The PACT Project: Feasibility of a Multidisciplinary, Multi-Faceted Intervention to Promote Goals of Care Conversations

BACKGROUND

Patients living with serious illness generally want their physicians to facilitate Goals of Care conversations (GoCc), yet physicians may lack time and skills to engage in these conversations in the outpatient setting. The problem may be addressed by supporting multiple members of the clinical team to facilitate GoCc with the patient while admitted to the hospital.

METHODS

A multi-modal training and mentored implementation program was developed. A group of 10 hospitals were recruited to participate. Each hospital selected a primary inpatient unit on which to start the intervention, then expanded to a secondary unit later in the project. The number of trained facilitators (champions) and the number of documented GoCc were tracked over time.

RESULTS

Nine of 10 hospitals completed the 3-year project. Most of the units were general medical-surgical units. Forty-eight champions were trained at the kick-off conference, attended primarily by nurses, physicians, and social workers. By the end of the project, 153 champions had been trained. A total of 51 087 patients were admitted to PACT units with 85.4% being screened for eligibility. Of the patients who were eligible, over 68% had documented GoCc.

CONCLUSION

A multifaceted quality improvement intervention focused on serious illness communication skills can support a diverse clinical workforce to facilitate inpatient GoCc over time.

Improve Advance Care Planning: A Brief Report Discussing Goals of Care Interventions to Improve Communication Among Health Care Teams and Patients Maximizing the Use of the Electronic Health Record Tools

Introduction: A key element of advance care planning (ACP) is the goals of care (GOC) conversation between the provider and the patient. The value of meaningful GOC conversations for the patient, provider, and health care institution is well documented. However, if the GOC documentation is buried in the medical record, not well defined, or poorly documented, that value is squandered. The Improvement Process: Interventions were implemented with oncology physicians and nurse practitioners (NPs). These included education, system reform including improving the ease and consistency of documentation of ACP, and regular feedback. Results: Participants reported increased confidence in communication skills about GOC conversations postworkshops. Data results for the tracked metrics, health care power of attorney, code status, and GOC, all showed improvement. Conclusion: Physicians and NPs recognized the importance of GOC conversations as part of ACP. Considerable progress was made by focusing on GOC conversations, maximizing information technology, participating in coaching, and ongoing data monitoring.

Barriers to advance care planning among patients with advanced serious illnesses: A national survey of health-care professionals in Singapore

OBJECTIVES

To assess the barriers that health-care professionals (HCPs) face in having advance care planning (ACP) conversations with patients suffering from advanced serious illnesses and to provide care consistent with patients' documented preferences.

METHODS

We conducted a national survey of HCPs trained in facilitating ACP conversations in Singapore between June and July 2021. HCPs responded to hypothetical vignettes about a patient with an advanced serious illness and rated the importance of barriers (HCP-, patient-, and caregiver-related) in (i) conducting and documenting ACP conversations and (ii) providing care consistent with documented preferences.

RESULTS

Nine hundred eleven HCPs trained in facilitating ACP conversations responded to the survey; 57% of them had not facilitated any in the last 1 year. HCP factors were reported as the topmost barriers to facilitating ACP. These included lack of allocated time to have ACP conversations and ACP facilitation being time-consuming. Patient's refusal to engage in ACP conversations and family experiencing difficulty in accepting patient's poor prognosis were the topmost patient- and caregiver-related factors. Non-physician HCPs were more likely than physicians to report being fearful of upsetting the patient/family and lack of confidence in facilitating ACP conversations. About 70% of the physicians perceived caregiver factors (surrogate wanting a different course of treatment and family caregivers being conflicted about patients' care) as barriers to providing care consistent with preferences.

SIGNIFICANCE OF RESULTS

Study findings suggest that ACP conversations be simplified, ACP training framework be improved, awareness regarding ACP among patients, caregivers, and general public be increased, and ACP be made widely accessible.

The Team-Based Serious Illness Care Program, A Qualitative Evaluation of Implementation and Teaming

CONTEXT

Earlier and more frequent serious illness conversations with patients allow clinical teams to better align care with patients' goals and values. Nonphysician clinicians often have unique perspectives and understanding of patients' wishes and are thus well-positioned to support conversations with seriously ill patients. The Team-based Serious Illness Care Program (SICP) at Stanford aimed to involve all care team members to support and conduct serious illness conversations with patients and their caregivers and families.

OBJECTIVES

We conducted interviews with clinicians to understand how care teams implement team-based approaches to conduct serious illness conversations and navigate resulting team complexity.

METHODS

We used a rapid qualitative approach to analyze semistructured interviews of clinicians and administrative stakeholders in two team-based SICP implementation groups (i.e., inpatient oncology and hospital medicine) (n = 25). Analysis was informed by frameworks/theory: cross-disciplinary role agreement, team formation and functioning, and organizational theory.

RESULTS

Implementing team-based SICP was feasible. Theme 1 centered on how teams formed and managed to come to an agreement: teams with rapidly changing staffing/responsibilities prioritized communication, whereas teams with consistent staffing/responsibilities primarily relied on protocols. Theme 2 demonstrated that leaders and managers at multiple levels could support implementation. Theme 3 explored strengths and opportunities. Positively, team-based SICP distributed work burden, timed conversations in alignment with patient needs, and added unique value from nonphysician team members. Role ambiguity and conflict were attributed to miscommunication and ethical conflicts.

CONCLUSION

Team-based serious illness communication is viable and valuable, with a range of successful workflow and leadership approaches.

Applying the Tailored Implementation in Chronic Diseases framework to inform implementation of the Preferences Elicited and Respected for Seriously Ill Veterans through enhanced decision-making program in the United States Veterans Health Administration

In 2017, the National Center for Ethics in Health Care for the United States Department of Veterans Affairs (VA) commenced national roll-out of the Life-Sustaining Treatment Decisions Initiative. This national VA initiative aimed to promote personalized, proactive, patient-driven care for seriously ill Veterans by documenting Veterans' goals and preferences for life-sustaining treatments in a durable electronic health record note template known as the life-sustaining treatment template. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) quality improvement program was created to address the high variation in life-sustaining treatment template completion in VA Home Based Primary Care (HBPC) and Community Nursing Home programs. This manuscript describes the program that focuses on improving life sustaining treatment template completion rates amongst HBPC programs. To increase life-sustaining treatment template completion for Veterans receiving care from HBPC programs, the PERSIVED team applies two implementation strategies: audit with feedback and implementation facilitation. The PERSIVED team conducts semi-structured interviews, needs assessments, and process mapping with HBPC programs in order to identify barriers and facilitators to life-sustaining treatment template completion to inform tailored facilitation. Our interview data is analyzed using the Tailored Implementation in Chronic Diseases (TICD) framework, which identifies 57 determinants that might influence practice or implementation of interventions. To quickly synthesize and use baseline data to inform the tailored implementation plan, we adapted a rapid analysis process for our purposes. This paper describes a six-step process for conducting and analyzing baseline interviews through applying the TICD that can be applied and adapted by implementation scientists to rapidly inform tailoring of implementation facilitation.

Medical decision making about long-term artificial nutrition after severe stroke: a case report

Choosing to use a percutaneous endoscopic gastrostomy (PEG tube) for long term artificial nutrition in the setting of inadequate oral intake after stroke is complex because the decision must be made in a relatively short amount of time and prognosis is often uncertain. This case study utilized interviews with attending and resident neurologists, and surrogate medical decision makers in order to examine how neurologists and surrogate medical decision makers approached the decision to either receive a PEG tube or pursue comfort measures after severe stroke in two patients. Although these two patients presented with similar clinical characteristics and faced similar medical decisions, different decisions regarding PEG tube placement were made. Major challenges included physicians who did not agree on prognosis and surrogates who did not agree on whether to place a PEG tube. These cases demonstrate the importance of the role of the surrogate medical decision maker and the necessity of physicians and surrogate medical decision makers approaching the complex decision of PEG tube placement after stroke together. Additionally, these cases highlight the differing views on what defines a good quality of life and show the vital importance of high-quality goals of care conversations about prognosis and quality of life when deciding whether to place a PEG tube after severe stroke.

Advance Care Planning Shared Decision-Making Tools for Non-Cancer Chronic Serious Illness: A Mixed Method Systematic Review

CONTEXT

Shared decision-making tools can facilitate advance care planning and goals of care conversations in non-cancer serious illness. More information on integrating these tools in ambulatory care could better support clinicians and patients/caregivers in these conversations.

OBJECTIVES

We evaluated effectiveness and implementation of integrating palliative care shared decision-making tools into ambulatory care for U.S. adults with serious, life-threatening illness and their caregivers.

DATA SOURCES

We searched PubMed, CINAHL, and the Cochrane Central Register of Controlled Trials (2000 - May 2020) for quantitative controlled, qualitative, and mixed-methods studies.

REVIEW METHODS

Two reviewers screened articles, abstracted data, and independently assessed risk of bias or study quality. For quantitative trials, we graded strength of evidence for key outcomes: patient/caregiver satisfaction, depression or anxiety, concordance between patient preferences for care and care received, and healthcare utilization, including advance directive documentation.

RESULTS

We included 6 quantitative effectiveness randomized, controlled trials and 5 qualitative implementation studies across primary care and specialty populations. Shared decision-making tools all addressed goals-of-care communication or advance care planning. Palliative care shared decision-making tools may be effective for improving patient satisfaction with communication and advance directive documentation. We were unable to draw conclusions about concordance between preferences and care received. Patients and caregivers preferred advance care planning discussions grounded in patient and caregiver experiences with individualized timing.

CONCLUSIONS

For non-cancer serious illness, advance care planning shared decision-making tools may improve several outcomes. Future trials should evaluate concordance with care received and other health care utilization.

KEY MESSAGE

This mixed-methods review concludes that when integrating palliative care into ambulatory care for serious illness and conditions other than cancer, advance care planning shared decision-making tools may improve patient satisfaction and advance directive documentation.

The Role and Activities of Board-Certified Chaplains in Advance Care Planning

BACKGROUND

Healthcare chaplains have key roles in providing palliative support to patients and families, and they are well-suited to facilitate advance care planning (ACP). However, empirical data on the roles and responsibilities of chaplains in facilitating ACP are limited.

OBJECTIVES

To examine the roles of board-certified healthcare chaplains in ACP in various healthcare settings.

METHODS

A cross-sectional, web-based self-report survey was conducted with 585 board-certified chaplains recruited from 3 major professional chaplains' organizations in the U.S. The survey data included chaplains' demographic and professional characteristics, their roles and responsibilities, and responses regarding communication and participation with other healthcare team members in facilitating ACP, including experienced barriers.

RESULTS

More participants worked in community hospital settings (42%) and academic medical centers (19.6%) than in any other setting. Over 90% viewed ACP as an important part of their work, 70% helped patients complete advance directives, and 90% helped patients discuss their preferences about end-of-life treatments. Many chaplains were not consistently included in team discussions regarding decision-making, although most chaplains reported that they could always find ways to communicate with their teams.

CONCLUSION

Professional board-certified chaplains regularly engage in facilitating ACP discussions with patients and families in various healthcare settings. There is a need to recognize and provide systematic support for the role of chaplains in facilitating ACP conversations and to integrate chaplains into routine interdisciplinary team and family meetings.