Effect of a Patient and Clinician Communication-Priming Intervention on Patient-Reported Goals-of-Care Discussions Between Patients With Serious Illness and Clinicians: A Randomized Clinical Trial

Tips from clinicians about if, when, and how to discuss life expectancy with older adults

OBJECTIVES

Estimates of life expectancy can inform clinical recommendations and decisions for older adults, but many clinicians find it difficult to discuss. We interviewed primary care clinicians to identify best practices for discussing life expectancy with older adults.

METHODS

Twenty-one primary care clinicians (Internal Medicine, Family Medicine, and Geriatrics) completed in-depth interviews on Zoom or by telephone. Topics included estimation and discussion of life expectancy with older patients to guide cancer screening and preventive care decisions. We transcribed, coded, and inductively analyzed interviews using a thematic analysis approach.

RESULTS

Most clinicians recommended individualizing communication about life expectancy versus a standardized approach. Although many clinicians worry that conversations about life expectancy won't go well, successful conversations are possible when clinicians bring humility, care, and attention to these interactions. Clinicians identified seven steps that they find effective for deciding if, when, and how to discuss life expectancy with older patients and detailed tips for using these steps in practice.

CONCLUSIONS

Clinicians can take multiple steps to optimize conversations about life expectancy to personalize medical decision making.

PRACTICE IMPLICATIONS

The tips and language presented provide a helpful starting point for clinicians to have conversations about life expectancy and appropriate care with older adults.

Advance care planning readiness, barriers, and facilitators among seriously ill Black older adults and their surrogates: A mixed methods study

OBJECTIVES

Advance care planning (ACP) supports communication and medical decision-making and is best conceptualized as part of the care planning continuum. Black older adults have lower ACP engagement and poorer quality of care in serious illness. Surrogates are essential to effective ACP but are rarely integrated in care planning. Our objective was to describe readiness, barriers, and facilitators of ACP among seriously ill Black older adults and their surrogates.

METHODS

We used an explanatory sequential mixed methods study design. The setting was 2 ambulatory specialty clinics of an academic medical center and 1 community church in Northern California, USA. Participants included older adults and surrogates. Older adults were aged 60+, self-identified as Black, and had received care at 1 of the 2 clinics or were a member of the church congregation. Surrogates were aged 18+ and could potentially make medical decisions for the older adult. The validated ACP engagement survey was used to assess confidence and readiness for ACP. What "matters most" and barriers and facilitators to ACP employed questions from established ACP materials and trials. Semi-structured interviews were conducted after surveys to further explain survey results.

RESULTS

Older adults (N = 30) and surrogates (N = 12) were confident that they could engage in ACP (4.1 and 4.7 out of 5), but many were not ready for these conversations (3.1 and 3.9 out of 5). A framework with 4 themes - illness experience, social connections, interaction with health providers, burden - supports identification of barriers and facilitators to ACP engagement.

SIGNIFICANCE OF RESULTS

We identified barriers and facilitators and present a framework to support ACP engagement. Future research can assess the impact of this framework on communication and decision-making.

Communication needs regarding heart failure trajectory and palliative care between patients and healthcare providers: A cross-sectional study

INTRODUCTION

Heart failure (HF) is a chronic condition with an unpredictable trajectory, making effective communication between patients and healthcare providers crucial for optimizing outcomes. This study aims to investigate and compare the communication needs regarding HF trajectory and palliative care between patients and healthcare providers and to identify factors associated with the communication needs of patients with HF.

METHODS

A cross-sectional study design was employed, involving 100 patients with HF and 35 healthcare providers. Data were collected using structured questionnaires assessing communication needs, health literacy, self-care behavior, and social support. Statistical analyses were performed, including Spearman's rank correlation, Pearson's correlation, and multiple regression analyses.

RESULTS

Patients prioritized communication related to device-related questions, whereas healthcare providers focused more on aspects of HF in daily life. Both groups ranked end-of-life communication as the lowest priority. The communication needs of patients were positively correlated with health literacy (r = 0.27, p = .007), self-care behavior (r = 0.32, p = .001), and social support (r = 0.24, p = .016). Multiple regression analyses indicated that self-care behavior was a significant factor influencing the communication needs of patients (β = 0.27, p = .011).

CONCLUSIONS

Enhanced patient-centered communication strategies are required to address the communication priority gaps between patients and healthcare providers. Improving health literacy, supporting self-care behaviors, and leveraging social support are critical in meeting patients' communication needs. Tailored communication training for healthcare providers can bridge this gap and improve overall HF management.

Development of a measure of clinicians' self-efficacy for medical communication (SEMC)

OBJECTIVES

Studies of clinician-patient communication have used varied, ad hoc measures for communication efficacy. We developed and validated the Self-Efficacy for Medical Communication (SEMC) scale as a standard, quantitative measure of clinician-reported skills in communicating difficult news.

METHODS

Using evidence-based scale development guidelines, we created two 16-item forms of the SEMC, one assessing communication with patients and one assessing communication with families. Clinicians providing oncological care in four organisations were invited to participate and provided consent. Participant demographics, responses to the SEMC items and responses to convergent and discriminant measures (those expected to relate strongly and weakly to the SEMC) were collected online. We performed analyses to determine the convergent and discriminant validity of the SEMC as well as its reliability and factor structure.

RESULTS

Overall, 221 oncology clinicians (including physicians, residents, fellows, medical students, nurses, nurse practitioners and physician assistants) participated. The patient and family forms both demonstrated high internal consistency reliability (alpha=0.94 and 0.96, respectively) and were strongly correlated with one another (r=0.95, p<0.001). Exploratory factor analysis demonstrated that the SEMC measures a unitary construct (eigenvalue=9.0), and its higher mean correlation with convergent (r=0.46) than discriminant (r=0.22) measures further supported its validity.

CONCLUSIONS

Our findings support the SEMC's validity and reliability as a measure of clinician-rated communication skills regarding conducting difficult conversations with patients and families. It provides a useful standard tool for future research in oncology provider-patient serious illness communication.

Implementing Goals of Care Notes in a Statewide Health System: A Quality Improvement Initiative

BACKGROUND

Goals of care (GOC) documentation for seriously ill patients is integral to patient-centered care but not standardized. Collaborative efforts within the health system to improve the frequency and documentation of GOC to communicate patient preferences and values are essential to ensure both quality of life and quality of death.

MEASURES

We created a standard GOC note type and location in the electronic medical record for a large, statewide health system in the Midwest. Utilization and note content for all unique GOC note types documented in the first year were reviewed. A framework of GOC topics including treatment plan, prognosis, patient preferences and values, and quality of life was used to review the note content. Demographic data and outcomes including death during the observation period and hospice enrollment were also collected.

OUTCOMES

In the first year, 934 GOC notes were documented. Palliative care (PC) clinicians addressed more GOC fields compared to other clinicians (70% vs 31%, P < .0001) and had earlier discussions (median 19 days before death vs 4 days, P < .0001). Hospice was discussed more by PC (50% vs 27%, P = .0001) and PC discussions were followed by higher hospice enrollments before death (50% vs 35% P = .0166).

CONCLUSIONS

We successfully implemented a standard electronic medical record location for GOC notes which improved GOC documentation across a state healthcare system and found variations and gaps in fields addressed by all clinicians as well as key differences between PC clinicians vs other clinicians.

Holding back in communications with clinicians: Patient and care partner perspectives in Parkinson's disease

Objectives

To describe how patients with Parkinson's disease (PD) and care partners choose to share or withhold information from clinicians.

Methods

This is a qualitative, descriptive study nested within a multisite, randomized clinical trial of outpatient palliative care compared to standard neurologic care for PD. Interviews with patients (n = 30) and care partners (n = 30) explored experiences communicating with neurology clinicians. Thematic analyses identified themes relevant to patient-care partner-clinician communication.

Results

There were four themes relevant to sharing and/or withholding information from clinicians: (1) Suppressing Concerns During Visits, (2) Care Partner Awareness of Patients' Communication Barriers due to Cognitive Impairment, (3) Limited Sharing of Sensitive or Intimate Issues by Patients and Care Partners, and (4) Patient and Care Partner Suggestions to Overcome 'Holding Back'.

Conclusion

Limitations to communication between patients, care partners, and clinicians should be acknowledged and recognized in routine Parkinson's disease care to foster accurate disclosure of unmet palliative care and other needs. Triadic communication strategies may help patients and care partners talk about unmet palliative care needs.

Innovation

By recognizing that cognitive impairment and sensitive topics can be barriers, clinicians can adjust or adopt targeted communication strategies for identifying and discussing care needs.

Using Human-Centered Design to Improve Serious Illness Care for Older Adults With Advanced Dementia

CONTEXT

Older adults with advanced dementia increasingly receive potentially non-beneficial, high-intensity life-sustaining treatments and goal-discordant care in the United States. Interventions to address this issue have shown limited success.

OBJECTIVES

To use human-centered design (HCD) with clinicians caring for older adults with advanced dementia to develop intervention ideas to reduce high-intensity, goal-discordant treatments near the end of life.

METHODS

We used the first two steps of HCD, inspiration, and ideation, to understand clinicians' perspectives regarding challenges in providing goal-concordant care for older adults with advanced dementia and to generate intervention ideas. In inspiration, we conducted in-depth interviews with clinicians caring for older adults with advanced dementia. We analyzed interviews using thematic analysis to identify themes and insights, which we synthesized into design opportunities using HCD. In ideation, we completed structured brainstorming sessions with study investigators, physicians, and designers to generate ideas for interventions at different healthcare system levels.

RESULTS

During inspiration, we developed seven themes about clinicians' experiences providing serious illness care for older adults with advanced dementia. We identified six instances where two or more themes were in tension. We synthesized these tensions into five insight statements capturing clinicians' key challenges, which we reframed as three design opportunities. Brainstorming sessions conducted as part of ideation generated 132 solution ideas for these three opportunities, with participants selecting nine for testing.

CONCLUSION

The HCD process generated ideas at multiple healthcare system levels to address an enduring challenge in serious illness care by involving clinicians, researchers, and designers in intervention design.

Evaluating surgeon communication of pancreatic cancer prognosis using the VitalTalk ADAPT framework

BACKGROUND AND OBJECTIVES

Few data exist to guide optimal communication practices for surgical oncologists. VitalTalk, an evidence-based communication skills training model for clinicians, offers the five-step ADAPT tool for discussing prognosis. This study aimed to characterize surgeon communication of pancreatic cancer prognosis using VitalTalk's ADAPT framework.

METHODS

Contemporaneous audio recordings from 12 initial surgeon-patient encounters for borderline resectable pancreatic cancer were transcribed. Directed qualitative content analysis based on ADAPT (Ask, Discover, Anticipate, Provide, and Track) was used to deductively code transcripts.

RESULTS

All encounters contained at least one ADAPT step while only one (8%) incorporated four or five steps. Surgeons provided prognostic information (Provide) in all but one encounter (92%); most was qualitative and clustered into themes: serious illness, surgical candidacy, prognostic ambiguity, and cancer recurrence. Surgeons elicited understanding (Ask), requested information preferences (Discover), anticipated ambivalence (Anticipate), and responded to emotion (Track) in a minority of encounters (25%-42%); of 15 patient emotional cues, six were not addressed by surgeons.

CONCLUSIONS

During an initial encounter for pancreatic cancer, surgeons focus heavily on providing information but omit critical prognostic communication steps. Future studies are needed to investigate if surgeon training in palliative care-based communication is feasible and impacts patient-perceived quality of communication.

Protocol for a type 3 hybrid implementation cluster randomized clinical trial to evaluate the effect of patient and clinician nudges to advance the use of genomic medicine across a diverse health system

BACKGROUND

Germline genetic testing is recommended for an increasing number of conditions with underlying genetic etiologies, the results of which impact medical management. However, genetic testing is underutilized in clinics due to system, clinician, and patient level barriers. Behavioral economics provides a framework to create implementation strategies, such as nudges, to address these multi-level barriers and increase the uptake of genetic testing for conditions where the results impact medical management.

METHODS

Patients meeting eligibility for germline genetic testing for a group of conditions will be identified using electronic phenotyping algorithms. A pragmatic, type 3 hybrid cluster randomization study will test nudges to patients and/or clinicians, or neither. Clinicians who receive nudges will be prompted to either refer their patient to genetics or order genetic testing themselves. We will use rapid cycle approaches informed by clinician and patient experiences, health equity, and behavioral economics to optimize these nudges before trial initiation. The primary implementation outcome is uptake of germline genetic testing for the pre-selected health conditions. Patient data collected through the electronic health record (e.g. demographics, geocoded address) will be examined as moderators of the effect of nudges.

DISCUSSION

This study will be one of the first randomized trials to examine the effects of patient- and clinician-directed nudges informed by behavioral economics on uptake of genetic testing. The pragmatic design will facilitate a large and diverse patient sample, allow for the assessment of genetic testing uptake, and provide comparison of the effect of different nudge combinations. This trial also involves optimization of patient identification, test selection, ordering, and result reporting in an electronic health record-based infrastructure to further address clinician-level barriers to utilizing genomic medicine. The findings may help determine the impact of low-cost, sustainable implementation strategies that can be integrated into health care systems to improve the use of genomic medicine.

TRIAL REGISTRATION

ClinicalTrials.gov. NCT06377033. Registered on March 31, 2024. https://clinicaltrials.gov/study/NCT06377033?term=NCT06377033&rank=1.

Outcomes of a Multisite Mentored Implementation Approach to Promoting Goals of Care Conversations

CONTEXT

The Preference-Aligned Communication and Treatment (PACT) Project is a multisite quality improvement effort that has been shown to increase the frequency of goals of care (GOC) conversations in hospitalized patients with serious illness.

OBJECTIVES

To evaluate the effect of PACT on goal-discordant care and resource utilization.

METHODS

Hospitals enrolled in a multiyear mentored implementation quality improvement initiative to facilitate GOC conversations for seriously ill hospitalized patients. The primary outcome was the percentage of patients with care discordant with stated preferences, assessed by comparing documented wishes to Medicare claims data for patients who were admitted to intervention units and died over the study period. Secondary outcomes evaluated end-of-life resource utilization by comparing Medicare claims data for intervention patients with propensity score-matched controls.

RESULTS

In the 9 hospitals included in the study, 1347 intervention group patients were compared to 4019 in the control group. Rates of discordance between wishes and care were generally low in the intervention group. Compared to the control group, patients in the intervention group had lower costs (-976.05 dollars, P = 0.010), were less likely to be admitted to the ICU (OR 0.9, P = 0.005), less likely to be on a ventilator or undergo CPR or cardioversion, more likely to enroll in hospice (OR 1.81, P < 0.001) and had a longer hospice stay (3.35 more days, P = 0.041).

CONCLUSION

A multisite mentored implementation quality improvement intervention for seriously ill hospitalized patients resulted in care aligned with goals and decreased resource utilization at the end of life.

Integration of Germline Genetic Testing Into Routine Clinical Practice for Patients With Pancreatic Adenocarcinoma

PURPOSE

Germline genetic testing (GT) is recommended for all patients with pancreatic ductal adenocarcinoma (PDAC), but the traditional clinical genetics infrastructure is limited in addressing the unique needs of this population. We describe the integration of point of care (POC) GT into routine clinical practice for all patients with PDAC at an academic medical center.

METHODS

We developed a clinical POC workflow that leverages electronic health record (EHR) tools and behavioral nudges to enhance the sustainability and scalability of our previously described research-based POC model. For each of the research and clinical POC cohorts, we calculated the percentage of eligible patients who underwent GT. We used Wilcoxon rank-sum and Pearson's chi-squared tests to compare patients who did and did not undergo GT. We conducted surveys among oncology clinicians to evaluate the acceptability, appropriateness, and feasibility of the clinical POC model.

RESULTS

The research POC cohort included 905 patients, of whom 694 (76.7%) underwent GT. The clinical POC cohort included 148 patients, of whom 126 (85.1%) underwent GT. Patients who underwent GT in the research POC cohort were significantly younger (median age, 67.0 v 70.9 years; P = .031) and more likely to be White (82.1% v 68.7%; P < .001) and commercially insured (41.8% v 28.0%; P < .001) compared with those who did not; there were no significant differences between GT groups in the clinical POC cohort. Oncology clinicians found the clinical POC model to be acceptable (mean 4.4/5), appropriate (4.6/5), feasible (4.0/5), and have a positive impact on their patients (4.9/5).

CONCLUSION

A clinical POC model leveraging EHR tools and behavioral nudges is acceptable, appropriate, feasible, and associated with a >85% GT rate among patients with PDAC.

Applying human-centered design to adapt the Jumpstart Guide for goals-of-care discussions in persons living with dementia

BACKGROUND

Goals-of-care discussions (GOCD) are uncommon in persons living with dementia (PLWD) despite the likelihood of eventual loss of decisional capacity in the population. The Jumpstart Guide, an existing serious illness communication priming tool, can improve GOCD in certain populations, but has not previously been adapted for use among PLWD and their caregivers.

METHODS

Using human-centered design (HCD), we adapted the Jumpstart Guide for use with PLWD and their caregivers. We conducted qualitative interviews with clinicians and caregivers of PLWD. Six team members conducted qualitative rapid analysis of interviews leading to the development of summary templates and integrative matrices. Four iterations of the Jumpstart Guide led to the final version.

RESULTS

Thirteen clinicians and 11 caregivers were interviewed. Interviews provided key insights into the unique barriers PLWD and their caregivers face during GOCD, including discomfort with accepting a dementia diagnosis and concern with using "serious illness" to describe dementia, as is commonly done in palliative care. Clinicians described differences in GOCD with PLWD compared to other serious illnesses, and the challenge of getting patients and families to think about future health states. Interviews led to Jumpstart Guide adaptations in the following domains: (1) format and structure, (2) content, and (3) specific language. Suggested changes included prioritizing naming a decision-maker, changing conversation prompts to improve accessibility and understandability, ensuring the Jumpstart Guide could be used with patients as well as their caregivers, and altering language to avoid references to "serious illness" and "abilities."

CONCLUSION

Using HCD yielded valuable insights from clinicians and caregivers about the unique barriers to conducting GOCD among PLWD and their caregivers. These insights were used to adapt the Jumpstart Guide for use with PLWD and their caregivers, which is currently being tested in a pragmatic randomized controlled trial in outpatient clinics.

Clinician- and Patient-Directed Communication Strategies for Patients With Cancer at High Mortality Risk: A Cluster Randomized Trial

Importance

Serious illness conversations (SICs) that elicit patients' values, goals, and care preferences reduce anxiety and depression and improve quality of life, but occur infrequently for patients with cancer. Behavioral economic implementation strategies (nudges) directed at clinicians and/or patients may increase SIC completion.

Objective

To test the independent and combined effects of clinician and patient nudges on SIC completion.

Design, Setting, and Participants

A 2 × 2 factorial, cluster randomized trial was conducted from September 7, 2021, to March 11, 2022, at oncology clinics across 4 hospitals and 6 community sites within a large academic health system in Pennsylvania and New Jersey among 163 medical and gynecologic oncology clinicians and 4450 patients with cancer at high risk of mortality (≥10% risk of 180-day mortality).

Interventions

Clinician clusters and patients were independently randomized to receive usual care vs nudges, resulting in 4 arms: (1) active control, operating for 2 years prior to trial start, consisting of clinician text message reminders to complete SICs for patients at high mortality risk; (2) clinician nudge only, consisting of active control plus weekly peer comparisons of clinician-level SIC completion rates; (3) patient nudge only, consisting of active control plus a preclinic electronic communication designed to prime patients for SICs; and (4) combined clinician and patient nudges.

Main Outcomes and Measures

The primary outcome was a documented SIC in the electronic health record within 6 months of a participant's first clinic visit after randomization. Analysis was performed on an intent-to-treat basis at the patient level.

Results

The study accrued 4450 patients (median age, 67 years [IQR, 59-75 years]; 2352 women [52.9%]) seen by 163 clinicians, randomized to active control (n = 1004), clinician nudge (n = 1179), patient nudge (n = 997), or combined nudges (n = 1270). Overall patient-level rates of 6-month SIC completion were 11.2% for the active control arm (112 of 1004), 11.5% for the clinician nudge arm (136 of 1179), 11.5% for the patient nudge arm (115 of 997), and 14.1% for the combined nudge arm (179 of 1270). Compared with active control, the combined nudges were associated with an increase in SIC rates (ratio of hazard ratios [rHR], 1.55 [95% CI, 1.00-2.40]; P = .049), whereas the clinician nudge (HR, 0.95 [95% CI, 0.64-1.41; P = .79) and patient nudge (HR, 0.99 [95% CI, 0.73-1.33]; P = .93) were not.

Conclusions and Relevance

In this cluster randomized trial, nudges combining clinician peer comparisons with patient priming questionnaires were associated with a marginal increase in documented SICs compared with an active control. Combining clinician- and patient-directed nudges may help to promote SICs in routine cancer care.

Trial Registration

ClinicalTrials.gov Identifier: NCT04867850.

Feasibility of a Serious Illness Communication Program for Pediatric Advance Care Planning

Importance

Pediatric advance care planning (ACP), which aims to ensure care is aligned with family goals and values, is associated with better end-of-life outcomes; however, ACP in pediatrics remains uncommon.

Objectives

To determine the feasibility and acceptability of the Pediatric Serious Illness Communication Program (PediSICP) and explore family-centered outcomes.

Design, Setting, and Participants

This cohort study was a single-group pilot study of the PediSICP in adolescents and young adults (AYAs; age ≥13 y) with serious illness, parents of seriously ill children, and interprofessional clinicians from April 2021 to March 2023 in a quaternary care pediatric hospital. Duration of follow-up was 1 month. Data were analyzed from January 2022 to March 2023.

Exposure

The PediSICP includes clinician training preceding an ACP communication occasion supported by communication guides and a template for electronic medical record documentation.

Main Outcomes and Measures

Outcomes of interest were parent, patient, and clinician experiences with and perceptions of the PediSICP. Feasibility was defined a priori as at least 70% clinician intervention completion rates.

Results

A total of 10 virtual trainings were conducted among 40 clinicians, including 27 physicians, 7 nurse practitioners, 5 nurses, and 1 respiratory therapist, and 30 trained clinicians (75%) conducted and documented 42 ACP conversations with 33 parents (median [IQR] age, 43 [35-51] years; 25 [76%] female) and 5 AYAs (median [IQR] age, 19 [17-19] years; 3 [60%] female) who completed the intervention. The median (IQR) conversation duration was 27 (10-45) minutes. Most clinicians (29 clinicians [97%]) agreed that they felt prepared for the conversation, and all clinicians recommended the PediSICP. Parents reported participation was worthwhile (27 parents [84%]), they felt listened to (31 parents [94%]), and would recommend the PediSICP (28 parents [85%]). Parents endorsed higher therapeutic alliance after the PediSICP intervention compared with before (The Human Connection scale mean [SD] score, 57.6 [6.4] vs 55.3 [7.8]; P = .03) and decreased anxiety immediately after the intervention (Generalized Anxiety Disorder-7-item mean [SD] score, 10.1 [7.3] vs 8.4 [6.9]; P = .003), which persisted at the 1-month follow-up (mean [SD] score, 7.7 [6.8]; P = .03).

Conclusions and Relevance

This pilot cohort study found that the PediSICP was feasible, acceptable, and highly valued by clinicians and parents of children with serious illness. These findings suggest that the PediSICP may empower interprofessional clinicians and improve ACP with families of children and AYAs who are seriously ill.

Relationships Between Personality Traits and Perceived Stress in Surrogate Decision-Makers of Intensive Care Unit Patients

INTRODUCTION

Personality traits, specifically neuroticism, are related to stress in surrogate decision-makers (SDMs) in outpatient settings. We hypothesized that intrinsic traits are related to SDM stress in the intensive care unit (ICU) to determine if personality considerations should be included in interventions to support SDMs.

METHODS

Eligible participants (adult SDMs of non-capacitated ICU patients) completed validated questionnaires including stress (Impact of Events Scale-Revised, IES-R) and personality (Big Five Inventory, BFI) within 72 hours of ICU admission and again at 3 months post-ICU discharge (in addition to a qualitative interview). Bivariate Pearson correlations explored the relationship between BFI and IES-R at each time point (95% CI) and t-tests explored the relationship between stress and COVID-19. Mixed-methods analysis integrated qualitative and quantitative data.

RESULTS

Of 32 SDMs, 71.9% were female, 93.8% white, and 97.0% were family members. Neuroticism was not significantly correlated to IES-R at 72 hours (r = 0.09; p = 0.64), but r increased 3 months post-discharge (r = 0.32; p = 0.07). Other BFI traits did not show similar patterns. Total stress was greater in surrogates of COVID-19-positive patients (COVID-19-positive: 60.6; COVID-19-negative: 49.8; p = 0.025). Mixed-methods analysis demonstrated that participants with high neuroticism scores had poorer emotional regulation than those with low neuroticism scores.

CONCLUSIONS

This study supports that personality, particularly neuroticism, influences the stress of SDMs in the ICU. Further study of personality traits may identify surrogates who are at higher risk of stress-related disorders, which can guide future interventions.

Supporting health and social care professionals in serious illness conversations: Development, validation, and preliminary evaluation of an educational booklet

Serious illness conversations aim to align the care process with the goals and preferences of adult patients suffering from any advanced disease. They represent a challenge for healthcare professionals and require specific skills. Conversation guides consistent with task-centered instructional strategies may be particularly helpful to improve the quality of communication. This study aims to develop, validate, and preliminarily evaluate an educational booklet to support Italian social and healthcare professionals in serious illness conversations. A three-step approach, including development, validation, and evaluation, was followed. A co-creation process with meaningful stakeholders led to the development of the booklet, validated by 15 experts on clarity, completeness, coherence, and relevance. It underwent testing on readability (Gulpease index, 0 = lowest-100 = maximum) and design (Baker Able Leaflet Design criteria, 0 = worst to 32 = best). Twenty-two professionals with different scope of practice and care settings evaluated acceptability (acceptable if score ≥30), usefulness, feasibility to use (1 = not at all to 10 = extremely), and perceived acquired knowledge (1 = not at all to 5 = extremely). After four rounds of adjustments, the booklet scored 97% for relevance, 60 for readability, and 25/32 for design. In all, 18 (81.8%), 19 (86.4%) and 17 (77.3%) professionals deemed the booklet acceptable, moderate to highly useful, and feasible to use, respectively; 18/22 perceived gain in knowledge and all would recommend it to colleagues. The booklet has good readability, excellent design, high content validity, and a high degree of perceived usefulness and acquired knowledge. The booklet is tailored to users' priorities, mirrors their most frequent daily practice challenges, and offers 1-minute, 2-minute and 5-minute solutions for each scenario. The co-creation process ensured the development of an educational resource that could be useful regardless of the scope of practice and the care setting to support professionals in serious illness conversations.

The trajectory of prognostic cognition in patients with advanced cancer: is the traditional advance care planning approach desirable for patients?

Most patients with advanced cancer initially express a desire to be informed of their prognosis, and prognostic discussions between patients and their oncologists can trigger the subsequent trajectory of prognostic cognitions. On the continuum of prognostic cognition, including inaccurate/accurate prognostic awareness (awareness of incurability of cancer, terminal nature of illness or life expectancy) and prognostic acceptance (accepting one's prognosis), patients' perceptions of being informed of their prognosis by oncologists and patients' coping strategy for serious medical conditions regulate prognostic cognitions. However, nearly half of the patients with advanced cancer have poor prognostic awareness, and few patients achieve prognostic acceptance. These phenomena partly act as barriers to participation in advance care planning. When oncologists engage in advance care planning conversations, they must assess the patient's prognostic cognition and readiness for advance care planning. Considering the inaccurate prognostic awareness in a non-negligible proportion of patients and that astatic patients' preferences for future treatment and care are influenced by prognostic cognition, more research on decision-making support processes for high-quality and goal-concordant end-of-life care is needed along with research of advance care planning. In addition to making decisions regarding future medical treatment and care, oncologists must engage in continuous and dynamic goal-of-care conversations with empathic communication skills and compassion from diagnosis to end-of-life care.

Serious Illness Communication in Cirrhosis Care: Tools to Improve Illness Understanding, Prognostic Understanding, and Care Planning

Patients with cirrhosis frequently experience an unpredictable illness trajectory, with frequent hospitalizations and complications. Along with the uncertain nature of the disease, the possibility of a lifesaving and curative transplant often makes prognostic discussions and future care decisions challenging. Serious illness communication (SIC) refers to supportive communication whereby clinicians assess patients' illness understanding, share prognostic information according to patients' preferences, explore patients' goals, and make recommendations for care that align with these goals. SIC includes 3 key components: (1) illness understanding; (2) prognostic understanding; and (3) care planning. In this piece, we explore current barriers to early implementation of SIC in cirrhosis care and share possible solutions, including adopting a multidisciplinary approach, delivering culturally competent care, and training clinicians in SIC core skills. By use of a case example, we aim to demonstrate SIC in action and to provide clinicians with tools and skills that can be used in practice.

Outcomes and Experiences of Patients and Their Caregivers After Severe Stroke Requiring Tube Feeding in Peru

OBJECTIVES

Evaluate clinical outcomes of stroke survivors in Peru discharged with artificial nutrition via a feeding tube (FT), and explore perspectives and experiences of these patients and their caregivers.

METHODS

Retrospective chart review to describe the prevalence of FT placement and characteristics of patients admitted with stroke to the Instituto Nacional de Ciencias Neurológicas in Lima, Peru between January 2019 and 2021. Follow-up calls to stroke survivors discharged home with FTs or their caregivers included quantitative and qualitative questions to assess long-term outcome and explore perspectives around poststroke care and FT management. We analyzed quantitative data descriptively and applied thematic analysis to qualitative data using a consensus-driven codebook.

RESULTS

Of 812 hospitalized patients with stroke, 146 (18%) were discharged home with FT, all with nasogastric tubes (NGTs). Follow-up calls were performed a median of 18 months after stroke with 96 caregivers and three patients. Twenty-five patients (25%) had died, and 82% of survivors (n = 61) remained dependent for some care. Four themes emerged from interviews: (1) perceived suffering (physical, emotional, existential) associated with the NGT and stroke-related disability, often exacerbated by lack of preparedness or prognostic awareness; (2) concerns around compromised personhood and value-discordant care; (3) coping with their loved-one's illness and the caregiving role; and (4) barriers to NGT care and skill acquisition.

CONCLUSION

We identified a high burden of palliative and supportive needs among severe stroke survivors with NGTs and their caregivers suggesting opportunities to improve poststroke care through education, communication, and support.

Participatory research with carers: A systematic review and narrative synthesis

INTRODUCTION

As patient and public involvement (PPI) in research has become increasingly common, research-based recommendations on its principles and impacts have been established. The specifics of conducting PPI are likely to differ when involving different groups. Family/informal carers for those with health conditions or disabilities have a lot to contribute to research, but instances of their involvement have yet to be reviewed.

OBJECTIVE

To systematically review and synthesize studies where family/informal carers have been involved in the research process, to develop an understanding of the benefits, barriers and facilitating factors.

METHODS

A search of five electronic databases was conducted using a combination of terms relating to carers, involvement and research. A grey literature search, expert consultation and hand-searching were also used. Following screening, data extraction and quality assessment, a narrative synthesis incorporating thematic analysis was conducted.

FINDINGS

A total of 55 studies met the inclusion criteria, with diverse design and participatory approaches. Four themes were identified, relating to the outcomes, challenges, and practicalities of involving carers: (re) building relationships with carers; carers as equals not afterthoughts; carers have unique experiences; carers create change. Full involvement throughout the research was not always possible, due to barriers from the research world and responsibilities of the caring role. The literature demonstrated ways for carers to contribute in ways that suited them, maximizing their impact, while attending to relationships and power imbalances.

CONCLUSION

By summarizing the reported instances of carer involvement in research, this review brings together different examples of how successful research partnerships can be built with carers, despite various challenges. Carers are a heterogeneous group, and participatory approaches should be tailored to specific situations. Wider understanding of the challenges of conducting empowering research with carers, and the resources required to address these, are needed.

PATIENT AND PUBLIC INVOLVEMENT

The initial findings and themes were presented to a group of carers who had been involved in research and whose reflections informed the final synthesis.

Physician Perspectives on Addressing Anti-Black Racism

Importance

Uncertainty remains among clinicians regarding processes to address and resolve conflict around anti-Black racism.

Objective

To elicit clinicians' perceptions of their role in addressing concerns about anti-Black racism among Black patients with serious illness as well as their families.

Design, Setting, and Participants

In this qualitative study, one-on-one semistructured interviews were conducted with 21 physicians at an academic county hospital between August 1 and October 31, 2022. Participants were provided clinical scenarios where anti-Black racism was a concern of a patient with serious illness. Participants were asked open-ended questions about initial impressions, prior similar experiences, potential strategies to address patients' concerns, and additional resources to support these conversations. A framework based on restorative justice was used to guide qualitative analyses.

Main Outcomes and Measures

Perspectives on addressing anti-Black racism as described by physicians.

Results

A total of 21 medical subspecialists (mean [SD] age, 44.2 [7.8] years) participated in the study. Most physicians were women (14 [66.7%]), 4 were Asian (19.0%), 3 were Black (14.3%), and 14 were White (66.7%). Participants identified practices that are normalized in clinical settings that may perpetuate and exacerbate perceptions of anti-Black racism. Using provided scenarios and personal experiences, participants were able to describe how Black patients are harmed as a result of these practices. Last, participants identified strategies and resources for addressing Black patients' concerns and facilitating conflict resolution, but they stopped short of promoting personal or team accountability for anti-Black racism.

Conclusions and Relevance

In this qualitative study, physicians identified resources, skills, and processes that partially aligned with a restorative justice framework to address anti-Black racism and facilitate conflict resolution, but did not provide steps for actualizing accountability. Restorative justice and similar processes may provide space within a mediated setting for clinicians to repair harm, provide accountability, and facilitate racial healing.

JPSM Controversies in Palliative Care: "What is the Most Important, Measurable Goal of Serious Illness Conversations in the Ambulatory Setting?"

There is widespread agreement that clinicians should talk to seriously ill patients and their families about their illnesses. However, advance directives as a quality metric have been called into question because of the lack of data that these conversations lead to goal-concordant care. The controversy has led many to reexamine the purpose of conversations with seriously ill patients and what should be discussed in ambulatory visits.  In this Controversies in Palliative care, experts in palliative care review the literature and suggest both how it influences their clinical practice and what research needs to be done to clarify the controversy. While there is not a single outcome that the experts agree on, they posit a variety of different ways to assess these conversations.

The differences in code status conversation approaches reported by emergency medicine and palliative care clinicians: A mixed-method study

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.

Patient and Family Outcomes of Community Neurologist Palliative Education and Telehealth Support in Parkinson Disease

Importance

Parkinson disease and related disorders (PDRD) are the fastest growing neurodegenerative illness in terms of prevalence and mortality. As evidence builds to support palliative care (PC) for PDRD, studies are needed to guide implementation.

Objective

To determine whether PC training for neurologists and remote access to a PC team improves outcomes in patients with PDRD in community settings.

Design, Setting, and Participants

This pragmatic, stepped-wedge comparative effectiveness trial enrolled and observed participants from 19 community neurology practices supported by PC teams at 2 academic centers from March 8, 2017, to December 31, 2020. Participants were eligible if they had PDRD and moderate to high PC needs. A total of 612 persons with PDRD were referred; 253 were excluded. Patients were excluded if they had another diagnosis meriting PC, were receiving PC, or were unable or unwilling to follow study procedures. Patients received usual care or the intervention based on when their community neurologist was randomized to start the intervention. Data were analyzed from January 2021 to September 2023.

Intervention

The intervention included (1) PC education for community neurologists and (2) team-based PC support via telehealth.

Main Outcomes and Measures

The primary outcomes were differences at 6 months in patient quality of life (QOL; measured by the Quality of Life in Alzheimer Disease Scale [QOL-AD]) and caregiver burden (Zarit Burden Interview) between the intervention and usual care.

Results

A total of 359 patients with PDRD (233 men [64.9%]; mean [SD] age, 74.0 [8.8] years) and 300 caregivers were enrolled. At 6 months, compared with usual care, participants receiving the intervention had better QOL (QOL-AD score, 0.09 [95% CI, -0.63 to 0.82] vs -0.88 [95% CI, -1.62 to -0.13]; treatment effect estimate, 0.97; 95% CI, 0.07-1.86; P = .03). No significant difference was observed in caregiver burden (Zarit Burden Interview score, 1.19 [95% CI, 0.16 to 2.23] vs 0.55 [95%, -0.44 to 1.54]; treatment effect estimate, 0.64; 95% CI, -0.62 to 1.90; P = .32). Advance directive completion was higher under the intervention (19 of 38 [50%] vs 6 of 31 [19%] among those without directives at the beginning of the study; P = .008). There were no differences in other outcomes.

Conclusions and Relevance

PC education for community neurologists and provision of team-based PC via telehealth is feasible and may improve QOL and advance care planning. Overall treatment effects were small and suggest opportunities to improve both the intervention and implementation.

Trial Registration

ClinicalTrials.gov Identifier: NCT03076671.

Online Forums as a Tool for Broader Inclusion of Voices on Health Care Communication Experiences and Serious Illness Care: Mixed Methods Study

BACKGROUND

Existing health care research, including serious illness research, often underrepresents individuals from historically marginalized communities. Capturing the nuanced perspectives of individuals around their health care communication experiences is difficult. New research strategies are needed that increase engagement of individuals from diverse backgrounds.

OBJECTIVE

The aim of this study was to develop a mixed methods approach with qualitative online forums to better understand health communication experiences of individuals, including people from groups historically marginalized such as Black and Latino individuals; older adults; and people with low income, disability, or serious illness.

METHODS

We used a multiphase mixed methods, community-informed research approach to design study instruments and engage participants. We engaged a diverse group of collaborators with lived experience of navigating the health care system who provided feedback on instruments, added concepts for testing, and offered guidance on creating a safe experience for participants (phase 1). We conducted a national quantitative survey between April and May 2021 across intrapersonal, interpersonal, and systems-level domains, with particular focus on interpersonal communication between patients and clinicians (phase 2). We conducted two asynchronous, qualitative online forums, a technique used in market research, between June and August 2021, which allowed us to contextualize the learnings and test concepts and messages (phase 3). Using online forums allowed us to probe more deeply into results and hypotheses from the survey to better understand the "whys" and "whats" that surfaced and to test public messages to encourage action around health.

RESULTS

We engaged 46 community partners, including patients and clinicians from a Federally Qualified Health Center, to inform study instrument design. In the quantitative survey, 1854 adults responded, including 50.5% women, 25.2% individuals over 65 years old, and 51.9% individuals with low income. Nearly two-thirds identified as non-Hispanic white (65.7%), 10.4% identified as non-Hispanic Black, and 15.5% identified as Hispanic/Latino. An additional 580 individuals participated in online forums, including 60.7% women, 17.4% individuals over 65 years old, and 49.0% individuals with low income. Among the participants, 70.3% identified as non-Hispanic white, 16.0% as non-Hispanic Black, and 9.5% as Hispanic/Latino. We received rich, diverse input from our online forum participants, and they highlighted satisfaction and increased knowledge with engagement in the forums.

CONCLUSIONS

We achieved modest overrepresentation of people who were over 65 years old, identified as non-Hispanic Black, and had low income in our online forums. The size of the online forums (N=580) reflected the voices of 93 Black and 55 Hispanic/Latino participants. Individuals who identify as Hispanic/Latino remained underrepresented, likely because the online forums were offered only in English. Overall, our findings demonstrate the feasibility of using the online forum qualitative approach in a mixed methods study to contextualize, clarify, and expound on quantitative findings when designing public health and clinical communications interventions.

Implementing a Serious Illness Risk Prediction Model: Impact on Goals of Care Documentation

CONTEXT

Goals of care conversations can promote high value care for patients with serious illness, yet documented discussions infrequently occur in hospital settings.

OBJECTIVES

We sought to develop a quality improvement initiative to improve goals of care documentation for hospitalized patients.

METHODS

Implementation occurred at an academic medical center in Pittsburgh, Pennsylvania. Intervention included integration of a 90-day mortality prediction model grouping patients into low, intermediate, and high risk; a centralized goals of care note; and automated notifications and targeted palliative consults. We compared documented goals of care discussions by risk score before and after implementation.

RESULTS

Of the 12,571 patients hospitalized preimplementation and 10,761 postimplementation, 1% were designated high risk and 11% intermediate risk of mortality. Postimplementation, goals of care documentation increased for high (17.6%-70.8%, P< 0.0001) and intermediate risk patients (9.6%-28.0%, P < 0.0001). For intermediate risk patients, the percentage of goals of care documentation performed by palliative medicine specialists increased from pre- to postimplementation (52.3%-71.2%, P = 0.0002). For high-risk patients, the percentage of goals of care documentation completed by the primary service increased from pre-to postimplementation (36.8%-47.1%, P = 0.5898, with documentation performed by palliative medicine specialists slightly decreasing from pre- to postimplementation (63.2%-52.9%, P = 0.5898).

CONCLUSIONS

Implementation of a goals of care initiative using a mortality prediction model significantly increased goals of care documentation especially among high-risk patients. Further study to assess strategies to increase goals of care documentation for intermediate risk patients is needed especially by nonspecialty palliative care.

Impact of an Institution-Wide Goals of Care Program on the Timing of Referrals to Outpatient Palliative Care

CONTEXT

Palliative care has received increased interest since the COVID-19 pandemic due to its role in guiding goals of care (GOC) discussions.

OBJECTIVES

We assessed the change in the timing of outpatient palliative care referrals before and after implementing an institution-wide multicomponent interdisciplinary GOC (myGOC) program.

METHODS

We reviewed 200 random supportive care center (SCC) consult visits each from June to November 2019 (before myGOC) and June to November 2020 (after myGOC). Data regarding Edmonton Symptom Assessment Scale (ESAS) scores, time from hospital registration to SCC visit, SCC visit until death/last follow-up, and advance care planning (ACP) notes were collected. Kaplan-Meier curves were used to evaluate overall survival (OS).

RESULTS

The median OS from the SCC consult visit was 15.2 months (95% CI:11.7-19.7) before and 14.0 months (95% CI:10.8-17.9) after the myGOC program (P = 0.646). There were no significant differences in the median time between the SCC consult visit to death/last follow-up (11.95 vs. 12.0 months after myGOC; P = 0.841) and the first visits to our cancer center and SCC (6.1 vs. 5.29 months after myGOC; P = 0.689). Patients seen after myGOC had significantly lower ESAS symptom scores, better performance status (2 [1-2] vs. 2 [1-3]; P = 0.018], and more ACP notes composed by medical oncology teams (25.5% vs. 4.5%; P < 0.001).

CONCLUSION

There were no significant differences in OS among patients seen in the SCC before and after myGOC, likely related to a ceiling effect. More oncologists had ACP discussions with patients, and patients had lower symptom scores on ESAS after myGOC, likely indicating that more patients were referred for GOC discussions and ACP rather than for symptom distress.

Rural Hospital Disparities in Goals of Care Documentation

CONTEXT

Goals of care conversations for seriously ill hospitalized patients are associated with high-quality patient-centered care.

OBJECTIVES

We aimed to assess the prevalence of documented goals of care conversations for rural hospitalized patients compared to nonrural hospitalized patients.

METHODS

We retrospectively assessed goals of care documentation using a template note for adult patients with predicted 90-day mortality greater than 30% admitted to eight rural and nine nonrural community hospitals between July 2021 and April 2023. We compared predictors and prevalence of goals of care documentation among rural and nonrural hospitals.

RESULTS

Of the 31,098 patients admitted during the study period, 21% were admitted to a rural hospital. Rural patients were more likely than nonrural patients to be >65 years old (89% vs. 86%, P = <.0001), more likely to live in a neighborhood classified in the highest quintile of socioeconomic disadvantage (40% vs. 16%, P = <.0001), and less likely to receive a palliative care consult (8% vs. 18%, P = <.0001). Goals of care documentation occurred less often for patients admitted to rural vs. nonrural community hospitals (2% vs. 7%, P < .0001). In the base multivariable logistic regression model adjusting for patient characteristics, the odds of goals care documentation were lower in rural vs. nonrural community hospitals (aOR 0.4, P = .0232). In a second multivariable logistic regression model including both patient characteristics and severity of illness, the odds of goals of care documentation in rural community hospitals were no longer statistically different than nonrural community hospitals (aOR 0.5, P = .1080). Patients who received a palliative care consult had a lower prevalence of goals of care documentation in rural vs. nonrural hospitals (16% vs. 37%, P = <.0001).

CONCLUSION

In this study of 17 rural and nonrural community hospitals, we found low overall prevalence of goals of care documentation with particularly infrequent documentation occurring within rural hospitals. Future study is needed to assess barriers to goals of care documentation contributing to low prevalence of goals of care conversations in rural hospital settings.

The importance of facilitating goal-concordant care (GCC) in a pandemic: the MD Anderson Experience with hospitalized COVID-19-positive patients

PURPOSE

Provider-patient communication (PPC) about goals of care (GOC) facilitates goal-concordant care (GCC) delivery. Hospital resource limitations imposed during the pandemic made it vital to deliver GCC to a patient cohort with COVID-19 and cancer. We aimed to evaluate the implementation of a real-time goals of care intervention and to make recommendations for future pandemics with similar clinical scenarios.

METHODS

This is a retrospective cohort study, of all COVID-19 positive patients admitted to The University of Texas MD Anderson Cancer Center between March of 2020 and January of 2021. The cohort included the following: (1) patients 18 years of age or older; (2) positive COVID-19 infection; (3) requiring hospitalization. Medical records were reviewed and all patient data including demographics, comorbidities, and outcomes were collected and analyzed in the Syntropy platform, Palantir Foundry, as part of the institutional Data-Driven Determinants of COVID-19 Oncology Discovery Effort (D3CODE) protocol. A multidisciplinary GOC task force developed processes for ease of conducting GOC-PPC and implemented structured documentation. We looked at ACP documentation pre- and post-implementation alongside demographics, length of stay (LOS), 30-day readmission rate and mortality.

RESULTS

There were 494 unique patients identified, 53% male, 61.5% Caucasian, 16.8% African American, and 3.2% Asian. Active cancer was identified in 84.6% patients, of which 65.6% were solid tumors and 34.4% hematologic malignancies. LOS was 9 days with a 30-day readmission rate of 15% and inpatient mortality of 14%. Inpatient ACP note documentation was significantly higher post-implementation as compared to pre-implementation (90% vs 8%, P<0.05). We saw sustained ACP documentation throughout the pandemic suggesting effective processes.

CONCLUSIONS

The implementation of institutional structured processes for GOC-PPC resulted in rapid sustainable adoption of ACP documentation for COVID-19-positive cancer patients. This was highly beneficial for this population during the pandemic, as it demonstrated the role of agile processes in care delivery models, which will be beneficial in the future when rapid implementation is needed.

Effective communication in palliative care from the perspectives of patients and relatives: A systematic review

OBJECTIVES

In palliative care, effective communication is essential to adequately meet the needs and preferences of patients and their relatives. Effective communication includes exchanging information, facilitates shared decision-making, and promotes an empathic care relationship. We explored the perspectives of patients with an advanced illness and their relatives on effective communication with health-care professionals.

METHODS

A systematic review was conducted. We searched Embase, Medline, Web of Science, CINAHL, and Cochrane for original empirical studies published between January 1, 2015 and March 4, 2021.

RESULTS

In total, 56 articles on 53 unique studies were included. We found 7 themes that from the perspectives of patients and relatives contribute to effective communication: (1) open and honest information. However, this open and honest communication can also trigger anxiety, stress, and existential disruption. Patients and relatives also indicated that they preferred (2) health-care professionals aligning to the patient's and relative's process of uptake and coping with information; (3) empathy; (4) clear and understandable language; (5) leaving room for positive coping strategies, (6) committed health-care professionals taking responsibility; and (7) recognition of relatives in their role as caregiver. Most studies in this review concerned communication with physicians in a hospital setting.

SIGNIFICANCE OF RESULTS

Most patients and relatives appreciate health-care professionals to not only pay attention to strictly medical issues but also to who they are as a person and the process they are going through. More research is needed on effective communication by nurses, in nonhospital settings and on communication by health-care professionals specialized in palliative care.

Culturally Acceptable Emotional Expressions Perceived by Non-U.S. Physicians Undergoing U.S.-Based Serious Illness Communication Skills Training: A Cross-Sectional Study

CONTEXT

Responding to emotions is a key feature of U.S.-based serious illness communication skills training, VitalTalk®, of which trained actors portraying seriously ill patients is a component. The cultural appropriateness and perceived utility of the actors' emotional expressions remain to be empirically evaluated outside of the U.S.

OBJECTIVES

To determine the cultural appropriateness and educational utility of VitalTalk® actors' emotional expressions, as perceived by clinicians.

METHODS

From January 2021-April 2022, we conducted a cross-sectional study of physicians in Japan attending virtual VitalTalk® training in Japanese, each session focusing on: responding to emotions (#1) and discussing goals of care (#2), respectively. We examined their perceived authenticity and utility of the actively and passively intense emotional expressions portrayed by actors in VitalTalk® role-plays.

RESULTS

Physicians (N = 100, 94% response rate) from across Japan voluntarily attended two-session workshops and completed post-session surveys. Eighty-eight participants (88%) responded that both actively and passively intense emotions portrayed by the actors provided useful learning experiences. For session #1, the participants found actively intense emotional expressions to be more clinically authentic, compared to passively intense ones (4.21 vs 4.06 out of a 5-point Likert scale, PP= .02). For session #2, no such difference was observed (4.16 vs 4.08 of a 5-point Likert scale, P = .24).

CONCLUSIONS

Even in a culture where patients may express emotions passively, any intense and authentic emotional expressions by actors can be perceived as facilitating learning. Most participants perceived both the Name, Understand, Respect, Support, and Explore '(NURSE)' statements and Reframe, Expect emotion, Map out patient goals Align with goals and Propose a plan '(REMAP)' frameworks as useful in routine clinical practice in Japan.

Interventions to Promote End-of-Life Conversations: A Systematic Review and Meta-Analysis

CONTEXT

Although several interventions aimed to promote end-of-life conversations are available, it is unclear whether and how these affect delivery of end-of-life conversations. Measuring the processes associated with high-quality end-of-life care may trigger improvement.

OBJECTIVES

To estimate the effect of interventions aimed to promote end-of-life conversations in clinical encounters with patients with advanced chronic or terminal illness or their family, on process indicators of end-of-life conversations.

METHODS

Systematic review with meta-analysis (PROSPERO no. CRD42021289471). Four databases (PubMed, CINAHL, PsycINFO, and Scopus) were searched up to September 30, 2021. The primary outcomes were any process indicators of end-of-life conversations. Results of pairwise meta-analyses were presented as Risk Ratio (RR) for occurrence, standardized mean difference (SMD) for quality and ratio of means (ROM) for duration. Meta-analysis was not performed when fewer than four studies were available.

RESULTS

A total of 4,663 articles were scanned. Eighteen studies were included in the systematic review and 16 entered at least one meta-analysis: documented occurrence (n = 8), patient-reported occurrence (n = 4), patient-reported-quality (n = 4), duration (n = 4). There was significant variability in settings, patients' clinical conditions, and professionals. No significant effect of interventions on documented occurrence (RR 1.54, 95% CI 0.84-2.84; I2 91%), patient-reported occurrence (RR 1.52, 95% CI 0.80-2.91; I2 95%), patient-reported quality (SMD 0.83, 95% CI -1.06 to 2.71; I2 99%), or duration (ROM 1.20, 95% CI 0.95-1.51; I2 65%) of end-of-life conversations was found. Data on frequency were conflicting. Interventions targeting multiple stakeholders promoted earlier and more comprehensive conversations.

CONCLUSION

Heterogeneity was considerable, but findings suggest no significant effect of interventions on occurrence, patient-reported quality and duration of end-of-life conversations. Nevertheless, we found indications for interventions targeting multiple stakeholders to promote earlier and more comprehensive conversations.

Implementation Challenges for a Multisite Advance Care Planning Pragmatic Trial: Lessons Learned

BACKGROUND/PROBLEM

Advance care planning (ACP) pragmatic trials are needed.

PROPOSED SOLUTION

We determined key system-level activities to implement ACP interventions for a cluster-randomized pragmatic trial. We identified patients with serious illness from 50 primary care clinics across three University of California health systems using a validated algorithm. If patients lacked documented ACP within the last 3 years, they were eligible for an intervention: (Arm 1) an advance directive (AD); (Arm 2) AD + PREPAREforYourCare.org; (Arm 3) AD + PREPARE + lay health navigator outreach. Triggered by an appointment, we mailed and sent interventions through automated electronic health record (EHR) messaging. We collaborated with patients/caregivers, clinicians, payors, and national/health system leader advisors. We are currently finalizing 24 months follow-up data.

OUTCOMES/METHODS

We used the Consolidated Framework for Implementation Research (CFIR) and Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) frameworks to track secular trends and implementation efforts.

KEY MESSAGE/RESULTS

Required multisite, system-level activities: 1) obtaining leadership, legal/privacy, and EHR approvals; 2) standardizing ACP documentation; 3) providing clinician education; 3) validating an automated serious illness identification algorithm; 4) standardizing ACP messaging with input from over 100 key advisors; 5) monitoring secular trends (e.g., COVID); and 6) standardizing ACP workflows (e.g., scanned ADs). Of 8707 patients with serious illness, 6883 were eligible for an intervention. Across all arms, 99% received the mailed intervention, 78.3% had an active patient portal (64.2% opened intervention), and 90.5% of arm three patients (n = 2243) received navigator outreach.

LESSONS LEARNED

Implementing a multisite health system-wide ACP program and pragmatic trial, with automated EHR-based cohort identification and intervention delivery, requires a high level of multidisciplinary key advisor engagement, standardization, and monitoring. These activities provide guidance for the implementation of other large-scale, population-based ACP efforts.

Intervention to Promote Communication About Goals of Care for Hospitalized Patients With Serious Illness: A Randomized Clinical Trial

Importance

Discussions about goals of care are important for high-quality palliative care yet are often lacking for hospitalized older patients with serious illness.

Objective

To evaluate a communication-priming intervention to promote goals-of-care discussions between clinicians and hospitalized older patients with serious illness.

Design, Setting, and Participants

A pragmatic, randomized clinical trial of a clinician-facing communication-priming intervention vs usual care was conducted at 3 US hospitals within 1 health care system, including a university, county, and community hospital. Eligible hospitalized patients were aged 55 years or older with any of the chronic illnesses used by the Dartmouth Atlas project to study end-of-life care or were aged 80 years or older. Patients with documented goals-of-care discussions or a palliative care consultation between hospital admission and eligibility screening were excluded. Randomization occurred between April 2020 and March 2021 and was stratified by study site and history of dementia.

Intervention

Physicians and advance practice clinicians who were treating the patients randomized to the intervention received a 1-page, patient-specific intervention (Jumpstart Guide) to prompt and guide goals-of-care discussions.

Main Outcomes and Measures

The primary outcome was the proportion of patients with electronic health record-documented goals-of-care discussions within 30 days. There was also an evaluation of whether the effect of the intervention varied by age, sex, history of dementia, minoritized race or ethnicity, or study site.

Results

Of 3918 patients screened, 2512 were enrolled (mean age, 71.7 [SD, 10.8] years and 42% were women) and randomized (1255 to the intervention group and 1257 to the usual care group). The patients were American Indian or Alaska Native (1.8%), Asian (12%), Black (13%), Hispanic (6%), Native Hawaiian or Pacific Islander (0.5%), non-Hispanic (93%), and White (70%). The proportion of patients with electronic health record-documented goals-of-care discussions within 30 days was 34.5% (433 of 1255 patients) in the intervention group vs 30.4% (382 of 1257 patients) in the usual care group (hospital- and dementia-adjusted difference, 4.1% [95% CI, 0.4% to 7.8%]). The analyses of the treatment effect modifiers suggested that the intervention had a larger effect size among patients with minoritized race or ethnicity. Among 803 patients with minoritized race or ethnicity, the hospital- and dementia-adjusted proportion with goals-of-care discussions was 10.2% (95% CI, 4.0% to 16.5%) higher in the intervention group than in the usual care group. Among 1641 non-Hispanic White patients, the adjusted proportion with goals-of-care discussions was 1.6% (95% CI, -3.0% to 6.2%) higher in the intervention group than in the usual care group. There was no evidence of differential treatment effects of the intervention on the primary outcome by age, sex, history of dementia, or study site.

Conclusions and Relevance

Among hospitalized older adults with serious illness, a pragmatic clinician-facing communication-priming intervention significantly improved documentation of goals-of-care discussions in the electronic health record, with a greater effect size in racially or ethnically minoritized patients.

Trial Registration

ClinicalTrials.gov Identifier: NCT04281784.

The Importance of Facilitating Goal-Concordant Care (GCC) in a Pandemic: The MD Anderson Experience with hospitalized COVID-19 positive patients

Purpose

Provider-patient communication (PPC) about goals of care (GOC) facilitates goal-concordant care (GCC) delivery. Hospital resource limitations imposed during the pandemic made it vital to deliver GCC to a patient cohort with COVID-19 and cancer. Our aim was to understand the population and adoption of GOC-PPC along with structured documentation in the form of an Advance Care Planning (ACP) note.

Methods

A multidisciplinary GOC task force developed processes for ease of conducting GOC-PPC and implemented structured documentation. Data were obtained from multiple electronic medical record elements, with each source identified, data integrated and analyzed. We looked at PPC and ACP documentation pre and post implementation alongside demographics, length of stay (LOS), 30-day readmission rate and mortality.

Results

494 unique patients were identified, 52% male, 63% Caucasian, 28% Hispanic, 16% African American and 3% Asian. Active cancer was identified in 81% patients, of which 64% were solid tumors and 36% hematologic malignancies. LOS was 9 days with a 30-day readmission rate of 15% and inpatient mortality of 14%. Inpatient ACP note documentation was significantly higher post-implementation as compared to pre-implementation (90% vs 8%, P < 0.05). We saw sustained ACP documentation throughout the pandemic suggesting effective processes.

Conclusions

The implementation of institutional structured processes for GOC-PPC resulted in rapid sustainable adoption of ACP documentation for COVID-19 positive cancer patients. This was highly beneficial for this population during the pandemic, as it demonstrated the role of agile processes in care delivery models, which will be beneficial in the future when rapid implementation is needed.

Prevalence and Correlates of Preference-Concordant Care Among Hospitalized People Receiving Maintenance Dialysis

Key Points

A large proportion of hospitalized patients receiving dialysis report not receiving preference-concordant care. Hospitalized patients on dialysis desiring a comfort-oriented medical plan were likely to report receiving preference-concordant care.

Background

Preference-concordant care is a cornerstone of high-quality medical decision-making, yet the prevalence and correlates of preference-concordant care have not been well-studied in patients receiving dialysis. We surveyed hospitalized people receiving maintenance dialysis to estimate the prevalence and correlates of preference-concordant care among this population.

Methods

We assessed preference concordance by asking participants (223/380, 59% response rate), “How strongly do you agree or disagree that your current treatment plan meets your preference?” We assessed treatment plan preference by asking whether patients preferred a plan that focused on (1 ) extending life or (2 ) relieving pain and discomfort. We assessed shared dialysis decision-making using the 9-item Shared Decision-Making Questionnaire. We examined the differences between those reporting lack of preference-concordant care and those reporting receipt of preference-concordant care using chi-squared analyses. We also studied whether patients' treatment plan preferences or shared dialysis decision-making scores were correlated with their likelihood of receiving preference-concordant care.

Results

Of the 213 respondents who provided data on preference concordance, 90 (42.3%) reported that they were not receiving preference-concordant care. Patients who preferred pain and discomfort relief over life extension were less likely (odds ratio, 0.15 [95% confidence interval, 0.08 to 0.28] P = <0.0001) to report receiving preference-concordant care; patients with higher shared decision-making scores were more likely (odds ratio, 1.02 [95% confidence interval, 1.01 to 1.03], P = 0.02) to report preference-concordant care.

Conclusions

A substantial proportion of this sample of hospitalized people receiving maintenance dialysis reported not receiving preference-concordant care. Efforts to improve symptom management and enhance patient engagement in dialysis decision-making may improve the patients' perceptions of receiving preference-concordant care.

An emergency department nurse led intervention to facilitate serious illness conversations among seriously ill older adults: A feasibility study

BACKGROUND

Serious illness conversations may lead to care consistent with patients' goals near the end of life. The emergency department could serve as an important time and location for these conversations.

AIM

To determine the feasibility of an emergency department-based, brief motivational interview to stimulate serious illness conversations among seriously ill older adults by trained nurses.

DESIGN

A pre-/post-intervention study.

SETTINGS/PARTICIPANTS

In an urban, tertiary care, academic medical center and a community hospital from January 2021 to January 2022, we prospectively enrolled adults ⩾50 years of age with serious illness and an expected prognosis <1 year. We measured feasibility outcomes using the standardized framework for feasibility studies. In addition, we also collected the validated 4-item Advance Care Planning Engagement Survey (a 5-point Likert scale) at baseline and 4-week follow-up and reviewing the electronic medical record for documentation related to newly completed serious illness conversations.

RESULTS

Among 116 eligible patients who were willing and able to participate, 76 enrolled (65% recruitment rate), and 68 completed the follow-up (91% retention rate). Mean patient age was 64.4 years (SD 8.4), 49% were female, and 58% had metastatic cancer. In all, 16 nurses conducted the intervention, and all participants completed the intervention with a median duration of 27 min. Self-reported Advance Care Planning Engagement increased from 2.78 pre to 3.31 post intervention (readiness to "talk to doctors about end-of-life wishes," p < 0.008). Documentation of health care proxy forms increased (62-70%) as did Medical Order for Life Sustaining Treatment (1-11%) during the 6 months after the emergency department visit.

CONCLUSION

A novel, emergency department-based, nurse-led brief motivational interview to stimulate serious illness conversations is feasible and may improve advance care planning engagement and documentation in seriously ill older adults.

Value Placed on Comfort vs Life Prolongation Among Patients Treated With Maintenance Dialysis

Importance

Patients receiving maintenance dialysis experience intensive patterns of end-of-life care that might not be consistent with their values.

Objective

To evaluate the association of patients' health care values with engagement in advance care planning and end-of-life care.

Design, Setting, and Participants

Survey study of patients who received maintenance dialysis between 2015 and 2018 at dialysis centers in the greater metropolitan areas of Seattle, Washington, and Nashville, Tennessee, with longitudinal follow-up of decedents. Logistic regression models were used to estimate probabilities. Data analysis was conducted between May and October 2022.

Exposures

A survey question about the value that the participant would place on longevity-focused vs comfort-focused care if they were to become seriously ill.

Main Outcomes and Measures

Self-reported engagement in advance care planning and care received near the end of life through 2020 using linked kidney registry data and Medicare claims.

Results

Of 933 patients (mean [SD] age, 62.6 [14.0] years; 525 male patients [56.3%]; 254 [27.2%] identified as Black) who responded to the question about values and could be linked to registry data (65.2% response rate [933 of 1431 eligible patients]), 452 (48.4%) indicated that they would value comfort-focused care, 179 (19.2%) that they would value longevity-focused care, and 302 (32.4%) that they were unsure about the intensity of care they would value. Many had not completed an advance directive (estimated probability, 47.5% [95% CI, 42.9%-52.1%] of those who would value comfort-focused care vs 28.1% [95% CI, 24.0%-32.3%] of those who would value longevity-focused care or were unsure; P < .001), had not discussed hospice (estimated probability, 28.6% [95% CI, 24.6%-32.9%] comfort focused vs 18.2% [95% CI, 14.7%-21.7%] longevity focused or unsure; P < .001), or had not discussed stopping dialysis (estimated probability, 33.3% [95% CI, 29.0%-37.7%] comfort focused vs 21.9% [95% CI, 18.2%-25.8%] longevity focused or unsure; P < .001). Most respondents wanted to receive cardiopulmonary resuscitation (estimated probability, 78.0% [95% CI, 74.2%-81.7%] comfort focused vs 93.9% [95% CI, 91.4%-96.1%] longevity focused or unsure; P < .001) and mechanical ventilation (estimated probability, 52.0% [95% CI, 47.4%-56.6%] comfort focused vs 77.9% [95% CI, 74.0%-81.7%] longevity focused or unsure; P < .001). Among decedents, the percentages of participants who received an intensive procedure during the final month of life (estimated probability, 23.5% [95% CI, 16.5%-31.0%] comfort focused vs 26.1% [95% CI, 18.0%-34.5%] longevity focused or unsure; P = .64), discontinued dialysis (estimated probability, 38.3% [95% CI, 32.0%-44.8%] comfort focused vs 30.2% [95% CI, 23.0%-37.8%] longevity focused or unsure; P = .09), and enrolled in hospice (estimated probability, 32.2% [95% CI, 25.7%-38.7%] comfort focused vs 23.3% [95% CI, 16.4%-30.5%] longevity focused or unsure; P = .07) were not statistically different.

Conclusions and Relevance

This survey study found that there appeared to be a disconnect between patients' expressed values, which were largely comfort focused, and their engagement in advance care planning and end-of-life care, which reflected a focus on longevity. These findings suggest important opportunities to improve the quality of care for patients receiving dialysis.

"It helps us say what's important..." Developing Serious Illness Topics: A clinical visit agenda-setting tool

BACKGROUND

Skillful communication with attention to patient and care partner priorities can help people with serious illnesses. Few patient-facing agenda-setting tools exist to facilitate such communication.

OBJECTIVE

To develop a tool to facilitate prioritization of patient and care partner concerns during serious illness visits.

PATIENT OR FAMILY INVOLVEMENT

Two family members of seriously ill individuals advised.

METHODS

We performed a literature review and developed a prototype agenda-setting tool. We modified the tool based on cognitive interviews with patients, families and clinicians. We piloted the tool with patients, care partners and clinicians to gain an initial impression of its perceived value.

RESULTS

Interviews with eight patients, eight care partners and seven clinicians, resulted in refinements to the initial tool, including supplementation with visual cues. In the pilot test, seven clinicians used the tool with 11 patients and 12 family members. Qualitatively, patients and care partners reported the guide helped them consider and assert their priorities. Clinicians reported the tool complemented usual practice. Most participants reported no distress, disruption or confusion.

DISCUSSION

Patients, care partners and clinicians appreciated centering patient priorities in serious illness visits using the agenda-setting tool. More thorough evaluation is required.

PRACTICAL VALUE

The agenda-setting tool may operationalize elements of good serious illness care.

A Novel Curriculum to Improve Medical Student Preparedness to have Advance Care Planning Discussions

Background: Physicians report inadequate training in advance care planning (ACP) discussions despite the importance of these skills for practicing physicians including new residents. Objectives: To evaluate the effectiveness of a novel curriculum to prepare graduating medical students to have ACP discussions. Design: An ACP curriculum was implemented within a new fourth-year medical student elective with a focus on interactive educational methods and simulated experiences. Setting/Subjects: Forty-seven students received the curriculum over 3 years at a medium-sized, urban medical school. Measurements: Students were surveyed regarding attitudes and comfort related to ACP discussions and end-of-life (EOL) topics before and after the course. Additionally, students were asked about baseline experiences in the pre-course survey and perceived effectiveness of the educational methods in the post-course survey. Results: Comfort discussing EOL care decisions without supervision rose from 4% to 36% after the course with none of the students feeling they needed maximal help from a supervisor after the course compared to 51% before the course. All students agree or strongly agreed (Likert 4 or 5) that they felt prepared to discuss patient's wishes and values in EOL care with a real patient or family after the course. Conclusions: An ACP curriculum can increase student comfort and preparedness to have these conversations as residents. Students found small group discussions and the chance for direct practice with simulated patients to be most helpful. These findings can help guide implementation of ACP curricula in medical education.

[Implementation of a multimodal strategy for information and collection of advance directives in a comprehensive cancer center]

INTRODUCTION

In France, advance directives (AD) remain unknown and underused by healthcare users and professionals. This is particularly true in oncology. This work was carried out with patients and caregivers of a Comprehensive Cancer Center to improve their appropriation and information.

METHODS

The project, built by the Ethics Committee, the Patients Committee and the Palliative Care Team, made it possible to develop over 6 months a training program, an information procedure and several original documents.

RESULTS

A total of 34 one-hour training courses for all professionals were organized. A procedure for making information available, including the right to draft ADs, has been implemented. This procedure is personalized, gradual and multi-professional. When a patient wishes to write his AD, he is accompanied by a dedicated team and benefits from a specific form, which enlighten values and preferences before addressing the desired level of therapeutic commitment. Communication elements were diffused, and a specific training on "anticipated discussions" was created. A dedicated space in the computerized chart makes it possible to locate the existence of ADs and to display them instantaneously. DISCUSSION - CONCLUSION: Based on the observation of the obstacles to the use of ADs, the strategy we implemented aims to provide information that is both efficient and ethically respectful for both patients and caregivers. ADs are only one element facilitating autonomy and anticipation, and must be associated with a shared continuous definition of the project and of the goals of care.

Predictors of Documented Goals-of-Care Discussion for Hospitalized Patients With Chronic Illness

CONTEXT

Goals-of-care discussions are important for patient-centered care among hospitalized patients with serious illness. However, there are little data on the occurrence, predictors, and timing of these discussions.

OBJECTIVES

To examine the occurrence, predictors, and timing of electronic health record (EHR)-documented goals-of-care discussions for hospitalized patients.

METHODS

This retrospective cohort study used natural language processing (NLP) to examine EHR-documented goals-of-care discussions for adults with chronic life-limiting illness or age ≥80 hospitalized 2015-2019. The primary outcome was NLP-identified documentation of a goals-of-care discussion during the index hospitalization. We used multivariable logistic regression to evaluate associations with baseline characteristics.

RESULTS

Of 16,262 consecutive, eligible patients without missing data, 5,918 (36.4%) had a documented goals-of-care discussion during hospitalization; approximately 57% of these discussions occurred within 24 hours of admission. In multivariable analysis, documented goals-of-care discussions were more common for women (OR=1.26, 95%CI 1.18-1.36), older patients (OR=1.04 per year, 95%CI 1.03-1.04), and patients with more comorbidities (OR=1.11 per Deyo-Charlson point, 95%CI 1.10-1.13), cancer (OR=1.88, 95%CI 1.72-2.06), dementia (OR=2.60, 95%CI 2.29-2.94), higher acute illness severity (OR=1.12 per National Early Warning Score point, 95%CI 1.11-1.14), or prior advance care planning documents (OR=1.18, 95%CI 1.08-1.30). Documentation of these discussions was less common for racially or ethnically minoritized patients (OR=0.823, 95%CI 0.75-0.90).

CONCLUSION

Among hospitalized patients with serious illness, documented goals-of-care discussions identified by NLP were more common among patients with older age and increased burden of acute or chronic illness, and less common among racially or ethnically minoritized patients. This suggests important disparities in goals-of-care discussions.

Study protocol of a randomized controlled trial of fistula vs. graft arteriovenous vascular access in older adults with end-stage kidney disease on hemodialysis: the AV access trial

BACKGROUND

Treatment of end-stage kidney disease (ESKD) with hemodialysis requires surgical creation of an arteriovenous (AV) vascular access-fistula (AVF) or graft (AVG)-to avoid (or limit) the use of a central venous catheter (CVC). AVFs have long been considered the first-line vascular access option, with AVGs as second best. Recent studies have suggested that, in older adults, AVGs may be a better strategy than AVFs. Lacking evidence from well-powered randomized clinical trials, integration of these results into clinical decision making is challenging. The main objective of the AV Access Study is to compare, between the two types of AV access, clinical outcomes that are important to patients, physicians, and policy makers.

METHODS

This is a prospective, multicenter, randomized controlled trial in adults ≥ 60 years old receiving chronic hemodialysis via a CVC. Eligible participants must have co-existing cardiovascular disease, peripheral arterial disease, and/or diabetes mellitus; and vascular anatomy suitable for placement of either type of AV access. Participants are randomized, in a 1:1 ratio, to a strategy of AVG or AVF creation. An estimated 262 participants will be recruited across 7 healthcare systems, with average follow-up of 2 years. Questionnaires will be administered at baseline and semi-annually. The primary outcome is the rate of CVC-free days per 100 patient-days. The primary safety outcome is the cumulative incidence of vascular access (CVC or AV access)-related severe infections-defined as access infections that lead to hospitalization or death. Secondary outcomes include access-related healthcare costs and patients' experiences with vascular access care between the two treatment groups.

DISCUSSION

In the absence of studies using robust and unbiased research methodology to address vascular access care for hemodialysis patients, clinical decisions are limited to inferences from observational studies. The goal of the AV Access Study is to generate evidence to optimize vascular access care, based on objective, age-specific criteria, while incorporating goals of care and patient preference for vascular access type in clinical decision-making.

TRIAL REGISTRATION

This study is being conducted in accordance with the tenets of the Helsinki Declaration, and has been approved by the central institutional review board (IRB) of Wake Forest University Health Sciences (approval number: 00069593) and local IRB of each participating clinical center; and was registered on Nov 27, 2020, at ClinicalTrials.gov (NCT04646226).

Non-beneficial admission to the intensive care unit: A nationwide survey of practices

INTRODUCTION

In a nationwide survey of practices, we sought to define the criteria, circumstances and consequences of non-beneficial admissions to the intensive care unit (ICU), with a view to proposing measures to avoid such situations.

METHODS

ICU physicians from a French research in ethics network participated in an online survey. The first part recorded age, sex, and years' experience of the participants. In the second part, there were 8 to 12 proposals on each of 4 main domains: (1) What criteria could be used to qualify an ICU stay as non-beneficial? (2) What circumstances result in the admission of a patient whose ICU stay may later be deemed non-beneficial? (3) What are the consequences of a non-beneficial stay in the ICU? (4) What measures could be implemented to avoid admissions that later come to be considered as non-beneficial? Responses were on a 5-point Likert scale ranging from "Strongly disagree" to "Strongly agree".

RESULTS

Among 164 physicians contacted, 154 (94%) responded. The majority cited several criteria used to qualify a stay as non-beneficial. Similarly, >80% cited several possible circumstances that could result in non-beneficial admissions, including lack of knowledge of the case and the patient's history, and failure to anticipate acute deterioration. Possible consequences of non-beneficial stays included stress and anxiety for the patient/family, misunderstandings and conflict. Discussing the utility of possible ICU admission in the framework of the patient's overall healthcare goals was hailed as a means to prevent non-beneficial admissions.

CONCLUSION

The results of this survey suggest that joint discussions should take place during the patient's healthcare trajectory, before the acute need for ICU arises, with a view to limiting or avoiding ICU stays that may later come to be deemed "non-beneficial".