Impact of end-of-life discussions on the reduction of Latino/non-Latino disparities in do-not-resuscitate order completion

Inequity in Cancer and Cancer Care Delivery in the United States

Inequity exists along the continuum of cancer and cancer care delivery in the United States. Marginalized populations have later stage cancer at diagnosis, decreased likelihood of receiving cancer-directed care, and worse outcomes from treatment. These inequities are driven by historical, structural, systemic, interpersonal, and internalized factors that influence cancer across the pathologic and clinical continuum. To ensure equity in cancer care, interventions are needed at the level of policy, care delivery, interpersonal communication, diversity within the clinical workforce, and clinical trial accessibility and design.

Refinement of an Emergency Department-Based, Advance Care Planning Intervention for Patients With Cognitive Impairment and Their Caregivers

BACKGROUND AND OBJECTIVES

Advance care planning (ACP) conversations are important to provide goal-concordant care (i.e., the care that matches the patient's previously stated goals) near end of life. While 31% of older adults presenting to the emergency department (ED) have dementia, only 39% have previously had ACP conversations. We refined and piloted an ED-based, motivational interview designed to stimulate ACP conversations (ED GOAL) for patients living with cognitive impairment and their caregivers.

RESEARCH DESIGN AND METHODS

We systematically refined ED GOAL and then conducted an acceptability study in an urban, academic medical center. We prospectively enrolled adults aged 50+ with cognitive impairment and their caregivers. Trained clinicians conducted the intervention. We measured acceptability after the intervention and participants' ACP engagement at baseline and 1-month follow-up.

RESULTS

Specific statements to address both the patient and caregiver were added to the ED GOAL script. Of 60 eligible patient/caregiver dyads approached, 26 participated, and 20 (77%) completed follow-up assessments. Patient mean age was 79 years (SD 8.5); 65% were female, 92.3% were White, 96.2% were non-Hispanic, and 69% had moderate dementia. Most patients/caregivers reported feeling completely heard and understood by the study clinician about their future medical care preferences (58%, 15/26). They also reported that the study clinician was very respectful (96%, 25/26) when eliciting those preferences.

DISCUSSION AND IMPLICATIONS

Patients living with cognitive impairment and their caregivers found our refined ED GOAL acceptable and respectful. Future studies need to examine the effect of ED GOAL on ACP engagement among these dyads in the ED.

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.

Advance Care Planning for Spanish-Language Speakers: Patient, Family, and Interpreter Perspectives

Language access barriers for individuals with limited-English proficiency are a challenge to advance care planning (ACP). Whether Spanish-language translations of ACP resources are broadly acceptable by US Spanish-language speakers from diverse countries is unclear. This ethnographic qualitative study ascertained challenges and facilitators to ACP with respect to Spanish-language translation of ACP resources. We conducted focus groups with a heterogeneous sample of 29 Spanish-speaking persons who had experience with ACP as a patient, family member, and/or medical interpreter. We conducted thematic analysis with axial coding. Themes include: (1). ACP translations are confusing; (2). ACP understanding is affected by country of origin; (3). ACP understanding is affected by local healthcare provider culture and practice; and (4). ACP needs to be normalized into local communities. ACP is both a cultural and clinical practice. Recommendations for increasing ACP uptake extend beyond language translation to acknowledging users' culture of origin and local healthcare culture.

Planning for Your Advance Care Needs (PLAN): A Communication Intervention to Improve Advance Care Planning among Latino Patients with Advanced Cancer

BACKGROUND

The goal of this study was to develop and optimize an intervention designed to address barriers to engagement in advance care planning (ACP) among Latino patients with advanced cancer. The resulting intervention, titled Planning Your Advance Care Needs (PLAN), is grounded in theoretical models of communication competence and sociocultural theory.

MATERIALS AND METHODS

An initial version of the PLAN manual was developed based on a prior intervention, Ca-HELP, that was designed to improve communication around pain among cancer patients. PLAN uses this framework to coach patients on how to plan for and communicate their end-of-life care needs through ACP. In the present study, feedback was obtained from key stakeholders (n = 11 patients, n = 11 caregivers, n = 10 experts) on this preliminary version of the PLAN manual. Participants provided ratings of acceptability and feedback around the intervention content, format, design, modality, and delivery through quantitative survey questions and semi-structured qualitative interviews.

RESULTS

Results indicated that the PLAN manual was perceived to be helpful and easy to understand. All stakeholder groups liked the inclusion of explicit communication scripts and guidance for having conversations about ACP with loved ones and doctors. Specific feedback was given to modify PLAN to ensure it was optimized and tailored for Latino patients. Some patients noted reviewing the manual motivated engagement in ACP.

CONCLUSIONS

Feedback from stakeholders resulted in an optimized, user-centered version of PLAN tailored to Latino patients. Future research will examine the acceptability, feasibility, and potential efficacy of this intervention to improve engagement in ACP.

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.

How does ethnicity affect presence of advance care planning in care records for individuals with advanced disease? A mixed-methods systematic review

BACKGROUND

Advance care planning (ACP) is the process supporting individuals with life-limiting illness to make informed decisions about their future healthcare. Ethnic disparities in ACP have been widely highlighted, but interpretation is challenging due to methodological heterogeneity. This review aims to examine differences in the presence of documented ACP in individuals' care records for people with advanced disease by ethnic group, and identify patient and clinician related factors contributing to this.

METHODS

Mixed-methods systematic review. Keyword searches on six electronic databases were conducted (01/2000-04/2022). The primary outcome measure was statistically significant differences in the presence of ACP in patients' care records by ethnicity: quantitative data was summarised and tabulated. The secondary outcome measures were patient and clinician-based factors affecting ACP. Data was analysed qualitatively through thematic analysis; themes were developed and presented in a narrative synthesis. Feedback on themes was gained from Patient and Public Involvement (PPI) representatives. Study quality was assessed through Joanna Briggs Institute Critical Appraisal tools and Gough's Weight of Evidence.

RESULTS

N=35 papers were included in total; all had Medium/High Weight of Evidence. Fifteen papers (comparing two or more ethnic groups) addressed the primary outcome measure. Twelve of the fifteen papers reported White patients had statistically higher rates of formally documented ACP in their care records than patients from other ethnic groups. There were no significant differences in the presence of informal ACP between ethnic groups. Nineteen papers addressed the secondary outcome measure; thirteen discussed patient-based factors impacting ACP presence with four key themes: poor awareness and understanding of ACP; financial constraints; faith and religion; and family involvement. Eight papers discussed clinician-based factors with three key themes: poor clinician confidence around cultural values and ideals; exacerbation of institutional constraints; and pre-conceived ideas of patients' wishes.

CONCLUSIONS

This review found differences in the presence of legal ACP across ethnic groups despite similar presence of informal end of life conversations. Factors including low clinician confidence to deliver culturally sensitive, individualised conversations around ACP, and patients reasons for not wishing to engage in ACP (including, faith, religion or family preferences) may begin to explain some documented differences.

TRIAL REGISTRATION

PROSPERO-CRD42022315252.

Relationship Between Religion/Spirituality and the Aggressiveness of Cancer Care: A Scoping Review

CONTEXT

Religiosity/spirituality/religious-spiritual coping (RS) are resources used by cancer patients with cancer to help cope with the disease and may influence the preference and receipt of end-of-life (EOL) treatment.

OBJECTIVES

To examine the relationship between RS and the EOL care preferred or received by cancer patients.

METHODS

This review protocol is registered on (International Prospective Register of Systematic Review, CRD42021251833) and follows the recommendations of the preferred reporting items for systematic reviews and meta-analyses checklist. Embase, Proquest, PubMed, Scopus, and Web of Science databases were consulted. Google Scholar was consulted for additional publications and gray literature. Quantitative studies including adults with any cancer type/stage were eligible. The paper selection was performed by two independent reviewers; the methodological quality was measured using the Newcastle Ottawa scale.

RESULTS

Seventeen studies were included in the review. In general, RS is related to the preference or receipt of aggressive EOL care and with less advance care planning. Spiritual care by the medical team is related to higher referral to hospice and less aggressive care; in contrast, high spiritual support from religious communities is associated with less hospice and more aggressive care. Religious denominations influenced health care preferences, as Catholics were less likely to sign a do-not-resuscitate order and Buddhists or Taoists received more aggressive interventions at the EOL. Most studies (70%) were of high quality according to the Newcastle Ottawa scale.

CONCLUSION

RS is associated with more aggressive EOL treatments, as well as with lower rates of ACP in cancer patients. On the other hand, spiritual care provided by the medical team seems to be associated with less aggressive EOL care.

Emergency department-based, nurse-initiated, serious illness conversation intervention for older adults: a protocol for a randomized controlled trial

BACKGROUND

Visits to the emergency department (ED) are inflection points in patients' illness trajectories and are an underutilized setting to engage seriously ill patients in conversations about their goals of care. We developed an intervention (ED GOAL) that primes seriously ill patients to discuss their goals of care with their outpatient clinicians after leaving the ED. The aims of this study are (i) to test the impact of ED GOAL administered by trained nurses on self-reported, advance care planning (ACP) engagement after leaving the ED and (ii) to evaluate whether ED GOAL increases self-reported completion of serious illness conversation and other patient-centered outcomes.

METHODS

This is a two-armed, parallel-design, single-blinded, randomized controlled trial of 120 seriously ill older adults in two academic and one community EDs in Boston, MA. Participants are English-speaking adults 50 years and older with a serious life-limiting illness with a recent ED visit. Patients with a valid MOLST (medical order for life-sustaining treatment) form or other documented goals of care within the last 3 months are excluded. We enroll the caregivers of patients with cognitive impairment. Patients are assigned to the intervention or control group using block randomization. A blinded research team member will perform outcome assessments. We will assess (i) changes in ACP engagement within 6 months and (ii) qualitative assessments of the effect of ED GOAL.

DISCUSSION

In seriously ill older adults arriving in the ED, this randomized controlled trial will test the effects of ED GOAL on patients' self-reported ACP engagement, EMR documentation of new serious illness conversations, and improving patient-centered outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT05209880.

The effect of end-of-life decision-making tools on patient and family-related outcomes of care among ethnocultural minorities: A systematic review

Background

End-of-life decision-making tools are used to establish a shared understanding among patients, families and healthcare providers about medical treatment and goals of care. This systematic review aimed to understand the availability and effect of end-of-life decision-making tools on: (i) goals of care and advance care planning; (ii) patient and/or family satisfaction and well-being; and (iii) healthcare utilization among racial/ethnic, cultural, and religious minorities.

Methods

A search was conducted in four electronic databases (inception to June 2021). Articles were screened for eligibility using pre-specified criteria. We focused on adult patients (aged ≥18 years) and included primary research articles that used quantitative, qualitative, and mixed-methods designs. Complementary quality assessment tools were used to generate quality scores for individual studies. Extracted data were synthesized by outcome measure for each type of tool, and an overall description of findings showed the range of effects.

Results

Among 14,316 retrieved articles, 37 articles were eligible. We found that advance care planning programs (eleven studies), healthcare provider-led interventions (four studies), and linguistically-tailored decision aids (three studies) increased the proportion of patients documenting advance care plans. Educational tools (three studies) strongly reduced patient preferences for life-prolonging care. Palliative care consultations (three studies) were strongly associated with do-not-resuscitate orders. Advance care planning programs (three studies) significantly influenced the quality of patient-clinician communication and healthcare provider-led interventions (two studies) significantly influenced perceived patient quality of life.

Conclusion

This review identified several end-of-life decision-making tools with impact on patient and family-related outcomes of care among ethnocultural minorities. Advance care planning programs, healthcare provider-led interventions and decision aids increased documentation of end-of-life care plans and do-not-resuscitate orders, and educational tools reduced preferences for life-prolonging care. Further research is needed to investigate the effect of tools on healthcare utilization, and with specific patient population subgroups across different illness trajectories and healthcare settings.

Full Code to Do-Not-Resuscitate: Culturally Adapted Palliative Care Consultations and Code Status Change Among Seriously Ill Hispanic Patients

BACKGROUND

Palliative care and hospice services are disproportionately underutilized by ethnic minority patients. Addressing barriers to utilization of these services is critical to reducing disparities. The purpose of this study was to assess the impact of a culturally adapted palliative care consultation service for Hispanics on end-of-life decisions, specifically likelihood of changing from full code to do-not-resuscitate (DNR) status during index admission for serious illness.

METHODS

A cross-sectional study design was applied to data extracted from electronic health records (EHR) of patients seen by a Geriatric Palliative Care service during inpatient stays between 2018 and 2019. The majority of referrals came from critical care sites. Culturally adapted palliative care consultations using the SPIKES tool featured a Spanish-speaking team member leading discussions, involvement of multiple and key family members, and a chaplain who is a Catholic Priest.

RESULTS

The analytic sample included 351 patients who were, on average, 72 years old. 54.42% were female, 59.54% were Hispanic, and of Hispanic patients, 47.37% spoke primarily Spanish. Culturally adapted consults resulted in higher rates of conversion to DNR status in palliative cases of the target population. Both primary language and ethnicity were associated with likelihood of change from full code to DNR status, such that Spanish speakers and those of Hispanic ethnicity were more likely to switch to DNR than non-Hispanics and English-Speakers.

CONCLUSION

This study illustrates how culturally adapted palliative care consultations can help reduce barriers and improve end-of-life decision-making, and can be applied with similar populations of seriously ill Hispanic patients.

End-of-life discussions reduce the utilization of life-sustaining treatments during the last three months of life in cancer patients

Studies to examine the impact of end-of-life (EOL) discussions on the utilization of life-sustaining treatments near death are limited and have inconsistent findings. This nationwide population-based cohort study determined the impact of EOL discussions on the utilization of life-sustaining treatments in the last three months of life in Taiwanese cancer patients. From 2012 to 2018, this cohort study included adult cancer patients, which were confirmed by pathohistological reports. Life-sustaining treatments during the last three months of life included cardiopulmonary resuscitation, intubation, and defibrillation. EOL discussions in cancer patients were confirmed by their medical records. Association of EOL discussions with utilization of life-sustaining treatments were assessed using multiple logistic regression. Of 381,207 patients, the mean age was 70.5 years and 19.4% of the subjects received life-sustaining treatments during the last three months of life. After adjusting for other covariates, those who underwent EOL discussions were less likely to receive life-sustaining treatments during the last three months of life compared to those who did not (Adjusted odds ratio [AOR] 0.87; 95% confidence interval [CI] 0.85–0.89). Considering the type of treatments, EOL discussions correlated with a lower likelihood of receiving cardiopulmonary resuscitation (AOR = 0.45, 95% CI 0.43–0.47), endotracheal intubation (AOR = 0.92, 95%CI 0.90–0.95), and defibrillation (AOR = 0.54, 95%CI 0.49–0.59). Since EOL discussions are associated with less aggressive care, our study supports the importance of providing these discussions to cancer patients during the EOL treatment.

Utilisation of goals of care discussions and palliative care prior to image-guided procedures near the end of life

AIM

To characterise image-guided procedures performed near the end of life and the use of goals of care discussions (GOC) and palliative care consultation (PCC) prior to these procedures.

MATERIALS AND METHODS

Retrospective chart review of 3,714 consecutive inpatient procedures performed for 2,351 patients and 8,206 outpatient procedures performed for 5,225 patients within a suburban medical system. Data were collected on demographics, procedures performed, mortality, and use of GOC or PCC prior to the procedures. Procedures near the end of life were classified as emergent, elective, or palliative. Logistic regression was used to assess for demographic disparities in care.

RESULTS

Nine percent of inpatients died within 30 days of their procedure, 57% of which were within the same hospitalisation. Of these patients, 59% had a documented GOC and 35% had a PCC. Similarly, 7% of outpatients died within 6 months of their procedure. A minority of these patients had a documented GOC (37%) or PCC (13%). There were few statistically significant demographic disparities in this care and the associated odds ratios were small.

CONCLUSION

A wide array of image-guided procedures is performed near the end of life. GOC and PCC are underutilised prior to these procedures. Few demographic disparities exist in this care.

Noninvasive respiratory support outside the intensive care unit for acute respiratory failure related to coronavirus-19 disease: a systematic review and meta-analysis

BACKGROUND

Noninvasive respiratory support (NIRS) has been diffusely employed outside the intensive care unit (ICU) to face the high request of ventilatory support due to the massive influx of patients with acute respiratory failure (ARF) caused by coronavirus-19 disease (COVID-19). We sought to summarize the evidence on clinically relevant outcomes in COVID-19 patients supported by NIV outside the ICU.

METHODS

We searched PUBMED®, EMBASE®, and the Cochrane Controlled Clinical trials register, along with medRxiv and bioRxiv repositories for pre-prints, for observational studies and randomized controlled trials, from inception to the end of February 2021. Two authors independently selected the investigations according to the following criteria: (1) observational study or randomized clinical trials enrolling ≥ 50 hospitalized patients undergoing NIRS outside the ICU, (2) laboratory-confirmed COVID-19, and (3) at least the intra-hospital mortality reported. Preferred Reporting Items for Systematic reviews and Meta-analysis guidelines were followed. Data extraction was independently performed by two authors to assess: investigation features, demographics and clinical characteristics, treatments employed, NIRS regulations, and clinical outcomes. Methodological index for nonrandomized studies tool was applied to determine the quality of the enrolled studies. The primary outcome was to assess the overall intra-hospital mortality of patients under NIRS outside the ICU. The secondary outcomes included the proportions intra-hospital mortalities of patients who underwent invasive mechanical ventilation following NIRS failure and of those with 'do-not-intubate' (DNI) orders.

RESULTS

Seventeen investigations (14 peer-reviewed and 3 pre-prints) were included with a low risk of bias and a high heterogeneity, for a total of 3377 patients. The overall intra-hospital mortality of patients receiving NIRS outside the ICU was 36% [30-41%]. 26% [21-30%] of the patients failed NIRS and required intubation, with an intra-hospital mortality rising to 45% [36-54%]. 23% [15-32%] of the patients received DNI orders with an intra-hospital mortality of 72% [65-78%]. Oxygenation on admission was the main source of between-study heterogeneity.

CONCLUSIONS

During COVID-19 outbreak, delivering NIRS outside the ICU revealed as a feasible strategy to cope with the massive demand of ventilatory assistance.

REGISTRATION

PROSPERO, https://www.crd.york.ac.uk/prospero/ , CRD42020224788, December 11, 2020.

End of Life Decision-Making Challenges in a Latino Patient with COVID-19: Facing Barriers

COVID-19 pandemic brought difficult scenarios that patients and families are facing about end- of-life decisions. This exposed some weak areas in the healthcare system where we can continue improve in reducing disparities and emphasizing advance care planning from a primary level of care. We present a case of challenges in end-of-life decision-making in a Latino patient.

Nurses' Perceptions of Facilitating Advance Care Planning Conversations in the Emergency Department

Background: Nurses are well positioned to initiate advance care planning (ACP) conversations because of their unique strength in communication and central patient-facing role in the interdisciplinary team. Nurse-led ACP conversations have demonstrated promising results in settings outside of the emergency department (ED). Understanding ED nurses' perspectives regarding ACP conversations is needed before implementing similar practices in the ED.

Objective: To explore ED nurses' perception of facilitating ACP conversations.

Design: We conducted a cross-sectional survey to assess ED nurses' perceptions of facilitating ACP conversations in the ED.

Setting: ED nurses at one academic hospital and one community hospital located within the northeastern region of the United States.

Results: Seventy-seven (53.1%) out of 145 eligible ED nurses completed the survey. All participants perceived ACP conversations in the ED as at least somewhat important. Forty (51.9%) felt somewhat comfortable in facilitating these conversations. The majority of participants (77.9%) agreed that a specially trained nurse consultation model might be helpful in the ED. We found a correlation between total clinical experience and interest in facilitating ACP conversations in the ED (p = 0.045).

Conclusion: ED nurses are well positioned to help patients clarify their goals-of-care and end-of-life care preferences. They perceived ACP conversations to be important and felt comfortable to facilitate them in the ED. Additional studies are needed to empirically test its implementation.

Tough Decisions During the COVID 19 Pandemic: A Frail Latino Patient

The pandemic of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had overwhelmed the healthcare system worldwide with multiple ethical dilemmas. Several tools have been used to assess risk factors in these patients. One of them, the Clinical Frailty scale, has shown good correlation between the patient functional status and hospital stay with overall mortality. We present a case were the Clinical Frailty Scale was used to assess patient management and goals of care.

An Exploratory Study of Goals of Care Conversations Initiated with Seriously Ill Veterans in the Emergency Room

Background: Emergency department (ED) visits are common for older patients with chronic, life-limiting illnesses and may offer a valuable opportunity for clinicians to initiate proactive goals of care conversations (GoCC) to ensure end-of-life care that aligns with the patients' values, goals, and preferences. Objectives: The purpose of this study is to assess whether GoCC are occurring with patients in Department of Veteran Affairs (VA) EDs, to characterize these patients' goals of care and life-sustaining treatment (LST) decisions, and to examine the extent to which palliative or hospice consultations occur following the ED visit. Design: We conducted a cross-sectional retrospective study using health record data. Settings/Subjects: A total of 10,780 patients receiving care in VA, whose first GoCC occurred during an ED visit. Results: Of the patients in the study, approximately half were at least 70 years of age, three-quarters were white, and half had multiple serious disease comorbidities. The percentage of patients who desired cardiopulmonary resuscitation was lower among the highest risk (i.e., of hospitalization and death) patients (64% vs. 51%). The percentage of patients wanting other LSTs (e.g., mechanical ventilation) was higher among the lowest risk patients; and the percentage of patients requesting limits to LSTs was highest among higher risk patients. Eighteen percent of patients had a palliative or hospice care consult within three months of their ED visit. Conclusions: In this study, we verified that GoCC are being initiated in the ED with Veterans at differing stages in their illness trajectory and that higher proportions of higher risk patients preferred to limit LSTs.

Promotion of Advance Care Planning Among Young Adults: A Pilot Study of Health Engagement Workshop Feasibility, Implementation, and Efficacy

OBJECTIVE

This pilot study set out to evaluate the feasibility and efficacy of an interactive, peer-led, health engagement workshop to improve confidence and comprehension related to advance care planning (ACP) among young adults. Secondarily, this study evaluated if such workshops could promote ACP related behavior changes within this population.

METHODS

This observational cohort study utilized a repeated measures, mixed-method design. Six hour-long, in-person workshops were conducted with undergraduate students during meetings of university student organizations. Participants were evaluated across 3 mixed-method surveys, evaluating confidence, knowledge, and behaviors related to ACP prior to participation, directly after, and during a 2-week follow-up.

RESULTS

Workshop participation improved the average participant confidence and knowledge related to ACP as well as encouraged some participants to engage in discussions related to end-of-life care with friends and family. Alongside the impact of the workshops on knowledge and confidence, participants positively evaluated the design of the workshops through collected qualitative feedback.

CONCLUSION

These results are encouraging in assessing this population's willingness to learn about end-of-life care planning. The tools developed and the corresponding results should be used for further exploration of engaging the young adult population in ACP to promote improved healthcare outcomes.

Community Tele-pal: A community-developed, culturally based palliative care tele-consult randomized controlled trial for African American and White Rural southern elders with a life-limiting illness

BACKGROUND

Patients living in rural areas experience a variety of unmet needs that result in healthcare disparities. The triple threat of rural geography, racial inequities, and older age hinders access to high-quality palliative care (PC) for a significant proportion of Americans. Rural patients with life-limiting illness are at risk of not receiving appropriate palliative care due to a limited specialty workforce, long distances to treatment centers, and limited PC clinical expertise. Although culture strongly influences people's response to diagnosis, illness, and treatment preferences, culturally based care models are not currently available for most seriously ill rural patients and their family caregivers. The purpose of this randomized clinical trial (RCT) is to compare a culturally based tele-consult program (that was developed by and for the rural southern African American (AA) and White (W) population) to usual hospital care to determine the impact on symptom burden (primary outcome) and patient and care partner quality of life (QOL), care partner burden, and resource use post-discharge (secondary outcomes) in hospitalized AA and White older adults with a life-limiting illness.

METHODS

Community Tele-pal is a three-site RCT that will test the efficacy of a community-developed, culturally based PC tele-consult program for hospitalized rural AA and W older adults with life-limiting illnesses (n = 352) and a care partner. Half of the participants (n = 176) and a care partner (n = 176) will be randomized to receive the culturally based palliative care consult. The other half of the patient participants (n = 176) and care partners (n = 176) will receive usual hospital care appropriate to their illness.

DISCUSSION

This is the first community-developed, culturally based PC tele-consult program for rural southern AA and W populations. If effective, the tele-consult palliative program and methods will serve as a model for future culturally based PC programs that can reduce patients' symptoms and care partner burden.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03767517 . Registered on 27 December 2018.

Do Hispanics prefer to be full code at the end of life? The impact of palliative care consults on clarifying code status preferences and hospice referrals in Spanish-speaking patients

BACKGROUND

Hispanics often have disparities at the end of life. They are more likely to die full code and less likely to have discussions regarding prognosis and do not resuscitate (DNR)/do not intubate (DNI), despite studies showing Hispanic values comfort over the extension of life. Barriers to patient-centered care include language,socioeconomic status and health literacy.

CONTEXT

We evaluated the impact of palliative care (PC) consults on the change of code status and hospice referrals, comparing seriously ill Hispanic and non-Hispanic white patients.

METHOD

A retrospective cohort study of all white and Hispanic patients referred to the PC service of a county hospital from 2006 to 2012. We evaluated ethnicity, language, code status at admission and after PC consult, and hospice discharge. Chi-squared tests were used to analyze characteristics among three groups: non-Hispanic white, English-speaking Hispanic, and Spanish-speaking Hispanic patients.

RESULTS

Of 925 patients, 511 (55%) were non-Hispanic white, 208 (23%) were English-speaking Hispanic, and 206 (22%) were Spanish-speaking Hispanic patients. On admission, there was no statistically significant difference in code status among the three groups (57%, 64%, and 59% were full code, respectively, p = 0.5). After PC consults, Spanish-speaking Hispanic patients were more likely to change their code status to DNR/DNI when compared with non-Hispanic white and English-speaking Hispanic patients (44% vs. 32% vs. 28%, p = 0.05). Spanish-speaking Hispanic patients were more likely to be discharged to hospice when compared with English-speaking Hispanics and non-Hispanic whites (33%, 29%, and 23%, respectively, p = 0.04).

SIGNIFICANCE OF RESULTS

Spanish-speaking Hispanic patients were more likely to change from full code to DNR/DNI compared with non-Hispanic white and English-speaking Hispanic patients, despite similar code status preferences on admission. They were also more likely to be discharged to hospice. PC consults may play an important role in helping patients to align their care with their values and may prevent unwanted aggressive interventions at the end of life.

Do-not-intubate orders in patients with acute respiratory failure: a systematic review and meta-analysis

PURPOSE

To assess the rates and variability of do-not-intubate orders in patients with acute respiratory failure.

METHODS

We conducted a systematic review of observational studies that enrolled adult patients with acute respiratory failure requiring noninvasive ventilation or high-flow nasal cannula oxygen from inception to 2019.

RESULTS

Twenty-six studies evaluating 10,755 patients were included. The overall pooled rate of do-not-intubate orders was 27%. The pooled rate of do-not-intubate orders in studies from North America was 14% (range 9-22%), from Europe was 28% (range 13-58%), and from Asia was 38% (range 9-83%), p = 0.001. Do-not-intubate rates were higher in studies with higher patient age and in studies where do-not-intubate decisions were made without reported patient/family input. There were no significant differences in do-not-intubate orders according to illness severity, observed mortality, malignancy comorbidity, or methodological quality. Rates of do-not-intubate orders increased over time from 9% in 2000-2004 to 32% in 2015-2019. Only 12 studies (46%) reported information about do-not-intubate decision-making processes. Only 4 studies (15%) also reported rates of do-not-resuscitate.

CONCLUSIONS

One in four patients with acute respiratory failure (who receive noninvasive ventilation or high-flow nasal cannula oxygen) has a do-not-intubate order. The rate of do-not-intubate orders has increased over time. There is high inter-study variability in do-not-intubate rates-even when accounting for age and illness severity. There is high variability in patient/family involvement in do-not-intubate decision making processes. Few studies reported differences in rates of do-not-resuscitate and do-not-intubate-even though recovery is very different for acute respiratory failure and cardiac arrest.

Association of Emergency Clinicians' Assessment of Mortality Risk With Actual 1-Month Mortality Among Older Adults Admitted to the Hospital

IMPORTANCE

The accuracy of mortality assessment by emergency clinicians is unknown and may affect subsequent medical decision-making.

OBJECTIVE

To determine the association of the question, "Would you be surprised if your patient died in the next one month?" (known as the surprise question) asked of emergency clinicians with actual 1-month mortality among undifferentiated older adults who visited the emergency department (ED).

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study at a single academic medical center in Portland, Maine, included consecutive patients 65 years or older who received care in the ED and were subsequently admitted to the hospital from January 1, 2014, to December 31, 2015. Data analyses were conducted from January 2018 to March 2019.

EXPOSURES

Treating emergency clinicians were required to answer the surprise question, "Would you be surprised if your patient died in the next one month?" in the electronic medical record when placing a bed request for all patients who were being admitted to the hospital.

MAIN OUTCOMES AND MEASURES

The primary outcome was mortality at 1 month, assessed from the National Death Index. The secondary outcomes included accuracies of responses by both emergency clinicians and admitting internal medicine clinicians to the surprise question in identifying older patients with high 6-month and 12-month mortality.

RESULTS

The full cohort included 10 737 older adults (mean [SD] age, 75.9 [8.8] years; 5532 [52%] women; 10 157 [94.6%] white) in 16 223 visits treated in the ED and admitted to the hospital. There were 5132 patients (31.6%) with a Charlson Comorbidity Index score of 2 or more. Mortality rates were 8.3% at 1 month, 17.2% at 6 months, and 22.5% at 12 months. Emergency clinicians stated that they would not be surprised if the patient died in the next month for 2104 patients (19.6%). In multivariable analysis controlling for age, sex, race, admission diagnosis, and comorbid conditions, the odds of death at 1 month were higher in patients for whom clinicians answered that they would not be surprised if the patient died in the next 1 month compared with patients for whom clinicians answered that they would be surprised if the patient died in the next 1 month (odds ratio, 2.4 [95% CI, 2.2-2.7]; P < .001). However, the diagnostic test characteristics of the surprise question were poor (sensitivity, 20%; specificity, 93%; positive predictive value, 43%; negative predictive value, 82%; accuracy, 78%; area under the receiver operating curve of the multivariable model, 0.73 [95% CI, 0.72-0.74; P < .001]).

CONCLUSIONS AND RELEVANCE

This study found that asking the surprise question of emergency clinicians may be a valuable tool to identify older patients in the ED with a high risk of 1-month mortality. The effect of implementing the surprise question to improve population-level health care for older adults in the ED who are seriously ill remains to be seen.

Goals-of-Care Conversations for Older Adults With Serious Illness in the Emergency Department: Challenges and Opportunities

During the last 6 months of life, 75% of older adults with preexisting serious illness, such as advanced heart failure, lung disease, and cancer, visit the emergency department (ED). ED visits often mark an inflection point in these patients' illness trajectories, signaling a more rapid rate of decline. Although most patients are there seeking care for acute issues, many of them have priorities other than to simply live as long as possible; yet without discussion of preferences for treatment, they are at risk of receiving care not aligned with their goals. An ED visit may offer a unique "teachable moment" to empower patients to consider their ability to influence future medical care decisions. However, the constraints of the ED setting pose specific challenges, and little research exists to guide clinicians treating patients in this setting. We describe the current state of goals-of-care conversations in the ED, outline the challenges to conducting these conversations, and recommend a research agenda to better equip emergency physicians to guide shared decisionmaking for end-of-life care. Applying best practices for serious illness communication may help emergency physicians empower such patients to align their future medical care with their values and goals.

Discussing End-of-Life Care Preferences With Family: Role of Race and Ethnicity

This study examined racial, ethnic, and other factors associated with whether older adults discussed their end-of-life (EOL) care wishes with family. A sample of 223 White, 95 African American, and 46 Hispanic adults aged 50 and older from a five-county area of Florida answered questions about sociodemographics, health, and preferences for involving family/friends in health-care decision-making. Analyses describe associations between whether discussions occurred and race/ethnicity and other factors, including preferences for family/friend involvement in health care. In descriptive analyses, one third ( n = 113) had not discussed EOL care. No differences were evident between African Americans and non-Hispanic Whites. In multivariate analyses, EOL care discussions were less likely for Hispanics. Further analysis showed this lower likelihood existed among Hispanics with lesser family/friend involvement. Ethnicity influences EOL care discussion, moderated by family/friend involvement, though results are considered preliminary. Knowing the involvement of patients’ family/friends could help providers initiate EOL care discussions.

Wellness in Sickness and Health (The W.I.S.H. Project): Advance Care Planning Preferences and Experiences Among Elderly Latino Patients

OBJECTIVE

To assess advance care planning (ACP) preferences, experiences, and comfort in discussing end-of-life (EOL) care among elderly Latinos.

METHODS

Patients aged 60 and older from the Los Angeles County and University of Southern California (LAC+USC) Medical Center Geriatrics Clinic (n = 41) participated in this intervention. Trained staff conducted ACP counseling with participants in their preferred language, which included: (a) pre-counseling survey about demographics and EOL care attitudes, (b) discussion of ACP and optional completion of an advance directive (AD), and (c) post-session survey.

RESULTS

Patients were primarily Spanish speaking with an average of 2.7 chronic medical conditions. Most had not previously documented (95%) or discussed (76%) EOL wishes. Most were unaware they had control over their EOL treatment (61%), but valued learning about EOL options (83%). Post-counseling, 85% reported comfort discussing EOL goals compared to 66% pre-session, and 88% elected to complete an AD. Nearly half of patients reported a desire to discuss EOL wishes sooner.

CONCLUSIONS

Elderly Latino patients are interested in ACP, given individualized, culturally competent counseling in their preferred language.

CLINICAL IMPLICATIONS

Patients should be offered the opportunity to discuss and document EOL wishes at all primary care appointments, regardless of health status. Counseling should be completed in the patient's preferred language, using culturally competent materials, and with family members present if this is the patient's preference. Cultural-competency training for providers could enhance the impact of EOL discussions and improve ACP completion rates for Latino patients.

Impact of Race and Ethnicity on End-of-Life Experiences for Children With Cancer

Background:

Racial and ethnic disparities in the provision of end-of-life care are well described in the adult oncology literature. However, the impact of racial and ethnic disparities at end of life in the context of pediatric oncology remains poorly understood.

Objective:

To investigate associations between end-of-life experiences and race/ethnicity for pediatric patients with cancer.

Methods:

A retrospective cohort study was conducted on 321 children with cancer enrolled on a palliative care service at an urban pediatric cancer who died between 2011 and 2015.

Results:

Compared to white patients, black patients were more likely to receive cardiopulmonary resuscitation (CPR; odds ratio [OR]: 4.109, confidence interval [CI]: 1.432-11.790, P = .009) and underwent 3.136 (CI: 1.433-6.869, P = .004) CPR events for every 1 white patient CPR event. The remainder of variables related to treatment and end-of-life care were not significantly correlated with race. Hispanic patients were less likely to receive cancer-directed therapy within 28 days prior to death (OR: 0.493, CI: 0.247-0.982, P = .044) as compared to non-Hispanic patients, yet they were more likely to report a goal of cure over comfort as compared to non-Hispanic patients (OR: 3.094, CI: 1.043-9.174, P = .042). The remainder of variables were not found to be significantly correlated with ethnicity.

Conclusions:

Race and ethnicity influenced select end-of-life variables for pediatric palliative oncology patients treated at a large urban pediatric cancer center. Further multicenter investigation is needed to ascertain the impact of racial/ethnic disparities on end-of-life experiences of children with cancer.

Palliative Care Clinician Overestimation of Survival in Advanced Cancer: Disparities and Association With End-of-Life Care

CONTEXT

Clinicians frequently overestimate survival time in serious illness.

OBJECTIVE

The objective of this study was to understand the frequency of overestimation in palliative care (PC) and the relation with end-of-life (EOL) treatment.

METHODS

This is a multisite cohort study of 230 hospitalized patients with advanced cancer who consulted with PC between 2013 and 2016. We asked the consulting PC clinician to make their "best guess" about the patients' "most likely survival time, assuming that their illnesses are allowed to take their natural course" (<24 hours; 24 hours to less than two weeks; two weeks to less than three months; three months to less than six months; six months or longer). We followed patients for up to six month for mortality and EOL treatment utilization. Patients completed a brief interviewer-facilitated questionnaire at study enrollment.

RESULTS

Median survival was 37 days (interquartile range: 12 days, 97 days) and 186/230 (81%) died during the follow-up period. Forty-one percent of clinicians' predictions were accurate. Among inaccurate prognoses, 85% were overestimates. Among those who died, overestimates were substantially associated with less hospice use (OR_adj: 0.40; 95% CI: 0.16-0.99) and later hospice enrollment (within 72 hours of death OR_adj: 0.33; 95% CI: 0.15-0.74). PC clinicians were substantially more likely to overestimate survival for patients who identified as Black or Latino compared to others (OR_adj: 3.89; 95% CI: 1.64-9.22). EOL treatment preferences did not explain either of these findings.

CONCLUSION

Overestimation is common in PC, associated with lower hospice use and a potentially mutable source of racial/ethnic disparity in EOL care.

Fidelity and Feasibility of a Brief Emergency Department Intervention to Empower Adults With Serious Illness to Initiate Advance Care Planning Conversations

CONTEXT

Emergency department (ED) visits provide opportunities to empower patients to discuss advance care planning with their outpatient clinicians, but systematically developed, feasible interventions do not currently exist. Brief negotiated interview (BNI) interventions, which allow ED clinicians to efficiently motivate patients, have potential to meet this need.

OBJECTIVES

We developed a BNI ED intervention to empower older adults with life-limiting illness to formulate and communicate medical care goals to their primary outpatient clinicians. This study assessed the fidelity and feasibility of this intervention in a high-volume ED.

METHODS

We enrolled adult patients with serious illnesses (advanced cancer, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease on dialysis, predicted survival <12 months) in an urban, tertiary care academic medical center ED. All participants received the BNI intervention. We video-recorded the encounters. Two reviewers assessed the recordings for intervention fidelity based on adherence to the BNI steps (Part I) and communication skills (Part II).

RESULTS

We reviewed 46 video recordings. The mean total adherence score was 21.07/27 (SD 3.68) or 78.04%. The Part I mean adherence score was 12.07/15 (SD 2.07) or 80.47%. The Part II mean adherence score was 9.0/12 (SD 2.51) or 75%. The majority (75.6%) of recordings met the prespecified threshold for high intervention fidelity.

CONCLUSION

ED clinicians can deliver a BNI intervention to increase advance care planning conversations with high fidelity. Future research is needed to study the intervention's efficacy in a wider patient population.

The interactive effect of advanced cancer patient and caregiver prognostic understanding on patients' completion of Do Not Resuscitate orders

OBJECTIVE

Advanced cancer patients' prognostic understanding is associated with completion of Do Not Resuscitate (DNR) orders, which often represent engagement in advance care planning (ACP). Given caregivers' critical roles in patient decision-making about ACP and end-of-life care, caregivers' prognostic understanding may have a large additive effect. The present study examined the association between the main and interactive effects of advanced cancer patient and caregiver prognostic understanding on DNR order completion.

METHODS

Data were analyzed from a combined dataset of 2 sequential multi-institutional, longitudinal cohort studies of patients with advanced cancer and their informal caregivers (n = 279 dyads) from 2002 to 2008 (Coping with Cancer 1) and 2010 to 2015 (Coping with Cancer 2). Patients' and caregivers' prognostic understanding regarding life-expectancy (≤ 12 months [prognostic understanding], >12 months [lack of prognostic understanding]) was assessed. DNR order completion was assessed through self-report and confirmed through cross-checking with medical records.

RESULTS

Multivariable modeling of the main and interactive effects revealed the interactive effect, but not the individual effects, of patients' and caregivers' prognostic understanding was significantly associated with higher odds of patients' DNR order completion, adjusting for potential confounds (AOR = 5.89, P = 0.04). For dyads in which both the patient and caregiver had prognostic understanding regarding life expectancy of ≤12 months, 70.7% of patients had completed DNR orders compared with 31.6% to 38.9% in which 1 or both lacked prognostic understanding.

CONCLUSIONS

Findings highlight the need for ensuring accurate patient and caregiver prognostic understanding in increasing DNR order completion, which may provide a framework for improving engagement in ACP more broadly.