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Abbas M, Chua IS, Tabata-Kelly M, Bulger AL, Gershanik E, Sheu C, Kerr E, Ruan M, Dey T, Lakin JR, Bernacki RE. Racial and Ethnic Disparities in Serious Illness Conversation Quality during the COVID-19 Pandemic. J Pain Symptom Manage 2024:S0885-3924(24)00785-1. [PMID: 38782305 DOI: 10.1016/j.jpainsymman.2024.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 05/03/2024] [Accepted: 05/14/2024] [Indexed: 05/25/2024]
Abstract
CONTEXT The COVID-19 pandemic disproportionately impacted non-Hispanic Black and Hispanic patients. However, little is known about the quality of serious illness communication in these communities during this time. OBJECTIVE We aimed to determine whether racial and ethnic disparities manifested in serious illness conversations during the pandemic. METHODS This was a retrospective, observational, cohort study of adult patients with a documented serious illness conversation from March 2020 to April 2021. Serious illness conversation documentation quality was assessed by counting the median number (IQR) of conversation domains and their elements included in the documentation. Domains included (1) values and goals, (2) prognosis and illness understanding, (3) end-of-life care planning, and (4) life-sustaining treatment preferences. A multivariable ordinal logistic regression analysis was conducted to assess associations between differences in serious illness documentation quality with patient race and ethnicity. RESULTS Among 291 patients, 149 (51.2%) were non-Hispanic White; 81 (27.8%) were non-Hispanic Black; and 61 (21.0%) were Hispanic patients. Non-Hispanic Black patients were associated with fewer domains (OR 0.46 [95% CI 0.25, 0.84]; P=.01) included in their serious illness conversation documentation compared to non-Hispanic White patients. Both non-Hispanic Black (OR 0.35 [95% CI 0.20, 0.62]; P<.001) and Hispanic patients (OR 0.29 [95% CI 0.14, 0.58]; P<.001) were associated with fewer elements in the values and goals domain compared to non-Hispanic White patients in their serious illness documentation. CONCLUSION During the COVID-19 pandemic, serious illness conversation documentation among non-Hispanic Black and Hispanic patients was less comprehensive compared to non-Hispanic White patients.
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Affiliation(s)
- Muhammad Abbas
- Department of General Surgery(M.A.), Rabin Medical Centre, Beilinson Hospital, Petah Tikva, Israel
| | - Isaac S Chua
- Division of General Internal Medicine and Primary Care(I.S.C., E.G.), Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Department of Psychosocial Oncology and Palliative Care(I.S.C., J.R.L., R.E.B.), Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School(I.S.C., J.L.R., R.E.B.), Boston, MA, USA.
| | - Masami Tabata-Kelly
- The Center for Surgery and Public Health(M.T.K., E.K., M.R., T.D., C.S.), Brigham and Women's Hospital, Boston, MA, USA; The Center for Geriatric Surgery(M.T.K., A.L.B., C.S., R.E.B.), Brigham and Women's Hospital, Boston, MA, USA; The Heller School for Social Policy and Management(M.T.K.), Waltham, MA, USA
| | - Amy L Bulger
- The Center for Geriatric Surgery(M.T.K., A.L.B., C.S., R.E.B.), Brigham and Women's Hospital, Boston, MA, USA; Department of Care Continuum Management(A.L.B.), Brigham and Women's Hospital, Boston, MA, USA
| | - Esteban Gershanik
- Division of General Internal Medicine and Primary Care(I.S.C., E.G.), Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School(I.S.C., J.L.R., R.E.B.), Boston, MA, USA
| | - Christina Sheu
- The Center for Surgery and Public Health(M.T.K., E.K., M.R., T.D., C.S.), Brigham and Women's Hospital, Boston, MA, USA; The Center for Geriatric Surgery(M.T.K., A.L.B., C.S., R.E.B.), Brigham and Women's Hospital, Boston, MA, USA
| | - Emma Kerr
- The Center for Surgery and Public Health(M.T.K., E.K., M.R., T.D., C.S.), Brigham and Women's Hospital, Boston, MA, USA
| | - Mengyuan Ruan
- The Center for Surgery and Public Health(M.T.K., E.K., M.R., T.D., C.S.), Brigham and Women's Hospital, Boston, MA, USA
| | - Tanujit Dey
- The Center for Surgery and Public Health(M.T.K., E.K., M.R., T.D., C.S.), Brigham and Women's Hospital, Boston, MA, USA
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care(I.S.C., J.R.L., R.E.B.), Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School(I.S.C., J.L.R., R.E.B.), Boston, MA, USA; Division of Palliative Medicine (J.R.L., R.E.B.), Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Rachelle E Bernacki
- Department of Psychosocial Oncology and Palliative Care(I.S.C., J.R.L., R.E.B.), Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School(I.S.C., J.L.R., R.E.B.), Boston, MA, USA; The Center for Geriatric Surgery(M.T.K., A.L.B., C.S., R.E.B.), Brigham and Women's Hospital, Boston, MA, USA; Division of Palliative Medicine (J.R.L., R.E.B.), Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Singh N, Giannitrapani KF, Gamboa RC, O’Hanlon CE, Fereydooni S, Holdsworth LM, Lindvall C, Walling AM, Lorenz KA. What Patients Facing Cancer and Caregivers Want From Communication in Times of Crisis: A Qualitative Study in the Early Months of the COVID-19 Pandemic. Am J Hosp Palliat Care 2024; 41:558-567. [PMID: 37390466 PMCID: PMC10315453 DOI: 10.1177/10499091231187351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND Interpersonal communication is a cornerstone of patient-centered care. We aimed to identify what patients with cancer and caregivers may want from communication during a public health crisis. METHODS We interviewed 15 patients (8 Veteran, 7 non-Veteran) and caregivers from regionally, racially, and ethnically diverse backgrounds across the US about serious illness care and quality of care during the COVID-19 pandemic Using an iterative, inductive and deductive process, 2 coders analyzed content associated with the code "Communication," which appeared 71 times, and identified 5 themes. RESULTS Participants identified as White (10), Latino/a (3), Asian (1), and Black (1). (1) Help patients and caregivers prepare for care during crisis by communicating medical information directly and proactively. (2) Explain how a crisis might influence medical recommendations and impact on recovery from illness. (3) Use key messengers to improve communication between primary teams, patients, and caregivers. (4) Include caregivers and families in communication when they cannot be physically present. (5) Foster bidirectional communication with patients and families to engage them in shared decision-making during a vulnerable time. CONCLUSION Communication is critical during a public health crisis yet overwhelmed clinicians may not be able to communicate effectively. Communicating with caregivers and family, transparent and timely communication, ensuring diverse providers are on the same page, and effective listening are known gaps even before the COVID-19 pandemic. Clinicians may need quick interventions, like education about goals of care, to remind them about what seriously ill patients and their caregivers want from communication and offer patient-centered care during crises.
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Affiliation(s)
- Nainwant Singh
- Stanford University School of Medicine, Palo Alto, CA, USA
- VA HSR&D Center for Innovation to Implementation (Ci2i), Menlo Park, CA, USA
| | - Karleen F. Giannitrapani
- Stanford University School of Medicine, Palo Alto, CA, USA
- VA HSR&D Center for Innovation to Implementation (Ci2i), Menlo Park, CA, USA
| | - Raziel C. Gamboa
- Stanford University School of Medicine, Palo Alto, CA, USA
- VA HSR&D Center for Innovation to Implementation (Ci2i), Menlo Park, CA, USA
| | | | | | | | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Anne M. Walling
- Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, CA, USA
- VA Greater Los Angeles Healthcare Center, Los Angeles, CA, USA
| | - Karl A. Lorenz
- Stanford University School of Medicine, Palo Alto, CA, USA
- VA HSR&D Center for Innovation to Implementation (Ci2i), Menlo Park, CA, USA
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Bange EM, Li Y, Kumar P, Doucette A, Gabriel P, Parikh R, Li EH, Mamtani R, Getz KD. The association between telemedicine, advance care planning, and unplanned hospitalizations among high-risk patients with cancer. Cancer 2024; 130:636-644. [PMID: 37987207 PMCID: PMC10922036 DOI: 10.1002/cncr.35116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 08/31/2023] [Accepted: 10/15/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Despite the widespread implementation of telemedicine, there are limited data regarding its impact on key components of care for patients with incurable or high-risk cancer. For these patients, high-quality care requires detailed conversations regarding treatment priorities (advance care planning) and clinical care to minimize unnecessary acute care (unplanned hospitalizations). Whether telemedicine affects these outcomes relative to in-person clinic visits was examined among patients with cancer at high risk for 6-month mortality. METHODS This retrospective cohort study included adult patients with cancer with any tumor type treated at the University of Pennsylvania who were newly identified between April 1 and December 31, 2020, to be at high risk for 6-month mortality via a validated machine learning algorithm. Separate modified Poisson regressions were used to assess the occurrence of advance care planning and unplanned hospitalizations for telemedicine as compared to in-person visits. Additional analyses were done comparing telemedicine type (video or phone) as compared to in-person clinic visits. RESULTS The occurrence of advance care planning was similar between telemedicine and in-person visits (6.8% vs. 6.0%; adjusted risk ratio [aRR], 1.25; 95% CI, 0.92-1.69). In regard to telemedicine subtype, patients exposed to video encounters were modestly more likely to have documented advance care planning in comparison to those seen in person (7.5% vs. 6.0%; aRR, 1.48; 95% CI, 1.03-2.11). The 3-month risk for unplanned hospitalization was comparable for telemedicine compared to in-person clinic encounters (21% vs. 18%; aRR, 1.06; 95% CI, 0.81-1.38). CONCLUSIONS In this study, care delivered by telemedicine, compared to in-person clinic visits, produced comparable rates of advance care planning conversations without increasing hospitalizations, which suggests that vulnerable patients can be managed safely by telemedicine.
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Affiliation(s)
- Erin M Bange
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Yimei Li
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Pallavi Kumar
- Palliative and Hospice Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Abigail Doucette
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter Gabriel
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ravi Parikh
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Hematology/Oncology, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Eric H Li
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ronac Mamtani
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kelly D Getz
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Baxter R, Pusa S, Andersson S, Fromme EK, Paladino J, Sandgren A. Core elements of serious illness conversations: an integrative systematic review. BMJ Support Palliat Care 2024:spcare-2023-004163. [PMID: 37369576 DOI: 10.1136/spcare-2023-004163] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Ariadne Labs' Serious Illness Care Program (SICP), inclusive of the Serious Illness Conversation Guide (SICG), has been adapted for use in a variety of settings and among diverse population groups. Explicating the core elements of serious illness conversations could support the inclusion or exclusion of certain components in future iterations of the programme and the guide. AIM This integrative systematic review aimed to identify and describe core elements of serious illness conversations in relation to the SICP and/or SICG. DESIGN Literature published between 1 January 2014 and 20 March 2023 was searched in MEDLINE, PsycINFO, CINAHL and PubMed. All articles were evaluated using the Joanna Briggs Institute Critical Appraisal Guidelines. Data were analysed with thematic synthesis. RESULTS A total of 64 articles met the inclusion criteria. Three themes were revealed: (1) serious illness conversations serve different functions that are reflected in how they are conveyed; (2) serious illness conversations endeavour to discover what matters to patients and (3) serious illness conversations seek to align what patients want in their life and care. CONCLUSIONS Core elements of serious illness conversations included explicating the intention, framing, expectations and directions for the conversation. This encompassed discussing current and possible trajectories with a view towards uncovering matters of importance to the patient as a person. Preferences and priorities could be used to inform future preparation and recommendations. Serious illness conversation elements could be adapted and altered depending on the intended purpose of the conversation.
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Affiliation(s)
- Rebecca Baxter
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University-Vaxjo Campus, Vaxjo, Sweden
| | - Susanna Pusa
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University-Vaxjo Campus, Vaxjo, Sweden
| | - Sofia Andersson
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University-Vaxjo Campus, Vaxjo, Sweden
| | - Erik K Fromme
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Joanna Paladino
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Anna Sandgren
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University-Vaxjo Campus, Vaxjo, Sweden
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Lavecchia M, Myers J, Bainbridge D, Incardona N, Levine O, Steinberg L, Schep D, Vautour J, Kumar SJ, Seow H. Education modalities for serious illness communication training: A scoping review on the impact on clinician behavior and patient outcomes. Palliat Med 2024; 38:170-183. [PMID: 37424275 PMCID: PMC10865772 DOI: 10.1177/02692163231186180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
BACKGROUND Several clinician training interventions have been developed in the past decade to address serious illness communication. While numerous studies report on clinician attitudes and confidence, little is reported on individual education modalities and their impact on actual behavior change and patient outcomes. AIM To examine what is known about the education modalities used in serious illness communication training and their impact on clinician behaviors and patient outcomes. DESIGN A scoping review using the Joanna Briggs Methods Manual for Scoping Reviews was conducted to examine studies measuring clinician behaviors or patient outcomes. DATA SOURCES Ovid MEDLINE and EMBASE databases were searched for English-language studies published between January 2011 and March 2023. RESULTS The search identified 1317 articles: 76 met inclusion criteria describing 64 unique interventions. Common education modalities used were: single workshop (n = 29), multiple workshops (n = 11), single workshop with coaching (n = 7), and multiple workshops with coaching (n = 5); though they were inconsistently structured. Studies reporting improved clinician skills tended to be in simulation settings with neither clinical practice nor patient outcomes explored. While some studies reported behavior changes or improved patient outcomes, they did not necessarily confirm improvements in clinician skills. As multiple modalities were commonly used and often embedded within quality improvement initiatives, the impact of individual modalities could not be determined. CONCLUSION This scoping review of serious illness communication interventions found heterogeneity among education modalities used and limited evidence supporting their effectiveness in impacting patient-centered outcomes and long-term clinician skill acquisition. Well-defined educational modalities and consistent measures of behavior change and standard patient-centered outcomes are needed.
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Affiliation(s)
- Melissa Lavecchia
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, McMaster University, Hamilton, ON, Canada
| | - Jeff Myers
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Daryl Bainbridge
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Nadia Incardona
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Oren Levine
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Leah Steinberg
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Daniel Schep
- Division of Radiation Oncology, Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Joanna Vautour
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | | | - Hsien Seow
- Department of Oncology, McMaster University, Hamilton, ON, Canada
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Davila C, Chan SH, Gosline A, Arenas Z, Kavanagh J, Feltz B, McCarthy E, Pitts T, Ritchie C. Online Forums as a Tool for Broader Inclusion of Voices on Health Care Communication Experiences and Serious Illness Care: Mixed Methods Study. J Med Internet Res 2023; 25:e48550. [PMID: 38055311 PMCID: PMC10733833 DOI: 10.2196/48550] [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] [Received: 04/28/2023] [Revised: 09/10/2023] [Accepted: 09/28/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Existing health care research, including serious illness research, often underrepresents individuals from historically marginalized communities. Capturing the nuanced perspectives of individuals around their health care communication experiences is difficult. New research strategies are needed that increase engagement of individuals from diverse backgrounds. OBJECTIVE The aim of this study was to develop a mixed methods approach with qualitative online forums to better understand health communication experiences of individuals, including people from groups historically marginalized such as Black and Latino individuals; older adults; and people with low income, disability, or serious illness. METHODS We used a multiphase mixed methods, community-informed research approach to design study instruments and engage participants. We engaged a diverse group of collaborators with lived experience of navigating the health care system who provided feedback on instruments, added concepts for testing, and offered guidance on creating a safe experience for participants (phase 1). We conducted a national quantitative survey between April and May 2021 across intrapersonal, interpersonal, and systems-level domains, with particular focus on interpersonal communication between patients and clinicians (phase 2). We conducted two asynchronous, qualitative online forums, a technique used in market research, between June and August 2021, which allowed us to contextualize the learnings and test concepts and messages (phase 3). Using online forums allowed us to probe more deeply into results and hypotheses from the survey to better understand the "whys" and "whats" that surfaced and to test public messages to encourage action around health. RESULTS We engaged 46 community partners, including patients and clinicians from a Federally Qualified Health Center, to inform study instrument design. In the quantitative survey, 1854 adults responded, including 50.5% women, 25.2% individuals over 65 years old, and 51.9% individuals with low income. Nearly two-thirds identified as non-Hispanic white (65.7%), 10.4% identified as non-Hispanic Black, and 15.5% identified as Hispanic/Latino. An additional 580 individuals participated in online forums, including 60.7% women, 17.4% individuals over 65 years old, and 49.0% individuals with low income. Among the participants, 70.3% identified as non-Hispanic white, 16.0% as non-Hispanic Black, and 9.5% as Hispanic/Latino. We received rich, diverse input from our online forum participants, and they highlighted satisfaction and increased knowledge with engagement in the forums. CONCLUSIONS We achieved modest overrepresentation of people who were over 65 years old, identified as non-Hispanic Black, and had low income in our online forums. The size of the online forums (N=580) reflected the voices of 93 Black and 55 Hispanic/Latino participants. Individuals who identify as Hispanic/Latino remained underrepresented, likely because the online forums were offered only in English. Overall, our findings demonstrate the feasibility of using the online forum qualitative approach in a mixed methods study to contextualize, clarify, and expound on quantitative findings when designing public health and clinical communications interventions.
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Affiliation(s)
- Carine Davila
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, MA, United States
- Department of Medicine, Harvard Medical School, Boston, MA, United States
| | - Stephanie H Chan
- Massachusetts Coalition for Serious Illness Care, Boston, MA, United States
- Blue Cross Blue Shield of Massachusetts, Boston, MA, United States
| | - Anna Gosline
- Massachusetts Coalition for Serious Illness Care, Boston, MA, United States
- Blue Cross Blue Shield of Massachusetts, Boston, MA, United States
| | | | - Jane Kavanagh
- Massachusetts Coalition for Serious Illness Care, Boston, MA, United States
- Ariadne Labs, Boston, MA, United States
| | - Brian Feltz
- Flowetik, Boston, MA, United States
- 3D Research Partners LLC, Harvard, MA, United States
| | - Elizabeth McCarthy
- Flowetik, Boston, MA, United States
- Elizabeth M McCarthy Consulting, Boston, MA, United States
| | - Tyrone Pitts
- The Coalition to Transform Advanced Care, Washington, DC, United States
| | - Christine Ritchie
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, MA, United States
- Department of Medicine, Harvard Medical School, Boston, MA, United States
- Center for Aging in Serious Illness, Mongan Institute, Boston, MA, United States
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Wheless M, Lee JJ, Domenico HJ, Martin BJ, Bennett ML, Martin SF, Berlin J, Green JK, Agarwal R. Factors and Barriers to Goals-of-Care Conversations for Patients With Cancer and Inpatient Mortality. JCO Oncol Pract 2023; 19:767-776. [PMID: 37390380 PMCID: PMC10538893 DOI: 10.1200/op.23.00095] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 05/02/2023] [Accepted: 05/25/2023] [Indexed: 07/02/2023] Open
Abstract
PURPOSE Conversations about personal values and goals of care (GOC) at the end of life are essential in caring for patients with advanced cancer. However, GOC conversations may be influenced by patient and oncologist factors during transitions of care. METHODS We electronically administered surveys to medical oncologists of inpatients who died from May 1, 2020, to May 31, 2021. Primary outcomes included oncologists' knowledge of inpatient death, anticipation of patient death, and recollection of GOC discussions. Secondary outcomes, including GOC documentation and advance directives (ADs), were collected retrospectively from electronic health records. Outcomes were analyzed for association with patient, oncologist, and patient-oncologist relationship factors. RESULTS For 75 patients who died, 104/158 (66%) surveys were completed by 40 inpatient and 64 outpatient oncologists. Eighty-one oncologists (77.9%) were aware of patients' deaths, 68 (65.4%) anticipated patients' deaths within 6 months, and 67 (64.4%) recalled having GOC discussions before or during the terminal hospitalization. Outpatient oncologists were more likely to report knowledge of patient death (P < .001), as were those with longer therapeutic relationships (P < .001). Inpatient oncologists were more likely to correctly anticipate patient death (P = .014). Secondary outcomes revealed 21.3% of patients had documented GOC discussions before admission and 33.3% had ADs; patients with a longer duration of cancer diagnosis were more likely to have ADs (P = .003). Oncologist-reported barriers to GOC included unrealistic expectations from patients or family (25%) and decreased patient participation because of clinical conditions (15%). CONCLUSION Most oncologists recalled having GOC discussions for patients with inpatient mortality, yet documentation of serious illness conversations remained suboptimal. Further studies are needed to examine barriers to GOC conversations and documentation during transitions of care and across health care settings.
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Affiliation(s)
- Margaret Wheless
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Julie J. Lee
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Henry J. Domenico
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt Office of Quality, Safety, and Risk Prevention, Vanderbilt University Medical Center, Nashville, TN
| | - Barbara J. Martin
- Vanderbilt Office of Quality, Safety, and Risk Prevention, Vanderbilt University Medical Center, Nashville, TN
| | - Marc L. Bennett
- Vanderbilt Office of Quality, Safety, and Risk Prevention, Vanderbilt University Medical Center, Nashville, TN
- Department of Otolaryngology Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Sara F. Martin
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Jordan Berlin
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Jennifer K. Green
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt Office of Quality, Safety, and Risk Prevention, Vanderbilt University Medical Center, Nashville, TN
| | - Rajiv Agarwal
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt-Ingram Cancer Center, Nashville, TN
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Frydman JL, Dow LA, Smith CB, Kelley AS, Lindenberger EC, Gelfman LP. Virtual Geritalk: Does Intensive Virtual Communication Skills Training Improve Use of Serious Illness Communication Skills? Am J Hosp Palliat Care 2023; 40:620-623. [PMID: 35857414 PMCID: PMC9979275 DOI: 10.1177/10499091221116078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Background: The COVID-19 pandemic presented a unique opportunity to adapt in-person communication skills training to a virtual format. Objective: Examine use of serious illness communication skills by learners after participating in an intensive virtual communication skills training. Design: Prospective cohort study. Setting/Subjects: Icahn School of Medicine at Mount Sinai, Clinical Fellows. Measurements: Family Meeting Communication Assessment Tool (FAMCAT) assessed fundamental and advanced communication skills. Results: As compared to a historical benchmark obtained after a prior in-person course, the virtual course showed equivalent or better use of communication skills across fundamental skills and advanced skills. Conclusions: Our findings suggest that a virtual communication skills training is associated with the use of serious illness communication skills in the clinical setting by learners.
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Affiliation(s)
- Julia L. Frydman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Lindsay A. Dow
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Cardinale B. Smith
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Amy S. Kelley
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Elizabeth C. Lindenberger
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- Geriatric Research, Education & Clinical Center, James J. Peters Veterans’ Affairs Medical Center, Bronx, NY
| | - Laura P. Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- Geriatric Research, Education & Clinical Center, James J. Peters Veterans’ Affairs Medical Center, Bronx, NY
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Chi S, Kim S, Reuter M, Ponzillo K, Oliver DP, Foraker R, Heard K, Liu J, Pitzer K, White P, Moore N. Advanced Care Planning for Hospitalized Patients Following Clinician Notification of Patient Mortality by a Machine Learning Algorithm. JAMA Netw Open 2023; 6:e238795. [PMID: 37071421 PMCID: PMC10114011 DOI: 10.1001/jamanetworkopen.2023.8795] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 02/28/2023] [Indexed: 04/19/2023] Open
Abstract
Importance Goal-concordant care is an ongoing challenge in hospital settings. Identification of high mortality risk within 30 days may call attention to the need to have serious illness conversations, including the documentation of patient goals of care. Objective To examine goals of care discussions (GOCDs) in a community hospital setting with patients identified as having a high risk of mortality by a machine learning mortality prediction algorithm. Design, Setting, and Participants This cohort study took place at community hospitals within 1 health care system. Participants included adult patients with a high risk of 30-day mortality who were admitted to 1 of 4 hospitals between January 2 and July 15, 2021. Patient encounters of inpatients in the intervention hospital where physicians were notified of the computed high risk mortality score were compared with patient encounters of inpatients in 3 community hospitals without the intervention (ie, matched control). Intervention Physicians of patients with a high risk of mortality within 30 days received notification and were encouraged to arrange for GOCDs. Main Outcomes and Measures The primary outcome was the percentage change of documented GOCDs prior to discharge. Propensity-score matching was completed on a preintervention and postintervention period using age, sex, race, COVID-19 status, and machine learning-predicted mortality risk scores. A difference-in-difference analysis validated the results. Results Overall, 537 patients were included in this study with 201 in the preintervention period (94 in the intervention group; 104 in the control group) and 336 patients in the postintervention period. The intervention and control groups included 168 patients per group and were well-balanced in age (mean [SD], 79.3 [9.60] vs 79.6 [9.21] years; standardized mean difference [SMD], 0.03), sex (female, 85 [51%] vs 85 [51%]; SMD, 0), race (White patients, 145 [86%] vs 144 [86%]; SMD 0.006), and Charlson comorbidities (median [range], 8.00 [2.00-15.0] vs 9.00 [2.00 to 19.0]; SMD, 0.34). Patients in the intervention group from preintervention to postintervention period were associated with being 5 times more likely to have documented GOCDs (OR, 5.11 [95% CI, 1.93 to 13.42]; P = .001) by discharge compared with matched controls, and GOCD occurred significantly earlier in the hospitalization in the intervention patients as compared with matched controls (median, 4 [95% CI, 3 to 6] days vs 16 [95% CI, 15 to not applicable] days; P < .001). Similar findings were observed for Black patient and White patient subgroups. Conclusions and Relevance In this cohort study, patients whose physicians had knowledge of high-risk predictions from machine learning mortality algorithms were associated with being 5 times more likely to have documented GOCDs than matched controls. Additional external validation is needed to determine if similar interventions would be helpful at other institutions.
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Affiliation(s)
- Stephen Chi
- Division of Pulmonary and Critical Care Medicine, Washington University in St Louis, St Louis, Missouri
| | - Seunghwan Kim
- Institute for Informatics, Washington University in St Louis, St Louis, Missouri
| | | | | | - Debra Parker Oliver
- Division of Palliative Medicine, Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Randi Foraker
- Institute for Informatics, Washington University in St Louis, St Louis, Missouri
| | | | - Jingxia Liu
- Division of Public Health Sciences, Department of Surgery, Washington University in St Louis, St Louis, Missouri
- Division of Biostatistics, Washington University in St Louis, St Louis, Missouri
| | - Kyle Pitzer
- Division of Palliative Medicine, Department of Medicine, Washington University in St Louis, St Louis, Missouri
- Division of Biostatistics, Washington University in St Louis, St Louis, Missouri
| | - Patrick White
- Division of Palliative Medicine, Department of Medicine, Washington University in St Louis, St Louis, Missouri
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10
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LeBaron V, Flickinger T, Ling D, Lee H, Edwards J, Tewari A, Wang Z, Barnes LE. Feasibility and acceptability testing of CommSense: A novel communication technology to enhance health equity in clinician-patient interactions. Digit Health 2023; 9:20552076231184991. [PMID: 37456129 PMCID: PMC10338668 DOI: 10.1177/20552076231184991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Background Quality patient-clinician communication is paramount to achieving safe and compassionate healthcare, but evaluating communication performance during real clinical encounters is challenging. Technology offers novel opportunities to provide clinicians with actionable feedback to enhance their communication skills. Methods This pilot study evaluated the acceptability and feasibility of CommSense, a novel natural language processing (NLP) application designed to record and extract key metrics of communication performance and provide real-time feedback to clinicians. Metrics of communication performance were established from a review of the literature and technical feasibility verified. CommSense was deployed on a wearable (smartwatch), and participants were recruited from an academic medical center to test the technology. Participants completed a survey about their experience; results were exported to SPSS (v.28.0) for descriptive analysis. Results Forty (n = 40) healthcare participants (nursing students, medical students, nurses, and physicians) pilot tested CommSense. Over 90% of participants "strongly agreed" or "agreed" that CommSense could improve compassionate communication (n = 38, 95%) and help healthcare organizations deliver high-quality care (n = 39, 97.5%). Most participants (n = 37, 92.5%) "strongly agreed" or "agreed" they would be willing to use CommSense in the future; 100% (n = 40) "strongly agreed" or "agreed" they were interested in seeing information analyzed by CommSense about their communication performance. Metrics of most interest were medical jargon, interruptions, and speech dominance. Conclusion Participants perceived significant benefits of CommSense to track and improve communication skills. Future work will deploy CommSense in the clinical setting with a more diverse group of participants, validate data fidelity, and explore optimal ways to share data analyzed by CommSense with end-users.
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Affiliation(s)
| | | | - David Ling
- University of Virginia School of Medicine, Charlottesville, VA
| | - Hansung Lee
- University of Virginia School of Medicine, Charlottesville, VA
| | - James Edwards
- University of Virginia School of Nursing, Charlottesville, VA
| | - Anant Tewari
- University of Virginia School of Medicine, Charlottesville, VA
| | - Zhiyuan Wang
- University of Virginia School of Engineering & Applied Science, Charlottesville, VA
| | - Laura E Barnes
- University of Virginia School of Engineering & Applied Science, Charlottesville, VA
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11
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Bullard JT, Kowalkowski M, Sparling A, Roberge J, Barkley JE. A Retrospective Evaluation of the Impacts of a Multidisciplinary Care Model for Managing Patients with Advanced Illness on Acute Care Utilization and Quality of Care at End of Life. J Palliat Med 2022; 25:1835-1843. [PMID: 36137010 DOI: 10.1089/jpm.2022.0264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background: A home-based goal-concordant care model targeting patients with advanced illnesses may reduce acute care utilization and improve quality outcomes at end of life. Aim: Study aim was to determine impact of the Advanced Illness Management (AIM) program on end-of-life utilization and quality of care. Design: A retrospective observational study design using propensity score fine stratum weighting methodologies was applied to decedent patients identified for AIM enrollment/eligibility in 2018 to 2019. Setting/Participants: A total of 3859 decedents, 216 of whom were AIM enrollees, were identified from a metropolitan health system's electronic medical records (EMR) and met study eligibility criteria. Results: Compared with usual care, AIM enrollees spent more days away from acute care in the last 30, 90, and 180 days of life. Furthermore, AIM enrollees were less likely to expire in an acute care hospital. Conclusions: Enrollment in programs such as AIM should be considered for patients with advanced illnesses approaching end of life.
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Affiliation(s)
- Jarrod T Bullard
- Clinical Analytic, Center for Outcomes, Research, and Evaluation, Atrium Health, Charlotte, North Carolina, USA
| | - Marc Kowalkowski
- Clinical Analytic, Center for Outcomes, Research, and Evaluation, Atrium Health, Charlotte, North Carolina, USA
| | - Alica Sparling
- Health Economics, Novant Health, Charlotte, North Carolina, USA
| | - Jason Roberge
- Clinical Analytic, Center for Outcomes, Research, and Evaluation, Atrium Health, Charlotte, North Carolina, USA
| | - John E Barkley
- Clinical Analytic, Center for Outcomes, Research, and Evaluation, Atrium Health, Charlotte, North Carolina, USA
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12
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Tranberg M, Jacobsen J, Fürst CJ, Engellau J, Schelin ME. Patterns of Communication About Serious Illness in the Years, Months, and Days before Death. Palliat Med Rep 2022; 3:116-122. [PMID: 36059906 PMCID: PMC9438435 DOI: 10.1089/pmr.2022.0024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 11/30/2022] Open
Abstract
Background: Communication with patients and families about serious illness impacts quality of life and helps facilitate decision-making. Objective: To elucidate the pattern of communication about serious illness for patients who have died in an inpatient setting. Design: Three hundred patients from the Swedish Registry of Palliative Care 2015–2017 were randomly selected for manual chart review. Setting: Patients who died in a palliative care, oncology, or internal medicine unit in Sweden were selected. Measurements: We report on the frequency of conversations at three time points, 6 months or longer before death (“Years”), 15 days–6 months before death (“Months”), and 0–14 days before death (“Days”). We also report the timing of the conversation about dying. Results: A total of 249 patients were included after exclusions; they had an average of 2.1 conversations (range 1–6). The first conversation took place a median of 53 days before death and the last conversation took place a median of 9 days before death. Separate conversations with the next of kin took place a median of two days before death. We could verify a conversation about dying in only 156/249 (63%) medical records. Conclusions: Communication about serious illness between clinicians, patients, and families occurs iteratively over a period before death. Measuring the quality of communication about serious illness using a years, months, and days framework may help ensure that patients and families have sufficient information for medical and personal decision making.
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Affiliation(s)
- Mattias Tranberg
- Division of Palliative Care, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- The Institute for Palliative Care at Lund University and Region Skåne, Lund, Sweden
| | - Juliet Jacobsen
- The Institute for Palliative Care at Lund University and Region Skåne, Lund, Sweden
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Carl Johan Fürst
- Division of Palliative Care, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- The Institute for Palliative Care at Lund University and Region Skåne, Lund, Sweden
| | - Jacob Engellau
- Department of Oncology Hematology and Radiophysics, Skåne University Hospital, Lund, Sweden
| | - Maria E.C. Schelin
- Division of Palliative Care, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- The Institute for Palliative Care at Lund University and Region Skåne, Lund, Sweden
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13
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Martin P. Clinical communication: A core clinical skill that underpins quality cancer care. Asia Pac J Oncol Nurs 2022; 9:100067. [PMID: 35634134 PMCID: PMC9136267 DOI: 10.1016/j.apjon.2022.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 04/10/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Peter Martin
- Clinical Communication and End-of-Life Care, School of Medicine, Deakin University, Geelong, Australia
- Centre for Organisational Change in Person-Centred Healthcare, Faculty of Health, Deakin University, Geelong, Australia
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Oppenheim S, Figlin RA, Seferian EG, Reed M, Irwin SA, Rosen BT. Advance Care Planning in Patients With Metastatic Cancer: A Quality Improvement Initiative. JCO Oncol Pract 2022; 18:e1562-e1566. [DOI: 10.1200/op.22.00160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE: An initiative aimed to increase the rate of advance care planning (ACP) activities for outpatients with metastatic cancer, an essential step to achieving goal concordant care. METHODS: Patients with metastatic cancer were identified by International Classification of Diseases-10 coding and later by oncologists' electronic health record documentation of metastatic tumor status. ACP activities were defined as either an ACP note, Advance Directive, Physician Orders for Life-Sustaining Therapy (POLST), or a Palliative Medicine (PM) consultation within the prior year. From 2017 to 2020, the initiative screened more than 5,000 total unique cancer patients per year. PM consultants were embedded in tumor boards, oncology care team meetings, and shared oncology clinic space. Quarterly reports were sent to 60 oncologists at three cancer care sites with data of their percentage of ACP activities for patients with metastatic cancer compared with their peers. Oncologists' identities were initially blinded, but later unblinded. Oncologists also received a monthly list of patients with metastatic cancer without ACP activities. RESULTS: The rate of ACP activities for patients with metastatic cancer increased from a baseline of 37% in July 2017 to 57% by the end of 2020. PM consultations increased from 12% to 39% and ACP notes increased from 16% to 29% during the same interval. There was no change in Advance Directive (17%-20%) or POLST completion (7%-6%). CONCLUSION: ACP activities are an essential step to achieve goal concordant care, and this initiative successfully increased ACP activities for patients with metastatic cancer. However, given that the main source of increased ACP activities during this initiative was PM referrals, further progress will depend upon strengthening the oncology care teams' ACP skills and motivation for completion.
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15
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Anhang Price R, Bradley MA, Ye F, Schlang D, DeYoreo M, Cleary PD, Elliott MN, Montemayor CK, Timmer M, Tolpadi A, Teno JM. Reliable and Valid Survey-Based Measures to Assess Quality of Care in Home-Based Serious Illness Programs. J Palliat Med 2022; 25:864-872. [PMID: 34936490 PMCID: PMC9145570 DOI: 10.1089/jpm.2021.0424] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background: There is a pressing need for standardized measures to assess the quality of home-based serious illness care. Currently, there are no validated quality measures that are specific to home-based serious illness programs (SIPs) and the unique needs of their patients. Objective: To develop and evaluate standardized survey-based measures of serious illness care experiences for assessing and comparing quality of home-based serious illness care programs. Methods: From October 2019 through January 2020, we administered a survey to patients who received care from 32 home-based SIPs across the United States. Using the 2263 survey responses, we assessed item performance and constructed composite measures via factor analysis, evaluated item-scale correlations, estimated reliability, and examined validity by regressing overall ratings and willingness to recommend care on each composite. Results: The overall survey response rate was 36%. Confirmatory factor analyses supported five composite quality measures: Communication, Care Coordination, Help for Symptoms, Planning for Care, and Support for Family and Friends. Cronbach's alpha estimates for the composite measures ranged from 0.69 to 0.85, indicating adequate internal consistency in assessing their underlying constructs. Interprogram reliability ranged from 0.67 to 0.80 at 100 completed surveys per measure, meeting common standards for distinguishing between programs' performance. Together, the composites explained 45% of the variance in patients' overall care ratings. Communication, Care Coordination, and Planning for Care were the strongest predictors of overall ratings. Conclusion: Our analyses provide evidence of the feasibility, reliability, and validity of proposed survey-based measures to assess the quality of home-based serious illness care from the perspective of patients and their families.
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Affiliation(s)
- Rebecca Anhang Price
- RAND Corporation, Arlington, Virginia, USA
- Address correspondence to: Rebecca Anhang Price, PhD, RAND Corporation, 1200 S Hayes Street, Arlington, VA 22202, USA
| | | | - Feifei Ye
- RAND Corporation, Pittsburgh, Pennsylvania, USA
| | | | | | - Paul D. Cleary
- Yale School of Public Health, New Haven, Connecticut, USA
| | | | | | | | | | - Joan M. Teno
- Oregon Health and Science University, Portland, Oregon, USA
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16
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Andersson S, Sandgren A. Organizational readiness to implement the Serious Illness Care Program in hospital settings in Sweden. BMC Health Serv Res 2022; 22:539. [PMID: 35459204 PMCID: PMC9026003 DOI: 10.1186/s12913-022-07923-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 04/08/2022] [Indexed: 11/29/2022] Open
Abstract
Background The Serious Illness Care Program (SICP) is a model developed for structured communication, identifying patients, and training physicians to use a structured guide for conversations with patients and family members. However, there is a lack of knowledge regarding the sustainable implementation of this conversation model. Therefore, the aim of this study was to identify barriers and enablers during the implementation of the SICP in hospital settings. Methods The SICP was implemented at 20 units in two hospitals in Sweden. During the implementation process, seven individual interviews and two group interviews were conducted with seven facilitators (five physicians, one behavioral therapist, and one administrator). Data were analyzed using qualitative content analysis, first inductively, and then deductively using the organizational readiness for change as a theoretical framework. Result The analysis resulted in three factors acting as enablers and eight factors acting as enablers and/or barriers during the implementation of the SICP. The three factors considered as enablers were preliminaries, identifying patients, and facilitator’s role. The eight factors considered as enablers and/or barriers were broad implementation, leadership, time, confidence, building foundation, motivation to work change, motivation for training in serious illness conversations, and attitudes. Conclusion This study indicates limited readiness to implement the SICP in hospital settings due to considerable variation in organizational contextual factors, change efficacy, and change commitment. The identified enablers and barriers for implementation of the SICP could guide and support future implementations to be sustainable over time. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07923-5.
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Affiliation(s)
- Sofia Andersson
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden.
| | - Anna Sandgren
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
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17
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Myers J, Kim GL, Bytautas J, Webster F. Differing Conceptualizations of the Goals of Care Discussion: A Critical Discourse Analysis. J Pain Symptom Manage 2022; 63:495-502. [PMID: 34954070 DOI: 10.1016/j.jpainsymman.2021.12.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/03/2021] [Accepted: 12/11/2021] [Indexed: 11/24/2022]
Abstract
CONTEXT The goals of care discussion (GOCD) has been positioned as an improvement strategy to address discordance between care decisions made by seriously ill patients and care received. Interventions aimed at improving GOCDs however have had limited success. This may in part be due to the considerable variation in views on the essential components and expected outcomes of a GOCD. This variability, and consequently clinical approaches to GOCDs, may reflect fundamental differences in how the GOCD is conceptualized. OBJECTIVE To identify and characterize differing conceptualizations of the GOCD. METHODS Critical discourse analysis was used to qualitatively examine GOCDs documented for inpatients of 35 Canadian palliative medicine (PM), critical care medicine (CCM) and general internal medicine (GIM) physicians. Patterns in the ways the GOCD had been constructed were characterized by identifying different aspects of the approaches used by clinicians. RESULTS GOCD notes varied in the predominant style and tone (from narrative to biomedical), predominant information source (patient/family to physician), and contribution of the patient's perspective. Notably binary differences were also found in the locus of goals and located either with the patient or with the broad concept of treatments. Although not exclusively, locus of goals tended to be with the patient among PM physicians and with treatments among CCM and GIM physicians. CONCLUSION These findings offer clinical evidence for differing conceptualizations of the GOCD and orientations to goals as either person-centered or treatment-centered. This phenomenon may be in part discipline-based and has important implications for both clinical practice and training experiences.
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Affiliation(s)
- Jeff Myers
- Division of Palliative Care, Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.
| | - Ginah L Kim
- Division of Palliative Care, Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Jessica Bytautas
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Fiona Webster
- Labatt Family School of Nursing, Faculty of Health Sciences, Western University, London, Canada
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18
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Li EH, Ferrell W, Klaiman T, Kumar P, O'Connor N, Schuchter LM, Chen J, Patel MS, Manz CR, Parikh RB. Impact of Behavioral Nudges on the Quality of Serious Illness Conversations Among Patients With Cancer: Secondary Analysis of a Randomized Controlled Trial. JCO Oncol Pract 2022; 18:e495-e503. [PMID: 34767481 PMCID: PMC9014420 DOI: 10.1200/op.21.00024] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Serious Illness Conversations (SICs) are structured conversations between clinicians and patients about prognosis, treatment goals, and end-of-life preferences. Although behavioral interventions may prompt earlier or more frequent SICs, their impact on the quality of SICs is unclear. METHODS This was a secondary analysis of a randomized clinical trial (NCT03984773) among 78 clinicians and 14,607 patients with cancer testing the impact of an automated mortality prediction with behavioral nudges to clinicians to prompt more SICs. We analyzed 318 randomly selected SICs matched 1:1 by clinicians (159 control and 159 intervention) to compare the quality of intervention vs. control conversations using a validated codebook. Comprehensiveness of SIC documentation was used as a measure of quality, with higher integer numbers of documented conversation domains corresponding to higher quality conversations. A conversation was classified as high-quality if its score was ≥ 8 of a maximum of 10. Using a noninferiority design, mixed effects regression models with clinician-level random effects were used to assess SIC quality in intervention vs. control groups, concluding noninferiority if the adjusted odds ratio (aOR) was not significantly < 0.9. RESULTS Baseline characteristics of the control and intervention groups were similar. Intervention SICs were noninferior to control conversations (aOR 0.99; 95% CI, 0.91 to 1.09). The intervention increased the likelihood of addressing patient-clinician relationship (aOR = 1.99; 95% CI, 1.23 to 3.27; P < .01) and decreased the likelihood of addressing family involvement (aOR = 0.56; 95% CI, 0.34 to 0.90; P < .05). CONCLUSION A behavioral intervention that increased SIC frequency did not decrease their quality. Behavioral prompts may increase SIC frequency without sacrificing quality.
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Affiliation(s)
- Eric H. Li
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - William Ferrell
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Tamar Klaiman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Pallavi Kumar
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Nina O'Connor
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lynn M. Schuchter
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Jinbo Chen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mitesh S. Patel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA,Penn Medicine Nudge Unit, Philadelphia, PA,Wharton School of the University of Pennsylvania, Philadelphia, PA
| | - Christopher R. Manz
- Dana Farber Cancer Institute, Boston, MA,Harvard Medical School, Harvard University, Boston, MA
| | - Ravi B. Parikh
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA,Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA,Ravi B. Parikh, MD, MPP, 423 Guardian Drive, Blockley 1102, Philadelphia, PA 19104; e-mail:
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19
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Chiec L, Szmuilowicz E, Neagle J, Clepp K, Wood GJ. Identifying Patients in Need of Goals of Care Conversations: Reliability, Acceptability, and Prognostic Significance of the Preference-Aligned Communication and Treatment Conversation Trigger Tool for Patients with Cancer. J Palliat Med 2022; 25:1249-1253. [PMID: 35363050 DOI: 10.1089/jpm.2021.0401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Simple methods to help teams identify patients with goals of care (GOC) conversation needs are lacking. Objectives: To develop a tool to identify hospitalized patients who may benefit from GOC conversations. Methods: The Preference-Aligned Communication and Treatment (PACT) Conversation Trigger Tool was implemented as part of a quality improvement initiative in 10 Illinois hospitals and validated in a cohort of patients admitted to the coordinating site's oncology unit (n = 135). Results: The tool was reliable and acceptable to clinicians using it across sites. Thirty percent (n = 40) of patients screened at the coordinating site's oncology unit triggered positive. These patients were more likely to have a do-not-resuscitate order (43% vs. 11%) and palliative care consult (53% vs. 20%) and had lower mean survival time (125 vs. 248 days) than those who did not trigger (p < 0.001). Conclusions: The tool is reliable, acceptable, and can identify hospitalized oncology patients who may benefit from GOC conversations.
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Affiliation(s)
- Lauren Chiec
- Division of Hematology-Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Eytan Szmuilowicz
- Division of Hospital Medicine (Palliative Care), Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jayson Neagle
- Division of Hospital Medicine (Palliative Care), Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Katie Clepp
- Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Gordon J Wood
- Division of Hospital Medicine (Palliative Care), Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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LeBaron V, Boukhechba M, Edwards J, Flickinger T, Ling D, Barnes LE. Exploring the use of wearable sensors and natural language processing technology to improve patient-clinician communication: Protocol for a feasibility study (Preprint). JMIR Res Protoc 2022; 11:e37975. [PMID: 35594139 PMCID: PMC9166632 DOI: 10.2196/37975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 03/24/2022] [Accepted: 03/30/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Virginia LeBaron
- School of Nursing, University of Virginia, Charlottesville, VA, United States
| | - Mehdi Boukhechba
- School of Engineering & Applied Science, University of Virginia, Charlottesville, VA, United States
| | - James Edwards
- School of Nursing, University of Virginia, Charlottesville, VA, United States
| | - Tabor Flickinger
- School of Medicine, University of Virginia, Charlottesville, VA, United States
| | - David Ling
- School of Medicine, University of Virginia, Charlottesville, VA, United States
| | - Laura E Barnes
- School of Engineering & Applied Science, University of Virginia, Charlottesville, VA, United States
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21
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Paladino J, Sanders J, Kilpatrick LB, Prabhakar R, Kumar P, O'Connor N, Durieux B, Fromme EK, Benjamin E, Mitchell S. Serious Illness Care Programme-contextual factors and implementation strategies: a qualitative study. BMJ Support Palliat Care 2022:bmjspcare-2021-003401. [PMID: 35168931 DOI: 10.1136/bmjspcare-2021-003401] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/24/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES The Serious Illness Care Programme (SICP) is a multicomponent evidence-based intervention that improves communication about patients' values and goals in serious illness. We aim to characterise implementation strategies for programme delivery and the contextual factors that influence implementation in three 'real-world' health system SICP initiatives. METHODS We employed a qualitative thematic framework analysis of field notes collected during the first 1.5 years of implementation and a fidelity survey. RESULTS Analysis revealed empiric evidence about implementation and institutional context. All teams successfully implemented clinician training and an electronic health record (EHR) template for documentation of serious illness conversations. When training was used as the primary strategy to engage clinicians, however, clinician receptivity to the programme and adoption of conversations remained limited due to clinical culture-related barriers (eg, clinicians' attitudes, motivations and practice environment). Visible leadership involvement, champion facilitation and automated EHR-based data feedback on documented conversations appeared to improve adoption. Implementing these strategies depended on contextual factors, including leadership support at the specialty level, champion resources and capacity, and EHR capabilities. CONCLUSIONS Health systems need multifaceted implementation strategies to move beyond the limited impact of clinician training in driving improvement in serious illness conversations. These include EHR-based data feedback, involvement of specialty leaders to message the programme and align incentives, and local champions to problem-solve frontline challenges longitudinally. Implementation of these strategies depended on a favourable institutional context. Greater attention to the influence of contextual factors and implementation strategies may enable sustained improvements in serious illness conversations at scale.
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Affiliation(s)
- Joanna Paladino
- Ariadne Labs, Brigham & Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Justin Sanders
- Ariadne Labs, Brigham & Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Family Medicine, Palliative Care, McGill University, Montreal, Québec, Canada
| | - Laurel B Kilpatrick
- Division of Supportive and Palliative Care, Baylor Scott and White Health, Temple, Texas, USA
| | | | | | | | | | - Erik K Fromme
- Ariadne Labs, Brigham & Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Evan Benjamin
- Ariadne Labs, Brigham & Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Suzanne Mitchell
- Ariadne Labs, Brigham & Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, MA, USA
- UMass Memorial Health Care, Worcester, Massachusetts, USA
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22
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Bloom JR, Marshall DC, Rodriguez-Russo C, Martin E, Jones JA, Dharmarajan KV. Prognostic disclosure in oncology - current communication models: a scoping review. BMJ Support Palliat Care 2022; 12:167-177. [PMID: 35144938 DOI: 10.1136/bmjspcare-2021-003313] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 01/08/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Prognostic disclosure is essential to informed decision making in oncology, yet many oncologists are unsure how to successfully facilitate this discussion. This scoping review determines what prognostic communication models exist, compares and contrasts these models, and explores the supporting evidence. METHOD A protocol was created for this study using the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols extension for Scoping Reviews. Comprehensive literature searches of electronic databases MEDLINE, EMBASE, PsycINFO and Cochrane CENTRAL were executed to identify relevant publications between 1971 and 2020. RESULTS In total, 1532 articles were identified, of which 78 met inclusion criteria and contained 5 communication models. Three of these have been validated in randomised controlled trials (the Serious Illness Conversation Guide, the Four Habits Model and the ADAPT acronym) and have demonstrated improved objective communication measures and patient reported outcomes. All three models emphasise the importance of exploring patients' illness understanding and treatment preferences, communicating prognosis and responding to emotion. CONCLUSION Communicating prognostic estimates is a core competency skill in advanced cancer care. This scoping review highlights available communication models and identifies areas in need of further assessment. Such areas include how to maintain learnt communication skills for lifelong practice, how to assess patient and caregiver understanding during and after these conversations, and how to best scale these protocols at the institutional and national levels.
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Affiliation(s)
- Julie Rachel Bloom
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Carlos Rodriguez-Russo
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emily Martin
- Palliative Care Program, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Joshua Adam Jones
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kavita Vyas Dharmarajan
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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23
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Shepherd J, Waller A, Chan S, Kim M, Kang SJ, Chan C, Chow M, Clapham M, Sanson-Fisher R. Barriers to the provision of optimal care to dying patients in hospital: An international cross-sectional comparison study of nurses’ perceptions. Collegian 2022. [DOI: 10.1016/j.colegn.2021.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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24
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Enhancing serious illness communication using artificial intelligence. NPJ Digit Med 2022; 5:14. [PMID: 35087172 PMCID: PMC8795189 DOI: 10.1038/s41746-022-00556-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 12/22/2021] [Indexed: 11/08/2022] Open
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25
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Desai AV, Agarwal R, Epstein AS, Kuperman GJ, Michael CL, Mittelstaedt H, Connor M, Bernal C, Lynch KA, Ostroff JS, Katz B, Corrigan KL, Kramer D, Davis ME, Nelson JE. Needs and Perspectives of Cancer Center Stakeholders for Access to Patient Values in the Electronic Health Record. JCO Oncol Pract 2021; 17:e1524-e1536. [PMID: 33555928 PMCID: PMC9810135 DOI: 10.1200/op.20.00644] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE High-quality cancer care must incorporate patients' personal values in decision making throughout illness. Unfortunately, patient values are neither consistently elicited nor easily accessible in the electronic health record (EHR). Memorial Sloan Kettering Cancer Center is deploying a major EHR innovation, called the Patient Values Tab, which provides ready access to patients' values and personhood. To inform the Tab's design, we interviewed a large, diverse group of institutional stakeholders to understand their user needs for this Tab. METHODS Qualitative data were collected through semistructured, audio-recorded, in-person, individual interviews. An interdisciplinary team of four coders conducted a process of thematic content analysis. Thematic saturation was achieved, and member checking was performed. RESULTS A total of 110 stakeholders were approached and interviewed. Participants comprised a wide range of disciplines or professions and others involved in hospital and/or clinic administration. Analysis revealed the following themes related to important Tab content: personhood, support system or resources, social history, communication preferences, future planning, end of life, and illness and treatment understanding. Participants also discussed implementation considerations, the Tab's potential to improve communication, and privacy implications. CONCLUSION This study focused on a major EHR innovation to centralize information about values and personhood of patients with cancer. We elicited views of over 100 institutional stakeholders through in-depth interviews that were rigorously analyzed, yielding themes related to content and format that helped guide the Tab's design. The interviews generated a sense of ownership and enthusiasm for the Tab among future users. The Tab's introduction advances the use of the EHR as a driver of the delivery of patient-centered care.
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Affiliation(s)
- Anjali V. Desai
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY,Weill Cornell Medical College, New York, NY,Anjali V. Desai, MD, MSCE, 1275 York Avenue, New York, NY 10065; e-mail:
| | - Rajiv Agarwal
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Andrew S. Epstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY,Weill Cornell Medical College, New York, NY
| | - Gilad J. Kuperman
- Department of Health Informatics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Chelsea L. Michael
- Department of Health Informatics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Haley Mittelstaedt
- Department of Health Informatics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - MaryAnn Connor
- Department of Nursing Informatics, Memorial Sloan Kettering Cancer Center, New York, NY,New York University, New York, NY
| | - Camila Bernal
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kathleen A. Lynch
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jamie S. Ostroff
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Brittany Katz
- Weill Cornell Medical College, New York, NY,Department of Medicine, New York-Presbyterian Hospital, New York, NY
| | - Kelsey L. Corrigan
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Dana Kramer
- Department of Advanced Practice Providers, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Judith E. Nelson
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY,Weill Cornell Medical College, New York, NY
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Ernecoff NC, Wessell KL, Bennett AV, Hanson LC. Measuring Goal-Concordant Care in Palliative Care Research. J Pain Symptom Manage 2021; 62:e305-e314. [PMID: 33675919 PMCID: PMC9082654 DOI: 10.1016/j.jpainsymman.2021.02.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 02/23/2021] [Accepted: 02/23/2021] [Indexed: 10/22/2022]
Abstract
>Goal-concordant care is a priority outcome for palliative care research, yet the field lacks consensus on optimal methods for measurement. We sought to 1) categorize methods used to measure goal-concordant care, and 2) discuss strengths and limitations of each method using empirical examples from palliative care research. We categorized measurement methods for goal-concordant care. We identified empirical examples of each method to illustrate the strengths, limitations, and applicability of each method to relevant study designs. We defined four methods used to measure goal-concordant care: 1) Patient- or Caregiver-Reported, 2) Caregiver-Reported After Death, 3) Concordance in Longitudinal Data, and 4) Population-Level Indicators. Patient or caregiver-reported goal-concordant care draws on strengths of patient-reported outcomes, and can be captured for multiple aspects of treatment; these methods are subject to recall bias or family-proxy bias. Concordance in longitudinal data is optimal when a treatment preference can be specifically and temporally linked to actual treatment; the method is limited to common life-sustaining treatment choices and validity may be affected by temporal variation between preference and treatment. Population-level indicators allow pragmatic research to include large populations; its primary limitation is the assumption that preferences held by a majority of persons should correspond to patterns of actual treatment in similar populations. Methods used to measure goal-concordant care have distinct strengths and limitations, and methods should be selected based on research question and study design. Existing methods could be improved, yet a future gold standard is unlikely to suit all research designs.
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Affiliation(s)
- Natalie C Ernecoff
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Kathryn L Wessell
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, NC, USA
| | - Antonia V Bennett
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, USA
| | - Laura C Hanson
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, NC, USA; Division of Geriatric Medicine and Palliative Care Program, University of North Carolina at Chapel Hill, NC, USA
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27
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Development and Validation of a 30-Day In-hospital Mortality Model Among Seriously Ill Transferred Patients: a Retrospective Cohort Study. J Gen Intern Med 2021; 36:2244-2250. [PMID: 33506405 PMCID: PMC7840078 DOI: 10.1007/s11606-021-06593-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 01/01/2021] [Indexed: 12/02/2022]
Abstract
BACKGROUND Predicting the risk of in-hospital mortality on admission is challenging but essential for risk stratification of patient outcomes and designing an appropriate plan-of-care, especially among transferred patients. OBJECTIVE Develop a model that uses administrative and clinical data within 24 h of transfer to predict 30-day in-hospital mortality at an Academic Health Center (AHC). DESIGN Retrospective cohort study. We used 30 putative variables in a multiple logistic regression model in the full data set (n = 10,389) to identify 20 candidate variables obtained from the electronic medical record (EMR) within 24 h of admission that were associated with 30-day in-hospital mortality (p < 0.05). These 20 variables were tested using multiple logistic regression and area under the curve (AUC)-receiver operating characteristics (ROC) analysis to identify an optimal risk threshold score in a randomly split derivation sample (n = 5194) which was then examined in the validation sample (n = 5195). PARTICIPANTS Ten thousand three hundred eighty-nine patients greater than 18 years transferred to the Indiana University (IU)-Adult Academic Health Center (AHC) between 1/1/2016 and 12/31/2017. MAIN MEASURES Sensitivity, specificity, positive predictive value, C-statistic, and risk threshold score of the model. KEY RESULTS The final model was strongly discriminative (C-statistic = 0.90) and had a good fit (Hosmer-Lemeshow goodness-of-fit test [X2 (8) =6.26, p = 0.62]). The positive predictive value for 30-day in-hospital death was 68%; AUC-ROC was 0.90 (95% confidence interval 0.89-0.92, p < 0.0001). We identified a risk threshold score of -2.19 that had a maximum sensitivity (79.87%) and specificity (85.24%) in the derivation and validation sample (sensitivity: 75.00%, specificity: 85.71%). In the validation sample, 34.40% (354/1029) of the patients above this threshold died compared to only 2.83% (118/4166) deaths below this threshold. CONCLUSION This model can use EMR and administrative data within 24 h of transfer to predict the risk of 30-day in-hospital mortality with reasonable accuracy among seriously ill transferred patients.
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28
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Bazargan M, Bazargan-Hejazi S. Disparities in Palliative and Hospice Care and Completion of Advance Care Planning and Directives Among Non-Hispanic Blacks: A Scoping Review of Recent Literature. Am J Hosp Palliat Care 2021; 38:688-718. [PMID: 33287561 PMCID: PMC8083078 DOI: 10.1177/1049909120966585] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Published research in disparities in advance care planning, palliative, and end-of-life care is limited. However, available data points to significant barriers to palliative and end-of-life care among minority adults. The main objective of this scoping review was to summarize the current published research and literature on disparities in palliative and hospice care and completion of advance care planning and directives among non-Hispanc Blacks. METHODS The scoping review method was used because currently published research in disparities in palliative and hospice cares as well as advance care planning are limited. Nine electronic databases and websites were searched to identify English-language peer-reviewed publications published within last 20 years. A total of 147 studies that addressed palliative care, hospice care, and advance care planning and included non-Hispanic Blacks were incorporated in this study. The literature review include manuscripts that discuss the intersection of social determinants of health and end-of-life care for non-Hispanic Blacks. We examined the potential role and impact of several factors, including knowledge regarding palliative and hospice care; healthcare literacy; communication with providers and family; perceived or experienced discrimination with healthcare systems; mistrust in healthcare providers; health care coverage, religious-related activities and beliefs on palliative and hospice care utilization and completion of advance directives among non-Hispanic Blacks. DISCUSSION Cross-sectional and longitudinal national surveys, as well as local community- and clinic-based data, unequivocally point to major disparities in palliative and hospice care in the United States. Results suggest that national and community-based, multi-faceted, multi-disciplinary, theoretical-based, resourceful, culturally-sensitive interventions are urgently needed. A number of practical investigational interventions are offered. Additionally, we identify several research questions which need to be addressed in future research.
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Affiliation(s)
- Mohsen Bazargan
- Department of Family Medicine, Charles R. Drew University of Medicine and Science (CDU), Los Angeles, CA, USA
- Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Shahrzad Bazargan-Hejazi
- Department of Psychiatry, Charles R. Drew University of Medicine and Science (CDU), Los Angeles, CA, USA
- Department of Psychiatry, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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29
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Hunt LJ, Garrett SB, Dressler G, Sudore R, Ritchie CS, Harrison KL. "Goals of Care Conversations Don't Fit in a Box": Hospice Staff Experiences and Perceptions of Advance Care Planning Quality Measurement. J Pain Symptom Manage 2021; 61:917-927. [PMID: 33096214 PMCID: PMC8055723 DOI: 10.1016/j.jpainsymman.2020.09.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 09/28/2020] [Accepted: 09/30/2020] [Indexed: 11/22/2022]
Abstract
CONTEXT With rising concerns about quality of care in hospice, federal agencies recently began mandating quality measurement in hospice, including measures of advance care planning (ACP). OBJECTIVES To characterize hospice providers' experiences with ACP quality measurement and their reflections on ways to improve it. METHODS Semi-structured in-depth interviews of fifty-one hospice providers from various clinical backgrounds and organizational roles in four geographically diverse non-profit, community-based hospices in the U.S. Participants were queried about their experiences with and barriers to ACP quality measurement processes in their organization, opinions about the impacts of federally mandated quality measures, and ideas for improvement. Data were analyzed using thematic analysis with an interdisciplinary team, facilitated by ATLAS.ti and Excel. RESULTS Four key findings of the ACP quality measurement experience for hospice staff included variation, barriers, attitudes, and recommendations for improvement. 1) Variation: Within and across organizations, participants applied a variety of processes to measure ACP quality, and exposure to and experiences with quality measurement varied based on organizational role. 2) Barriers: ACP quality measurement was impeded by limited resources, technological problems, and measurement challenges. 3) Attitudes: Participants' opinions of recently implemented federally mandated requirements for ACP quality measurement highlighted numerous downsides, unintended consequences, and few upsides. 4) Recommendations: improvements included personalizing ACP quality measures, elevating the importance of quality measurement, and streamlining processes. CONCLUSION Hospice staff take ACP quality measurement seriously, but insufficient organizational resources and regulatory bureaucracy create challenges. Efforts to enhance ACP quality measure nuance and assess outcomes are needed to improve care.
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Affiliation(s)
- Lauren J Hunt
- Department of Physiological Nursing, University of California, San Francisco, California, USA.
| | - Sarah B Garrett
- Division of Geriatrics, University of California, San Francisco, California, USA; Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
| | - Gabrielle Dressler
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Rebecca Sudore
- Division of Geriatrics, University of California, San Francisco, California, USA; San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Christine S Ritchie
- The Mongan Institute and the Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Krista L Harrison
- Division of Geriatrics, University of California, San Francisco, California, USA; Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
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Strict isolation requires a different approach to the family of hospitalised patients with COVID-19: A rapid qualitative study. Int J Nurs Stud 2021; 117:103858. [PMID: 33621720 PMCID: PMC7834466 DOI: 10.1016/j.ijnurstu.2020.103858] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 12/12/2020] [Accepted: 12/16/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND The outbreak of the COVID-19 pandemic influenced family-centred care dramatically due to restricting visiting policies. In this new situation, nurses were challenged to develop new approaches to involve family members in patient care. A better understanding of these changes and the experiences of nurses is essential to make an adaptation of procedures, and to secure a family-centred approach in care as much as possible. OBJECTIVES The aim of this study was to investigate how family involvement had taken place, and to explore the experiences of nurses with family involvement during the COVID-19 outbreak. In addition, we aimed to formulate recommendations for the involvement of family. METHODS We conducted a qualitative study using patient record review and focus-group interviews between April and July 2020. We reviewed records of patients with confirmed COVID-19, who were admitted to the COVID-19 wards at two affiliated university hospitals in the Netherlands. All records were searched for notations referring to family involvement. In two focus-groups, nurses who worked at the COVID-19 wards were invited to share their experiences. The Rigorous and Accelerated Data Reduction (RADaR) method was used to collect, reduce and analyse the data. RESULTS In total, 189 patient records were reviewed and nine nurses participated in the focus-group meetings. Patient records revealed infrequent and often unstructured communication with focus on physical condition. Nurses confirmed that communication with family was far less than before and that the physical condition of the patient was predominant. The involvement of family in care was limited to practicalities, although more involvement was described in end-of-life situations. Nurses experienced moral distress due to the visiting restrictions, though some acknowledged that they had experienced the direct patient care so intense and burdensome, that family contact simply felt too much. CONCLUSION The communication with and involvement of family in hospital care changed enormously during the COVID-19 outbreak. Based on the identified themes, we formulated recommendations that may be helpful for family-centered care in hospitals during periods of restricted visiting policy.
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31
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Desai AV, Michael CL, Kuperman GJ, Jordan G, Mittelstaedt H, Epstein AS, Connor M, B Villar RP, Bernal C, Kramer D, Davis ME, Chen Y, Malisse C, Markose G, Nelson JE. A Novel Patient Values Tab for the Electronic Health Record: A User-Centered Design Approach. J Med Internet Res 2021; 23:e21615. [PMID: 33595448 PMCID: PMC7929751 DOI: 10.2196/21615] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/21/2020] [Accepted: 10/21/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic has shined a harsh light on a critical deficiency in our health care system: our inability to access important information about patients' values, goals, and preferences in the electronic health record (EHR). At Memorial Sloan Kettering Cancer Center (MSK), we have integrated and systematized health-related values discussions led by oncology nurses for newly diagnosed cancer patients as part of routine comprehensive cancer care. Such conversations include not only the patient's wishes for care at the end of life but also more holistic personal values, including sources of strength, concerns, hopes, and their definition of an acceptable quality of life. In addition, health care providers use a structured template to document their discussions of patient goals of care. OBJECTIVE To provide ready access to key information about the patient as a person with individual values, goals, and preferences, we undertook the creation of the Patient Values Tab in our center's EHR to display this information in a single, central location. Here, we describe the interprofessional, interdisciplinary, iterative process and user-centered design methodology that we applied to build this novel functionality as well as our initial implementation experience and plans for evaluation. METHODS We first convened a working group of experts from multiple departments, including medical oncology, health informatics, information systems, nursing informatics, nursing education, and supportive care, and a user experience designer. We conducted in-depth, semistructured, audiorecorded interviews of over 100 key stakeholders. The working group sought consensus on the tab's main content, homing in on high-priority areas identified by the stakeholders. The core content was mapped to various EHR data sources. We established a set of high-level design principles to guide our process. Our user experience designer then created wireframes of the tab design. The designer conducted usability testing with physicians, nurses, and other health professionals. Data validation testing was conducted. RESULTS We have already deployed the Patient Values Tab to a pilot sample of users in the MSK Gastrointestinal Medical Oncology Service, including physicians, advanced practice providers, nurses, and administrative staff. We have early evidence of the positive impact of this EHR innovation. Audit logs show increasing use. Many of the initial user comments have been enthusiastically positive, while others have provided constructive suggestions for additional tab refinements with respect to format and content. CONCLUSIONS It is our challenge and obligation to enrich the EHR with information about the patient as a person. Realization of this capability is a pressing public health need requiring the collaboration of technological experts with a broad range of clinical leaders, users, patients, and families to achieve solutions that are both principled and practical. Our new Patient Values Tab represents a step forward in this important direction.
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Affiliation(s)
- Anjali Varma Desai
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Department of Medicine, Weill Cornell Medical College, New York, NY, United States
| | | | - Gilad J Kuperman
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Gregory Jordan
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | | | - Andrew S Epstein
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Department of Medicine, Weill Cornell Medical College, New York, NY, United States
| | - MaryAnn Connor
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | | | - Camila Bernal
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Dana Kramer
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | | | - Yuxiao Chen
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | | | - Gigi Markose
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Judith E Nelson
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Department of Medicine, Weill Cornell Medical College, New York, NY, United States
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Fassbender K, Biondo P, Holroyd-Leduc J, Potapov A, Wityk Martin TL, Wasylenko E, Hagen NA, Simon J. Identification and operationalisation of indicators to monitor successful uptake of advance care planning policies: a modified Delphi study. BMJ Support Palliat Care 2021; 12:bmjspcare-2020-002780. [PMID: 33579796 DOI: 10.1136/bmjspcare-2020-002780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/11/2021] [Accepted: 01/15/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND In 2014, the province of Alberta, Canada implemented a province-wide policy and procedures for advance care planning (ACP) and goals of care designation (GCD) across its complex, integrated public healthcare system. This study was conducted to identify and operationalise performance indicators for ACP/GCD to monitor policy implementation success and sustainment of ACP/GCD practice change. METHODS A systematic review and environmental scan was conducted to identify potential indicators of ACP/GCD uptake (n=132). A purposive sample of ACP/GCD stakeholders was invited to participate in a modified Delphi study to evaluate, reduce and refine these indicators through a combination of face-to-face meetings and online surveys. RESULTS An evidence-informed Donabedian by Institute of Medicine (IOM) framework was adopted as an organising matrix for the indicators in an initial face-to-face meeting. Three online survey rounds reduced and refined the 132 indicators to 18. A final face-to-face meeting operationalised the indicators into a measurable format. Nine indicators, covering 11 of the 18 Donabedian×IOM domains, were operationalised. CONCLUSIONS Nine ACP/GCD evidence-informed indicators mapping to 11 of 18 Donabedian×IOM domains were endorsed, and have been operationalised into an online ACP/GCD dashboard. The indicators provide a characterisation of ACP/GCD uptake that could be generalised to other healthcare settings, measuring aspects related to ACP/GCD documentation, patient satisfaction and agreement between medical orders and care received. The final nine indicators reflect the stakeholders' expressed intent to strike a balance between comprehensiveness and feasibility within a large provincial healthcare system.
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Affiliation(s)
- Konrad Fassbender
- Department of Oncology, University of Alberta Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
| | - Patricia Biondo
- Department of Oncology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Jayna Holroyd-Leduc
- Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Alexei Potapov
- Department of Oncology, University of Alberta Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
| | | | - Eric Wasylenko
- Department of Oncology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- John Dossetor Health Ethics Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Neil Angus Hagen
- Department of Oncology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Jessica Simon
- Department of Oncology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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Affiliation(s)
- Justin J Sanders
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Levoy K, Tarbi EC, De Santis JP. End-of-life decision making in the context of chronic life-limiting disease: a concept analysis and conceptual model. Nurs Outlook 2020; 68:784-807. [PMID: 32943221 PMCID: PMC7704858 DOI: 10.1016/j.outlook.2020.07.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 06/26/2020] [Accepted: 07/10/2020] [Indexed: 01/23/2023]
Abstract
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.
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Affiliation(s)
- Kristin Levoy
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA.
| | - Elise C Tarbi
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA
| | - Joseph P De Santis
- University of Miami School of Nursing and Health Studies, Coral Gables, FL
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Communication Tools to Support Advance Care Planning and Hospital Care During the COVID-19 Pandemic: A Design Process. Jt Comm J Qual Patient Saf 2020; 47:127-136. [PMID: 33191165 PMCID: PMC7584878 DOI: 10.1016/j.jcjq.2020.10.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 12/18/2022]
Abstract
The COVID-19 pandemic has exposed the medical and social vulnerability of an unprecedented number of people. Consequently, there has never been a more important time for clinicians to engage patients in advance care planning (ACP) discussions about their goals, values, and preferences in the event of critical illness. An evidence-based communication tool-the Serious Illness Conversation Guide-was adapted to address COVID-related ACP challenges using a user-centered design process: convening relevant experts to propose initial guide adaptations; soliciting feedback from key clinical stakeholders from multiple disciplines and geographic regions; and iteratively testing language with patient actors. With feedback focused on sharing risk about COVID-19-related critical illness, recommendations for treatment decisions, and use of person-centered language, the team also developed conversation guides for inpatient and outpatient use. These tools consist of open-ended questions to elicit perception of risk, goals, and care preferences in the event of critical illness, and language to convey prognostic uncertainty. To support use of these tools, publicly available implementation materials were also developed for clinicians to effectively engage high-risk patients and overcome challenges related to the changed communication context, including video demonstrations, telehealth communication tips, and step-by-step approaches to identifying high-risk patients and documenting conversation findings in the electronic health record. Well-designed communication tools and implementation strategies can equip clinicians to foster connection with patients and promote shared decision making. Although not an antidote to this crisis, such high-quality ACP may be one of the most powerful tools we have to prevent or ameliorate suffering due to COVID-19.
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Flint L, Kotwal A. The New Normal: Key Considerations for Effective Serious Illness Communication Over Video or Telephone During the Coronavirus Disease 2019 (COVID-19) Pandemic. Ann Intern Med 2020; 173:486-488. [PMID: 32422084 PMCID: PMC7236893 DOI: 10.7326/m20-1982] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
In-person communication with patients hospitalized with COVID-19 and their families is often not possible. This article provides helpful guidance on how to have meaningful conversations about serious illness using telecommunication.
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Affiliation(s)
- Lynn Flint
- University of California-San Francisco, and Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, California (L.F., A.K.)
| | - Ashwin Kotwal
- University of California-San Francisco, and Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, California (L.F., A.K.)
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37
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Bradford N, Rolfe M, Ekberg S, Mitchell G, Beane T, Ferranti K, Herbert A. Family meetings in paediatric palliative care: an integrative review. BMJ Support Palliat Care 2020; 11:288-295. [PMID: 32680893 DOI: 10.1136/bmjspcare-2020-002333] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/21/2020] [Accepted: 06/01/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Our aim was to synthesise the available evidence surrounding the structure, processes and outcomes of family meetings in the paediatric palliative care literature. METHODS We undertook an integrative literature review informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The protocol was registered with PROSPERO (CRD42019138938). Electronic databases were systematically search using keywords and hand searching of reference articles and grey literature was also completed. RESULTS Ten empirical studies and five theoretical articles were included in the synthesis. Empirical studies provided more information about meeting structure, whereas theoretical articles more frequently described a desired process for planning and undertaking meetings. No articles identified how the success of a meeting was defined or made recommendations for doing so. Despite reports that family meetings are commonly occurring, few articles described outcomes from either the family or clinician perspectives. CONCLUSIONS Family meetings are essential communication strategies commonly used in paediatric palliative care, yet there is little guidance about how meetings should be organised and conducted, who should participate and when they should occur. The limited data available on the outcomes of family meetings suggest improvements are required to meet the needs of families. We present a framework that synthesises the available evidence. The framework offers an overview of the elements to consider when planning for and undertaking family meetings in paediatric palliative care and may be useful for both clinicians and researchers.
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Affiliation(s)
- Natalie Bradford
- Centre for Healthcare Transformation at Centre for Children's Health Research, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Melanie Rolfe
- Centre for Healthcare Transformation at Centre for Children's Health Research, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Stuart Ekberg
- Institute of Health and Biomedical Innovation/School of Psychology and Counselling/Centre for Children's Health Research, Queensland University of Technology Kelvin Grove, Brisbane, Queensland, Australia
| | - Geoffrey Mitchell
- Primary Care Clinical Unit, The University of Queensland, Saint Lucia, Queensland, Australia
| | - Theresa Beane
- Cancer Care Service, Hervey Bay Hospital, Hervey Bay, Queensland, Australia
| | - Kahli Ferranti
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Anthony Herbert
- Institute of Health and Biomedical Innovation/Centre for Children's Health Research, Queensland University of Technology (QUT), Brisbane, Queensland, Australia.,Paediatric Palliative Care Service, Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia
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