Processes of code status transitions in hospitalized patients with advanced cancer

General Surgery Resuscitation Preference Documentation: A Quality Improvement Initiative

BACKGROUND/PURPOSE

Documentation of resuscitation preferences is crucial for patients undergoing surgery. Unfortunately, this remains an area for improvement at many institutions. We conducted a quality improvement initiative to enhance documentation percentages by integrating perioperative resuscitation checks into the surgical workflow. Specifically, we aimed to increase the percentage of general surgery patients with documented resuscitation statuses from 82% to 90% within a 1-year period.

METHODS

Three key change ideas were developed. First, surgical consent forms were modified to include the patient's resuscitation status. Second, the resuscitation status was added to the routinely used perioperative surgical checklist. Finally, patient resources on resuscitation processes and options were updated with support from patient partners. An audit survey was distributed mid-way through the interventions to evaluate process measures.

RESULTS

The initiatives were successful in reaching our study aim of 90% documentation rate for all general surgery patients. The audit revealed a high uptake of the new consent forms, moderate use of the surgical checklist, and only a few patients for whom additional resuscitation details were added to their clinical note.

CONCLUSIONS

We successfully increased the documentation percentage of resuscitation statuses within our large tertiary care center by incorporating checks into routine forms to prompt the conversation with patients early.

In-Hospital Code Status Updates: Trends Over Time and the Impact of COVID-19

OBJECTIVE

The primary objective was to evaluate if the percentage of patients with missing or inaccurate code status documentation at a Trauma Level 1 hospital could be reduced through daily updates. The secondary objective was to examine if patient preferences for DNR changed during the COVID-19 pandemic.

METHODS

This retrospective study, spanning March 2019 to December 2022, compared the code status in ICU and ED patients drawn from two data sets. The first was based on historical electronic medical records (EHR), and the second involved daily updates of code status following patient admission.

RESULTS

Implementing daily updates upon admission was more effective in ICUs than in the ED in reducing missing code status documentation. Around 20% of patients without a specific code status chose DNR under the new system. During COVID-19, a decrease in ICU patients choosing DNR and an increase in full code (FC) choices were observed.

CONCLUSION

This study highlights the importance of regular updates and discussions regarding code status to enhance patient care and resource allocation in ICU and ED settings. The COVID-19 pandemic's influence on shifting patient preferences towards full code status underscores the need for adaptable documentation practices. Emphasizing patient education about DNR implications and benefits is key to supporting informed decisions that reflect individual health contexts and values. This approach will help balance the considerations for DNR and full code choices, especially during health care crises.

Oncology hospitalist impact on hospice utilization

BACKGROUND

Unplanned hospitalizations among patients with advanced cancer are often sentinel events prompting goals of care discussions and hospice transitions. Late referrals to hospice, especially those at the end of life, are associated with decreased quality of life and higher total health care costs. Inpatient management of patients with solid tumor malignancies is increasingly shifting from oncologists to oncology hospitalists. However, little is known about the impact of oncology hospitalists on the timing of transition to hospice.

OBJECTIVE

To compare hospice discharge rate and time to hospice discharge on an inpatient oncology service led by internal medicine-trained hospitalists and a service led by oncologists.

METHODS

At Smilow Cancer Hospital, internal medicine-trained hospitalists were integrated into one of two inpatient medical oncology services allowing comparison between the new, hospitalist-led service (HS) and the traditional, oncologist-led service (TS). Discharges from July 26, 2021, through January 31, 2022, were identified from the electronic medical record. The odds ratio for discharge disposition by team was calculated by logistic regression using a multinomial distribution. Adjusted length of stay before discharge was assessed using multivariable linear regression.

RESULTS

The HS discharged 47/400 (11.8%) patients to inpatient hospice, whereas the TS service discharged 18/313 (5.8%), yielding an adjusted odds ratio of 1.94 (95% CI, 1.07-3.51; p = .03). Adjusted average length of stay before inpatient hospice disposition was 6.83 days (95% CI, 4.22-11.06) for the HS and 16.29 days (95% CI, 7.73-34.29) for the TS (p = .003).

CONCLUSIONS

Oncology hospitalists improve hospice utilization and time to inpatient hospice referral on an inpatient medical oncology service.

PLAIN LANGUAGE SUMMARY

Patients with advanced cancer are often admitted to the hospital near the end of life. These patients generally have a poor chance of long-term survival and may prefer comfort-focused care with hospice. In this study, oncology hospitalists discharged a higher proportion of patients to inpatient hospice with less time spent in the hospital before discharge.

Sufficient Death Preparedness Correlates to Better Mental Health, Quality of Life, and EOL Care

CONTEXT

Patients can prepare for end of life and their forthcoming death to enhance the quality of dying.

OBJECTIVES

We aimed to longitudinally evaluate the never-before-examined associations of cancer patients' death-preparedness states by conjoint cognitive prognostic awareness and emotional preparedness for death with psychological distress, quality of life (QOL), and end-of-life care received.

METHODS

In this cohort study, we simultaneously evaluated associations of four previously identified death-preparedness states (no-death-preparedness, cognitive-death-preparedness-only, emotional-death-preparedness-only, and sufficient-death-preparedness states) with anxiety symptoms, depressive symptoms, and QOL over 383 cancer patients' last six months and end-of-life care received in the last month using multivariate hierarchical linear modeling and logistic regression modeling, respectively. Minimal clinically important differences (MCIDs) have been established for anxiety- (1.3-1.8) and depressive- (1.5-1.7) symptom subscales (0-21 Likert scales).

RESULTS

Patients in the no-death-preparedness and cognitive-death-preparedness-only states reported increases in anxiety symptoms and depressive symptoms that exceed the MCIDs, and a decline in QOL from those in the sufficient-death-preparedness state. Patients in the emotional-death-preparedness-only state were more (OR [95% CI]=2.38 [1.14, 4.97]) and less (OR [95% CI]=0.38 [0.15, 0.94]) likely to receive chemotherapy/immunotherapy and hospice care, respectively, than those in the sufficient-death-preparedness state. Death-preparedness states were not associated with life-sustaining treatments received in the last month.

CONCLUSION

Conjoint cognitive and emotional preparedness for death is associated with cancer patients' lower psychological distress, better QOL, reduced anti-cancer therapy, and increased hospice-care utilization. Facilitating accurate prognostic awareness and emotional preparedness for death is justified when consistent with patient circumstances and preferences.

Code Status Transitions in Patients with High-Risk Acute Myeloid Leukemia

Patients with AML often undergo code status transitions near the end of life; median time from last code status change to death was 2 days.

Patients participated in only 60.5% of final code status transitions, highlighting a need for earlier conversations to improve involvement.

Patients with high-risk acute myeloid leukemia (AML) often experience intensive medical care at the end of life (EOL), including high rates of hospitalizations and intensive care unit (ICU) admissions. Despite this, studies examining code status transitions are lacking. We conducted a mixed-methods study of 200 patients with high-risk AML enrolled in supportive care studies at Massachusetts General Hospital between 2014 and 2021. We defined high-risk AML as relapsed/refractory or diagnosis at age ≥60. We used a consensus-driven medical record review to characterize code status transitions. At diagnosis, 86.0% (172/200) of patients were “full code” (38.5% presumed, 47.5% confirmed) and 8.5% had restrictions on life-sustaining therapies. Overall, 57.0% of patients experienced a transition during the study period. The median time from the last transition to death was 2 days (range, 0-350). Most final transitions (71.1%) were to comfort measures near EOL; only 60.5% of patients participated in these last transitions. We identified 3 conversation types leading to transitions: informative conversations focusing on futility after clinical deterioration (51.0%), anticipatory conversations at the time of acute deterioration (32.2%), and preemptive conversations (15.6%) before deterioration. Younger age (B = 0.04; P = .002) and informative conversations (B = −2.79; P < .001) were associated with shorter time from last transition to death. Over two-thirds of patients were “presumed full code” at diagnosis of high-risk AML, and most experienced code status transitions focused on the futility of continuing life-sustaining therapies near EOL. These results suggest that goals-of-care discussions occur late in the illness course for patients with AML and warrant interventions to increase earlier discussions regarding EOL preferences.

Associations of prognostic-awareness-transition patterns with end-of-life care in cancer patients' last month

PURPOSE

Cancer patients heterogeneously develop prognostic awareness, and end-of-life cancer care has become increasingly aggressive to the detriment of patients and healthcare sustainability. We aimed to explore the never-before-examined associations of prognostic-awareness-transition patterns with end-of-life care.

METHODS

Prognostic awareness was categorized into four states: (1) unknown and not wanting to know; (2) unknown but wanting to know; (3) inaccurate awareness; and (4) accurate awareness. We examined associations of our previously identified three prognostic-awareness-transition patterns during 334 cancer patients' last 6 months (maintaining accurate prognostic awareness, gaining accurate prognostic awareness, and maintaining inaccurate/unknown prognostic awareness) and end-of-life care (cardiopulmonary resuscitation, intensive care unit care, mechanical ventilation, chemotherapy/immunotherapy, and hospice care) in cancer patients' last month by multivariate logistic regressions.

RESULTS

Cancer patients in the maintaining-accurate-prognostic-awareness and gaining-accurate-prognostic-awareness groups had significantly lower odds of cardiopulmonary resuscitation (adjusted odds ratio [95% confidence interval]: 0.22 [0.06-0.78]; and 0.10 [0.01-0.97], respectively) but higher odds of hospice care (3.44 [1.64-7.24]; and 3.28 [1.32-8.13], respectively) in the last month than those in the maintaining inaccurate/unknown prognostic awareness. The maintaining-accurate-prognostic-awareness group had marginally lower odds of chemotherapy or immunotherapy received than the gaining-accurate-prognostic-awareness group (0.58 [0.31-1.10], p = .096]). No differences in intensive care unit care and mechanical ventilation among cancer patients in different prognostic-awareness-transition patterns were observed.

CONCLUSION

End-of-life care received in cancer patients' last month was associated with the three distinct prognostic-awareness-transition patterns. Cancer patients' accurate prognostic awareness should be facilitated earlier to reduce their risk of receiving aggressive end-of-life care, especially for avoiding chemotherapy/immunotherapy close to death.

TRIAL REGISTRATION

ClinicalTrials.gov:NCT01912846.

Tracheostomy Decision-making Communication among Patients Receiving Prolonged Mechanical Ventilation

Rationale: Patients receiving prolonged mechanical ventilation experience high morbidity and mortality, poor quality of life, and significant caregiving and financial burden. It is unclear what is discussed with patients and families during the tracheostomy decision-making process.Objectives: The aim of this study was to identify themes of communication related to tracheostomy decision-making in patients receiving prolonged mechanical ventilation and to explore patient and clinical factors associated with more discussion of these themes.Methods: We conducted a mixed-methods study involving adult patients in medical or cardiac intensive care units who received continuous mechanical ventilation for ≥7 days and were considered for tracheostomy placement during the same admission. We performed a consensus-driven review of documented family meeting conversations to identify characteristics and themes related to tracheostomy decision-making. A multivariate analysis was performed to investigate patient and clinical factors associated with the discussion of one or more of the identified themes.Results: Of the 241 patients included, 191 (79.2%) had at least one documented conversation regarding tracheostomy decision-making, and 148 (61.4%) required further discussions before reaching a decision. We identified the following four themes related to tracheostomy decision-making: patient's previously expressed preferences, patient's baseline condition and functional status, long-term complications, and long-term prognosis. Of the documented conversations, 45.3% addressed none of the identified themes. Patients who did not undergo tracheostomy placement were more likely to have documented discussion of one or more themes compared with those who did (74.6% vs. 41.6%). In multivariate analysis, age ≥75, female sex, significant preadmission functional dependence, home oxygen requirement, and involvement of palliative care were associated with more documented discussion of one or more themes.Conclusions: Our findings suggest inadequate information exchange regarding patient preferences and long-term prognosis during tracheostomy decision-making, especially among patients who went on to pursue tracheostomy. There is a critical need to promote effective shared decision-making to better align tracheostomy intervention with patient values and to prevent unwanted health states at the end of life.

Goals of Care Discussions Over the Course of a Patient's End of Life Admission: A Retrospective Study

BACKGROUND

As deaths in hospitals increase, clear discussions regarding resuscitation status and treatment limitations, referred to as goals of care (GOC), are vital. GOC may need revision as disease and patient priorities change over time. There is limited data about who is involved in GOC discussions, and how this changes as patients deteriorate in hospital.

AIMS

To review the timing and clinicians involved in GOC discussions for a cohort of patients who died in hospital.

METHODS

Retrospective observational audit of 80 consecutive end of life admissions between March 11th and April 9th, 2019.

RESULTS

Of 80 patients, 75 (93.6%) had GOC recorded during their admission, about half for ward-based non-burdensome symptom management or end-of-life care. GOC were revised in 68.0% of cases. Medical staff involved in initial versus final GOC discussions included home team junior doctor (54.7% versus 72.5%), home team consultant (37.3% versus 56.9%) and ICU doctor (16.0% versus 21.6%). For initial versus final GOC decisions, patients were involved in 34.7% versus 31.4%, and family in 53.3% versus 86.3%. Dying was documented for 92.0% of patients and this was documented to have been communicated to the family and patient in 98.6% and 19.5% of cases respectively.

CONCLUSIONS

As patients deteriorated, family and senior clinician involvement in GOC discussions increased, but patient involvement did not. Junior doctors were most heavily involved in discussions. We advocate for further GOC training and modeling to enhance junior doctors' confidence and competence in conducting and involving patients and families in GOC conversations.

"Has Anything Changed Since Then?": A Framework to Incorporate Prior Goals-of-Care Conversations Into Decision-Making for Acutely Ill Patients

When assuming care for a seriously ill hospitalized patient, we should find documentation of previous decisions about goals of care so that our conversation takes advantage of previous discussions and reduces decision-making burden on the patient, particularly when the patient is clinically declining and time is short. This article presents a framework to help clinicians incorporate prior goals of care conversations into decision-making for an acutely ill patient. When there is strong evidence that a previous decision still applies, clinicians should, after a brief check-in about the previous decision with the patient, then present a plan consistent with their previous decision as a default option, to which they can opt out. If there is less evidence of the basis for a previous decision, clinicians should explore the thinking behind the decision and, if there is clarity about patient preferences, propose a treatment plan. If there is conflict or uncertainty about the patient's preferences, clinicians should engage in a more comprehensive goals-of-care conversation, which involves exploring the patient's understanding of their illness, patient values, and reasonable treatment options, before offering a plan. By giving the patient the ability to opt out of a previous decision they made about goals of care, rather than another choice, we make it more likely that they will receive care consistent with their known wishes.

Associations of Skeletal Muscle With Symptom Burden and Clinical Outcomes in Hospitalized Patients With Advanced Cancer

BACKGROUND

Low muscle mass (quantity) is common in patients with advanced cancer, but little is known about muscle radiodensity (quality). We sought to describe the associations of muscle mass and radiodensity with symptom burden, healthcare use, and survival in hospitalized patients with advanced cancer.

METHODS

We prospectively enrolled hospitalized patients with advanced cancer from September 2014 through May 2016. Upon admission, patients reported their physical (Edmonton Symptom Assessment System [ESAS]) and psychological (Patient Health Questionnaire-4 [PHQ-4]) symptoms. We used CT scans performed per routine care within 45 days before enrollment to evaluate muscle mass and radiodensity. We used regression models to examine associations of muscle mass and radiodensity with patients' symptom burden, healthcare use (hospital length of stay and readmissions), and survival.

RESULTS

Of 1,121 patients enrolled, 677 had evaluable muscle data on CT (mean age, 62.86 ± 12.95 years; 51.1% female). Older age and female sex were associated with lower muscle mass (age: B, -0.16; P<.001; female: B, -6.89; P<.001) and radiodensity (age: B, -0.33; P<.001; female: B, -1.66; P=.014), and higher BMI was associated with higher muscle mass (B, 0.58; P<.001) and lower radiodensity (B, -0.61; P<.001). Higher muscle mass was significantly associated with improved survival (hazard ratio, 0.97; P<.001). Notably, higher muscle radiodensity was significantly associated with lower ESAS-Physical (B, -0.17; P=.016), ESAS-Total (B, -0.29; P=.002), PHQ-4-Depression (B, -0.03; P=.006), and PHQ-4-Anxiety (B, -0.03; P=.008) symptoms, as well as decreased hospital length of stay (B, -0.07; P=.005), risk of readmission or death in 90 days (odds ratio, 0.97; P<.001), and improved survival (hazard ratio, 0.97; P<.001).

CONCLUSIONS

Although muscle mass (quantity) only correlated with survival, we found that muscle radiodensity (quality) was associated with patients' symptoms, healthcare use, and survival. These findings underscore the added importance of assessing muscle quality when seeking to address adverse muscle changes in oncology.

Evaluating if an Advance Care Planning Intervention Promotes Do-Not-Resuscitate Orders by Facilitating Accurate Prognostic Awareness

BACKGROUND

Issuing do-not-resuscitate (DNR) orders has seldom been an outcome in randomized clinical trials of advance care planning (ACP) interventions. The aim of this study was to examine whether an ACP intervention facilitating accurate prognostic awareness (PA) for patients with advanced cancer was associated with earlier use of DNR orders.

PATIENTS AND METHODS

Participants (n=460) were randomly assigned 1:1 to the experimental and control arms, with 392 deceased participants constituting the final sample of this secondary analysis study. Participants in the intervention and control arms had each received an intervention tailored to their readiness for ACP/prognostic information and symptom-management education, respectively. Effectiveness in promoting a DNR order by facilitating accurate PA was determined by intention-to-treat analysis using multivariate logistic regression with hierarchical linear modeling.

RESULTS

At enrollment in the ACP intervention and before death, 9 (4.6%) and 8 (4.1%) participants and 168 (85.7%) and 164 (83.7%) participants in the experimental and control arms, respectively, had issued a DNR order, without significant between-arm differences. However, participants in the experimental arm with accurate PA were significantly more likely than participants in the control arm without accurate PA to have issued a DNR order before death (adjusted odds ratio, 2.264; 95% CI, 1.036-4.951; P=.041). Specifically, participants in the experimental arm who first reported accurate PA 31 to 90 days before death were significantly more likely than their counterparts in the control arm who reported accurate PA to have issued a DNR order in the next wave of assessment (adjusted odds ratio, 13.365; 95% CI, 1.989-89.786; P=.008). Both arms issued DNR orders close to death (median, 5-6 days before death).

CONCLUSIONS

Our ACP intervention did not promote the overall presence of a DNR order. However, our intervention facilitated the issuance of NDR orders before death among patients with accurate PA, especially those who reported accurate PA 31 to 90 days before death, but it did not facilitate the issuance of DNR orders earlier than their counterparts in the control arm.ClinicalTrial.gov Identification: NCT01912846.

Associations of baseline patient-reported outcomes with treatment outcomes in advanced gastrointestinal cancer

BACKGROUND

Patient-reported outcomes (PROs) assessing quality of life (QOL) and symptom burden correlate with clinical outcomes in patients with cancer. However, to the authors' knowledge, data regarding associations between PROs and treatment response are lacking.

METHODS

The authors prospectively approached consecutive patients with advanced gastrointestinal cancer who were initiating a new treatment. Prior to treatment, patients reported their QOL (Functional Assessment of Cancer Therapy-General [FACT-G], 4 subscales: Functional, Physical, Emotional, Social; higher scores indicate better QOL) and symptom burden (Edmonton Symptom Assessment System [ESAS], Patient Health Questionnaire-4 [PHQ-4]; higher scores represent greater symptoms). Regression models were used to examine associations of baseline PROs with treatment response (clinical benefit or progressive disease [PD] at time of first scan), healthcare utilization, and survival.

RESULTS

From May 2019 to April 2020, a total of 112 patients with advanced gastrointestinal cancer were enrolled. For treatment response, 64.3% had CB and 35.7% had PD. Higher baseline ESAS-Physical (odds ratio, 1.04; P = .027) and lower FACT-G Functional (odds ratio, 0.92; P = .038) scores were associated with PD. Higher ESAS-Physical (hazard ratio [HR], 1.03; P = .044) and lower FACT-G Total (HR, 0.96; P = .005), FACT-G Physical (HR, 0.89; P < .001), and FACT-G Functional (HR, 0.87; P < .001) scores were associated with a greater hospitalization risk. Lower FACT-G Total (HR, 0.96; P = .009) and FACT-G Emotional (HR, 0.86; P = .012) scores as well as higher ESAS-Total (HR, 1.03; P = .014) and ESAS-Physical (HR, 1.04; P = .032) scores were associated with worse survival.

CONCLUSIONS

Baseline PROs are associated with treatment response in patients with advanced gastrointestinal cancer, namely physical symptoms and functional QOL, in addition to health care use and survival. The findings of the current study support the association between PROs and important clinical outcomes, including the novel finding of treatment response.

End-of-life decision making in the context of chronic life-limiting disease: a concept analysis and conceptual model

BACKGROUND

Conceptual ambiguities prevent advancements in end-of-life decision making in clinical practice and research.

PURPOSE

To clarify the components of and stakeholders (patients, caregivers, healthcare providers) involved in end-of-life decision making in the context of chronic life-limiting disease and develop a conceptual model.

METHOD

Walker and Avant's approach to concept analysis.

FINDINGS

End-of-life decision making is a process, not a discrete event, that begins with preparation, including decision maker designation and iterative stakeholder communication throughout the chronic illness (antecedents). These processes inform end-of-life decisions during terminal illness, involving: 1) serial choices 2) weighed in terms of potential outcomes 3) through patient and caregiver collaboration (attributes). Components impact patients' death, caregivers' bereavement, and healthcare systems' outcomes (consequences).

DISCUSSION

Findings provide a foundation for improved inquiry into and measurement of the end-of-life decision making process, accounting for the dose, content, and quality the antecedent and attribute factors that collectively contribute to outcomes.

The Association of Advance Care Planning Documentation and End-of-Life Healthcare Use Among Patients With Multimorbidity

PURPOSE

Multimorbidity is associated with increased intensity of end-of-life healthcare. This association has been examined by number but not type of conditions. Our purpose was to understand how intensity of care is influenced by multimorbidity within specific chronic conditions to provide guidance for interventions to improve end-of-life care for these patients.

METHODS

We identified adults cared for in a multihospital healthcare system who died between 2010-2017. We categorized patients by 4 primary chronic conditions: heart failure, pulmonary disease, renal disease, or dementia. Within each condition, we examined the effect of multimorbidity (presence of 4 or more chronic conditions) on hospital and ICU admission in the last 30 days of life, in-hospital death, and advance care planning (ACP) documentation >30 days before death. We performed logistic regression to estimate associations between multimorbidity and end-of-life care utilization, stratified by the presence or absence of ACP documentation.

RESULTS

ACP documentation >30 days before death was associated with lower odds of in-hospital death for all 4 conditions both in patients with and without multimorbidity. With the exception of patients with renal disease without multimorbidity, we observed lower odds of hospitalization and ICU admission for all patients with ACP >30 days before death.

CONCLUSIONS

Patients with dementia and multimorbidity had the highest odds of high-intensity end-of-life care. For patients with dementia, heart failure, or pulmonary disease, ACP documentation >30 days before death was associated with lower likelihood of in-hospital death, hospitalization, and ICU use at end-of-life, regardless of multimorbidity.

The Association between Chronic Conditions, End-of-Life Health Care Use, and Documentation of Advance Care Planning among Patients with Cancer

Background: Multiple chronic conditions (MCCs) are associated with increased intensity of end-of-life (EOL) care, but their effect is not well explored in patients with cancer. Objective: We examined EOL health care intensity and advance care planning (ACP) documentation to better understand the association between MCCs and these outcomes. Design: Retrospective cohort study. Setting/Subjects: Patients aged 18+ years at UW Medicine who died during 2010-2017 with poor prognosis cancer, with or without chronic liver disease, chronic pulmonary disease, coronary artery disease, dementia, diabetes with end-stage organ damage, end-stage renal disease, heart failure, or peripheral vascular disease. Measurements: ACP documentation 30+ days before death, in-hospital death, and inpatient or intensive care unit (ICU) admission in the last 30 days. We performed logistic regression for outcomes. Results: Of 15,092 patients with cancer, 10,596 (70%) had 1+ MCCs (range 1-8). Patients with cancer and heart failure had highest odds of hospitalization (odds ratio [OR] 1.67, 95% confidence interval [CI] 1.46-1.91), ICU admission (OR 2.06, 95% CI 1.76-2.41), or in-hospital death (OR 1.62, 95% CI 1.43-1.84) versus patients with cancer and other conditions. Patients with ACP 30+ days before death had lower odds of in-hospital death (OR 0.65, 95% CI 0.60-0.71), hospitalization (OR 0.67, 95% CI 0.61-0.74), or ICU admission (OR 0.71, 95% CI 0.64-0.80). Conclusions: Patients with ACP 30+ days before death had lower odds of high-intensity EOL care. Further research needs to explore how to best use ACP to ensure patients receive care aligned with patient and family goals for care.

Impact of an Electronic Medical Record Alert on Code Status Documentation for Hospitalized Patients With Advanced Cancer

PURPOSE:

Cardiopulmonary resuscitation in hospitalized patients with advanced cancer is associated with high rates of morbidity and mortality. Although advance care planning (ACP) in this population improves quality, patient satisfaction, hospice use, rates of harm, and health care costs, ACP documentation rates remain low. We observed changes in ACP documentation by internal medicine residents within a tertiary hospital’s inpatient oncology service after a mandatory training module and enterprise-wide modification in electronic health medical records (EHMR).

METHODS:

For patients admitted to the Cleveland Clinic oncology service, this 16-week retrospective review observed resident code status (CS) documentation through admission notes and direct EHMR orders before and after implementation of an ACP training module and CS best practice alert (BPA). In addition, residents were surveyed on perceived barriers to CS documentation.

RESULTS:

In 535 unique admissions (244 before BPA, 291 after BPA), residents exhibited a 14.4% increase (from 47.1% to 61.5%) in admission note CS documentation and an 18.2% increase (from 12.7% to 30.9%) in CS orders at time of discharge. The most common self-reported barrier to ACP documentation was forgetting to discuss, with first-, second-, and third-year residents admitting to feeling uncomfortable in orchestrating ACP conversations at rates of 58%, 6%, and 5%, respectively.

CONCLUSION:

Resident ACP documentation remains suboptimal in the high-risk cohort of hospitalized patients with advanced cancer. However, rates seem to be positively influenced by online modules and EHMR-based interventions. Additional efforts to improve the current practice and culture of ACP remain a crucial aspect in the quality and safety of our approach to patient care.

TRIAD XII: Are Patients Aware of and Agree With DNR or POLST Orders in Their Medical Records

OBJECTIVE

The aim of the study was to determine (1) whether do-not-resuscitate (DNR) orders created upon hospital admission or Physician Orders for Life-Sustaining Treatment (POLST) are consistent patient preferences for treatment and (2) patient/health care agent (HCA) awareness and agreement of these orders.

METHODS

We identified patients with DNR and/or POLST orders after hospital admission from September 1, 2017, to September 30, 2018, documented demographics, relevant medical information, evaluated frailty, and interviewed the patient and when indicated the HCA.

RESULTS

Of 114 eligible cases, 101 met inclusion criteria. Patients on average were 76 years old, 55% were female, and most white (85%). Physicians (85%) commonly created the orders. A living will was present in the record for 22% of cases and a POLST in 8%. The median frailty score of "4" (interquartile range = 2.5) suggested patients who require minimal assistance. Thirty percent of patients requested cardiopulmonary resuscitation and 63% wanted a trial attempt of aggressive treatment if in improvement is deemed likely. In 25% of the cases, patients/HCAs were unaware of the DNR order, 50% were unsure of their prognosis, and another 40% felt their condition was not terminal. Overall, 44% of the time, the existing DNR, and POLST were discordant with patient wishes and 38% were rescinded. Of the 6% not rescinded, further clarifications were required. Discordant orders were associated with younger, slightly less-frail patients.

CONCLUSIONS

Do-not-resuscitate and POLST orders can often be inaccurate, undisclosed, and discordant with patient wishes for medical care. Patient safety and quality initiatives should be adopted to prevent medical errors.

Standardization of Inpatient CPR Status Discussions and Documentation Within the Division of Hematology-Oncology at UPMC Shadyside: Results From PDSA Cycles 1 and 2

PURPOSE

In December 2016, 49% of patients admitted to inpatient oncology services at University of Pittsburgh Medical Center Shadyside Hospital had cardiopulmonary resuscitation (CPR) status discussion documentation before discharge. The aim of this project was to improve the rate of CPR status conversations.

METHODS

During Plan-Do-Study-Act (PDSA) cycle 1, a stakeholder workgroup was formed in January 2017 by oncology faculty, fellows, nurses, advance practice providers (APPs), medicine housestaff, and palliative care faculty. All oncology clinicians and inpatient team members were reminded weekly to discuss and document CPR status preferences. APPs received training on efficient and effective CPR status assessment from palliative care faculty. Oncology leadership received monthly e-mail updates of CPR status documentation rates and endorsed CPR status best practice guidelines. For PDSA cycle 2, patient charts without CPR status documentation in March 2018 were reviewed, and themes were shared with oncology leadership and reviewed with APPs.

RESULTS

After PDSA cycle 1, CPR status assessment rates increased from 49% to greater than 80%. In 2017, more than 1,500 more CPR status discussions were documented than in 2016. The percentage of patients discharged with "comfort measures only" or "do not resuscitate" orders increased from 14.2% (95% CI, 9.5% to 19.0%) to 19.8% (95% CI, 15.6% to 24.0%). For PDSA cycle 2, charts of 60 patients without CPR assessment were reviewed. Of these, 52% were admitted overnight by nocturnists and 48% by daytime APPs. Fifty-five percent of patients (n = 33 of 60) had metastatic disease. CPR status was documented on previous admissions for 53% of patients (n = 31 of 60) in the past 12 months. Fifteen percent (n = 11 of 60) were admitted for scheduled inpatient chemotherapy.

CONCLUSION

A multipronged approach significantly increased CPR status assessments. More patients transitioned to comfort measures only or do not resuscitate when their preferences were clearly assessed and documented.

Association of Communication Interventions to Discuss Code Status With Patient Decisions for Do-Not-Resuscitate Orders: A Systematic Review and Meta-analysis

IMPORTANCE

Whether specific communication interventions to discuss code status alter patient decisions regarding do-not-resuscitate code status and knowledge about cardiopulmonary resuscitation (CPR) remains unclear.

OBJECTIVE

To conduct a systematic review and meta-analysis regarding the association of communication interventions with patient decisions and knowledge about CPR.

DATA SOURCES

PubMed, Embase, PsycINFO, and CINAHL were systematically searched from the inception of each database to November 19, 2018.

STUDY SELECTION

Randomized clinical trials focusing on interventions to facilitate code status discussions. Two independent reviewers performed the data extraction and assessed risk of bias using the Cochrane Risk of Bias Tool. Data were pooled using a fixed-effects model, and risk ratios (RRs) with corresponding 95% CIs are reported.

DATA EXTRACTION AND SYNTHESIS

The study was performed according to the PRISMA guidelines.

MAIN OUTCOMES AND MEASURES

The primary outcome was patient preference for CPR, and the key secondary outcome was patient knowledge regarding life-sustaining treatment.

RESULTS

Fifteen randomized clinical trials (2405 patients) were included in the qualitative synthesis, 11 trials (1463 patients) were included for the quantitative synthesis of the primary end point, and 5 trials (652 patients) were included for the secondary end point. Communication interventions were significantly associated with a lower preference for CPR (390 of 727 [53.6%] vs 284 of 736 [38.6%]; RR, 0.70; 95% CI, 0.63-0.78). In a preplanned subgroup analysis, studies using resuscitation videos as decision aids compared with other interventions showed a stronger decrease in preference for life-sustaining treatment (RR, 0.56; 95% CI, 0.48-0.64 vs 1.03; 95% CI, 0.87-1.22; between-group heterogeneity P < .001). Also, a significant association was found between communication interventions and better patient knowledge (standardized mean difference, 0.55; 95% CI, 0.39-0.71).

CONCLUSIONS AND RELEVANCE

Communication interventions are associated with patient decisions regarding do-not-resuscitate code status and better patient knowledge and may thus improve code status discussions.

Documenting Goals of Care Among Patients With Advanced Cancer: Results of a Quality Improvement Initiative

PURPOSE

Guidelines recommend that oncologists discuss goals of care (GOC) with patients who have advanced cancer and that these patients be referred for early palliative care (PC). An audit of practice between 2010 and 2015 at the Cancer Centre of Southeastern Ontario suggested that these rates were suboptimal. We sought to improve the rate of documentation of GOC and referral to PC through the implementation of a quality improvement (QI) initiative.

METHODS

Patients receiving palliative systemic treatment of lung, pancreatic, colorectal, and breast cancer were identified via electronic pharmacy records and the electronic patient care system. Using the Define, Measure, Analyze, Improve, Control QI methodology, we drafted a guideline for GOC documentation and PC referral and designed a standardized documentation system. E-mail reminders were sent to physicians and a QI scorecard was displayed to document overall and individual physician rates of GOC documentation. Data were analyzed monthly and presented on statistical process control P charts.

RESULTS

Between May 2016 and November 2017, a total of 303 unique patients were identified (52%, 21%, 17%, and 10% with lung, breast, colorectal, and pancreatic cancer, respectively). GOC documentation increased significantly over the study period (baseline, 0%; passive phase, 3%; active phase, 31%); this increase was likely because of our intervention. PC referral rates also increased over the study period (baseline, 36%; passive phase, 35%; active phase 48%). We did not identify any patient, physician, or disease factors that were associated with GOC discussion or referral to PC.

CONCLUSION

Our QI initiative was successful in improving rates of GOC documentation in patients with advanced cancer.