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Doherty C, Feder S, Gillespie-Heyman S, Akgün KM. Easing Suffering for ICU Patients and Their Families: Evidence and Opportunities for Primary and Specialty Palliative Care in the ICU. J Intensive Care Med 2024; 39:715-732. [PMID: 37822226 DOI: 10.1177/08850666231204305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
Intensive care unit (ICU) admissions are often accompanied by many physical and existential pressure points that can be extraordinarily wearing on patients and their families and surrogate decision makers (SDMs). Multidisciplinary palliative support, including physicians, advanced practice nurses, nutritionists, chaplains and other team members, may alleviate many of these sources of potential suffering. However, the palliative needs of ICU patients undoubtedly exceed the bandwidth of current consultative specialty palliative medicine teams. Informed by standard-of-care palliative medicine domains, we review common ICU symptoms (pain, dyspnea and thirst) and their prevalence, sources and their treatment. We then identify palliative needs and impacts in the domains of communication, SDM support and transitions of care for patients and their families through their journey in the ICU, from discharge and recovery at home to chronic critical illness, post-ICU disability or death. Finally, we examine the evidence for strategies to incorporate specialty palliative medicine and palliative principles into ICU care for the improvement of patient- and family-centered care. While randomized controlled studies have failed to demonstrate measurable improvement in pre-determined outcomes for patient- and family-relevant outcomes, embracing the principles of palliative medicine and assuring their delivery in the ICU is likely to translate to overall improvement in humanistic, person-centered care that supports patients and their SDMs during and following critical illness.
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Affiliation(s)
- Christine Doherty
- Department of Internal Medicine New Haven, Yale New Haven Hospital, New Haven, CT, USA
- Yale School of Medicine, New Haven, CT, USA
| | - Shelli Feder
- Yale University School of Nursing, Orange, CT, USA
| | | | - Kathleen M Akgün
- Yale School of Medicine, New Haven, CT, USA
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, VA-Connecticut and Yale University School of Medicine, New Haven, CT, USA
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2
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Sakamoto A, Inokuchi R, Iwagami M, Sun Y, Tamiya N. Association between advanced care planning and emergency department visits: A systematic review. Am J Emerg Med 2023; 68:84-91. [PMID: 36958094 DOI: 10.1016/j.ajem.2023.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 02/16/2023] [Accepted: 03/01/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Advance care planning can help provide optimal medical care according to a patient's wishes as a part of patient-centered discussions on end-of-life care. This can prevent undesired transfers to emergency departments. However, the effects of advance care planning on emergency department visits and ambulance calls in various settings or specific conditions remain unclear. AIM To evaluate whether advanced care planning affected the frequency of emergency department visits and ambulance calls. DESIGN Systematic review. This study was registered in PROSPERO (CRD42022340109). We assessed risk of bias using RoB 2.0, ROBINS-I, and ROBINS-E. DATA SOURCES We searched the PubMed, Cochrane CENTRAL, and EMBASE databases from their inception until September 22, 2022 for studies comparing patients with and without advanced care planning and reported the frequency of emergency department visits and ambulance calls as outcomes. RESULTS Eight studies were included. Regarding settings, two studies on patients in nursing homes showed that advanced care planning significantly reduced the frequency of emergency department visits and ambulance calls. However, two studies involving several medical care facilities reported inconclusive results. Regarding patient disease, a study on patients with depression or dementia showed that advanced care planning significantly reduced emergency department visits; in contrast, two studies on patients with severe respiratory diseases and serious illnesses showed no significant reduction. Seven studies showed a high risk of bias. CONCLUSIONS Advanced care planning may lead to reduced emergency department visits and ambulance calls among nursing home residents and patients with depression or dementia. Further research is warranted to identify the effectiveness of advanced care planning in specific settings and diseases.
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Affiliation(s)
- Ayaka Sakamoto
- Health Services Research and Development Center, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan
| | - Ryota Inokuchi
- Health Services Research and Development Center, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan; Department of Health Services Research, Institute of Medicine, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan.
| | - Masao Iwagami
- Health Services Research and Development Center, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan; Department of Health Services Research, Institute of Medicine, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan
| | - Yu Sun
- Health Services Research and Development Center, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan; Department of Health Services Research, Graduate School of Comprehensive Human Sciences, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan; Department of Health Services Research, Institute of Medicine, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan
| | - Nanako Tamiya
- Health Services Research and Development Center, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan; Department of Health Services Research, Institute of Medicine, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8577, Japan
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Ellis RJ, Moffatt CR, Aaron LT, Beaverson G, Chaw K, Curtis C, Freeman-Lamb R, Judd D, Khatry K, Li YS, Nash T, Macfarlane B, Slater K, Soonarane Y, Stickley M, Anuradha S. Factors associated with hospitalisations and deaths of residential aged care residents with COVID-19 during the Omicron (BA.1) wave in Queensland. Med J Aust 2023; 218:174-179. [PMID: 36524321 PMCID: PMC9877866 DOI: 10.5694/mja2.51813] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 10/19/2022] [Accepted: 10/26/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To identify characteristics associated with the hospitalisation and death of people with COVID-19 living in residential aged care facilities (RACFs). DESIGN Retrospective cohort study. SETTING, PARTICIPANTS All confirmed (polymerase chain reaction testing) or probable SARS-CoV-2 infections (rapid antigen tests) in residents of the 86 RACFs in the Metro South Hospital and Health Service area (southeast Queensland), 13 December 2021 - 24 January 2022. MAIN OUTCOME MEASURES Hospitalisation within 14 days or death within 28 days of COVID-19 diagnosis. RESULTS Of 1071 RACF residents with COVID-19, 151 were hospitalised within 14 days and 126 died within 28 days of diagnosis. Likelihood of death increased with age (per five years: adjusted odds ratio [aOR], 1.38; 95% confidence interval [CI], 1.21-1.57), but not that of hospitalisation. Men were more likely to be hospitalised (aOR, 1.7; 95% CI, 1.2-2.4) or die (aOR, 2.5; 95% CI, 1.7-3.6) than women. The likelihood of hospitalisation was greater for those with dementia (aOR, 1.9; 95% CI, 1.2-3.0), heart failure (aOR, 1.7; 95% CI, 1.1-2.7), chronic kidney disease (aOR, 1.7; 95% CI, 1.1-2.5), or asthma (aOR, 2.2; 95% CI, 1.2-3.8). The likelihood of death was greater for residents with dementia (aOR, 2.2; 95% CI, 1.3-3.7), diabetes mellitus (aOR, 1.9; 95% CI, 1.3-3.0), heart failure (aOR, 2.0; 95% CI, 1.1-3.3), or chronic lung disease (aOR, 1.7; 95% CI, 1.1-2.7). The likelihood of hospitalisation and death were each higher for residents who had received two or fewer vaccine doses than for those who had received three doses. CONCLUSIONS Most characteristics that influenced the likelihood of hospitalisation or death of RACF residents with COVID-19 were non-modifiable factors linked with frailty and general health status. Having received three COVID-19 vaccine doses was associated with much lower likelihood of hospitalisation or death.
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Affiliation(s)
- Robert J Ellis
- Metro South Public Health Unit, Brisbane, QLD.,The University of Queensland, Brisbane, QLD.,Princess Alexandra Hospital, Brisbane, QLD
| | | | | | | | - Khin Chaw
- Metro South Public Health Unit, Brisbane, QLD.,Australian Red Cross Lifeblood, Brisbane, QLD
| | | | | | | | - Khadija Khatry
- Metro South Public Health Unit, Brisbane, QLD.,Princess Alexandra Hospital, Brisbane, QLD
| | - Yee Sum Li
- Metro South Public Health Unit, Brisbane, QLD.,The University of Queensland, Brisbane, QLD
| | - Terry Nash
- Metro South Public Health Unit, Brisbane, QLD.,Princess Alexandra Hospital, Brisbane, QLD
| | | | - Karen Slater
- Metro South Public Health Unit, Brisbane, QLD.,Griffith University, Brisbane, QLD
| | | | - Mark Stickley
- Metro South Public Health Unit, Brisbane, QLD.,The University of Queensland, Brisbane, QLD
| | - Satyamurthy Anuradha
- Metro South Public Health Unit, Brisbane, QLD.,The University of Queensland, Brisbane, QLD
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Ye L, Jin G, Chen M, Xie X, Shen S, Qiao S. Prevalence and factors of discordance attitudes toward advance care planning between older patients and their family members in the primary medical and healthcare institution. Front Public Health 2023; 11:1013719. [PMID: 36908464 PMCID: PMC9996283 DOI: 10.3389/fpubh.2023.1013719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 02/06/2023] [Indexed: 02/25/2023] Open
Abstract
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.
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Affiliation(s)
- Ling Ye
- Department of Geriatrics, Jinhua Fifth Hospital, Jinhua, China
| | - Genhong Jin
- Department of Geriatrics, Jinhua Fifth Hospital, Jinhua, China
| | - Min Chen
- Department of Geriatrics, Jinhua Fifth Hospital, Jinhua, China
| | - Xingyuan Xie
- Department of Geriatrics, Jinhua Fifth Hospital, Jinhua, China
| | - Shanshan Shen
- Department of Geriatrics, Zhejiang Hospital, Hangzhou, China
| | - Song Qiao
- Department of Neurology, Zhejiang Hospital, Hangzhou, China
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Scott IA, Reymond L, Sansome X, Miller L. A whole-of-community program of advance care planning for end-of-life care. AUST HEALTH REV 2022; 46:442-449. [PMID: 35817410 DOI: 10.1071/ah22099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 06/15/2022] [Indexed: 11/23/2022]
Abstract
Since 2015 a whole-of-community program to promote advance care planning (ACP) within one Queensland Hospital and Health Service (HHS) catchment has spread statewide, financed by Queensland Health (QH) agencies and led by the Statewide Office of Advance Care Planning (SOACP). The program aims to identify ACP-eligible patients, invite and finalise ACP discussions, and ensure documented care preferences are easily retrievable by clinicians to guide future care if a person loses capacity. The SOACP established a digital infrastructure whereby quality-audited ACP documents are uploaded to a software platform accessible to all QH clinicians, private medical specialists, ambulance paramedics, general practitioners (GPs), and registered nurses, including those in residential aged care facilities (RACFs). The SOACP also hosts a website providing resources for clinicians and patients, delivers educational events and mentorship to GPs and hospital and RACF staff, and employs ACP facilitators working across all QH HHSs. The program has seen yearly increases in the numbers of ACP documents uploaded from around the state, with up to 79% of eligible patients in some hospitals receiving ACP, significant ACP uptake in RACFs, and acceptance by GPs to engage in ACP. Audits reveal high concordance between stated preferences and hospital care received, and ACP patients, compared to matched non-ACP controls, more frequently die out of hospital, have fewer inpatient days during their last 6 months of life, and receive less invasive care, with similar results seen among same-patient cohorts post-ACP. Barriers and enablers to ACP have been identified which will inform program evolution.
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Affiliation(s)
- Ian A Scott
- Princess Alexandra Hospital, 199 Ipswich Road, Brisbane, Qld 4102, Australia; and School of Clincial Medicine, University of Queensland, Qld, Australia
| | - Liz Reymond
- Eight Mile Plains Community Health, 51 McKechnie Drive, Eight Mile Plains, Qld 4113, Australia; and School of Public Health, Griffith School of Medicine, Qld, Australia
| | - Xanthe Sansome
- Eight Mile Plains Community Health, 51 McKechnie Drive, Eight Mile Plains, Qld 4113, Australia
| | - Leyton Miller
- Eight Mile Plains Community Health, 51 McKechnie Drive, Eight Mile Plains, Qld 4113, Australia
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Master JF, Wu B, Ni P, Mao J. The Compliance of End-of-Life Care Preferences Among Older Adults and Its Facilitators and Barriers: A Scoping Review. J Am Med Dir Assoc 2021; 22:2273-2280.e2. [PMID: 34087224 DOI: 10.1016/j.jamda.2021.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 04/11/2021] [Accepted: 05/03/2021] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To explore the compliance of end-of-life (EOL) care preferences, and the facilitators and barriers of promoting quality of EOL care among older adults. DESIGN A scoping review was used to identify key themes in the compliance of EOL care preferences among older adults. SETTING AND PARTICIPANTS Studies published between 2009 and 2020 were identified from the Medline and Cochrane libraries. Eligible articles containing components related to the compliance of EOL care preferences among older adults were selected. MEASURES The eligible articles were thematically synthesized. Factors that affected the compliance of EOL care preferences among older adults were identified from the key components. RESULTS In total, 35 articles were included to identify the key components in the compliance of EOL care preferences: (1) supportive policy, (2) supportive environment, (3) cultural characteristics, (4) advance care planning (ACP), (5) the concordance of EOL care preferences between patients and surrogate decision makers, (6) prognosis awareness, and (7) patient's health status and the type of disease. Facilitators for the compliance of EOL care preferences included enactment of relevant policy, sufficient care institutions, the utilization of ACP, and poor health status. Barriers included lack of supportive policy, different culture, and low utilization of ACP. CONCLUSIONS/IMPLICATIONS The compliance of EOL care preferences was low among older adults. The compliance of EOL care preferences can be improved through relevant policy development and the utilization of ACP.
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Affiliation(s)
- Jie Fu Master
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Bei Wu
- Rory Meyers College of Nursing and NYU Aging Incubator, New York University, New York, NY, USA
| | - Ping Ni
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
| | - Jing Mao
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
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Gabbard J, Pajewski NM, Callahan KE, Dharod A, Foley KL, Ferris K, Moses A, Willard J, Williamson JD. Effectiveness of a Nurse-Led Multidisciplinary Intervention vs Usual Care on Advance Care Planning for Vulnerable Older Adults in an Accountable Care Organization: A Randomized Clinical Trial. JAMA Intern Med 2021; 181:361-369. [PMID: 33427851 PMCID: PMC7802005 DOI: 10.1001/jamainternmed.2020.5950] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Advance care planning (ACP), especially among vulnerable older adults, remains underused in primary care. Additionally, many ACP initiatives fail to integrate directly into the electronic health record (EHR), resulting in infrequent and disorganized documentation. OBJECTIVE To determine whether a nurse navigator-led ACP pathway combined with a health care professional-facing EHR interface improves the occurrence of ACP discussions and their documentation within the EHR. DESIGN, SETTING, AND PARTICIPANTS This was a randomized effectiveness trial using the Zelen design, in which patients are randomized prior to informed consent, with only those randomized to the intervention subsequently approached to provide informed consent. Randomization began November 1, 2018, and follow-up concluded November 1, 2019. The study population included patients 65 years or older with multimorbidity combined with either cognitive or physical impairments, and/or frailty, assessed from 8 primary care practices in North Carolina. INTERVENTIONS Participants were randomized to either a nurse navigator-led ACP pathway (n = 379) or usual care (n = 380). MAIN OUTCOMES AND MEASURES The primary outcome was documentation of a new ACP discussion within the EHR. Secondary outcomes included the usage of ACP billing codes, designation of a surrogate decision maker, and ACP legal form documentation. Exploratory outcomes included incident health care use. RESULTS Among 759 randomized patients (mean age 77.7 years, 455 women [59.9%]), the nurse navigator-led ACP pathway resulted in a higher rate of ACP documentation (42.2% vs 3.7%, P < .001) as compared with usual care. The ACP billing codes were used more frequently for patients randomized to the nurse navigator-led ACP pathway (25.3% vs 1.3%, P < .001). Patients randomized to the nurse navigator-led ACP pathway more frequently designated a surrogate decision maker (64% vs 35%, P < .001) and completed ACP legal forms (24.3% vs 10.0%, P < .001). During follow-up, the incidence of emergency department visits and inpatient hospitalizations was similar between the randomized groups (hazard ratio, 1.17; 95% CI, 0.92-1.50). CONCLUSIONS AND RELEVANCE A nurse navigator-led ACP pathway integrated with a health care professional-facing EHR interface increased the frequency of ACP discussions and their documentation. Additional research will be required to evaluate whether increased EHR documentation leads to improvements in goal-concordant care. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03609658.
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Affiliation(s)
- Jennifer Gabbard
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Nicholas M Pajewski
- Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Division of Public Health Sciences, Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Kathryn E Callahan
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Ajay Dharod
- Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Section on General Internal Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Kristie L Foley
- Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Division of Public Health Sciences, Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Keren Ferris
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Adam Moses
- Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - James Willard
- Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Division of Public Health Sciences, Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jeff D Williamson
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Comer AR, Hickman SE, Slaven JE, Monahan PO, Sachs GA, Wocial LD, Burke ES, Torke AM. Assessment of Discordance Between Surrogate Care Goals and Medical Treatment Provided to Older Adults With Serious Illness. JAMA Netw Open 2020; 3:e205179. [PMID: 32427322 PMCID: PMC7237962 DOI: 10.1001/jamanetworkopen.2020.5179] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE An important aspect of high-quality care is ensuring that treatments are in alignment with patient or surrogate decision-maker goals. Treatment discordant with patient goals has been shown to increase medical costs and prolong end-of-life difficulties. OBJECTIVES To evaluate discordance between surrogate decision-maker goals of care and medical orders and treatments provided to hospitalized, incapacitated older patients. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study included 363 patient-surrogate dyads. Patients were 65 years or older and faced at least 1 major medical decision in the medical and medical intensive care unit services in 3 tertiary care hospitals in an urban Midwestern area. Data were collected from April 27, 2012, through July 10, 2015, and analyzed from October 5, 2018, to December 5, 2019. MAIN OUTCOMES AND MEASURES Each surrogate's preferred goal of care was determined via interview during initial hospitalization and 6 to 8 weeks after discharge. Surrogates were asked to select the goal of care for the patient from 3 options: comfort-focused care, life-sustaining treatment, or an intermediate option. To assess discordance, the preferred goal of care as determined by the surrogate was compared with data from medical record review outlining the medical treatment received during the target hospitalization. RESULTS A total of 363 dyads consisting of patients (223 women [61.4%]; mean [SD] age, 81.8 [8.3] years) and their surrogates (257 women [70.8%]; mean [SD] age, 58.3 [11.2] years) were included in the analysis. One hundred sixty-nine patients (46.6%) received at least 1 medical treatment discordant from their surrogate's identified goals of care. The most common type of discordance involved full-code orders for patients with a goal of comfort (n = 41) or an intermediate option (n = 93). More frequent in-person contact between surrogate and patient (adjusted odds ratio [AOR], 0.43; 95% CI, 0.23-0.82), patient residence in an institution (AOR, 0.44; 95% CI, 0.23-0.82), and surrogate-rated quality of communication (AOR, 0.98; 95% CI, 0.96-0.99) were associated with lower discordance. Surrogate marital status (AOR for single vs married, 1.92; 95% CI, 1.01-3.66), number of family members involved in decisions (AOR for ≥2 vs 0-1, 1.84; 95% CI, 1.05-3.21), and religious affiliation (AOR for none vs any, 4.87; 95% CI, 1.12-21.09) were associated with higher discordance. CONCLUSIONS AND RELEVANCE This study found that discordance between surrogate goals of care and medical treatments for hospitalized, incapacitated patients was common. Communication quality is a modifiable factor associated with discordance that may be an avenue for future interventions.
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Affiliation(s)
- Amber R. Comer
- Department of Health Sciences, Indiana University School of Health and Human Sciences, Indianapolis
- Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis
- Indiana University Purdue University Indianapolis Research in Palliative and End-of-Life Communication and Training (RESPECT) Center, School of Nursing, Indiana University, Indianapolis
| | - Susan E. Hickman
- Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis
- Indiana University Purdue University Indianapolis Research in Palliative and End-of-Life Communication and Training (RESPECT) Center, School of Nursing, Indiana University, Indianapolis
- Department of Community and Health Systems, School of Nursing, Indiana University, Indianapolis, Indiana
- Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis
| | - James E. Slaven
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Patrick O. Monahan
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Greg A. Sachs
- Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis
- Indiana University Purdue University Indianapolis Research in Palliative and End-of-Life Communication and Training (RESPECT) Center, School of Nursing, Indiana University, Indianapolis
- Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis
| | - Lucia D. Wocial
- Indiana University Purdue University Indianapolis Research in Palliative and End-of-Life Communication and Training (RESPECT) Center, School of Nursing, Indiana University, Indianapolis
- Department of Community and Health Systems, School of Nursing, Indiana University, Indianapolis, Indiana
- Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis
| | - Emily S. Burke
- Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis
| | - Alexia M. Torke
- Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis
- Indiana University Purdue University Indianapolis Research in Palliative and End-of-Life Communication and Training (RESPECT) Center, School of Nursing, Indiana University, Indianapolis
- Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis
- Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis
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