH, Hasdianda MA, Sudore R, Schonberg MA, Tulsky JA, Block SD. The differences in code status conversation approaches reported by emergency medicine and palliative care clinicians: A mixed-method study. Acad Emerg Med 2024; 31:18-27. [PMID: 37814372 PMCID: PMC10794002 DOI: 10.1111/acem.14818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/21/2023] [Accepted: 10/03/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND During acute health deterioration, emergency medicine and palliative care clinicians routinely discuss code status (e.g., shared decision making about mechanical ventilation) with seriously ill patients. Little is known about their approaches. We sought to elucidate how code status conversations are conducted by emergency medicine and palliative care clinicians and why their approaches are different. METHODS We conducted a sequential-explanatory, mixed-method study in three large academic medical centers in the Northeastern United States. Attending physicians and advanced practice providers working in emergency medicine and palliative care were eligible. Among the survey respondents, we purposefully sampled the participants for follow-up interviews. We collected clinicians' self-reported approaches in code status conversations and their rationales. A survey with a 5-point Likert scale ("very unlikely" to "very likely") was used to assess the likelihood of asking about medical procedures (procedure based) and patients' values (value based) during code status conversations, followed by semistructured interviews. RESULTS Among 272 clinicians approached, 206 completed the survey (a 76% response rate). The reported approaches differed greatly (e.g., 91% of palliative care clinicians reported asking about a patient's acceptable quality of life compared to 59% of emergency medicine clinicians). Of the 206 respondents, 118 (57%) agreed to subsequent interviews; our final number of semistructured interviews included seven emergency medicine clinicians and nine palliative care clinicians. The palliative care clinicians stated that the value-based questions offer insight into patients' goals, which is necessary for formulating a recommendation. In contrast, emergency medicine clinicians stated that while value-based questions are useful, they are vague and necessitate extended discussions, which are inappropriate during emergencies. CONCLUSIONS Emergency medicine and palliative care clinicians reported conducting code status conversations differently. The rationales may be shaped by their clinical practices and experiences.
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Affiliation(s)
- Kei Ouchi
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Thidathit Prachanukool
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Emily L. Aaronson
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joshua R. Lakin
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Masaya Higuchi
- Division of Palliative Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shan W. Liu
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Maura Kennedy
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Anna C. Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Anita N. Chary
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jenson Kaithamattam
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Brandon Lee
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Thanh H. Neville
- Division of Pulmonary and Critical Care, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Mohammad A. Hasdianda
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Rebecca Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, USA
| | - Mara A. Schonberg
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - James A. Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Susan D. Block
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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Murray GF, Lakin JR, Paasche-Orlow MK, Tulsky JA, Volandes A, Davis AD, Zupanc SN, Carney MT, Burns E, Martins-Welch D, LaVine N, Itty JE, Fix GM. Structural Barriers to Well-grounded Advance Care Planning for the Seriously Ill: a Qualitative Study of Clinicians' and Administrators' Experiences During a Pragmatic Trial. J Gen Intern Med 2023; 38:3558-3565. [PMID: 37488368 PMCID: PMC10713958 DOI: 10.1007/s11606-023-08320-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 07/03/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Advance Care Planning (ACP) comprises an iterative communication process aimed at understanding patients' goals, values, and preferences in the context of considering and preparing for future medical treatments and decision making in serious illness. The COVID pandemic heightened patients' and clinicians' awareness of the need for ACP. OBJECTIVE Our goal was to explore the experiences of clinicians and administrators in the context of an intervention to improve ACP during the COVID pandemic. DESIGN Qualitative interview study. PARTICIPANTS Clinicians and administrators across five sites that participated in the ACP-COVID trial. APPROACH We conducted semi-structured, qualitative interviews examining the context and approach to ACP. Interviews were analyzed using template analysis to systematically organize the data and facilitate review across the categories and participants. Templates were developed with iterative input and line-by-line review by the analytic team, to reach consensus. Findings were then organized into emergent themes. KEY RESULTS Across 20 interviews (4 administrators, 16 clinicians) we identified three themes related to how participants thought about ACP: (1) clinicians have varying views of what constitutes ACP; (2) the health system critically shapes ACP culture and norms; and (3) the centrality of clinicians' affective experience and own needs related to ACP. Varying approaches to ACP include a forms-focused approach; a discussion-based approach; and a parental approach. System features that shape ACP norms are (1) the primacy of clinician productivity measures; (2) the role of the EHR; and (3) the culture of quality improvement. CONCLUSIONS Despite high organizational commitment to ACP, we found that the health system channeled clinicians' ACP efforts narrowly on completion of forms, in tension with the ideal of well-grounded ACP. This resulted in a state of moral distress that risks undermining confidence in the process of ACP and may increase risk of harm for patients, family/caregivers, and providers. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04660422.
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Affiliation(s)
- Genevra F Murray
- Department of Public Health Policy and Management, School of Global Public Health, New York University, New York, NY, USA
| | - Joshua R Lakin
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Michael K Paasche-Orlow
- Tufts University School of Medicine, Division of General Internal Medicine, Department of Medicine, Tufts Medical Center, Boston, MA, USA
- Boston University Chobanian & Avedisian, School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - James A Tulsky
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Angelo Volandes
- Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital, Section of General Internal Medicine, Boston, MA, USA
- ACP Decisions, Waban, MA, USA
| | | | - Sophia N Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Maria T Carney
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Edith Burns
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Diana Martins-Welch
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Nancy LaVine
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Jennifer E Itty
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Gemmae M Fix
- Boston University Chobanian & Avedisian, School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
- Center for Healthcare Organization and Implementation Research, Bedford VA Healthcare System, Bedford, MA, USA
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8
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Hinkle J, Wiener L, Altschuler A, Brock KE, Casperson M, Chao CR, Fisher L, Kushi LH, Lakin JR, Lefebvre A, Schwartz CM, Shalman DM, Wall CB, Mack JW. What Constitutes Quality of Life? Perspectives of Adolescents and Young Adults With Advanced Cancer. J Natl Compr Canc Netw 2023; 21:1243-1250. [PMID: 38081124 DOI: 10.6004/jnccn.2023.7067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 08/02/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND Adolescents and young adults (AYAs) with advanced cancer identify maintaining a good quality of life (QoL) as a central goal of end-of-life care. QoL is a dynamic and subjective overarching concept that refers to an individual's relative satisfaction with their own life. Despite its importance to AYAs with advanced cancer, a patient-centered definition of QoL is lacking in this population. PATIENTS AND METHODS This qualitative secondary analysis of semistructured interviews was conducted across 3 institutions and 1 online support community among AYA patients with advanced cancer, family caregivers, and health care providers who cared for living or recently deceased AYAs. Interviewees were asked about priorities in receipt of care. Interviews were transcribed using NVivo software for primary analysis, and previously coded excerpts were screened for references to QoL. Relevant excerpts were sorted into organizing domains. RESULTS Participants included 23 AYA patients, 28 family caregivers, and 29 health care providers (including physicians, nurses, nurse practitioners, social workers, and psychologists). Four domains of QoL were identified: psychosocial and physical well-being, dignity, normalcy, and personal and family relationships. Within each domain there was agreement across AYAs, caregivers, and health care providers, with nuanced perspectives provided by AYAs of different ages. Personal and family relationships was the most frequently referenced domain of QoL among all participants. A common feature of each domain was that adaptation to current circumstances impacted perspectives on QoL. Patients valued active participation in the development of a care plan that supported these domains. CONCLUSIONS AYAs with advanced cancer, their caregivers, and health care providers agree on several broad domains of QoL in this population. To provide high-quality, patient-centered care, care plans should integrate these domains to enable AYAs to maximize their QoL throughout their advanced cancer care.
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Affiliation(s)
- Jane Hinkle
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Lori Wiener
- Psychosocial Support and Research Program, National Cancer Institute, Bethesda, Maryland
| | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Katharine E Brock
- Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Mallory Casperson
- Divisions of Pediatric Oncology and Palliative Care, Cactus Cancer Society, Oakland, California
| | - Chun R Chao
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Lauren Fisher
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lawrence H Kushi
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Anna Lefebvre
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Corey M Schwartz
- Division of Medical Oncology, Kaiser Permanente Northern California, Oakland, California
| | - Dov M Shalman
- Department of Palliative Care, Kaiser Permanente Southern California, Pasadena, California
| | - Catherine B Wall
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jennifer W Mack
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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9
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Zupanc SN, Lakin JR, Volandes AE, Paasche-Orlow MK, Moseley ET, Gundersen DA, Das S, Penumarthy A, Martins-Welch D, Burns EA, Carney MT, Itty JE, Emmert K, Tulsky JA, Lindvall C. Forms or Free-Text? Measuring Advance Care Planning Activity Using Electronic Health Records. J Pain Symptom Manage 2023; 66:e615-e624. [PMID: 37536523 PMCID: PMC10592170 DOI: 10.1016/j.jpainsymman.2023.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 07/20/2023] [Accepted: 07/25/2023] [Indexed: 08/05/2023]
Abstract
Advance care planning (ACP) discussions seek to guide future serious illness care. These discussions may be recorded in the electronic health record by documentation in clinical notes, structured forms and directives, and physician orders. Yet, most studies of ACP prevalence have only examined structured electronic health record elements and ignored data existing in notes. We sought to investigate the relative comprehensiveness and accuracy of ACP documentation from structured and unstructured electronic health record data sources. We evaluated structured and unstructured ACP documentation present in the electronic health records of 435 patients with cancer drawn from three separate healthcare systems. We extracted structured ACP documentation by manually annotating written documents and forms scanned into the electronic health record. We coded unstructured ACP documentation using a rule-based natural language processing software that identified ACP keywords within clinical notes and was subsequently reviewed for accuracy. The unstructured approach identified more instances of ACP documentation (238, 54.7% of patients) than the structured ACP approach (187, 42.9% of patients). Additionally, 16.6% of all patients with structured ACP documentation only had documents that were judged as misclassified, incomplete, blank, unavailable, or a duplicate of a previously entered erroneous document. ACP documents scanned into electronic health records represent a limited view of ACP activity. Research and measures of clinical practice with ACP should incorporate information from unstructured data.
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Affiliation(s)
- Sophia N Zupanc
- Department of Psychosocial Oncology and Palliative Care (S.N.Z., J.R.L., E.T.M., S.D., A.P., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care (S.N.Z., J.R.L., E.T.M., S.D., A.P., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School (J.R.L., A.E.V., J.A.T.), Boston, Massachusetts; Department of Medicine (J.R.L., J.A.T.), Brigham and Women's Hospital, Boston, Massachusetts
| | - Angelo E Volandes
- Harvard Medical School (J.R.L., A.E.V., J.A.T.), Boston, Massachusetts; Department of Medicine (A.E.V.), Massachusetts General Hospital, Boston, Massachusetts; ACP Decisions (A.E.V.), Waban, Massachusetts
| | | | - Edward T Moseley
- Department of Psychosocial Oncology and Palliative Care (S.N.Z., J.R.L., E.T.M., S.D., A.P., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Computer Science (E.T.M.), School of Engineering, Tufts University, Medford, Massachusetts
| | - Daniel A Gundersen
- Survey and Qualitative Methods Core (D.A.G.), Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Social and Behavioral Sciences (D.A.G.), Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Sophiya Das
- Department of Psychosocial Oncology and Palliative Care (S.N.Z., J.R.L., E.T.M., S.D., A.P., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Akhila Penumarthy
- Department of Psychosocial Oncology and Palliative Care (S.N.Z., J.R.L., E.T.M., S.D., A.P., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Diana Martins-Welch
- Institute of Health System Science (D.M.W., E.A.B., M.T.C., J.E.I., K.E.), Feinstein Institutes for Medical Research, Manhasset, New York; Department of Medicine (D.M.W., E.A.B., M.T.C.), Zucker School of Medicine Hofstra/Northwell, New Hyde Park, New York
| | - Edith A Burns
- Institute of Health System Science (D.M.W., E.A.B., M.T.C., J.E.I., K.E.), Feinstein Institutes for Medical Research, Manhasset, New York; Department of Medicine (D.M.W., E.A.B., M.T.C.), Zucker School of Medicine Hofstra/Northwell, New Hyde Park, New York
| | - Maria T Carney
- Institute of Health System Science (D.M.W., E.A.B., M.T.C., J.E.I., K.E.), Feinstein Institutes for Medical Research, Manhasset, New York; Department of Medicine (D.M.W., E.A.B., M.T.C.), Zucker School of Medicine Hofstra/Northwell, New Hyde Park, New York
| | - Jennifer E Itty
- Institute of Health System Science (D.M.W., E.A.B., M.T.C., J.E.I., K.E.), Feinstein Institutes for Medical Research, Manhasset, New York
| | - Kaitlin Emmert
- Institute of Health System Science (D.M.W., E.A.B., M.T.C., J.E.I., K.E.), Feinstein Institutes for Medical Research, Manhasset, New York
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care (S.N.Z., J.R.L., E.T.M., S.D., A.P., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School (J.R.L., A.E.V., J.A.T.), Boston, Massachusetts; Department of Medicine (J.R.L., J.A.T.), Brigham and Women's Hospital, Boston, Massachusetts
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care (S.N.Z., J.R.L., E.T.M., S.D., A.P., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School (J.R.L., A.E.V., J.A.T.), Boston, Massachusetts; Department of Medicine (J.R.L., J.A.T.), Brigham and Women's Hospital, Boston, Massachusetts.
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10
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Mendoza K, Killeen K, Lakin JR, Leiter RE, Sciacca KR, Gelfand SL. Adding Pals to KidneyPal: Creating a Virtual Patient and Family Advisory Council for Kidney Palliative Care. J Palliat Med 2023; 26:1450-1452. [PMID: 37625026 DOI: 10.1089/jpm.2023.0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2023] Open
Abstract
Patient and family advisory councils (PFACs) represent one method of engaging patients and families in clinical program development and research, but existing practices too often exclude marginalized and minority voices. As a kidney palliative care team (KidneyPal) at a large academic medical center, we sought to create a PFAC that explicitly considered equity and inclusion in its approach to advisor recruitment. We developed two major innovations to reduce selection bias in our KidneyPal PFAC: adaptation to an entirely virtual process and alteration of the advisor recruitment and enrollment process. We eliminated several potential barriers to participation for our patients and their family members, a population with higher rates of advanced age, nonwhite ethnicity, and limited English proficiency than the local general population. We removed application requirements including lengthy online training modules, detailed employment history, a personal essay, and a criminal background check. The KidneyPal PFAC may act as a model for improving equity and inclusion in virtual patient advisory councils.
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Affiliation(s)
- Kimberly Mendoza
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kelsey Killeen
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Joshua R Lakin
- Division of Palliative Medicine, 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
- Harvard Medical School, Boston, Massachusetts, USA
| | - Richard E Leiter
- Division of Palliative Medicine, 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
- Harvard Medical School, Boston, Massachusetts, USA
| | - Kate R Sciacca
- Division of Palliative Medicine, 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
| | - Samantha L Gelfand
- Division of Palliative Medicine, 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
- Harvard Medical School, Boston, Massachusetts, USA
- Renal Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
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11
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Mack JW, Cernik C, Uno H, Xu L, Laurent CA, Fisher L, Cannizzaro N, Munneke J, Cooper RM, Lakin JR, Schwartz CM, Casperson M, Altschuler A, Wiener L, Kushi L, Chao CR. Discussions About Goals of Care and Advance Care Planning Among Adolescents and Young Adults With Cancer Approaching the End of Life. J Clin Oncol 2023; 41:4739-4746. [PMID: 37625111 PMCID: PMC10602508 DOI: 10.1200/jco.23.00641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/12/2023] [Accepted: 07/19/2023] [Indexed: 08/27/2023] Open
Abstract
PURPOSE Adolescents and young adults (AYAs) with cancer receive high rates of medically intensive measures at the end of life. This study aimed to characterize the prevalence and timing of conversations about goals of care and advance care planning among AYAs at the end of life as one potential influence on care received. METHODS This was a review of electronic health data and medical records for 1,929 AYAs age 12-39 years who died after receiving care at one of three sites between 2003 and 2019, including documented conversations about goals of care and advance care planning, and care received. RESULTS A majority of AYAs were female (54%) and White (61%); 12% were Asian, 8% Black, and 27% Hispanic. Most patients had documented discussions about prognosis (86%), goals of care (83%), palliative care (79%), hospice (79%), and preferred location of death (64%). When last documented goals of care were evaluated, 69% of patients wanted care focused on palliation; however, 29% of those with palliative goals spent time in the intensive care unit (ICU) in the last month of life, and 32% had multiple emergency room (ER) visits. When goals-of-care discussions happened earlier, >30 days before death, AYAs were less likely to receive chemotherapy in the last 14 days of life (P = .001), ICU care (P < .001), ER visits (P < .001), and hospitalizations in the last month (P < .001). CONCLUSION High rates of medically intensive measures among AYAs near the end of life do not appear to be the result of a lack of discussions about goals of care and advance care planning. Although some interventions may be used to support palliative goals, earlier discussions have potential to reduce late-life intensive measures.
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Affiliation(s)
- Jennifer W. Mack
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Colin Cernik
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
| | - Hajime Uno
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
| | - Lanfang Xu
- MedHealth Statistical Consulting Inc, Solon, OH
| | - Cecile A. Laurent
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Lauren Fisher
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
| | - Nancy Cannizzaro
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Julie Munneke
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Robert M. Cooper
- Department of Pediatric Oncology, Kaiser Permanente Southern California, Pasadena, CA
| | - Joshua R. Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
| | - Corey M. Schwartz
- Department of Medical Oncology, Kaiser Permanente Northern California, Oakland, CA
| | | | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Lori Wiener
- Psychosocial Support and Research Program, National Cancer Institute, Bethesda, MD
| | - Lawrence Kushi
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Chun R. Chao
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
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12
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Leiter RE, Bischoff KE, Carey EC, Gelfand SL, Iyer AS, Jain N, Kramer NM, Lally K, Landzberg MJ, Lever N, Newport K, O'Donnell A, Patel A, Sciacca KR, Snaman JM, Tulsky JA, Rosa WE, Lakin JR. Top Ten Tips Palliative Care Clinicians Should Know About Delivering Specialty-Aligned Palliative Care. J Palliat Med 2023; 26:1401-1407. [PMID: 37001173 DOI: 10.1089/jpm.2023.0116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Specialty-aligned palliative care (SAPC) refers to interprofessional palliative care (PC) that is delivered to a specific population of patients in close partnership with other primary or specialty clinicians. As evolving PC models address physical, psychosocial, and spiritual suffering across illnesses and settings, PC clinicians must acquire advanced knowledge of disease-specific symptoms, common treatments, and complications that impact prognosis and outcomes. The tips provided in this article draw on the experience and knowledge of interprofessional PC and other specialist clinicians from diverse institutions across the United States who have developed and studied SAPC services across different disease groups. Recommendations include focusing on approaching specialty team partnerships with humility, curiosity, and diplomacy; focusing on patient populations where PC needs are great; clarifying how work and responsibilities will be divided between PC and other clinicians to the extent possible; using consults as opportunities for bidirectional learning; and adapting workflows and schedules to meet specialty team needs while managing expectations and setting limits as appropriate. Furthermore, to provide effective SAPC, PC clinicians must learn about the specific symptoms, prognoses, and common treatments of the patients they are serving. They must also build trusting relationships and maintain open communication with patients and referring clinicians to ensure integrated and aligned PC delivery.
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Affiliation(s)
- Richard E Leiter
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kara E Bischoff
- Division of Palliative Medicine, Department of Medicine, University of California San Francisco, San Francisco, USA
| | - Elise C Carey
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Samantha L Gelfand
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anand S Iyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Center for Palliative and Supportive Care, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Nelia Jain
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Neha M Kramer
- Department of Neurology and Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Kate Lally
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael J Landzberg
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Natasha Lever
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Kristina Newport
- Section of Palliative Medicine, Department of Medicine, Penn State University College of Medicine, Hershey, Pennsylvania, USA
| | - Arden O'Donnell
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Arpan Patel
- Division of Digestive Diseases, David Geffen School of Medicine, University of California, Los Angeles, California, USA
- VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Kate R Sciacca
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jennifer M Snaman
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - James A Tulsky
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - William E Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Joshua R Lakin
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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13
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Volandes AE, Zupanc SN, Lakin JR, Cabral HJ, Burns EA, Carney MT, Lopez S, Itty J, Emmert K, Martin NJ, Cole T, Dobie A, Cucinotta T, Joel M, Caruso LB, Henault L, Dugas JN, Astone K, Winter M, Wang N, Davis AD, Garde C, Rodriguez PM, El-Jawahri A, Moseley ET, Das S, Sciacca K, Ramirez AM, Gromova V, Lambert S, Sanghani S, Lindvall C, Paasche-Orlow MK. Video Intervention and Goals-of-Care Documentation in Hospitalized Older Adults: The VIDEO-PCE Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2332556. [PMID: 37695586 PMCID: PMC10495866 DOI: 10.1001/jamanetworkopen.2023.32556] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 07/27/2023] [Indexed: 09/12/2023] Open
Abstract
Importance Despite the benefits of goals-of-care (GOC) communication, many hospitalized individuals never communicate their goals or preferences to clinicians. Objective To assess whether a GOC video intervention delivered by palliative care educators (PCEs) increased the rate of GOC documentation. Design, Setting, and Participants This pragmatic, stepped-wedge cluster randomized clinical trial included patients aged 65 years or older admitted to 1 of 14 units at 2 urban hospitals in New York and Boston from July 1, 2021, to October 31, 2022. Intervention The intervention involved PCEs (social workers and nurses trained in GOC communication) facilitating GOC conversations with patients and/or their decision-makers using a library of brief, certified video decision aids available in 29 languages. Patients in the control period received usual care. Main Outcome and Measures The primary outcome was GOC documentation, which included any documentation of a goals conversation, limitation of life-sustaining treatment, palliative care, hospice, or time-limited trials and was obtained by natural language processing. Results A total of 10 802 patients (mean [SD] age, 78 [8] years; 51.6% male) were admitted to 1 of 14 hospital units. Goals-of-care documentation during the intervention phase occurred among 3744 of 6023 patients (62.2%) compared with 2396 of 4779 patients (50.1%) in the usual care phase (P < .001). Proportions of documented GOC discussions for Black or African American individuals (865 of 1376 [62.9%] vs 596 of 1125 [53.0%]), Hispanic or Latino individuals (311 of 548 [56.8%] vs 218 of 451 [48.3%]), non-English speakers (586 of 1059 [55.3%] vs 405 of 863 [46.9%]), and people living with Alzheimer disease and related dementias (520 of 681 [76.4%] vs 355 of 570 [62.3%]) were greater during the intervention phase compared with the usual care phase. Conclusions and Relevance In this stepped-wedge cluster randomized clinical trial of older adults, a GOC video intervention delivered by PCEs resulted in higher rates of GOC documentation compared with usual care, including among Black or African American individuals, Hispanic or Latino individuals, non-English speakers, and people living with Alzheimer disease and related dementias. The findings suggest that this form of patient-centered care delivery may be a beneficial decision support tool. Trial Registration ClinicalTrials.gov Identifier: NCT04857060.
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Affiliation(s)
- Angelo E. Volandes
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
- ACP Decisions, Waban, Massachusetts
| | - Sophia N. Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joshua R. Lakin
- Harvard Medical School, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Howard J. Cabral
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Edith A. Burns
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Maria T. Carney
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Santiago Lopez
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Jennifer Itty
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Kaitlin Emmert
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Narda J. Martin
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Therese Cole
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Alexandra Dobie
- Section of General Internal Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
- Palliative Care, Boston Medical Center, Boston, Massachusetts
| | - Traci Cucinotta
- Palliative Care, Boston Medical Center, Boston, Massachusetts
| | - Milton Joel
- Palliative Care, Boston Medical Center, Boston, Massachusetts
| | - Lisa B. Caruso
- Department of Medicine, Section of Geriatrics, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Lori Henault
- Section of General Internal Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Julianne N. Dugas
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | - Kristina Astone
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | - Michael Winter
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | - Na Wang
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | | | | | - Perla Macip Rodriguez
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Areej El-Jawahri
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
| | - Edward T. Moseley
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Sophiya Das
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kate Sciacca
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Ana Maria Ramirez
- Section of General Internal Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Valeria Gromova
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Sherene Lambert
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Shreya Sanghani
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Charlotta Lindvall
- Harvard Medical School, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Michael K. Paasche-Orlow
- Department of Medicine, Tufts University School of Medicine, Tufts Medical Center, Boston, Massachusetts
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14
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Mastropolo R, Altschuler A, Brock KE, Casperson M, Chao CR, Fisher L, Greenzang KA, Kushi LH, Lakin JR, Lefebvre A, Schwartz CM, Shalman DM, Wall CB, Wiener L, Mack JW. Patient, Caregiver, and Clinician Perspectives on Core Components of Therapeutic Alliance for Adolescents and Young Adults With Advanced Cancer: A Qualitative Study. JAMA Netw Open 2023; 6:e2328153. [PMID: 37556137 PMCID: PMC10413170 DOI: 10.1001/jamanetworkopen.2023.28153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/29/2023] [Indexed: 08/10/2023] Open
Abstract
IMPORTANCE The patient-clinician therapeutic alliance is an important aspect of high-quality cancer care. However, components of the therapeutic alliance in adolescents and young adults (AYAs, aged 12-39 years) with cancer have not been defined. OBJECTIVE To identify components of and barriers to the therapeutic alliance between AYAs, caregivers, and clinicians from the perspective of all key stakeholders. DESIGN, SETTING, AND PARTICIPANTS In this qualitative study, semistructured in-depth interviews with patients, caregivers, and clinicians were conducted from 2018 to 2021 with no additional follow-up, with content analysis of resulting transcripts. Participants were recruited from Dana-Farber Cancer Institute, Kaiser Permanente Northern California, Kaiser Permanente Southern California, and an online cancer support community (Cactus Cancer Society). Eligible participants were English- or Spanish-speaking. Eligible patients were aged 12 to 39 years with stage IV or recurrent cancer. Eligible caregivers cared for an AYA living with advanced cancer or one who had died within 5 years. Eligible clinicians routinely provided care for AYAs with cancer. MAIN OUTCOMES AND MEASURES Perspectives on therapeutic alliance. RESULTS Interviews were conducted with 80 participants: 23 were patients (48% were female; 78% were White), 28 were caregivers (82% were female; 50% were White), and 29 were clinicians (69% were female; 45% were White). The mean (SD) age of patients was 29 (7.3) years. Interviews identified 6 components of therapeutic alliance: (1) compassion; (2) sense of connection; (3) clinician presence; (4) information sharing; (5) shared goals; and (6) individualization of care. While some domains were represented in prior models of therapeutic alliance, a unique domain was identified related to the need for individualization of the approach to care for AYA patients and their caregivers. Interviews also identified potential barriers to building the therapeutic alliance specific to the AYA population, including managing discordant needs between patients and caregivers and communication challenges at the end of life. CONCLUSIONS AND RELEVANCE This study identified core components and barriers to building therapeutic alliance in the AYA advanced cancer population from the perspective of all the key stakeholders in the relationship. A novel component highlighting the need for individualization was identified. This model enables a deeper understanding of how to build therapeutic alliance in the AYA advanced cancer population, which may guide clinician training and facilitate improved care for this vulnerable population.
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Affiliation(s)
- Rosemarie Mastropolo
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Katharine E. Brock
- Department of Pediatric Oncology, Emory University and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Mallory Casperson
- Divisions of Pediatric Oncology and Palliative Care, Cactus Cancer Society, Oakland, California
| | - Chun R. Chao
- Department of Research and Evaluation (C.R.C.), Kaiser Permanente Southern California, Pasadena
| | - Lauren Fisher
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Katie A. Greenzang
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lawrence H. Kushi
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Joshua R. Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Anna Lefebvre
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Corey M. Schwartz
- Division of Medical Oncology, Kaiser Permanente Northern California, Oakland
| | - Dov M. Shalman
- Department of Palliative Care, Kaiser Permanente Southern California, Pasadena
| | - Catherine B. Wall
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lori Wiener
- Pediatric Oncology Branch, National Cancer Institute, Bethesda, Maryland
| | - Jennifer W. Mack
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
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15
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Mack JW, Fisher L, Khalaj A, Altschuler A, Chao CR, Kushi LH, Casperson M, Lakin JR, Lefebvre A, Schwartz CM, Shalman DM, Wall CB, Wiener L. Quality Indicators for Adolescents and Young Adults With Advanced Cancer: A Modified Delphi Process With Patients, Family Members, and Clinicians. J Pain Symptom Manage 2023; 66:54-61. [PMID: 36933749 PMCID: PMC10330073 DOI: 10.1016/j.jpainsymman.2023.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 03/18/2023]
Abstract
CONTEXT Quality measures have been devised for end-of-life care of older adults with cancer, but are lacking for adolescents and young adults (AYAs). OBJECTIVE We previously conducted interviews with AYAs, family caregivers, and clinicians to identify priority domains for high quality care of AYAs with advanced cancer. The goal of this study was to use a modified Delphi process to form consensus around the highest priority quality indicators. METHODS A modified Delphi process was conducted with 10 AYAs with recurrent or metastatic cancer, 11 family caregivers, and 29 multidisciplinary clinicians, using small group web conferences. Participants were asked to rate the importance of each of 41 potential quality indicators, rank the 10 most important, and engage in discussion to reconcile differences. RESULTS Of 41 initial indicators, 34 were rated as highly important (rating seven, eight, or nine on a nine-point scale) by >70% of participants. The panel was unable to reach consensus around the 10 most important indicators. Instead, participants recommended retaining a larger set of indicators to reflect potential for different priorities across the population, resulting in a final set of 32 indicators. Recommended indicators broadly encompassed attention to physical symptoms; quality of life; psychosocial, and spiritual care; communication and decision-making; relationships with clinicians; care and treatment; and independence. CONCLUSION A patient- and family-centered process for quality indicator development led to strong endorsement of multiple potential indicators by Delphi participants. Further validation and refinement will be performed using a survey of bereaved family members.
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Affiliation(s)
- Jennifer W Mack
- Division of Population Sciences (JWM, LF, AK), Dana-Farber Cancer Institute, Boston, Massachusetts, U.S.; Department of Pediatric Oncology (JWM, AL, CBW), Dana-Farber Cancer Institute, Boston, Massachusetts, U.S..
| | - Lauren Fisher
- Division of Population Sciences (JWM, LF, AK), Dana-Farber Cancer Institute, Boston, Massachusetts, U.S
| | - Andrew Khalaj
- Division of Population Sciences (JWM, LF, AK), Dana-Farber Cancer Institute, Boston, Massachusetts, U.S
| | - Andrea Altschuler
- Department of Pediatric Oncology (JWM, AL, CBW), Dana-Farber Cancer Institute, Boston, Massachusetts, U.S.; Division of Research (LHK, AA), Kaiser Permanente Northern California, Oakland, California, U.S
| | - Chun R Chao
- Department of Research and Evaluation (CRC), Kaiser Permanente Southern California, Pasadena, California, U.S
| | - Lawrence H Kushi
- Division of Research (LHK, AA), Kaiser Permanente Northern California, Oakland, California, U.S
| | | | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care (JRL), Dana-Farber Cancer Institute, Boston, Massachusetts, U.S
| | - Anna Lefebvre
- Department of Pediatric Oncology (JWM, AL, CBW), Dana-Farber Cancer Institute, Boston, Massachusetts, U.S
| | - Corey M Schwartz
- Medical Oncology (CMS), Kaiser Permanente Northern California, Oakland, California, U.S
| | - Dov M Shalman
- Palliative Care (DMS), Kaiser Permanente Southern California, Pasadena, California, U.S
| | - Catherine B Wall
- Department of Pediatric Oncology (JWM, AL, CBW), Dana-Farber Cancer Institute, Boston, Massachusetts, U.S
| | - Lori Wiener
- Psychosocial Support and Research Program (LW), National Cancer Institute, Bethesda, Maryland, U.S
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16
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Murakami N, Reich AJ, Pavlakis M, Lakin JR. Conservative Kidney Management in Kidney Transplant Populations. Semin Nephrol 2023; 43:151401. [PMID: 37499572 PMCID: PMC10543459 DOI: 10.1016/j.semnephrol.2023.151401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Conservative kidney management (CKM) has been increasingly accepted as a therapeutic option for seriously ill patients with advanced chronic kidney disease. CKM is active medical management of advanced chronic kidney disease without dialysis, with a focus on delaying the worsening of kidney disease and minimizing symptom burden. CKM may be considered a suitable option for kidney transplant recipients with poorly functioning and declining allografts, defined as patients with low estimated glomerular filtration rate (<20 mL/min per 1.73 m2) who are approaching allograft failure. CKM may be a fitting option for transplant patients facing high morbidity and mortality with or without dialysis resumption, and it should be offered as a choice for this patient population. In this review, we describe clinical considerations in caring for patients with poorly functioning and declining kidney allografts, especially the unique decision-making process around kidney replacement therapies. We discuss ways to incorporate CKM as an option for these patients. We also discuss financial and policy considerations in providing CKM for this population. Patients with poorly functioning and declining kidney allografts should be supported throughout transitions of care by an interprofessional and multidisciplinary team attuned to their unique challenges. Further research on when, who, and how to integrate CKM into existing care structures for patients with poorly functioning and declining kidney allografts is needed.
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Affiliation(s)
- Naoka Murakami
- Harvard Medical School, Boston, MA; Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA.
| | - Amanda J Reich
- Harvard Medical School, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
| | - Martha Pavlakis
- Harvard Medical School, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA
| | - Joshua R Lakin
- Harvard Medical School, Boston, MA; Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
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17
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Prachanukool T, Aaronson EL, Lakin JR, Higuchi M, Lee RS, Santangelo I, Hasdianda MA, Wang W, George N, Liu SW, Kennedy M, Schonberg MA, Block SD, Tulsky JA, Ouchi K. Communication Training and Code Status Conversation Patterns Reported by Emergency Clinicians. J Pain Symptom Manage 2023; 65:58-65. [PMID: 36265695 PMCID: PMC9790029 DOI: 10.1016/j.jpainsymman.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 10/06/2022] [Accepted: 10/11/2022] [Indexed: 11/16/2022]
Abstract
CONTEXT During acute health decompensations for seriously ill patients, emergency clinicians often determine the intensity end-of-life care. Little is known about how emergency clinicians conduct these conversations, especially among those who have received serious illness communication training. OBJECTIVES To determine the self-reported practice patterns of code status conversations by emergency clinicians with and without serious illness communication training. METHODS A cross-sectional survey was conducted among emergency clinicians with and without a recent evidence-based, serious illness communication training tailored for emergency clinicians. Emergency clinicians were included from two academic medical centers. A five-point Likert scale ("very unlikely" to "very likely" to ask) was used to assess the self-reported likelihood of asking about patients' preferences for medical procedures and patients' values and goals. RESULTS Among 161 respondents (71% response rate), 77 (48%) received the training. A total of 70% of emergency clinicians reported asking about procedure-based questions, and only 38% reported asking about patient's values regarding end-of-life care. For value-based questions, statistically significant differences were observed between emergency clinicians who underwent the training and those who did not in four of the seven questions asked (e.g., the higher odds of exploring the patient's life priorities [adjusted OR = 4.34, 95% CI = 1.95-9.65, P-value < 0.001]). No difference was observed in the self-reported rates of all procedure-based questions between the two groups. CONCLUSION Most emergency clinicians reported asking about procedure-based questions, and some asked about patient's value-based questions. Clinicians with recent serious illness communication training may ask more about some values and priorities.
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Affiliation(s)
- Thidathit Prachanukool
- Department of Emergency Medicine (T.P., R.S.L., M.A.H., K.O.), Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA; Department of Emergency Medicine (T.P.), Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| | - Emily L Aaronson
- Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA; Department of Emergency Medicine (E.L.A., I.S., S.W.L., M.K.), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joshua R Lakin
- Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA; Serious Illness Care Program (J.R.L., K.O.), Ariadne Labs, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care (J.R.L., S.D.B., J.A.T., K.O.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Masaya Higuchi
- Palliative Care and Geriatric Medicine (M.H.), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Rachel S Lee
- Department of Emergency Medicine (T.P., R.S.L., M.A.H., K.O.), Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ilianna Santangelo
- Department of Emergency Medicine (E.L.A., I.S., S.W.L., M.K.), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mohammad A Hasdianda
- Department of Emergency Medicine (T.P., R.S.L., M.A.H., K.O.), Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA
| | - Wei Wang
- Department of Medicine and Neurology, Brigham and Women's Hospital (W.W.), Boston, Massachusetts, USA
| | - Naomi George
- Department of Emergency Medicine `(N.G.), Division of Critical Care, University of New Mexico, Albuquerque, New Mexico, USA
| | - Shan W Liu
- Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA; Department of Emergency Medicine (E.L.A., I.S., S.W.L., M.K.), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Maura Kennedy
- Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA; Department of Emergency Medicine (E.L.A., I.S., S.W.L., M.K.), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mara A Schonberg
- Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA; Department of Medicine (M.A.S.), Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Susan D Block
- Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care (J.R.L., S.D.B., J.A.T., K.O.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Departments of Medicine (S.D.B., J.A.T.), Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - James A Tulsky
- Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care (J.R.L., S.D.B., J.A.T., K.O.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Departments of Medicine (S.D.B., J.A.T.), Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kei Ouchi
- Department of Emergency Medicine (T.P., R.S.L., M.A.H., K.O.), Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School (T.P., E.L.A., J.R.L., M.A.H., S.W.L., M.K., M.A.S., S.D.B., J.A.T., K.O.), Boston, Massachusetts, USA; Serious Illness Care Program (J.R.L., K.O.), Ariadne Labs, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care (J.R.L., S.D.B., J.A.T., K.O.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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18
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Umaretiya PJ, Fisher L, Altschuler A, Kushi LH, Chao CR, Vega B, Rodrigues G, Josephs I, Brock KE, Buchanan S, Casperson M, Fasciano KM, Kolevska T, Lakin JR, Lefebvre A, Schwartz CM, Shalman DM, Wall CB, Wiener L, Bona K, Mack JW. "The simple life experiences that every other human gets": Desire for normalcy among adolescents and young adults with advanced cancer. Pediatr Blood Cancer 2023; 70:e30035. [PMID: 36308744 DOI: 10.1002/pbc.30035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 09/07/2022] [Accepted: 09/09/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Adolescents and young adults (AYAs) with advanced cancer identify normalcy as an important component of quality end-of-life care. We sought to define domains of normalcy and identify ways in which clinicians facilitate or hinder normalcy during advanced cancer care. PROCEDURE This was a secondary analysis of a qualitative study that aimed to identify priority domains for end-of-life care. Content analysis of semi-structured interviews among AYAs aged 12-39 years with advanced cancer, caregivers, and clinicians was used to evaluate transcripts. Coded excerpts were reviewed to identify themes related to normalcy. RESULTS Participants included 23 AYAs with advanced cancer, 28 caregivers, and 29 clinicians. Participants identified five domains of normalcy including relationships, activities, career/school, milestones, and appearance. AYAs and caregivers identified that clinicians facilitate normalcy through exploration of these domains with AYAs, allowing flexibility in care plans, identification of short-term and long-term goals across normalcy domains, and recognizing losses of normalcy that occur during cancer care. CONCLUSIONS AYAs with cancer experience multiple threats to normalcy during advanced cancer care. Clinicians can attend to normalcy and improve AYA quality of life by acknowledging these losses through ongoing discussions on how best to support domains of normalcy and by reinforcing AYA identities beyond a cancer diagnosis.
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Affiliation(s)
- Puja J Umaretiya
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Lauren Fisher
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Lawrence H Kushi
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Chun R Chao
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Brenda Vega
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Gilda Rodrigues
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | - Katharine E Brock
- Divisions of Pediatric Oncology and Palliative Care, Emory University, Atlanta, Georgia, USA.,Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | | | | | - Karen M Fasciano
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Tatjana Kolevska
- Division of Medical Oncology, Kaiser Permanente Northern California, Oakland, California, USA
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Anna Lefebvre
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Corey M Schwartz
- Division of Medical Oncology, Kaiser Permanente Northern California, Oakland, California, USA
| | - Dov M Shalman
- Department of Palliative Care, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Catherine B Wall
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Lori Wiener
- Psychosocial Support and Research Program, National Cancer Institute, Bethesda, Maryland, USA
| | - Kira Bona
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jennifer W Mack
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
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19
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Lakin JR, Sciacca K, Leiter R, Killeen K, Gelfand S, Tulsky JA, Anderson S, Zupanc SN, Williams T, Mandel EI. Creating KidneyPal: A Specialty-Aligned Palliative Care Service for People with Kidney Disease. J Pain Symptom Manage 2022; 64:e331-e339. [PMID: 36058402 DOI: 10.1016/j.jpainsymman.2022.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/02/2022] [Accepted: 08/18/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Patients with kidney disease have notable unmet palliative care needs and represent an underserved population for specialty palliative care teams. INTERVENTION We designed a specialty-aligned interprofessional palliative care service called KidneyPal that is aimed at improving delivery of palliative care to patients with kidney disease through focus groups and iterative improvement cycles. MEASURES We iteratively measured the development of KidneyPal through clinical process metrics: percent of the inpatient nephrology census followed by KidneyPal, patient demographics, consult origin, clinician feedback, and self-reported team interventions. OUTCOMES KidneyPal saw 314 unique patients from January 2019 to January 2021. The majority of consultations came from nephrology services though the source of consultation changed over time. We consulted on an average of 13.5% of the entire inpatient nephrology patient hospital census with highest involvement with patients on the inpatient nephrology hemodialysis service (mean of 29.9%). KidneyPal was rated highly by surveyed nephrology clinicians and provided high rates of psychosocial support and goals of care interventions. LESSONS LEARNED The creation of KidneyPal led to us to serve a new cohort of patients with specialty palliative care. We grew over time to serve the full range of patients with kidney disease as defined by our nephrology service lines. We succeeded in doing so by embedding in nephrology and building relationships with those caring for people with kidney disease while tailoring our service and interventions over time.
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Affiliation(s)
- Joshua R Lakin
- Division of Palliative Medicine (J.R.L., K.S., R.L., S.G., J.A.T), Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.R.L., K.S., R.L., K.K., S.G., J.A.T, S.N.Z., T.W.), Boston, Massachusetts; Harvard Medical School (J.R.L., R.L., S.G., J.A.T, E.I.M.), Boston, Massachusetts.
| | - Kate Sciacca
- Division of Palliative Medicine (J.R.L., K.S., R.L., S.G., J.A.T), Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.R.L., K.S., R.L., K.K., S.G., J.A.T, S.N.Z., T.W.), Boston, Massachusetts
| | - Richard Leiter
- Division of Palliative Medicine (J.R.L., K.S., R.L., S.G., J.A.T), Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.R.L., K.S., R.L., K.K., S.G., J.A.T, S.N.Z., T.W.), Boston, Massachusetts; Harvard Medical School (J.R.L., R.L., S.G., J.A.T, E.I.M.), Boston, Massachusetts
| | - Kelsey Killeen
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.R.L., K.S., R.L., K.K., S.G., J.A.T, S.N.Z., T.W.), Boston, Massachusetts
| | - Samantha Gelfand
- Division of Palliative Medicine (J.R.L., K.S., R.L., S.G., J.A.T), Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.R.L., K.S., R.L., K.K., S.G., J.A.T, S.N.Z., T.W.), Boston, Massachusetts; Harvard Medical School (J.R.L., R.L., S.G., J.A.T, E.I.M.), Boston, Massachusetts; Division of Renal Medicine, Brigham and Women's Hospital (S.G., E.I.M.), Boston, Massachusetts
| | - James A Tulsky
- Division of Palliative Medicine (J.R.L., K.S., R.L., S.G., J.A.T), Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.R.L., K.S., R.L., K.K., S.G., J.A.T, S.N.Z., T.W.), Boston, Massachusetts; Harvard Medical School (J.R.L., R.L., S.G., J.A.T, E.I.M.), Boston, Massachusetts
| | | | - Sophia N Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.R.L., K.S., R.L., K.K., S.G., J.A.T, S.N.Z., T.W.), Boston, Massachusetts
| | - Trey Williams
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (J.R.L., K.S., R.L., K.K., S.G., J.A.T, S.N.Z., T.W.), Boston, Massachusetts
| | - Ernest I Mandel
- Harvard Medical School (J.R.L., R.L., S.G., J.A.T, E.I.M.), Boston, Massachusetts; Division of Renal Medicine, Brigham and Women's Hospital (S.G., E.I.M.), Boston, Massachusetts
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20
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Gelfand SL, Lakin JR, Sciacca KR, Rivkin ER, Eves JC, Anderson S, Mandel EI, Desai AS, Jain N, Landzberg MJ, Lever NM, Schaefer KG, Leiter RE, Tulsky JA. Specialty-Aligned Palliative Care: Responding to the Needs of a Tertiary Care Health System. J Pain Symptom Manage 2022; 64:e341-e346. [PMID: 36031081 DOI: 10.1016/j.jpainsymman.2022.08.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/02/2022] [Accepted: 08/18/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Expanding specialty palliative care within complex health systems involves consideration of patients' unmet needs, clinicians' perceptions of palliative care, and the availability of palliative care resources. Prior to this quality improvement (QI) project, palliative care services in our health system primarily served oncology patients. INTERVENTION We undertook a prospective strategic planning process that included executive sponsorship and engagement of institutional leaders and clinicians to help define which palliative care services were most needed by the health system. MEASURES We interviewed and surveyed a broad range of clinicians including physicians, nurse practitioners, and social workers. OUTCOMES The two most prominent themes that emerged from the stakeholder engagement process were clinicians' wish for specialty-aligned interprofessional palliative care teams and for expansion of nononcology palliative care access. CONCLUSION Careful needs assessment and stakeholder engagement can result in goal-directed and data-driven expansion of palliative care services within tertiary health care systems.
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Affiliation(s)
- Samantha L Gelfand
- Division of Palliative Medicine (S.L.G, J.R.L, K.R.S., N.J., M.J.L., N.M.L., K.G.S., R.E.L., J.A.T.), Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care (S.L.G, J.R.L, K.R.S., N.J., M.J.L., N.M.L., R.E.L., J.A.T.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Renal Medicine (S.L.G, E.I.M.), Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School (S.L.G, J.R.L, E.I.M., A.S.D., N.J., M.J.L., K.G.S., R.E.L., J.A.T.), Boston, Massachusetts, USA.
| | - Joshua R Lakin
- Division of Palliative Medicine (S.L.G, J.R.L, K.R.S., N.J., M.J.L., N.M.L., K.G.S., R.E.L., J.A.T.), Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care (S.L.G, J.R.L, K.R.S., N.J., M.J.L., N.M.L., R.E.L., J.A.T.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Harvard Medical School (S.L.G, J.R.L, E.I.M., A.S.D., N.J., M.J.L., K.G.S., R.E.L., J.A.T.), Boston, Massachusetts, USA
| | - Kate R Sciacca
- Division of Palliative Medicine (S.L.G, J.R.L, K.R.S., N.J., M.J.L., N.M.L., K.G.S., R.E.L., J.A.T.), Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care (S.L.G, J.R.L, K.R.S., N.J., M.J.L., N.M.L., R.E.L., J.A.T.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Emily R Rivkin
- Dana-Farber Cancer Institute (E.R.R., J.C.E.), Boston, Massachusetts, USA
| | - Jessica C Eves
- Dana-Farber Cancer Institute (E.R.R., J.C.E.), Boston, Massachusetts, USA
| | - Shelly Anderson
- Brigham and Women's Hospital (S.A.), Boston, Massachusetts, USA
| | - Ernest I Mandel
- Division of Renal Medicine (S.L.G, E.I.M.), Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School (S.L.G, J.R.L, E.I.M., A.S.D., N.J., M.J.L., K.G.S., R.E.L., J.A.T.), Boston, Massachusetts, USA
| | - Akshay S Desai
- Division of Cardiovascular Medicine (A.S.D., M.J.L.), Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School (S.L.G, J.R.L, E.I.M., A.S.D., N.J., M.J.L., K.G.S., R.E.L., J.A.T.), Boston, Massachusetts, USA
| | - Nelia Jain
- Division of Palliative Medicine (S.L.G, J.R.L, K.R.S., N.J., M.J.L., N.M.L., K.G.S., R.E.L., J.A.T.), Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care (S.L.G, J.R.L, K.R.S., N.J., M.J.L., N.M.L., R.E.L., J.A.T.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Harvard Medical School (S.L.G, J.R.L, E.I.M., A.S.D., N.J., M.J.L., K.G.S., R.E.L., J.A.T.), Boston, Massachusetts, USA
| | - Michael J Landzberg
- Division of Palliative Medicine (S.L.G, J.R.L, K.R.S., N.J., M.J.L., N.M.L., K.G.S., R.E.L., J.A.T.), Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care (S.L.G, J.R.L, K.R.S., N.J., M.J.L., N.M.L., R.E.L., J.A.T.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Cardiovascular Medicine (A.S.D., M.J.L.), Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School (S.L.G, J.R.L, E.I.M., A.S.D., N.J., M.J.L., K.G.S., R.E.L., J.A.T.), Boston, Massachusetts, USA
| | - Natasha M Lever
- Division of Palliative Medicine (S.L.G, J.R.L, K.R.S., N.J., M.J.L., N.M.L., K.G.S., R.E.L., J.A.T.), Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care (S.L.G, J.R.L, K.R.S., N.J., M.J.L., N.M.L., R.E.L., J.A.T.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Kristen G Schaefer
- Division of Palliative Medicine (S.L.G, J.R.L, K.R.S., N.J., M.J.L., N.M.L., K.G.S., R.E.L., J.A.T.), Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School (S.L.G, J.R.L, E.I.M., A.S.D., N.J., M.J.L., K.G.S., R.E.L., J.A.T.), Boston, Massachusetts, USA
| | - Richard E Leiter
- Division of Palliative Medicine (S.L.G, J.R.L, K.R.S., N.J., M.J.L., N.M.L., K.G.S., R.E.L., J.A.T.), Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care (S.L.G, J.R.L, K.R.S., N.J., M.J.L., N.M.L., R.E.L., J.A.T.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Harvard Medical School (S.L.G, J.R.L, E.I.M., A.S.D., N.J., M.J.L., K.G.S., R.E.L., J.A.T.), Boston, Massachusetts, USA
| | - James A Tulsky
- Division of Palliative Medicine (S.L.G, J.R.L, K.R.S., N.J., M.J.L., N.M.L., K.G.S., R.E.L., J.A.T.), Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care (S.L.G, J.R.L, K.R.S., N.J., M.J.L., N.M.L., R.E.L., J.A.T.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Harvard Medical School (S.L.G, J.R.L, E.I.M., A.S.D., N.J., M.J.L., K.G.S., R.E.L., J.A.T.), Boston, Massachusetts, USA
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21
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Odejide OO, Fisher L, Kushi LH, Chao CR, Vega B, Rodrigues G, Josephs I, Brock KE, Buchanan S, Casperson M, Cooper RM, Fasciano KM, Kolevska T, Lakin JR, Lefebvre A, Schwartz CM, Shalman DM, Wall CB, Wiener L, Altschuler A, Mack JW. Patient, Family, and Clinician Perspectives on Location of Death for Adolescents and Young Adults With Cancer. JCO Oncol Pract 2022; 18:e1621-e1629. [PMID: 35981281 PMCID: PMC9810128 DOI: 10.1200/op.22.00143] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/24/2022] [Accepted: 07/11/2022] [Indexed: 01/14/2023] Open
Abstract
PURPOSE Adolescents and young adults (AYAs) with cancer have high rates of hospital deaths. It is not clear if this reflects their preferences or barriers to dying at home. METHODS Between December 2018 and January 2021, we conducted in-depth interviews with AYAs (age 12-39 years) with stage IV or recurrent cancer, family caregivers including bereaved caregivers, and clinicians of AYAs with cancer. Patients were asked about their priorities for care including location of death, caregivers were asked what was most important in the care of their AYA family member, and clinicians were asked to reflect on priorities identified through caring for AYAs. Directed content analysis was applied to interview data, and themes regarding location of death were developed. RESULTS Eighty individuals (23 AYAs, 28 caregivers, and 29 clinicians) participated in interviews. Most AYAs and caregivers preferred a home death. However, some AYAs and caregivers opted for a hospital death to alleviate caregiver burden or protect siblings from the perceived trauma of witnessing a home death. Lack of adequate services to manage intractable symptoms at home and insufficient caregiver support led some AYAs/caregivers to opt for hospital death despite a preference for home death. Participants acknowledged the value of hospice while also pointing out its limitations in attaining a home death. CONCLUSION Although most AYAs prefer to die at home, this preference is not always achieved. Robust home-based services for effective symptom management and caregiver support are needed to close the gap between preferred and actual location of death for AYAs.
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Affiliation(s)
- Oreofe O. Odejide
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
| | - Lauren Fisher
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
| | - Lawrence H. Kushi
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Chun R. Chao
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Brenda Vega
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
| | - Gilda Rodrigues
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
| | | | - Katharine E. Brock
- Division of Pediatric Oncology, Emory University, Atlanta, GA
- Division of Palliative Care, Emory University, Atlanta, GA
- Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta, Atlanta, GA
| | - Susan Buchanan
- Agios Pharmaceuticals, Cambridge, MA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | | | - Robert M. Cooper
- Pediatric Oncology, Kaiser Permanente Southern California, Pasadena, CA
| | - Karen M. Fasciano
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
| | - Tatjana Kolevska
- Division of Medical Oncology, Kaiser Permanente Northern California, Oakland, CA
| | - Joshua R. Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
| | - Anna Lefebvre
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Corey M. Schwartz
- Division of Medical Oncology, Kaiser Permanente Northern California, Oakland, CA
| | - Dov M. Shalman
- Palliative Care, Kaiser Permanente Southern California, Pasadena, CA
| | - Catherine B. Wall
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Lori Wiener
- Psychosocial Support and Research Program, National Cancer Institute, Bethesda, MD
| | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Jennifer W. Mack
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
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22
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Serna MK, Fiskio J, Yoon C, Plombon S, Lakin JR, Schnipper JL, Dalal AK. Who Gets (and Who Should Get) a Serious Illness Conversation in the Hospital? An Analysis of Readmission Risk Score in an Electronic Health Record. Am J Hosp Palliat Care 2022:10499091221129602. [PMID: 36154485 DOI: 10.1177/10499091221129602] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Serious Illness Conversations (SICs) explore patients' prognostic awareness, hopes, and worries, and can help establish priorities for their care during and after hospitalization. While identifying patients who benefit from an SIC remains a challenge, this task may be facilitated by use of validated prediction scores available in most commercial electronic health records (EHRs), such as Epic's Readmission Risk Score (RRS). We identified the RRS on admission for all hospital encounters from October 2018 to August 2019 and measured the area under the receiver operating characteristic (AUROC) curve to determine whether RRS could accurately discriminate post discharge 6-month mortality. For encounters with standardized SIC documentation matched in a 1:3 ratio to controls by sex and age (±5 years), we constructed a multivariable, paired logistic regression model and measured the odds of SIC documentation per every 10% absolute increase in RRS. RRS was predictive of 6-month mortality with acceptable discrimination (AUROC .71) and was significantly associated with SIC documentation (adjusted OR 1.42, 95% CI 1.24-1.63). An RRS >28% used to identify patients with post discharge 6-month mortality had a high specificity (89.0%) and negative predictive value (NPV) (97.0%), but low sensitivity (25.2%) and positive predictive value (PPV) (7.9%). RRS may serve as a practical EHR-based screen to exclude patients not requiring an SIC, thereby leaving a smaller cohort to be further evaluated for SIC needs using other validated tools and clinical assessment.
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Affiliation(s)
- Myrna K Serna
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, 1861Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Julie Fiskio
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, 1861Brigham and Women's Hospital, Boston, MA, USA
| | - Catherine Yoon
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, 1861Brigham and Women's Hospital, Boston, MA, USA
| | - Savanna Plombon
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, 1861Brigham and Women's Hospital, Boston, MA, USA
| | - Joshua R Lakin
- Harvard Medical School, Boston, MA, USA.,Department of Psychosocial Oncology and Palliative Care, 1855Dana Farber Cancer Institute, Boston, MA, USA
| | - Jeffrey L Schnipper
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, 1861Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Anuj K Dalal
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, 1861Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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23
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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24
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Eneanya ND, Lakin JR, Paasche-Orlow MK, Lindvall C, Moseley ET, Henault L, Hanchate AD, Mandel EI, Wong SPY, Zupanc SN, Davis AD, El-Jawahri A, Quintiliani LM, Chang Y, Waikar SS, Bansal AD, Schell JO, Lundquist AL, Tamura MK, Yu MK, Unruh ML, Argyropoulos C, Germain MJ, Volandes A. Video Images about Decisions for Ethical Outcomes in Kidney Disease (VIDEO-KD): the study protocol for a multi-centre randomised controlled trial. BMJ Open 2022; 12:e059313. [PMID: 35396311 PMCID: PMC8996022 DOI: 10.1136/bmjopen-2021-059313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Older patients with advanced chronic kidney disease (CKD) often are inadequately prepared to make informed decisions about treatments including dialysis and cardiopulmonary resuscitation. Further, evidence shows that patients with advanced CKD do not commonly engage in advance care planning (ACP), may suffer from poor quality of life, and may be exposed to end-of-life care that is not concordant with their goals. We aim to study the effectiveness of a video intervention on ACP, treatment preferences and other patient-reported outcomes. METHODS AND ANALYSIS The Video Images about Decisions for Ethical Outcomes in Kidney Disease trial is a multi-centre randomised controlled trial that will test the effectiveness of an intervention that includes a CKD-related video decision aid followed by recording personal video declarations about goals of care and treatment preferences in older adults with advancing CKD. We aim to enrol 600 patients over 5 years at 10 sites. ETHICS AND DISSEMINATION Regulatory and ethical aspects of this trial include a single Institutional Review Board mechanism for approval, data use agreements among sites, and a Data Safety and Monitoring Board. We intend to disseminate findings at national meetings and publish our results. TRIAL REGISTRATION NUMBER NCT04347629.
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Affiliation(s)
- Nwamaka D Eneanya
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Joshua R Lakin
- Harvard Medical School, Boston, Massachusetts, USA
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Michael K Paasche-Orlow
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Charlotta Lindvall
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Edward T Moseley
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Lori Henault
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Amresh D Hanchate
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Ernest I Mandel
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Renal (Kidney) Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Susan P Y Wong
- University of Washington, Seattle, Washington State, USA
| | - Sophia N Zupanc
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | - Areej El-Jawahri
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lisa M Quintiliani
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Yuchiao Chang
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sushrut S Waikar
- Section of Nephrology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Amar D Bansal
- Section of Palliative Care and Medical Ethics, Department of General Medicine, Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, Pennsylvania, USA
| | - Jane O Schell
- Section of Palliative Care and Medical Ethics, Department of General Medicine, Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, Pennsylvania, USA
| | - Andrew L Lundquist
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Manjula Kurella Tamura
- Division of Nephrology, Stanford University School of Medicine; and Geriatric Research Education Clinical Center, VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Margaret K Yu
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Mark L Unruh
- Department of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Christos Argyropoulos
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Michael J Germain
- Baystate Medical Center-University of Massachusetts Springfield, Springfield, Massachusetts, USA
| | - Angelo Volandes
- Harvard Medical School, Boston, Massachusetts, USA
- ACP Decisions Non-profit Foundation, Newton, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Durieux BN, Berrier A, Catzen HZ, Gray TF, Lakin JR, Cunningham R, Morris SE, Tulsky JA, Sanders JJ. " I think that she would have wanted. . .": Qualitative interviews with bereaved caregivers reveal complexity in measuring goal-concordant care at the end of life. Palliat Med 2022; 36:742-750. [PMID: 35164612 DOI: 10.1177/02692163221078472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Experts consider goal-concordant care an important healthcare outcome for individuals with serious illness. Despite their relationship to the patient and knowledge about the patient's wishes and values, little is known about bereaved family caregivers' perceptions of how end-of-life care aligns with patient goals and preferences. AIM To understand caregivers' perceptions about patients' care experiences, the extent to which care was perceived as goal-concordant, and the factors that contextualized the end-of-life care experience. DESIGN Qualitative interview study employing a semi-structured interview guide based on the National Health and Aging Trends Survey end-of-life planning module. Template analysis was used to identify themes. SETTING/PARTICIPANTS Nineteen recently bereaved family caregivers of people with serious illness in two academic medical centers in the Northeastern United States. RESULTS Most caregivers reported goal-concordant care, though many also recalled experiences of goal discordance. Three themes characterized care perceptions and related to perceived quality: communication, relationships and humanistic care, and care transitions. Within communication, caregivers described the importance of clear communication, inadequate prognostic communication, and information gaps that undermined caregiver confidence in decision making. Patient-clinician relationships enriched care and were considered higher-quality when felt to be humanistic. Finally, care transitions impacted goal discordance when marked by logistical barriers, a need to establish relationships with new providers, inadequate information transfer, and poor care coordination. CONCLUSIONS Bereaved caregivers commonly rated care as goal-concordant while also identifying areas of disappointing and low-quality care. Communication, relationships and humanistic care, and care transitions are modifiable quality improvement targets for patients with advanced cancer.
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Affiliation(s)
| | - Anna Berrier
- Dana-Farber Cancer Institute, Boston, MA, USA.,Gillings School of Global Public Health at The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Tamryn F Gray
- Dana-Farber Cancer Institute, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Joshua R Lakin
- Dana-Farber Cancer Institute, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Rebecca Cunningham
- Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Sue E Morris
- Dana-Farber Cancer Institute, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - James A Tulsky
- Dana-Farber Cancer Institute, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Justin J Sanders
- Dana-Farber Cancer Institute, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Murakami N, Baggett ND, Schwarze ML, Ladin K, Courtwright AM, Goldberg HJ, Nolley EP, Jain N, Landzberg M, Wentlandt K, Lai JC, Shinall MC, Ufere NN, Jones CA, Lakin JR. Top Ten Tips Palliative Care Clinicians Should Know About Solid Organ Transplantation. J Palliat Med 2022; 25:1136-1142. [PMID: 35275707 PMCID: PMC9467633 DOI: 10.1089/jpm.2022.0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Solid organ transplantation (SOT) is a life-saving procedure for people with end-stage organ failure. However, patients experience significant symptom burden, complex decision making, morbidity, and mortality during both pre- and post-transplant periods. Palliative care (PC) is well suited and historically underdelivered for the transplant population. This article, written by a team of transplant specialists (surgeons, cardiologists, nephrologists, hepatologists, and pulmonologists), PC clinicians, and an ethics specialist, shares 10 high-yield tips for PC clinicians to consider when caring for SOT patients.
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Affiliation(s)
- Naoka Murakami
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Nathan D Baggett
- Division of Emergency Medicine, Health Partners Institute/Regions Hospital, St. Paul, Minnesota, USA
| | | | - Keren Ladin
- Department of Occupational Therapy, Tufts University, Medford, Massachusetts, USA.,Department of Community Health, Tufts University, Medford, Massachusetts, USA
| | - Andrew M Courtwright
- Department of Pulmonary and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hilary J Goldberg
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Eric P Nolley
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Nelia Jain
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Michael Landzberg
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kirsten Wentlandt
- Division of Palliative Care, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Jennifer C Lai
- Department of Medicine, University of California, San Francisco, California, USA
| | - Myrick C Shinall
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Section of Palliative Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nneka N Ufere
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christopher A Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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Volandes AE, Zupanc SN, Paasche-Orlow MK, Lakin JR, Chang Y, Burns EA, LaVine NA, Carney MT, Martins-Welch D, Emmert K, Itty JE, Moseley ET, Davis AD, El-Jawahri A, Gundersen DA, Fix GM, Yacoub AM, Schwartz P, Gabry-Kalikow S, Garde C, Fischer J, Henault L, Burgess L, Goldman J, Kwok A, Singh N, Alvarez Suarez AL, Gromova V, Jacome S, Tulsky JA, Lindvall C. Association of an Advance Care Planning Video and Communication Intervention With Documentation of Advance Care Planning Among Older Adults: A Nonrandomized Controlled Trial. JAMA Netw Open 2022; 5:e220354. [PMID: 35201306 PMCID: PMC8874350 DOI: 10.1001/jamanetworkopen.2022.0354] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE COVID-19 has disproportionately killed older adults and racial and ethnic minority individuals, raising questions about the relevance of advance care planning (ACP) in this population. Video decision aids and communication skills training offer scalable delivery models. OBJECTIVE To assess whether ACP video decision aids and a clinician communication intervention improved the rate of ACP documentation during an evolving pandemic, with a focus on African American and Hispanic patients. DESIGN, SETTING, AND PARTICIPANTS The Advance Care Planning: Communicating With Outpatients for Vital Informed Decisions trial was a pre-post, open-cohort nonrandomized controlled trial that compared ACP documentation across the baseline pre-COVID-19 period (September 15, 2019, to March 14, 2020), the COVID-19 wave 1 period (March 15, 2020, to September 14, 2020), and an intervention period (December 15, 2020, to June 14, 2021) at a New York metropolitan area ambulatory network of 22 clinics. All patients 65 years or older who had at least 1 clinic or telehealth visit during any of the 3 study periods were included. MAIN OUTCOMES AND MEASURES The primary outcome was ACP documentation. RESULTS A total of 14 107 patients (mean [SD] age, 81.0 [8.4] years; 8856 [62.8%] female; and 2248 [15.9%] African American or Hispanic) interacted with clinicians during the pre-COVID-19 period; 12 806 (mean [SD] age, 81.2 [8.5] years; 8047 [62.8%] female; and 1992 [15.6%] African American or Hispanic), during wave 1; and 15 106 (mean [SD] 80.9 [8.3] years; 9543 [63.2%] female; and 2535 [16.8%] African American or Hispanic), during the intervention period. Clinicians documented ACP in 3587 patients (23.8%) during the intervention period compared with 2525 (17.9%) during the pre-COVID-19 period (rate difference [RD], 5.8%; 95% CI, 0.9%-7.9%; P = .01) and 1598 (12.5%) during wave 1 (RD, 11.3%; 95% CI, 6.3%-12.1%; P < .001). Advance care planning was documented in 447 African American patients (30.0%) during the intervention period compared with 233 (18.1%) during the pre-COVID-19 period (RD, 11.9%; 95% CI, 4.1%-15.9%; P < .001) and 130 (11.0%) during wave 1 (RD, 19.1%; 95% CI, 11.7%-21.2%; P < .001). Advance care planning was documented for 222 Hispanic patients (21.2%) during the intervention period compared with 127 (13.2%) during the pre-COVID-19 period (RD, 8.0%; 95% CI, 2.1%-10.9%; P = .004) and 82 (10.2%) during wave 1 (RD, 11.1%; 95% CI, 5.5%-14.5%; P < .001). CONCLUSIONS AND RELEVANCE This intervention, implemented during the evolving COVID-19 pandemic, was associated with higher rates of ACP documentation, especially for African American and Hispanic patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04660422.
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Affiliation(s)
- Angelo E. Volandes
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
- ACP Decisions, Boston, Massachusetts
| | - Sophia N. Zupanc
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Michael K. Paasche-Orlow
- Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Joshua R. Lakin
- Harvard Medical School, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Yuchiao Chang
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
| | - Edith A. Burns
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Medicine, Zucker School of Medicine Hosftra/Northwell, New Hyde Park, New York
| | - Nancy A. LaVine
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Medicine, Zucker School of Medicine Hosftra/Northwell, New Hyde Park, New York
| | - Maria T. Carney
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Medicine, Zucker School of Medicine Hosftra/Northwell, New Hyde Park, New York
| | - Diana Martins-Welch
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Medicine, Zucker School of Medicine Hosftra/Northwell, New Hyde Park, New York
| | - Kaitlin Emmert
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Jennifer E. Itty
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Edward T. Moseley
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Areej El-Jawahri
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
| | - Daniel A. Gundersen
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Gemmae M. Fix
- Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
- Center for Healthcare Organization and Implementation Research, Veterans Affairs Bedford Healthcare System, Bedford, Massachusetts
| | - Andrea M. Yacoub
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | | | | | | | - Jonathan Fischer
- Department of Community Health and Family Medicine, Hospice and Palliative Care, Duke University Health System, Durham, North Carolina
| | - Lori Henault
- Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Leah Burgess
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Julie Goldman
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Anne Kwok
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Nimisha Singh
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Armando L. Alvarez Suarez
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Valeria Gromova
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - Sonia Jacome
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, New York
| | - James A. Tulsky
- Harvard Medical School, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Charlotta Lindvall
- Harvard Medical School, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Lindvall C, Deng CY, Moseley E, Agaronnik N, El-Jawahri A, Paasche-Orlow MK, Lakin JR, Volandes A, Tulsky TAPIJA. Natural Language Processing to Identify Advance Care Planning Documentation in a Multisite Pragmatic Clinical Trial. J Pain Symptom Manage 2022; 63:e29-e36. [PMID: 34271146 PMCID: PMC9124370 DOI: 10.1016/j.jpainsymman.2021.06.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/26/2021] [Accepted: 06/28/2021] [Indexed: 01/03/2023]
Abstract
CONTEXT Large multisite clinical trials studying decision-making when facing serious illness require an efficient method for abstraction of advance care planning (ACP) documentation from clinical text documents. However, the current gold standard method of manual chart review is time-consuming and unreliable. OBJECTIVES To evaluate the ability to use natural language processing (NLP) to identify ACP documention in clinical notes from patients participating in a multisite trial. METHODS Patients with advanced cancer followed in three disease-focused oncology clinics at Duke Health, Mayo Clinic, and Northwell Health were identified using administrative data. All outpatient and inpatient notes from patients meeting inclusion criteria were extracted from electronic health records (EHRs) between March 2018 and March 2019. NLP text identification software with semi-automated chart review was applied to identify documentation of four ACP domains: (1) conversations about goals of care, (2) limitation of life-sustaining treatment, (3) involvement of palliative care, and (4) discussion of hospice. The performance of NLP was compared to gold standard manual chart review. RESULTS 435 unique patients with 79,797 notes were included in the study. In our validation data set, NLP achieved F1 scores ranging from 0.84 to 0.97 across domains compared to gold standard manual chart review. NLP identified ACP documentation in a fraction of the time required by manual chart review of EHRs (1-5 minutes per patient for NLP, vs. 30-120 minutes for manual abstraction). CONCLUSION NLP is more efficient and as accurate as manual chart review for identifying ACP documentation in studies with large patient cohorts.
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Affiliation(s)
- Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (C.L., CY.D.,E.M., N.A., JR.L., JA.T.), Boston, Massachusetts; Department of Medicine, Brigham and Women's Hospital (C.L., JR.L., JA.T.), Boston, Massachusetts; Harvard Medical School, Boston (C.L., N.A., A.EJ., JR.L., A.V., JA.T.), Massachusetts.
| | - Chih-Ying Deng
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (C.L., CY.D.,E.M., N.A., JR.L., JA.T.), Boston, Massachusetts
| | - Edward Moseley
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (C.L., CY.D.,E.M., N.A., JR.L., JA.T.), Boston, Massachusetts
| | - Nicole Agaronnik
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (C.L., CY.D.,E.M., N.A., JR.L., JA.T.), Boston, Massachusetts; Harvard Medical School, Boston (C.L., N.A., A.EJ., JR.L., A.V., JA.T.), Massachusetts
| | - Areej El-Jawahri
- Harvard Medical School, Boston (C.L., N.A., A.EJ., JR.L., A.V., JA.T.), Massachusetts; Department of Medicine, Massachusetts General Hospital (A.EJ., A.V.), Boston, Massachusetts
| | - Michael K Paasche-Orlow
- Department of Medicine, Boston University School of Medicine, Boston Medical Center (MK.PO.), Boston, Massachusetts; ACP Decisions (MK.PO., A.V.), Boston, Massachusetts
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (C.L., CY.D.,E.M., N.A., JR.L., JA.T.), Boston, Massachusetts; Department of Medicine, Brigham and Women's Hospital (C.L., JR.L., JA.T.), Boston, Massachusetts; Harvard Medical School, Boston (C.L., N.A., A.EJ., JR.L., A.V., JA.T.), Massachusetts
| | - Angelo Volandes
- Harvard Medical School, Boston (C.L., N.A., A.EJ., JR.L., A.V., JA.T.), Massachusetts; Department of Medicine, Massachusetts General Hospital (A.EJ., A.V.), Boston, Massachusetts; ACP Decisions (MK.PO., A.V.), Boston, Massachusetts
| | - The Acp-Peace Investigators James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (C.L., CY.D.,E.M., N.A., JR.L., JA.T.), Boston, Massachusetts; Department of Medicine, Brigham and Women's Hospital (C.L., JR.L., JA.T.), Boston, Massachusetts; Harvard Medical School, Boston (C.L., N.A., A.EJ., JR.L., A.V., JA.T.), Massachusetts
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29
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Murakami N, Gelfand SL, Sciacca KR, Killeen K, Leiter RE, Adler JT, Chandraker AK, Lakin JR. Inpatient Kidney Palliative Care for Kidney Transplant Recipients With Failing Allografts. Kidney Med 2021; 4:100398. [PMID: 35243310 PMCID: PMC8861950 DOI: 10.1016/j.xkme.2021.10.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Naoka Murakami
- Division of Renal Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
- Address for Correspondence: Naoka Murakami, MD, PhD, Division of Renal Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 221 Longwood Ave. EBRC 312, Boston, MA 02115.
| | - Samantha L. Gelfand
- Division of Renal Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Kate R. Sciacca
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Kelsey Killeen
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Richard E. Leiter
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Joel T. Adler
- Division of Transplant Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Anil K. Chandraker
- Division of Renal Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Joshua R. Lakin
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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30
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Richesson RL, Marsolo KS, Douthit BJ, Staman K, Ho PM, Dailey D, Boyd AD, McTigue KM, Ezenwa MO, Schlaeger JM, Patil CL, Faurot KR, Tuzzio L, Larson EB, O'Brien EC, Zigler CK, Lakin JR, Pressman AR, Braciszewski JM, Grudzen C, Fiol GD. Enhancing the use of EHR systems for pragmatic embedded research: lessons from the NIH Health Care Systems Research Collaboratory. J Am Med Inform Assoc 2021; 28:2626-2640. [PMID: 34597383 PMCID: PMC8633608 DOI: 10.1093/jamia/ocab202] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/05/2021] [Accepted: 09/02/2021] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE We identified challenges and solutions to using electronic health record (EHR) systems for the design and conduct of pragmatic research. MATERIALS AND METHODS Since 2012, the Health Care Systems Research Collaboratory has served as the resource coordinating center for 21 pragmatic clinical trial demonstration projects. The EHR Core working group invited these demonstration projects to complete a written semistructured survey and used an inductive approach to review responses and identify EHR-related challenges and suggested EHR enhancements. RESULTS We received survey responses from 20 projects and identified 21 challenges that fell into 6 broad themes: (1) inadequate collection of patient-reported outcome data, (2) lack of structured data collection, (3) data standardization, (4) resources to support customization of EHRs, (5) difficulties aggregating data across sites, and (6) accessing EHR data. DISCUSSION Based on these findings, we formulated 6 prerequisites for PCTs that would enable the conduct of pragmatic research: (1) integrate the collection of patient-centered data into EHR systems, (2) facilitate structured research data collection by leveraging standard EHR functions, usable interfaces, and standard workflows, (3) support the creation of high-quality research data by using standards, (4) ensure adequate IT staff to support embedded research, (5) create aggregate, multidata type resources for multisite trials, and (6) create re-usable and automated queries. CONCLUSION We are hopeful our collection of specific EHR challenges and research needs will drive health system leaders, policymakers, and EHR designers to support these suggestions to improve our national capacity for generating real-world evidence.
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Affiliation(s)
- Rachel L Richesson
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Keith S Marsolo
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Brian J Douthit
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.,US Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Karen Staman
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - P Michael Ho
- Department of Medicine, University of Colorado Medicine, Denver, Colorado, USA
| | - Dana Dailey
- Center for Health Sciences, St. Ambrose University, Davenport, Iowa and Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, Iowa, USA
| | - Andrew D Boyd
- Department of Biomedical and Health Information Sciences University of Illinois Chicago, Chicago, Illinois, USA
| | - Kathleen M McTigue
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Miriam O Ezenwa
- Department of Biobehavioral Nursing Science, University of Florida, College of Nursing, Gainesville, Florida, USA
| | - Judith M Schlaeger
- Department of Human Development Nursing Science, University of Illinois Chicago, College of Nursing, Chicago, Illinois, USA
| | - Crystal L Patil
- Department of Human Development Nursing Science, University of Illinois Chicago, College of Nursing, Chicago, Illinois, USA
| | - Keturah R Faurot
- Department of Physical Medicine and Rehabilitation, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Leah Tuzzio
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Eric B Larson
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Emily C O'Brien
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Christina K Zigler
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Joshua R Lakin
- Palliative Medicine, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Alice R Pressman
- Center for Health Systems Research, Sutter Health Center for Health Systems Research, Walnut Creek, California, USA
| | - Jordan M Braciszewski
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan, USA
| | - Corita Grudzen
- Department of Emergency Medicine, New York University School of Medicine, New York, New York, USA
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
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31
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Mack JW, Fisher L, Kushi L, Chao CR, Vega B, Rodrigues G, Josephs I, Brock KE, Buchanan S, Casperson M, Cooper RM, Fasciano KM, Kolevska T, Lakin JR, Lefebvre A, Schwartz CM, Shalman DM, Wall CB, Wiener L, Altschuler A. Patient, Family, and Clinician Perspectives on End-of-Life Care Quality Domains and Candidate Indicators for Adolescents and Young Adults With Cancer. JAMA Netw Open 2021; 4:e2121888. [PMID: 34424305 PMCID: PMC8383130 DOI: 10.1001/jamanetworkopen.2021.21888] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE End-of-life care quality indicators specific to adolescents and young adults (AYAs) aged 12 to 39 years with cancer have not been developed. OBJECTIVE To identify priority domains for end-of-life care from the perspectives of AYAs, family caregivers, and clinicians, and to propose candidate quality indicators reflecting priorities. DESIGN, SETTING, AND PARTICIPANTS This qualitative study was conducted from December 6, 2018, to January 5, 2021, with no additional follow-up. In-depth interviews were conducted with patients, family caregivers, and clinicians and included a content analysis of resulting transcripts. A multidisciplinary advisory group translated priorities into proposed quality indicators. Interviews were conducted at the Dana-Farber Cancer Institute, Kaiser Permanente Northern California, Kaiser Permanente Southern California, and an AYA cancer support community (lacunaloft.org). Participants included 23 AYAs, 28 caregivers, and 29 clinicians. EXPOSURE Stage IV or recurrent cancer. MAIN OUTCOMES AND MEASURES Care priorities. RESULTS Interviews were conducted with 23 patients (mean [SD] age, 29.3 [7.3] years; 12 men [52%]; 18 White participants [78%]), 28 family caregivers (23 women [82%]; 14 White participants [50%]), and 29 clinicians (20 women [69%]; 13 White participants [45%]). Caregivers included 22 parents (79%), 5 spouses or partners (18%), and 1 other family member (4%); the 29 clinicians included 15 physicians (52%), 6 nurses or nurse practitioners (21%), and 8 social workers or psychologists (28%). Interviews identified 7 end-of-life priority domains: attention to physical symptoms, attention to quality of life, psychosocial and spiritual care, communication and decision-making, relationships with clinicians, care and treatment, and independence. Themes were consistent across the AYA age range and participant type. Although some domains were represented in quality indicators developed for adults, unique domains were identified, as well as AYA-specific manifestations of existing domains. For example, quality of life included global quality of life; attainment of life goals, legacy, and meaning; support of personal relationships; and normalcy. Within communication and decision-making, domains included communication early in the disease course, addressing prognosis and what to expect at the end of life, and opportunity for AYAs to hold desired roles in decision-making. Care and treatment domains relevant to cancer therapy, use of life-prolonging measures, and location of death emphasized the need for preference sensitivity rather than a standard path. This finding differs from existing adult indicators that propose that late-life chemotherapy, intensive measures, and hospital death should be rare. CONCLUSIONS AND RELEVANCE The findings of this qualitative study suggest that AYAs with cancer have priorities for care at the end of life that are not fully encompassed in existing indicators for adults. Use of new indicators for this young population may better reflect patient- and family-centered experiences of quality care.
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Affiliation(s)
- Jennifer W Mack
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lauren Fisher
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Larry Kushi
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Chun R Chao
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Brenda Vega
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Gilda Rodrigues
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Katharine E Brock
- Divisions of Pediatric Oncology and Palliative Care, Emory University and Aflac Cancer & Blood Disorders Center at Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Susan Buchanan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Now with Agios Pharmaceuticals, Cambridge, Massachusetts
| | | | - Robert M Cooper
- Department of Pediatric Oncology, Kaiser Permanente Southern California, Pasadena
| | - Karen M Fasciano
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Tatjana Kolevska
- Division of Medical Oncology, Kaiser Permanente Northern California, Oakland
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Anna Lefebvre
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Corey M Schwartz
- Division of Medical Oncology, Kaiser Permanente Northern California, Oakland
| | - Dov M Shalman
- Department of Palliative Care, Kaiser Permanente Southern California, Pasadena
| | - Catherine B Wall
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lori Wiener
- Psychosocial Support and Research Program, National Cancer Institute, Bethesda, Maryland
| | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, Oakland
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Lakin JR, Gundersen DA, Lindvall C, Paasche-Orlow MK, Tulsky JA, Brannen EN, Pollak KI, Kennedy D, McLeggon JA, Stout JJ, Volandes A. A Yet Unrealized Promise: Structured Advance Care Planning Elements in the Electronic Health Record. J Palliat Med 2021; 24:1221-1225. [PMID: 33826860 DOI: 10.1089/jpm.2020.0774] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Electronic health records (EHRs) may help enable reliable, rapid data management for many uses, such as facilitating communication of advance care planning (ACP). However, issues with validity and accuracy of EHRs hinder the use of ACP information for practical applications. Design: We present a cross-sectional pilot study of 433 older adults with cancer from three large health care systems, participating in an ongoing multisite pragmatic trial (4UH3AG060626-02). We compared data extracted from dedicated structured EHR fields for ACP to a chart review of corresponding ACP documentation contained in the medical chart. Results: Structured ACP data existed for 43.2% of patients and varied by site (25.7% -48.9%). Of the identified structured ACP data elements, 59.2% of recorded elements were correct, 23.7% were incorrect, and 17.1% were duplicates with heterogeneity across sites. Conclusion: Structured ACP data in EHRs were frequently incorrect. This represents a problem for patients and their families, as well as quality improvement and research efforts. Clinical Trials Registration: NCT03609177.
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Affiliation(s)
- Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel A Gundersen
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Michael K Paasche-Orlow
- Section of General Internal Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Elise N Brannen
- School of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Kathryn I Pollak
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA.,Cancer Control and Population Sciences, Duke Cancer Institute, Durham, North Carolina, USA
| | - Danielle Kennedy
- Cancer Control and Population Sciences, Duke Cancer Institute, Durham, North Carolina, USA
| | - Jody-Ann McLeggon
- Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | | | - Angelo Volandes
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Lakin JR, Arnold CG, Catzen HZ, Rangarajan A, Berger RS, Brannen EN, Cunningham RJ, Schaffer AC, Lamey J, Baker O, Bernacki RE. Early serious illness communication in hospitalized patients: A study of the implementation of the Speaking About Goals and Expectations (SAGE) program. Healthc (Amst) 2021; 9:100510. [PMID: 33517037 DOI: 10.1016/j.hjdsi.2020.100510] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 11/23/2020] [Accepted: 12/11/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Early conversations about patients' goals and values in advancing serious illness (serious illness conversations) can drive better healthcare. However, these conversations frequently happen during acute illness, often near death, without time to realize benefits of early communication. METHODS The Speaking About Goals and Expectations (SAGE) Program, adapted from the Serious Illness Care Program, is a multicomponent intervention designed to foster earlier and more comprehensive serious illness conversations for patients admitted to the hospital. We present a quality improvement study of the SAGE Program assessing older adults admitted to a general medicine service at the Brigham & Women's Hospital in Boston, Massachusetts. Our primary outcomes included the proportion of patients with at least one documented conversation, the timing between first conversation documented and death, the quality of conversations, and their interprofessional nature. Secondary outcomes assessed evaluations of the training and hospital utilization. RESULTS We trained 37 clinicians and studied 133 patients split between the SAGE intervention and a comparison population. Intervention patients were more likely to have documented serious illness conversations (89.1% vs. 26.1%, p < 0.001); these conversations occurred earlier (mean of 598.9 vs. 180.8 days before death, p < 0.001) and included more key elements of conversation (mean of 6.56 vs. 1.78, p < 0.001). CONCLUSIONS This study demonstrated significant differences in the frequency and quality of serious illness conversations completed earlier in the illness course for hospitalized patients. IMPLICATIONS Programs designed to drive serious illness conversations earlier in the hospital may be an effective way to improve care for patients not reached in the ambulatory setting. LEVEL OF EVIDENCE Prospectively designed trial, non-randomized sample.
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Affiliation(s)
- Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | | | | | | | - Rebecca S Berger
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Elise N Brannen
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Rebecca J Cunningham
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Brigham & Women's Physician Organization, Boston, MA, USA
| | - Adam C Schaffer
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Jan Lamey
- Brigham & Women's Physician Organization, Boston, MA, USA
| | - Olesya Baker
- Center for Clinical Investigation, Brigham and Women's Hospital, Boston, MA, USA
| | - Rachelle E Bernacki
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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Affiliation(s)
- Joshua R Lakin
- Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston Massachusetts (J.R.L., J.A.T., R.E.B.)
| | - James A Tulsky
- Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston Massachusetts (J.R.L., J.A.T., R.E.B.)
| | - Rachelle E Bernacki
- Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston Massachusetts (J.R.L., J.A.T., R.E.B.)
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Cross SH, Lakin JR, Mendu M, Mandel EI, Warraich HJ. Trends in Place of Death for Individuals With Deaths Attributed to Advanced Chronic or End-Stage Kidney Disease in the United States. J Pain Symptom Manage 2021; 61:112-120.e1. [PMID: 32791183 DOI: 10.1016/j.jpainsymman.2020.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/29/2020] [Accepted: 08/05/2020] [Indexed: 12/30/2022]
Abstract
CONTEXT An important aspect of end-of-life care, place of death is understudied in advanced chronic (CKD) and end-stage kidney disease (ESKD). OBJECTIVE We sought to examine trends and factors associated with where advanced CKD/ESKD patients die. METHODS We conducted a retrospective cross-sectional study using mortality data from 2003 to 2017 for deaths attributed primarily to advanced CKD/ESKD in the United States. RESULTS Between 2003 and 2017, 222,247 deaths were attributed to advanced CKD/ESKD. From 2003 to 2017, deaths occurring in hospitals declined from 56.0% (n = 5356) to 35.6% (n = 7764), whereas increases occurred in deaths at home (13.5% [n = 1292] to 24.3% [n = 5306]), nursing facilities (18.6% [n = 1776] to 19.3% [n = 4221]), and hospice facilities (0.3% [n = 29] to 13.4% [n = 2917]). Nonwhite race was associated with increased odds of hospital death (Black [OR = 1.59; 95% CI = 1.55, 1.62]; Native American [OR = 1.47; 95% CI = 1.32, 1.63]; Asian [OR = 1.43; 95% CI = 1.32, 1.55] and reduced odds of nursing facility (Black [OR = 0.622; 95% CI = 0.600, 0.645]; Native American [OR = 0.638; 95% CI = 0.572, 0.712]; Asian [OR = 0.574; 95% CI = 0.533, 0.619], or hospice facility death (Black [OR = 0.843; 95% CI = 0.773, 0.918]; Native American [OR = 0.380; 95% CI = 0.289, 0.500]; Asian [OR = 0.609; 95% CI = 0.502, 0.739]). Older age was associated with reduced odds of hospital death (≥85 [OR = 0.334; 95% CI = 0.312, 0.358]) and increased odds of home (≥85 [OR = 1.55; 95% CI = 1.43, 1.68]), nursing facility (≥85 [OR = 3.09; 95% CI = 2.76, 3.45]) or hospice facility death (≥85 [OR = 1.60; 95% CI = 1.49, 1.72]). CONCLUSIONS Hospitals remain the most common place of death from advanced CKD/ESKD; however, the proportion of home, nursing facility, and hospice facility deaths have increased.
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Affiliation(s)
- Sarah H Cross
- Sanford School of Public Policy, Duke University, Durham, North Carolina, USA.
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Mallika Mendu
- Harvard Medical School, Boston, Massachusetts, USA; Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ernest I Mandel
- Harvard Medical School, Boston, Massachusetts, USA; Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Haider J Warraich
- Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiology Section, Department of Medicine, Boston VA Healthcare System, Boston, Massachusetts, USA
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Gelfand SL, Mandel EI, Mendu ML, Lakin JR. Palliative Care in the Advancing American Kidney Health Initiative: A Call for Inclusion in Kidney Care Delivery Models. Am J Kidney Dis 2020; 76:877-882. [PMID: 33228851 PMCID: PMC9596188 DOI: 10.1053/j.ajkd.2020.07.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 07/15/2020] [Indexed: 11/21/2022]
Abstract
The Advancing American Kidney Health (AAKH) Initiative aims to promote high-value patient-centered care by improving access to and quality of treatment options for kidney failure. The 3 explicit goals of the initiative are to reduce the incidence of kidney failure, increase the number of available kidneys for transplantation, and increase transplantation and home dialysis. To ensure a patient-centered movement toward home dialysis modalities, actionable principles of palliative care, including systematic communication and customized treatment plans, should be incorporated into this policy. In this perspective, we describe 2 opportunities to strengthen the patience-centeredness of the AAKH Initiative through palliative care: (1) serious illness conversations should be required for all dialysis initiations in the End-Stage Renal Disease Treatment Choices model, and (2) conservative kidney management should be counted as a home modality alongside peritoneal dialysis and home hemodialysis. A serious illness conversation can help clinicians discern whether a patient’s goals and values are best respected by a home dialysis modality or whether a nondialytic strategy such as conservative kidney management should be considered. An intensive and careful patient- and family-centered selection process will be necessary to ensure that no patient is pressured to forego conventional dialysis.
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Sanders JJ, Miller K, Desai M, Geerse OP, Paladino J, Kavanagh J, Lakin JR, Neville BA, Block SD, Fromme EK, Bernacki R. Measuring Goal-Concordant Care: Results and Reflections From Secondary Analysis of a Trial to Improve Serious Illness Communication. J Pain Symptom Manage 2020; 60:889-897.e2. [PMID: 32599148 DOI: 10.1016/j.jpainsymman.2020.06.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 06/05/2020] [Accepted: 06/14/2020] [Indexed: 01/17/2023]
Abstract
CONTEXT Many consider goal-concordant care (GCC) to be the most important of advance care planning and palliative care. Researchers face significant challenges in attempting to measure this outcome. We conducted a randomized controlled trial to assess the effects of a system-level intervention to improve serious illness communication on GCC and other outcomes. OBJECTIVES To describe our measurement approach to GCC, present findings from a post-hoc analysis of trial data, and discuss lessons learned about measuring GCC. METHODS Using trial data collected to measure GCC, we analyzed ratings and rankings from a nonvalidated survey of patient priorities in the setting of advanced cancer, the Life Priorities Scale, and compared outcomes with correlative measures. RESULTS Participants commonly rated several predetermined and literature-derived priorities as important but did so in ways that were commonly incongruent with rankings. Ratings were frequently stable over time; rankings less so. Rankings are more likely to help assess the degree to which care is goal concordant but may be best augmented by corollary measures that signal achievement of a given priority. CONCLUSION Measuring GCC remains a fundamental challenge to palliative care researchers. Ratings attest to the fact that many things matter to patients; however, rankings can better determine what matters most. Insights gained from our experience may guide future research aiming to use this outcome to assess the effect of intervention to improve serious illness care.
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Affiliation(s)
- Justin J Sanders
- Harvard Medical School, Boston, MA, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Ariadne Labs, Brigham and Women's Hospital and Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | - Kate Miller
- Ariadne Labs, Brigham and Women's Hospital and Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Meghna Desai
- Ariadne Labs, Brigham and Women's Hospital and Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Olaf P Geerse
- Ariadne Labs, Brigham and Women's Hospital and Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Pulmonary Diseases, Academic Medical Center, Amsterdam, The Netherlands
| | - Joanna Paladino
- Harvard Medical School, Boston, MA, USA; Ariadne Labs, Brigham and Women's Hospital and Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jane Kavanagh
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Ariadne Labs, Brigham and Women's Hospital and Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Joshua R Lakin
- Harvard Medical School, Boston, MA, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Bridget A Neville
- Ariadne Labs, Brigham and Women's Hospital and Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Susan D Block
- Harvard Medical School, Boston, MA, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Ariadne Labs, Brigham and Women's Hospital and Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
| | - Erik K Fromme
- Harvard Medical School, Boston, MA, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Ariadne Labs, Brigham and Women's Hospital and Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Rachelle Bernacki
- Harvard Medical School, Boston, MA, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Ariadne Labs, Brigham and Women's Hospital and Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Azizoddin DR, Lakin JR, Hauser J, Rynar LZ, Weldon C, Molokie R, Enzinger AC, Payvar S, Martin JL. Meeting the guidelines: Implementing a distress screening intervention for veterans with cancer. Psychooncology 2020; 29:2067-2074. [PMID: 33009712 DOI: 10.1002/pon.5565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 09/02/2020] [Accepted: 09/29/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Guidelines recommend systematic evaluation of distress screening and referral for cancer patients. Implementation remains a notable gap for cancer centers serving disadvantaged communities. We present the implementation of a distress screening program within a Veterans Affairs hospital oncology clinic, serving a majority African American (AA) male population of low socioeconomic status (SES). METHODS The Coleman Foundation funded this program supporting a palliative care physician and psychologist to implement screening in a phased approach as follows: (1) Organizing key stakeholders, (2) educating clinical staff, (3) delivering distress screening, (4) generating documentation, and (5) implementing clinical action and referral pathways. We utilized validated measures in the "Patient Screening Questions for Supportive Care" screening tool. RESULTS This program was unsuccessful in screening all veterans with cancer; however, we were able to implement 3 years of longitudinal screening. In distress screens from the initial program period (n = 253), patients were primarily males (95.6%) of older age (m = 70, standard deviation = 9.45), AA (76.4%), with various cancers of advanced disease (69%). Males reported moderate psychosocial distress and elevated financial needs. For males with elevated psychosocial distress (n = 63, PHQ-4 ≥3), 36% were previously connected with psychosocial services. Following screening, engagement increased as the majority (77%) established psychosocial care. CONCLUSIONS This screening program had mixed success. Centralized program staff and available supportive care referrals were critical for program implementation. Screening may have increased engagement in social work/mental health services for males of low SES. Screening programs should be tailored to the needs of underserved communities with accessible housing/food subsidies.
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Affiliation(s)
- Desiree R Azizoddin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychiatry, Jesse Brown VA Medical Center, Chicago, Illinois, USA
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua Hauser
- Section of Palliative Care, Department of Medicine, Jesse Brown VA Medical Center, Chicago, Illinois, USA.,Section of Palliative Care, Department of Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lauren Z Rynar
- Department of Psychiatry, Jesse Brown VA Medical Center, Chicago, Illinois, USA.,Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Christine Weldon
- Department of Medicine, Hematology and Oncology, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA.,The Center for Business Models in Healthcare, Glencoe, Illinois, USA
| | - Robert Molokie
- Hematology/Medical Oncology, Department of Medicine, Jesse Brown VA Medical Center, Chicago, Illinois, USA.,Department of Hematology, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Andrea C Enzinger
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Susan Payvar
- Department of Psychiatry, Jesse Brown VA Medical Center, Chicago, Illinois, USA
| | - Joanna L Martin
- Section of Palliative Care, Department of Medicine, Jesse Brown VA Medical Center, Chicago, Illinois, USA.,Section of Palliative Care, Department of Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
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Dundin A, Siegert C, Miller D, Ouchi K, Lakin JR, Bernacki R, Sciacca K. A Pivot to Palliative: An Interdisciplinary Program Development in Preparation for a Coronavirus Patient Surge in the Emergency Department. J Emerg Nurs 2020; 46:760-767.e1. [PMID: 33023790 PMCID: PMC7442908 DOI: 10.1016/j.jen.2020.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 11/21/2022]
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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41
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Lakin JR, Brannen EN, Tulsky JA, Paasche-Orlow MK, Lindvall C, Chang Y, Gundersen DA, El-Jawahri A, Volandes A. Advance Care Planning: Promoting Effective and Aligned Communication in the Elderly (ACP-PEACE): the study protocol for a pragmatic stepped-wedge trial of older patients with cancer. BMJ Open 2020; 10:e040999. [PMID: 32665394 PMCID: PMC7365491 DOI: 10.1136/bmjopen-2020-040999] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Advance care planning (ACP) is associated with improved health outcomes for patients with cancer, and its absence is associated with unfavourable outcomes for patients and their caregivers. However, older adults do not complete ACP at expected rates due to patient and clinician barriers. We present the original design, methods and rationale for a trial aimed at improving ACP for older patients with advanced cancer and the modified protocol in response to changes brought by the COVID-19 pandemic. METHODS AND ANALYSIS The Advance Care Planning: Promoting Effective and Aligned Communication in the Elderly study is a pragmatic, stepped-wedge cluster randomised trial examining a Comprehensive ACP Program. The programme combines two complementary evidence-based interventions: clinician communication skills training (VitalTalk) and patient video decision aids (ACP Decisions). We will implement the programme at 36 oncology clinics across three unique US health systems. Our primary outcome is the proportion of eligible patients with ACP documentation completed in the electronic health record. Our secondary outcomes include resuscitation preferences, palliative care consultations, death, hospice use and final cancer-directed therapy. From a subset of our patient population, we will collect surveys and video-based declarations of goals and preferences. We estimate 11 000 patients from the three sites will be enrolled in the study. ETHICS AND DISSEMINATION Regulatory and ethical aspects of this trial include Institutional Review Board (IRB) approval via single IRB of record mechanism at Dana-Farber Cancer Institute, Data Use Agreements among partners and a Data Safety and Monitoring Board. We plan to present findings at national meetings and publish the results. TRIAL REGISTRATION NUMBER NCT03609177; Pre-results.
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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
| | - Elise N Brannen
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Michael K Paasche-Orlow
- Department of General Internal Medicine, Boston University School of Medicine, Boston Medical Center, 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
| | - Yuchiao Chang
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Daniel A Gundersen
- Department of Survey and Data Management Core, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Areej El-Jawahri
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Hematology-Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Angelo Volandes
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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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. Healthc (Amst) 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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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43
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Affiliation(s)
- Amy S Porter
- Center for Comprehensive Care, Rainbow Babies and Children's Hospital, Cleveland, OH 44106, USA.
| | - Stephanie Harman
- Department of Medicine, Stanford University School of Medicine, Stanford University, Stanford, CA, USA
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
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Wilson E, Bernacki R, Lakin JR, Alexander C, Jackson V, Jacobsen J. Rapid Adoption of a Serious Illness Conversation Electronic Medical Record Template: Lessons Learned and Future Directions. J Palliat Med 2020; 23:159-161. [DOI: 10.1089/jpm.2019.0420] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Erica Wilson
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Rachelle Bernacki
- Harvard Medical School, Boston, Massachusetts
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Joshua R. Lakin
- Harvard Medical School, Boston, Massachusetts
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Corinne Alexander
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Vicki Jackson
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Juliet Jacobsen
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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45
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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46
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Affiliation(s)
- Joanna Paladino
- Ariadne Labs, Brigham and Women's Hospital, the Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joshua R Lakin
- Ariadne Labs, Brigham and Women's Hospital, the Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Justin J Sanders
- Ariadne Labs, Brigham and Women's Hospital, the Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
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Wang L, Sha L, Lakin JR, Bynum J, Bates DW, Hong P, Zhou L. Development and Validation of a Deep Learning Algorithm for Mortality Prediction in Selecting Patients With Dementia for Earlier Palliative Care Interventions. JAMA Netw Open 2019; 2:e196972. [PMID: 31298717 PMCID: PMC6628612 DOI: 10.1001/jamanetworkopen.2019.6972] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 05/20/2019] [Indexed: 11/26/2022] Open
Abstract
Importance Early palliative care interventions drive high-value care but currently are underused. Health care professionals face challenges in identifying patients who may benefit from palliative care. Objective To develop a deep learning algorithm using longitudinal electronic health records to predict mortality risk as a proxy indicator for identifying patients with dementia who may benefit from palliative care. Design, Setting, and Participants In this retrospective cohort study, 6-month, 1-year, and 2-year mortality prediction models with recurrent neural networks used patient demographic information and topics generated from clinical notes within Partners HealthCare System, an integrated health care delivery system in Boston, Massachusetts. This study included 26 921 adult patients with dementia who visited the health care system from January 1, 2011, through December 31, 2017. The models were trained using a data set of 24 229 patients and validated using another data set of 2692 patients. Data were analyzed from September 18, 2018, to May 15, 2019. Main Outcomes and Measures The area under the receiver operating characteristic curve (AUC) for 6-month and 1- and 2-year mortality prediction models and the factors contributing to the predictions. Results The study cohort included 26 921 patients (16 263 women [60.4%]; mean [SD] age, 74.6 [13.5] years). For the 24 229 patients in the training data set, mean (SD) age was 74.8 (13.2) years and 14 632 (60.4%) were women. For the 2692 patients in the validation data set, mean (SD) age was 75.0 (12.6) years and 1631 (60.6%) were women. The 6-month model reached an AUC of 0.978 (95% CI, 0.977-0.978); the 1-year model, 0.956 (95% CI, 0.955-0.956); and the 2-year model, 0.943 (95% CI, 0.942-0.944). The top-ranked latent topics associated with 6-month and 1- and 2-year mortality in patients with dementia include palliative and end-of-life care, cognitive function, delirium, testing of cholesterol levels, cancer, pain, use of health care services, arthritis, nutritional status, skin care, family meeting, shock, respiratory failure, and swallowing function. Conclusions and Relevance A deep learning algorithm based on patient demographic information and longitudinal clinical notes appeared to show promising results in predicting mortality among patients with dementia in different time frames. Further research is necessary to determine the feasibility of applying this algorithm in clinical settings for identifying unmet palliative care needs earlier.
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Affiliation(s)
- Liqin Wang
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Long Sha
- Michtom School of Computer Science, Brandeis University, Waltham, Massachusetts
| | - Joshua R. Lakin
- Harvard Medical School, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Julie Bynum
- Division of Geriatrics and Palliative Care, Department of Medicine, University of Michigan School of Medicine, Ann Arbor
| | - David W. Bates
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Pengyu Hong
- Michtom School of Computer Science, Brandeis University, Waltham, Massachusetts
| | - Li Zhou
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
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48
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Lakin JR, Benotti E, Paladino J, Henrich N, Sanders J. Interprofessional Work in Serious Illness Communication in Primary Care: A Qualitative Study. J Palliat Med 2019; 22:751-763. [DOI: 10.1089/jpm.2018.0471] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Joshua R. Lakin
- Ariadne Labs, Brigham and Women's Hospital and Harvard Chan School of Public Health, Boston, Massachusetts
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Emily Benotti
- Ariadne Labs, Brigham and Women's Hospital and Harvard Chan School of Public Health, Boston, Massachusetts
| | - Joanna Paladino
- Ariadne Labs, Brigham and Women's Hospital and Harvard Chan School of Public Health, Boston, Massachusetts
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Natalie Henrich
- Ariadne Labs, Brigham and Women's Hospital and Harvard Chan School of Public Health, Boston, Massachusetts
| | - Justin Sanders
- Ariadne Labs, Brigham and Women's Hospital and Harvard Chan School of Public Health, Boston, Massachusetts
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
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Lakin JR, Desai M, Engelman K, O'Connor N, Teuteberg WG, Coackley A, Kilpatrick LB, Gawande A, Fromme EK. Earlier identification of seriously ill patients: an implementation case series. BMJ Support Palliat Care 2019; 10:e31. [PMID: 31253734 DOI: 10.1136/bmjspcare-2019-001789] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 05/12/2019] [Accepted: 05/29/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To describe the strategies used by a collection of healthcare systems to apply different methods of identifying seriously ill patients for a targeted palliative care intervention to improve communication around goals and values. METHODS We present an implementation case series describing the experiences, challenges and best practices in applying patient selection strategies across multiple healthcare systems implementing the Serious Illness Care Program (SICP). RESULTS Five sites across the USA and England described their individual experiences implementing patient selection as part of the SICP. They employed a combination of clinician screens (such as the 'Surprise Question'), disease-specific criteria, existing registries or algorithms as a starting point. Notably, each describes adaptation and evolution of their patient selection methodology over time, with several sites moving towards using more advanced machine learning-based analytical approaches. CONCLUSIONS Involving clinical and programme staff to choose a simple initial method for patient identification is the ideal starting place for selecting patients for palliative care interventions. However, improving and refining methods over time is important and we need ongoing research into better patient selection methodologies that move beyond mortality prediction and instead focus on identifying seriously ill patients-those with poor quality of life, worsening functional status and medical care that is negatively impacting their families.
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Affiliation(s)
| | | | | | - Nina O'Connor
- Palliative and Hospice Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Winifred G Teuteberg
- Section of Palliative Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Alison Coackley
- Clatterbridge Cancer Centre NHS Foundation Trust, Bebington, UK
| | - Laurel B Kilpatrick
- Division of Supportive and Palliative Care, Baylor Scott & White Health, Temple, Texas, USA
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Lakin JR, Brannen EN, Bernacki RE, Jones E. A Curriculum in Quality Improvement for Interprofessional Palliative Care Trainees. Am J Hosp Palliat Care 2019; 37:41-45. [PMID: 31096756 DOI: 10.1177/1049909119850794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION A structured and intentional approach to quality improvement is critical for clinicians specializing in palliative care and is a required component of training programs. METHODS We present a multimodal, comprehensive curriculum for teaching quality improvement to interdisciplinary trainees in palliative care. RESULTS The curriculum consists of 4 sessions, one and half hours long a piece, that focus on the purpose and practice of quality improvement and guide learners through a team-based project implementation experience. Course assessments demonstrate satisfaction with the course and improvement in targeted skills, knowledge, and attitudes. DISCUSSION Several key learnings stand out from our experience with this curriculum as central to the experience of students: project work completed as interdisciplinary teams, varying teaching methodologies over a longitudinal curriculum, and the opportunity for formal presentation of their work.
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Affiliation(s)
- Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.,Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Elise N Brannen
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Rachelle E Bernacki
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.,Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Emma Jones
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Pediatric Advanced Care Team (PACT), Boston Children's Hospital, Boston, MA, USA
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