Factors Affecting Patients' Preferences for and Actual Discussions About End-of-Life Care

Mid-Atlantic primary care providers' perception of barriers and facilitators to end-of-life conversation

Background

Among the chronically ill, end-of-life conversations are often delayed until emergently necessary and the quality of those conversations and subsequent decision-making become compromised by critical illness, uncertainty, and anxiety. Many patients receive treatment that they would have declined if they had a better understanding of benefits and risks. Primary care providers are ideal people to facilitate end-of-life conversations, but these conversations rarely occur in the out-patient setting.

Objective

To investigate the self-reported experiences of physicians and advanced practice nurses with conversational barriers and facilitators while leading end-of-life discussions in the primary care setting.

Design

A qualitative descriptive study.

Methods

Six physicians and eight advanced practice nurses participated in singular semi-structured interviews. Results were analyzed using a qualitative descriptive design and content analysis approach to coding.

Results

Reported barriers in descending order included resistance from patients and families, insufficient time, and insufficient understanding of prognosis and associated expectations. Reported facilitators in descending order included established trusting relationship with provider, physical and/or cognitive decline and poor prognosis; and discussion standardization per Medicare guidelines.

Conclusion

Recommendations for improving the end-of-life conversational process in the primary care setting include further research regarding end-of-life conversational facilitators within families, the improvement of patient/family education about hospice/palliative care resources and examining the feasibility of longer appointment allotment.1.

Hospital care for the dying patient with cancer: does an advance care planning invitation influence bereaved relatives' experiences? A two country survey

OBJECTIVES

Advance care planning (ACP) is not systematically performed in Argentina or Norway. We used the post-bereavement survey of the ERANet-LAC International Care Of the Dying Evaluation (CODE) project (2017-2020) to examine the proportion of relatives who were offered an ACP conversation, the proportion of those not offered it who would have wanted it and whether the outcomes differed between those offered a conversation and those not.

METHODS

Relatives after cancer deaths in hospitals answered the CODE questionnaire 6-8 weeks post bereavement, by post (Norway) or interview (Argentina). Two additional questions asked if the relative and patient had been invited to a conversation about wishes for the patient's remaining lifetime, and, if not invited, whether they would have wanted such a conversation. The data were analysed using mixed-effects ordinal regression models.

RESULTS

276 participants (Argentina 98 and Norway 178) responded (56% spouses, 31% children, 68% women, age 18-80+). Fifty-six per cent had been invited, and they had significantly more positive perceptions about care and support than those not invited. Sixty-eight per cent of the participants not invited would have wanted an invitation, and they had less favourable perceptions about the care, especially concerning emotional and spiritual support.

CONCLUSIONS

Relatives who had been invited to a conversation about wishes for the patient's remaining lifetime had more positive perceptions about patient care and support for the relatives in the patient's final days of life. A majority of the relatives who had not been invited to an ACP conversation would have wanted it.

Experiences and Perceptions of Healthcare Stakeholders in Disclosing Errors and Adverse Events to Historically Marginalized Patients

OBJECTIVES

We sought to assess the experiences and perceptions of healthcare stakeholders involved in the response to historically marginalized patients who have been harmed in healthcare. We investigated the challenges in disclosing errors and adverse events and the types of tools and resources that would better address the needs of historically marginalized patient populations.

METHODS

We conducted separate focus groups with two healthcare stakeholder groups: (1) frontline clinicians directly involved in the clinical care of historically marginalized patients and (2) risk and patient safety professionals involved in the hospital response to care breakdowns. We conducted an inductive analysis of the qualitative data to identify thematic clusters.

RESULTS

We interviewed 7 clinicians and 5 risk safety professionals, with a total sample size of 12 participants. Participants shared multilevel challenges in responding to historically marginalized patients after harm (system-, organizational-, and patient-level), such as fragmentation of care, lack of standardized protocols, and patient mistrust. Participants also identified their desired tools and resources for disclosure to meet the needs of historically marginalized patients, which included culturally appropriate toolkits, disclosure training, and the inclusion of multidisciplinary healthcare team members in the disclosure process.

CONCLUSIONS

Our results suggest that multiple interventions will be needed to achieve the goal of prompt disclosure of errors and adverse events across all populations engaged in health care. Future studies should investigate the perspectives of historically marginalized patients and their family members on how error and adverse event disclosure conversations should unfold.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Intervention

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Trial Registration

ClinicalTrials.gov Identifier: NCT04281784.

Prevalence and factors of discordance attitudes toward advance care planning between older patients and their family members in the primary medical and healthcare institution

Background

This study aimed at investigating the prevalence and factors of the discordant attitudes toward advance care planning (ACP) among older patients and their family members toward patients' engagement in ACP in the primary medical and healthcare institution.

Methods

In a cross-sectional study, a total of 117 older patients and 117 family members from Jinhua Fifth Hospital in China were enrolled. The questionnaire included sociodemographic characteristics, functional capacity assessment, and attitudes toward patients' engagement in ACP. Functional capacity assessment scales included the Modified Barthel Index (MBI), the Short-Form Mini-Nutritional Assessment (MNA-SF), the 15-item Geriatric Depression Scale (GDS-15), the Mini-Mental State Examination (MMSE), the Clinical Frailty Scale (CFS), and the SARC-F questionnaire.

Results

The discordance attitudes toward patients' engagement in ACP between patients and family members accounted for 41(35.0%). In the multivariate logistic analysis, factors associated with higher odds of discordance attitudes toward patients' engagement in ACP included greater age differences between patients and family members (OR = 1.043, 95% CI: 1.007-1.081), lower educational level for family members (OR = 3.373, 95% CI: 1.239-9.181), the patient's higher GDS-15 score (OR = 1.437, 95% CI: 1.185-1.742), and patient's higher MNA-SF score (OR = 1.754, 95% CI: 1.316-2.338).

Conclusion

Older patients and their family members had little ACP knowledge, and factors that influence discordance attitudes toward patients' engagement in ACP included the age gaps between patients and family members, family members' educational level, patients' depressive symptoms, and patients' nutritional status.

Seriously Ill Patients' Prioritized Goals and Their Clinicians' Perceptions of Those Goals

CONTEXT

Seriously ill patients whose prioritized healthcare goals are understood by their clinicians are likely better positioned to receive goal-concordant care.

OBJECTIVES

To examine the proportion of seriously ill patients whose prioritized healthcare goal is accurately perceived by their clinician and identify factors associated with accurate perception.

METHODS

Secondary analysis of a multicenter cluster-randomized trial of outpatients with serious illness and their clinicians. Approximately two weeks after a clinic visit, patients reported their current prioritized healthcare goal- extending life over relief of pain and discomfort, or relief of pain and discomfort over extending life - and clinicians reported their perception of their patients' current prioritized healthcare goal; matching these items defined accurate perception.

RESULTS

Of 252 patients with a prioritized healthcare goal, 60% had their goal accurately perceived by their clinician, 27% were cared for by clinicians who perceived prioritization of the alternative goal, and 13% had their clinician answer unsure. Patients who were older (OR 1.03 per year; 95%CI 1.01, 1.05), had stable goals (OR 2.52; 95%CI 1.26, 5.05), and had a recent goals-of-care discussion (OR 1.78, 95%CI 1.00, 3.16) were more likely to have their goals accurately perceived.

CONCLUSION

A majority of seriously ill outpatients are cared for by clinicians who accurately perceive their patients' prioritized healthcare goals. However, a substantial portion are not and may be at higher risk for goal-discordant care. Interventions that facilitate goals-of-care discussions may help align care with goals, as recent discussions were associated with accurate perceptions of patients' prioritized goals.

Improving communication about goals of care for hospitalized patients with serious illness: Study protocol for two complementary randomized trials

BACKGROUND

Although goals-of-care discussions are important for high-quality palliative care, this communication is often lacking for hospitalized older patients with serious illness. Electronic health records (EHR) provide an opportunity to identify patients who might benefit from these discussions and promote their occurrence, yet prior interventions using the EHR for this purpose are limited. We designed two complementary yet independent randomized trials to examine effectiveness of a communication-priming intervention (Jumpstart) for hospitalized older adults with serious illness.

METHODS

We report the protocol for these 2 randomized trials. Trial 1 has two arms, usual care and a clinician-facing Jumpstart, and is a pragmatic trial assessing outcomes with the EHR only (n = 2000). Trial 2 has three arms: usual care, clinician-facing Jumpstart, and clinician- and patient-facing (bi-directional) Jumpstart (n = 600). We hypothesize the clinician-facing Jumpstart will improve outcomes over usual care and the bi-directional Jumpstart will improve outcomes over the clinician-facing Jumpstart and usual care. We use a hybrid effectiveness-implementation design to examine implementation barriers and facilitators.

OUTCOMES

For both trials, the primary outcome is EHR documentation of a goals-of-care discussion within 30 days of randomization; additional outcomes include intensity of end-of-life care. Trial 2 also examines patient- or family-reported outcomes assessed by surveys targeting 3-5 days and 4-8 weeks after randomization including quality of goals-of-care communication, receipt of goal-concordant care, and psychological symptoms.

CONCLUSIONS

This novel study incorporates two complementary randomized trials and a hybrid effectiveness-implementation approach to improve the quality and value of care for hospitalized older adults with serious illness.

CLINICAL TRIALS REGISTRATION

STUDY00007031-A and STUDY00007031-B.

Interventions for interpersonal communication about end of life care between health practitioners and affected people

BACKGROUND

Communication about end of life (EoL) and EoL care is critically important for providing quality care as people approach death. Such communication is often complex and involves many people (patients, family members, carers, health professionals). How best to communicate with people in the period approaching death is not known, but is an important question for quality of care at EoL worldwide. This review fills a gap in the evidence on interpersonal communication (between people and health professionals) in the last year of life, focusing on interventions to improve interpersonal communication and patient, family member and carer outcomes.

OBJECTIVES

To assess the effects of interventions designed to improve verbal interpersonal communication about EoL care between health practitioners and people affected by EoL.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL from inception to July 2018, without language or date restrictions. We contacted authors of included studies and experts and searched reference lists to identify relevant papers. We searched grey literature sources, conference proceedings, and clinical trials registries in September 2019. Database searches were re-run in June 2021 and potentially relevant studies listed as awaiting classification or ongoing.

SELECTION CRITERIA

This review assessed the effects of interventions, evaluated in randomised and quasi-randomised trials, intended to enhance interpersonal communication about EoL care between patients expected to die within 12 months, their family members and carers, and health practitioners involved in their care. Patients of any age from birth, in any setting or care context (e.g. acute catastrophic injury, chronic illness), and all health professionals involved in their care were eligible. All communication interventions were eligible, as long as they included interpersonal interaction(s) between patients and family members or carers and health professionals. Interventions could be simple or complex, with one or more communication aims (e.g. to inform, skill, engage, support). Effects were sought on outcomes for patients, family and carers, health professionals and health systems, including adverse (unintended) effects. To ensure this review's focus was maintained on interpersonal communication in the last 12 months of life,  we excluded studies that addressed specific decisions, shared or otherwise, and the tools involved in such decision-making. We also excluded studies focused on advance care planning (ACP) reporting ACP uptake or completion as the primary outcome. Finally, we excluded studies of communication skills training for health professionals unless patient outcomes were reported as primary outcomes.

DATA COLLECTION AND ANALYSIS

Standard Cochrane methods were used, including dual review author study selection, data extraction and quality assessment of the included studies.

MAIN RESULTS

Eight trials were included. All assessed intervention effects compared with usual care. Certainty of the evidence was low or very low. All outcomes were downgraded for indirectness based on the review's purpose, and many were downgraded for imprecision and/or inconsistency. Certainty was not commonly downgraded for methodological limitations. A summary of the review's findings is as follows. Knowledge and understanding (four studies, low-certainty evidence; one study without usable data): interventions to improve communication (e.g. question prompt list, with or without patient and physician training) may have little or no effect on knowledge of illness and prognosis, or information needs and preferences, although studies were small and measures used varied across trials.  Evaluation of the communication (six studies measuring several constructs (communication quality, patient-centredness, involvement preferences, doctor-patient relationship, satisfaction with consultation), most low-certainty evidence): across constructs there may be minimal or no effects of interventions to improve EoL communication, and there is uncertainty about effects of interventions such as a patient-specific feedback sheet on quality of communication.  Discussions of EoL or EoL care (six studies measuring selected outcomes, low- or very low-certainty evidence): a family conference intervention may increase duration of EoL discussions in an intensive care unit (ICU) setting, while use of a structured serious illness conversation guide may lead to earlier discussions of EoL and EoL care (each assessed by one study). We are uncertain about effects on occurrence of discussions and question asking in consultations, and there may be little or no effect on content of communication in consultations.  Adverse outcomes or unintended effects (limited evidence): there is insufficient evidence to determine whether there are adverse outcomes associated with communication interventions  (e.g. question prompt list, family conference, structured discussions) for EoL and EoL care. Patient and/or carer anxiety was reported by three studies, but judged as confounded. No other unintended consequences, or worsening of desired outcomes, were reported. Patient/carer quality of life (four studies, low-certainty evidence; two without useable data): interventions to improve communication may have little or no effect on quality of life.  Health practitioner outcomes (three studies, low-certainty evidence; two without usable data): interventions to improve communication may have little or no effect on health practitioner outcomes (satisfaction with communication during consultation; one study); effects on other outcomes (knowledge, preparedness to communicate) are unknown. Health systems impacts: communication interventions (e.g. structured EoL conversations) may have little or no effect on carer or clinician ratings of quality of EoL care (satisfaction with care, symptom management, comfort assessment, quality of care) (three studies, low-certainty evidence), or on patients' self-rated care and illness, or numbers of care goals met (one study, low-certainty evidence). Communication interventions (e.g. question prompt list alone or with nurse-led communication skills training) may slightly increase mean consultation length (two studies), but other health service impacts (e.g. hospital admissions) are unclear.

AUTHORS' CONCLUSIONS

Findings of this review are inconclusive for practice. Future research might contribute meaningfully by seeking to fill gaps for populations not yet studied in trials; and to develop responsive outcome measures with which to better assess the effects of communication on the range of people involved in EoL communication episodes. Mixed methods and/or qualitative research may contribute usefully to better understand the complex interplay between different parties involved in communication, and to inform development of more effective interventions and appropriate outcome measures. Co-design of such interventions and outcomes, involving the full range of people affected by EoL communication and care, should be a key underpinning principle for future research in this area.

End of life care preference among hemodialysis population: Revisit Q methodology

OBJECTIVE

End-of-life care is often overlooked in the dialysis unit despite high mortality rates. This study aimed to understand the diverse subjectivity of opinions on end-of-life care preferences, feelings, needs, value and goals in life among a haemodialysis population.

METHODS

The Q methodology was used where 37 opinion statements were ranked in order of importance in a unimodal shaped grid. Results were explored using the Centroids factor extraction and Varimax rotation.

RESULTS

Four-three persons living with haemodialysis, mean age± SD= 56.58 ± 10.22 years, participated in the study. Five-factors were identified: living in the present, family preference, self preservation, power vs. control and autonomy in decision making, loaded by eleven, four, four, three and three participants with 16 individuals not loading significantly and two were confounded. Preferences for remaining positive in the face of illness through a healthy lifestyle and preserving relationships and autonomy were demonstrated.

CONCLUSIONS

End-of-life discussions are potentially inhibited by preferences to live for the present which should be explored in future studies.

PRACTICE IMPLICATION

Statement sets may be used to help facilitate end-of-life discussions through identification of opinion groups. Establishing preferences may guide identification of those willing to initiate discussions.

Advance Care Planning in Chronically Ill Patients With an Episodic Disease Trajectory in the Acute Care Setting: A Quality Improvement Project

INTRODUCTION

Advance care planning (ACP) is a fluid discussion between patients and providers to define preferences for future medical care. In the acute care setting, ACP is limited due to lack of structured process for identifying persons who may benefit from ACP. This quality improvement (QI) project aimed to increase the frequency of ACP discussions and documentation of preferences by targeting geriatric patients with an episodic disease trajectory for ACP.

METHODS

This project used an intervention and comparison group design to target English-speaking, geriatric adults at a large academic medical center with a diagnosis of NYHA class III/IV HF and/or GOLD criteria III/IV COPD for ACP discussions. The intervention group was compared to a group with a range of diagnoses who were approached in a non-systematic way.

RESULTS

Thirteen (n = 13) participants completed all aspects of the QI project. Results showed a non-significant increase in the number of patients with a diagnosis of HF and/or COPD who participated in an ACP discussion when compared to the comparison group (n = 20, p = 0.131), as well as a non-significant increase in the number of ACP tools documented in the HER (53.8% compared to 30%) (x = 1.877, p = 0.171).

CONCLUSION

While this project demonstrated non-significant statistical results in the incidence and documentation of an ACP tool, this project increased the number of ACP discussions had, which is clinically significant.

English and Spanish-speaking vulnerable older adults report many barriers to advance care planning

BACKGROUND/OBJECTIVES

Advance care planning (ACP) rates are low in diverse, vulnerable older adults, yet little is known about the unique barriers they face and how these barriers impact ACP documentation rates.

DESIGN

Validated questionnaires listing patient, family/friend, and clinician/system-level ACP barriers and an open-ended question on ACP barriers.

SETTING

Two San Francisco public/Department of Veterans Affairs hospitals.

PARTICIPANTS

One thousand two hundred and forty-one English and Spanish-speaking patients, aged 55 and older, with two or more chronic conditions.

MEASUREMENTS

The open-ended question on ACP barriers was analyzed using content analysis. We conducted chart review for prior ACP documentation. We used chi-square/Wilcoxon rank-sum tests and logistic regression to assess associations between ACP barriers and demographic characteristics/ACP documentation.

RESULTS

Participant mean age was 65 ± 7.4 years; they were 74% from racial/ethnic minority groups, 36% Spanish-speaking, and 36% with limited health literacy. A total of 26 barriers were identified (15 patient, 4 family/friend, 7 clinician/system-level), and 91% reported at least one ACP barrier (mean: 5.6 ± 4.0). The most common barriers were: (patient-level) discomfort thinking about ACP (60%), wanting to leave health decisions to "God" (44%); (family/friend-level) not wanting to burden friends/family (33%), assuming friends/family already knew their preferences (31%); (clinician/system-level) assuming doctors already knew their preferences (41%), and mistrust (37%). Compared with those with no barriers, participants with at least one reported barrier were more likely to be from a racial/ethnic minority group (76% vs 53%), Spanish-speaking (39% vs 6%), with fair-to-poor health (48% vs 34%), and limited health literacy (39% vs 9%) (p < 0.001 for all). Participants who reported barriers were less likely to have ACP documentation (adjusted odds ratio = 0.64, 95% confidence interval [0.42, 0.98]).

CONCLUSION

English- and Spanish-speaking older adults reported 26 unique barriers to ACP, with higher barriers among vulnerable populations, and barriers were associated with lower ACP documentation. Barriers must be considered when developing customized ACP interventions for diverse older adults.

Preferences for Communication About End-of-Life Care in Atypical Parkinsonism

BACKGROUND

Studies on preferences regarding discussions on end-of-life care (EOLC), advance care planning (ACP), medical assistance in dying (MAiD), and brain donation have not yet been conducted in patients with atypical parkinsonism (AP).

OBJECTIVE

The aim of this study was to know the preferences of patients with AP regarding discussions on EOLC, ACP, MAiD, and brain donation.

METHODS

This cross-sectional study was conducted in patients clinically diagnosed with AP. An adapted questionnaire that assessed various potential factors that affect patients' preferences regarding EOLC and ACP was sent through postal mail to 278 patients.

RESULTS

A total of 90 completed questionnaires were returned. Most patients preferred to discuss at the time of diagnosis information about the disease, its natural course, treatment options, and prognosis. In contrast, they preferred that EOLC and ACP be discussed when the disease has progressed. No demographic or disease-related factors were found to be predictors of the patient's preferences. Notably, most patients (63.3%) had previous actual discussions on these issues. Less than a third of patients were open to discussions about MAiD and brain donation; older age and the importance of spirituality and religion decreased the odds of discussing these.

CONCLUSIONS

Our study demonstrates that patients with AP have preferences regarding the timing of the discussion of the different themes surrounding EOLC and ACP. A needs-based approach in initiating and conducting timely discussions on these difficult but essential issues is proposed. A thorough explanation and recognition of a patient's beliefs are recommended when initiating conversations about MAiD and brain donation. © 2021 International Parkinson and Movement Disorder Society.

Perspectives on Aging-Related Preparation

When older adults face age-related life challenges, anticipating what to expect and how to access potential coping strategies can both prevent and provide the possibility of easier recovery from crises. Aging-Related Preparation (ARP) is defined as the continuum of thoughts and activities about how to age well, often beginning with the awareness of age-related changes, or the anticipation of retirement, and concluding with specifying end-of-life wishes. In the current paper, we introduce the concept of ARP and related formulations regarding plans for aging well, describe both predictors and outcomes of ARP for several the domains of ARP, and consider the elements of ARP within the context of existing social policy. We conclude that ARP is determined by a variety of influences both intrinsic to the older person (e.g., personality, cognitive ability, beliefs about planning, problem-solving skills), linked to social class and education, as well as dependent on family structures, access to and knowledge of options, services, and local community resources, and social policy. We further provide evidence that ARP has positive effects in the domain of pre-retirement planning (for retirement adjustment), of preparation for future care (for emotional well-being), and of ACP (for a good death). However, other domains of ARP, including planning for leisure, housing, and social planning are under-researched. Finally, we discuss policy implications of the existing research.

Identifying Goals of Care Conversations in the Electronic Health Record Using Natural Language Processing and Machine Learning

CONTEXT

Goals-of-care discussions are an important quality metric in palliative care. However, goals-of-care discussions are often documented as free text in diverse locations. It is difficult to identify these discussions in the electronic health record (EHR) efficiently.

OBJECTIVES

To develop, train, and test an automated approach to identifying goals-of-care discussions in the EHR, using natural language processing (NLP) and machine learning (ML).

METHODS

From the electronic health records of an academic health system, we collected a purposive sample of 3183 EHR notes (1435 inpatient notes and 1748 outpatient notes) from 1426 patients with serious illness over 2008-2016, and manually reviewed each note for documentation of goals-of-care discussions. Separately, we developed a program to identify notes containing documentation of goals-of-care discussions using NLP and supervised ML. We estimated the performance characteristics of the NLP/ML program across 100 pairs of randomly partitioned training and test sets. We repeated these methods for inpatient-only and outpatient-only subsets.

RESULTS

Of 3183 notes, 689 contained documentation of goals-of-care discussions. The mean sensitivity of the NLP/ML program was 82.3% (SD 3.2%), and the mean specificity was 97.4% (SD 0.7%). NLP/ML results had a median positive likelihood ratio of 32.2 (IQR 27.5-39.2) and a median negative likelihood ratio of 0.18 (IQR 0.16-0.20). Performance was better in inpatient-only samples than outpatient-only samples.

CONCLUSION

Using NLP and ML techniques, we developed a novel approach to identifying goals-of-care discussions in the EHR. NLP and ML represent a potential approach toward measuring goals-of-care discussions as a research outcome and quality metric.

Sex and gender considerations in implementation interventions to promote shared decision making: A secondary analysis of a Cochrane systematic review

Background

Shared decision making (SDM) in healthcare is an approach in which health professionals support patients in making decisions based on best evidence and their values and preferences. Considering sex and gender in SDM research is necessary to produce precisely-targeted interventions, improve evidence quality and redress health inequities. A first step is correct use of terms. We therefore assessed sex and gender terminology in SDM intervention studies.

Materials and methods

We performed a secondary analysis of a Cochrane review of SDM interventions. We extracted study characteristics and their use of sex, gender or related terms (mention; number of categories). We assessed correct use of sex and gender terms using three criteria: “non-binary use”, “use of appropriate categories” and “non-interchangeable use of sex and gender”. We computed the proportion of studies that met all, any or no criteria, and explored associations between criteria met and study characteristics.

Results

Of 87 included studies, 58 (66.7%) mentioned sex and/or gender. The most mentioned related terms were “female” (60.9%) and “male” (59.8%). Of the 58 studies, authors used sex and gender as binary variables respectively in 36 (62%) and in 34 (58.6%) studies. No study met the criterion “non-binary use”. Authors used appropriate categories to describe sex and gender respectively in 28 (48.3%) and in 8 (13.8%) studies. Of the 83 (95.4%) studies in which sex and/or gender, and/or related terms were mentioned, authors used sex and gender non-interchangeably in 16 (19.3%). No study met all three criteria. Criteria met did not vary according to study characteristics (p>.05).

Conclusions

In SDM implementation studies, sex and gender terms and concepts are in a state of confusion. Our results suggest the urgency of adopting a standardized use of sex and gender terms and concepts before these considerations can be properly integrated into implementation research.

Patient-Reported Receipt of Goal-Concordant Care Among Seriously Ill Outpatients-Prevalence and Associated Factors

CONTEXT

Goal-concordant care is an important indicator of high-quality care in serious illness.

OBJECTIVES

To estimate the prevalence of patient-reported receipt of goal-concordant care among seriously ill outpatients and identify factors associated with the absence of patient-reported goal concordance.

METHODS

Analysis of enrollment surveys from a multicenter cluster-randomized trial of outpatients with serious illness. Patients reported their prioritized health care goal and the focus of their current medical care; these items were matched to define receipt of goal-concordant care.

RESULTS

Of 405 patients with a prioritized health care goal, 58% reported receipt of goal-concordant care, 17% goal-discordant care, and 25% were uncertain of the focus of their care. Patient-reported receipt of goal concordance differed by patient goal. For patients who prioritized extending life, 86% reported goal-concordant care, 2% goal-discordant care, and 12% were uncertain of the focus of their care. For patients who prioritized relief of pain and discomfort, 51% reported goal-concordant care, 21% goal-discordant care, and 28% were uncertain of the focus of their care. Patients who prioritized a goal of relief of pain and discomfort were more likely to report goal-discordant care than patients who prioritized a goal of extending life (relative risk ratio 22.20; 95% CI 4.59, 107.38).

CONCLUSION

Seriously ill outpatients who prioritize a goal of relief of pain and discomfort are less likely to report receipt of goal-concordant care than patients who prioritize extending life. Future interventions designed to improve receipt of goal-concordant care should focus on identifying patients who prioritize relief of pain and discomfort and promoting care aligned with that goal.

Integration of Advance Care Planning Into Clinical Practice: A Quality Improvement Project for Leaders

OBJECTIVE

This quality improvement initiative sought to develop a proactive integrated system approach to advance care planning (ACP) through leadership and colleague engagement.

BACKGROUND

Nurse leaders have the capacity to influence the professional competencies of care teams in ACP. Nurse leaders were educated on the importance of ACP, national quality metrics, resources for staff education, and ways to integrate ACP into workflows based on a population management model.

METHODS

The project design is a prospective, mixed method design.

RESULTS

Nurse leader participants demonstrated a significant increase in knowledge of the importance of ACP and evidence-based models to increase staff engagement and competency.

CONCLUSIONS

Study supports nurse leader interventions, promoted engagement of proactive ACP to honor patient choice, and aligns with the mission and vision of one of the largest national Catholic healthcare organizations of being a trusted partner for life.

Advance Care Planning in Chronically Ill Persons Diagnosed With Heart Failure or Chronic Obstructive Pulmonary Disease: An Integrative Review

INTRODUCTION

Advance care planning (ACP) discussions help guide future medical care consistent with patient wishes. These discussions should be a part of routine care and should be readdressed frequently as a patient's medical condition changes. Limited literature exists supporting structured processes for identifying persons who may benefit from these conversations. The purpose of this integrative review was to understand whether targeting patients with episodic disease trajectories in the acute care setting will increase their willingness to participate in ACP discussions.

METHODS

Using the Johns Hopkins Nursing Evidence-Based Practice Model as a guideline, this integrative review focused on the research query "In the acute care setting, does targeting patients with heart failure or chronic obstructive pulmonary disease for ACP lead to increased willingness to participate in these discussions." Articles from 2009 to September 2019 were considered for review.

RESULTS

Six articles met inclusion criteria for final analysis. Articles outside of the United States were excluded. Four themes emerged from the literature: (1) improved patient attitudes toward ACP, (2) effective communication surrounding care preferences, (3) strengthened connection between preferred and delivered care, and (4) increased patient involvement in ACP.

CONCLUSION

Chronic diseases such as heart failure and COPD have a high symptom burden punctuated by exacerbations, making it difficult to know when introduction of ACP discussions would be most beneficial. Future research should focus on a deeper evaluation of when to introduce ACP conversations in this population and which ACP interventions are effective to facilitate these discussions.

Health-Care Provider Planned Responses to Patient Misunderstandings about End-of-Life Care

This study examined health-care provider planned responses to patient misunderstandings about end-of-life care using a multiple goals framework. Plan topics and content alignment with task, identity, and relational goal types were coded. Findings suggested that content was predominately task-oriented and concerned implications of treatment options such as choice outcomes and efficacy rates. A substantial percentage of providers planned to refer further discussion about the misunderstanding to another team member or occupational resource. Despite the prompt of patient misunderstanding, little attention was given to literacy and/or avoidance of medical jargon. Implications for these findings are discussed.

Patient-centered Outcomes Research in Pulmonary, Critical Care, and Sleep Medicine. An Official American Thoracic Society Workshop Report

Patient-centered outcomes research (PCOR) represents a paradigm shift in research methods aimed to create the body of evidence that supports clinical practice and informs health care decisions. PCOR integrates patients and other key stakeholders including family members, policy makers, clinicians, and patient advocates and advocacy groups as research partners throughout all stages of the research process. The importance of PCOR has received increased recognition, yet there is little evidence available to help guide researchers interested in the design and conduct of PCOR. In May 2014, we convened a workshop to identify key issues related to designing, conducting, and disseminating findings from PCOR studies. Workshop participants included a diverse group of patients, patient advocates, clinicians (physicians, nurses, psychologists, and advanced practice providers), researchers, administrators, and funders within and beyond the pulmonary, critical care, and sleep medicine communities. Participants identified important issues and considerations to address when undertaking PCOR. In this report, we summarize the results of this workshop to inform members of the pulmonary, sleep, and critical care community interested in participating in PCOR. Key findings include the following: 1) requirements for research to be considered PCOR; 2) the potential significant impact of PCOR on patients, clinicians, and researchers; 3) guiding principles and practical strategies to form successful patient-centered research partnerships, conduct PCOR, and disseminate study results to a broad audience of stakeholders; 4) benefits and challenges of PCOR for researchers; and 5) resources available within the American Thoracic Society to help with the conduct of PCOR.

Toward Understanding the Relationship Between Prioritized Values and Preferences for Cardiopulmonary Resuscitation Among Seriously Ill Adults

CONTEXT

Prioritizing among potentially conflicting end-of-life values may help patients discriminate among treatments and allow clinicians to align treatments with values.

OBJECTIVES

To investigate end-of-life values that patients prioritize when facing explicit trade-offs and identify predictors of patients whose values and treatment preferences seem inconsistent.

METHODS

Analysis of surveys from a multi-center cluster-randomized trial of patients with serious illness. Respondents prioritized end-of-life values and identified cardiopulmonary resuscitation (CPR) preferences in two health states.

RESULTS

Of 535 patients, 60% prioritized relief of discomfort over extending life, 17% prioritized extending life over relief of discomfort, and 23% were unsure. Patients prioritizing extending life were most likely to prefer CPR, with 93% preferring CPR in current health and 67% preferring CPR if dependent on others, compared with 69% and 21%, respectively, for patients prioritizing relief of discomfort, and 78% and 33%, respectively, for patients unsure of their prioritized value (P < 0.001 for all comparisons). Among patients prioritizing relief of discomfort, preference for CPR in current health was less likely among older patients (odds ratio 0.958 per year; 95% CI 0.935, 0.981) and more likely with better self-perceived health (odds ratio 1.402 per level of health; 95% CI 1.090, 1.804).

CONCLUSION

Clinicians face challenges as they clarify patient values and align treatments with values. Patients' values predicted CPR preferences, but a substantial proportion of patients expressed CPR preferences that appeared potentially inconsistent with their primary value. Clinicians should question assumptions about relationships between values and CPR preferences. Further research is needed to identify ways to use values to guide treatment decisions.

Preparing Older Patients With Serious Illness for Advance Care Planning Discussions in Primary Care

CONTEXT

Little is known about how to prepare older patients for advance care planning (ACP) discussions in primary care.

OBJECTIVES

The objective of the study was to explore older patients' perspectives and experiences on ACP discussions with family members and/or primary care clinicians.

METHODS

We conducted a qualitative interview study with 20 older patients who were involved in the clinic's ACP quality improvement initiative. We used an inductive approach to generate a coding scheme and used thematic analysis alongside a constant comparative methodology to iteratively refine emergent themes after coding the data. We used the transtheoretical behavior change model to conceptualize the process of ACP discussions, focusing on the contemplation, preparation, and action stages.

RESULTS

Four key themes emerged from our analyses: 1) the relevance/importance of ACP as a whole; 2) independently conceptualizing wishes and preferences for the future; 3) the process of engagement in ACP discussions; and 4) different outcomes of ACP discussions. While patients contemplated having an ACP discussion, they needed time to conceptualize their wishes on their own before documenting wishes or engaging with others. Moving to the preparation stage, patients shared their perspectives about how to engage family members and primary care clinicians in ACP discussions and reported different outcomes of these discussions, which varied according to patients' goals for ACP.

CONCLUSION

Understanding how to best prepare patients for ACP discussions from patients enrolled in an ACP primary clinic quality improvement initiative may assist primary care practices in developing interventions to improve the occurrence and effectiveness of such discussions.

Associated factors for discussing advance directives with family physicians by noncancer outpatients in Japan

BACKGROUND

Advance directives (ADs) are seldom discussed between primary care physicians (PCPs) and their patients, especially those with noncancer diseases. The aim was to identify the factors associated with discussing AD by noncancer patients with their physicians.

METHODS

This cross-sectional study was conducted in a hospital or clinic from October to December 2017. Physicians chose eligible noncancer patients aged 20 years or older to respond to an anonymous self-completed questionnaire inquiring about the objective variable "I want to discuss AD with my doctor," as well as basic characteristics, and facilitators and barriers to discussing AD identified in previous studies. The physicians responded to a survey comprising the Palliative Performance Scale (PPS) and inquiring about the disease category for each patient. Data were analyzed using binomial logistic regression analysis.

RESULTS

A total of 270 patients (valid response rate, 79.6%) were included. Multivariate analysis identified a period of visit to the study site ≥ 3 years (odds ratio [OR], 2.07; 95% confidence interval [CI], 1.05-4.10), physicians who are very good at taking care of patients' disease (OR, 12.68; 95% CI, 1.12-143.22), and patients' worry about their quality of life (QOL) in the future (OR, 2.69; 95% CI, 1.30-5.57) as facilitators for discussing AD with physicians, and PPS ≤ 90 (OR, 0.51; 95% CI, 0.26-0.98) as a barrier.

CONCLUSIONS

Our study indicates that patients' future QOL concerns, a long period of visit to a hospital, and the presence of physical symptoms were associated with the willingness of noncancer patients to discuss AD with PCPs.

Advance Care Planning Improves Psychological Symptoms But Not Quality of Life and Preferred End-of-Life Care of Patients With Cancer

Background: This study was conducted to examine whether a longitudinal advance care planning (ACP) intervention facilitates concordance between the preferred and received life-sustaining treatments (LSTs) of terminally ill patients with cancer and improves quality of life (QoL), anxiety symptoms, and depressive symptoms during the dying process. Patients and Methods: Of 795 terminally ill patients with cancer from a medical center in Taiwan, 460 were recruited and randomly assigned 1:1 to the experimental and control arms. The experimental arm received an interactive ACP intervention tailored to participants’ readiness to engage in this process. The control arm received symptom management education. Group allocation was concealed, data collectors were blinded, and treatment fidelity was monitored. Outcome measures included 6 preferred and received LSTs, QoL, anxiety symptoms, and depressive symptoms. Intervention effectiveness was evaluated by intention-to-treat analysis. Results: Participants providing data had died through December 2017. The 2 study arms did not differ significantly in concordance between the 6 preferred and received LSTs examined (odds ratios, 0.966 [95% CI, 0.653–1.428] and 1.107 [95% CI, 0.690–1.775]). Participants who received the ACP intervention had significantly fewer anxiety symptoms (β, −0.583; 95% CI, −0.977 to −0.189; P= .004) and depressive symptoms (β, −0.533; 95% CI, −1.036 to −0.030; P= .038) compared with those in the control arm, but QoL did not differ. Conclusions: Our ACP intervention facilitated participants’ psychological adjustment to the end-of-life (EoL) care decision-making process, but neither improved QoL nor facilitated EoL care honoring their wishes. The inability of our intervention to improve concordance may have been due to the family power to override patients’ wishes in deeply Confucian doctrine–influenced societies such as Taiwan. Nevertheless, our findings reassure healthcare professionals that such an ACP intervention does not harm but improves the psychological well-being of terminally ill patients with cancer, thereby encouraging physicians to discuss EoL care preferences with patients and involve family caregivers in EoL care decision-making to eventually lead to patient value–concordant EoL cancer care.

Did a Goals-of-Care Discussion Happen? Differences in the Occurrence of Goals-of-Care Discussions as Reported by Patients, Clinicians, and in the Electronic Health Record

CONTEXT

Goals-of-care discussions are associated with improved end-of-life care for patients and therefore may be used as a process measure in quality improvement, research, and reimbursement programs.

OBJECTIVES

To examine three methods to assess occurrence of a goals-of-care discussion-patient report, clinician report, and documentation in the electronic health record (EHR)-at a clinic visit for seriously ill patients and determine whether each method is associated with patient-reported receipt of goal-concordant care.

METHODS

We conducted a secondary analysis of a multicenter cluster-randomized trial, with 494 patients and 124 clinicians caring for them. Self-reported surveys collected from patients and clinicians two weeks after a clinic visit assessed occurrence of a goals-of-care discussion. Documentation of a goals-of-care discussion was abstracted from the EHR. Patient-reported receipt of goal-concordant care was assessed by survey two weeks after the visit.

RESULTS

Fifty-two percent of patients reported occurrence of a goals-of-care discussion at the clinic visit; clinicians reported occurrence of a discussion at 66% of visits. EHR documentation occurred in 42% of visits (P < 0.001 for each compared with other two). Patients who reported occurrence of a goals-of-care discussion at the visit were more likely to report receipt of goal-concordant care than patients who reported no discussion (β 0.441, 95% CI 0.190-0.692; P = 0.001). Neither occurrence of a discussion by clinician report nor by EHR documentation was associated with goal-concordant care.

CONCLUSION

Different approaches to assess goals-of-care discussions give differing results, yet each may have advantages. Patient report is most likely to correlate with patient-reported receipt of goal-concordant care.

Accurate Prognostic Awareness Facilitates, Whereas Better Quality of Life and More Anxiety Symptoms Hinder End-of-Life Care Discussions: A Longitudinal Survey Study in Terminally Ill Cancer Patients' Last Six Months of Life

CONTEXT

Terminally ill cancer patients do not engage in end-of-life (EOL) care discussions or do so only when death is imminent, despite guidelines for EOL care discussions early in their disease trajectory. Most studies on patient-reported EOL care discussions are cross sectional without exploring the evolution of EOL care discussions as death approaches. Cross-sectional studies cannot determine the direction of association between EOL care discussions and patients' prognostic awareness, psychological well-being, and quality of life (QOL).

OBJECTIVES/METHODS

We examined the evolution and associations of accurate prognostic awareness, functional dependence, physical and psychological symptom distress, and QOL with patient-physician EOL care discussions among 256 terminally ill cancer patients in their last six months by hierarchical generalized linear modeling with logistic regression and by arranging time-varying modifiable variables and EOL care discussions in a distinct time sequence.

RESULTS

The prevalence of physician-patient EOL care discussions increased as death approached (9.2%, 11.8%, and 18.3% for 91-180, 31-90, and 1-30 days before death, respectively) but only reached significance in the last month. Accurate prognostic awareness facilitated subsequent physician-patient EOL care discussions, whereas better patient-reported QOL and more anxiety symptoms hindered such discussions. The likelihood of EOL care discussions was not associated with levels of physical symptom distress, functional dependence, or depressive symptoms.

CONCLUSION

Physician-patient EOL care discussions for terminally ill Taiwanese cancer patients remain uncommon even when death approaches. Physicians should facilitate EOL care discussions by cultivating patients' accurate prognostic awareness early in their cancer trajectory when they are physically and psychologically competent, with better QOL, thus promoting informed and value-based EOL care decision making.

Exploring Opportunities for Primary Outpatient Palliative Care for Adults with Cystic Fibrosis: A Mixed-Methods Study of Patients' Needs

BACKGROUND

Persons with cystic fibrosis (CF) experience high morbidity and mortality, yet little is known about their palliative care needs and how clinicians may address these needs.

OBJECTIVES

(1) To identify palliative care and advance care planning needs of patients with CF and their families; and (2) to identify clinicians' potential roles in meeting these needs.

METHODS

A mixed-methods study of adult patients (age ≥18 years) with moderate-to-severe CF [forced expiratory volume in the first second (FEV₁) <65% predicted] were recruited from a CF Center. Semi-structured interviews (30-60 minutes) and questionnaires were administered in person or by phone. Grounded theory was used to analyze the interviews. Questionnaires were analyzed descriptively.

RESULTS

Forty-nine patients (FEV₁ % range = 19%-63%) participated; the participation rate was 80% for eligible patients. Three main domains of palliative care needs were identified: (1) to be listened to, feel heard, and be "seen"; (2) understanding the context around CF and its trajectory, with the goal of preparing for the future; and (3) information about, and potential solutions to, practical and current circumstances that cause stress. In questionnaires, few patients (4.3%) reported talking with their clinician about their wishes for care if they were to become sicker, but mixed-methods data demonstrated that more than half of participants were willing to receive palliative care services provided those services were adapted to CF.

CONCLUSION

Patients expressed a need for and openness to palliative care services, as well as some reluctance. They appreciated clinician communication that was open, forthcoming, and attuned to individualized concerns.

A concept map of death-related anxieties in patients with advanced cancer

OBJECTIVES

Fear of death and dying is common in patients with advanced cancer, but can be difficult to address in clinical conversations. We aimed to show that the experience of death anxiety may be deconstructed into a network of specific concerns and to provide a map of their interconnections to aid clinical exploration.

METHODS

We studied a sample of 382 patients with advanced cancer recruited from outpatient clinics at the Princess Margaret Cancer Centre, Toronto, Canada. Patients completed the 15-item Death and Dying Distress Scale (DADDS). We used item ratings to estimate a regularised partial correlation network of death and dying-related concerns. We calculated node closeness-centrality, clustering and global network characteristics.

RESULTS

Death-related anxieties were highly frequent, each associated with at least moderate distress in 22%-55% of patients. Distress about 'Running out of time' was a central concern in the network. The network was organised into two areas: one about more practical fears concerning the process of dying and another about more psychosocial or existential concerns including relational problems, uncertainty about the future and missed opportunities. Both areas were yet closely connected by bridges which, for example, linked fear of suffering and a prolonged death to fear of burdening others.

CONCLUSIONS

Patients with advanced cancer may have many interconnected death-related fears that can be patterned in individual ways. The bridging links between more practical and more psychosocial concerns emphasise that the alleviation of death anxiety may require interventions that integrate symptom management, advance care planning and psychological treatment approaches.