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Aller A, Shirazi A, Pedell L, Altschuler A, Hauser K, Cheslock M, Wei J, Duffens A, Whitehead H, Lim P, Katzel J, Martinez F, Lin A, Aller S, Aller C, Jones T, Yen SM, Liu R. What Matters Most: The Documented Goals, Values and Motivators of Advanced Cancer Patients. Am J Hosp Palliat Care 2024; 41:1297-1306. [PMID: 38112439 DOI: 10.1177/10499091231223144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Goals of care conversations are essential to delivery of goal concordant care. Infrequent and inconsistent goals of care documentation potentially limit delivery of goal concordant care. METHODS At Kaiser Permanente San Francisco Cancer Center, a standardized documentation template was designed and implemented to increase goals of care documentation by oncologists. The centralized, prompt-based template included value clarification of the goals and values of advanced cancer patients beyond treatment preferences. Documented conversations using the template during the initial pilot period were reviewed to characterization the clinical context in which conversations were recorded. Common goals and motivators were also identified. RESULTS A total of 178 advanced cancer patients had at least 1 documented conversation by a medical oncologist using the goals of care template. Oncologists consistently documented within the template goals of therapy and motivating factors in decision making. The most frequently documented goals of care were "Avoiding Pain and Suffering," "Physical Independence," and "Living as Long as Possible." The least recorded goal was "Comfort Focused Treatment Only." CONCLUSIONS Review of oncologist documented goals of care conversations using a prompt-based template allowed for characterization of the clinical context, therapy goals and motivators of advanced cancer patients. Communication of goals of care conversations by oncologists using a standardized prompt-based template within a centralized location has the potential to improve delivery of goal concordant care.
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Affiliation(s)
- Ashley Aller
- Department of Hematology and Oncology, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Aida Shirazi
- Department of Graduate Medical Education, Kaiser Permanente Northern California, San Francisco, CA, USA
| | | | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Karen Hauser
- Department of Internal Medicine, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Megan Cheslock
- Department of Geriatrics Medicine, Edith Nourse Rogers Memorial Veterans' Hospital, Bedford, MA, USA
| | - Jenny Wei
- Department of Internal Medicine, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Ali Duffens
- Department of Internal Medicine, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Hannah Whitehead
- The Permanente Medical Group Consulting Services, Kaiser Permanente, Oakland, CA, USA
| | - Peggy Lim
- The Permanente Medical Group Consulting Services, Kaiser Permanente, Oakland, CA, USA
| | - Jed Katzel
- Department of Hematology and Oncology, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Francisco Martinez
- Department of Hematology and Oncology, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Amy Lin
- Department of Hematology and Oncology, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Steve Aller
- Department of Hematology-Oncology, Seattle Children's Hospital, Seattle, WA, USA
| | - Cynthia Aller
- Department of Hematology, Providence Regional Cancer System Lacey Cancer Clinic, Lacey, WA, USA
| | - Tyler Jones
- The Permanente Medical Group Consulting Services, Kaiser Permanente, Oakland, CA, USA
| | - Sue May Yen
- The Permanente Medical Group Consulting Services, Kaiser Permanente, Oakland, CA, USA
| | - Raymond Liu
- Department of Hematology and Oncology, Kaiser Permanente Northern California, San Francisco, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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2
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Ma JE, Schlichte L, Haverfield M, Gambino J, Lange A, Blanchard K, Morgan B, Bekelman DB. Do goals of care documentation reflect the conversation?: Evaluating conversation-documentation accuracy. J Am Geriatr Soc 2024; 72:2500-2507. [PMID: 38593240 PMCID: PMC11323159 DOI: 10.1111/jgs.18913] [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: 09/05/2023] [Revised: 03/07/2024] [Accepted: 03/17/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Documenting goals of care in the electronic health record is meant to relay patient preferences to other clinicians. Evaluating the content and documentation of nurse and social worker led goals of care conversations can inform future goals of care initiative efforts. METHODS As part of the ADvancing symptom Alleviation with Palliative Treatment trial, this study analyzed goals of care conversations led by nurses and social workers and documented in the electronic health record. Informed by a goals of care communication guide, we identified five goals of care components: illness understanding, goals and values, end of life planning, surrogate, and advance directives. Forty conversation transcripts underwent content analysis. Through an iterative team process, we defined documentation accuracy as four categories: (1) Complete-comprehensive accurate documentation of the conversation, (2) Incomplete-partial documentation of the conversation, (3) Missing-discussed and not documented, and (4) Incorrect-misrepresented in documentation. We also defined-Not Discussed-for communication guide questions that were not discussed nor documented. A constant comparative approach was used to determine the presence or absence of conversation content in the documentation. RESULTS All five goals of care components were discussed in 67% (27/40) of conversation transcripts. Compared to the transcripts, surrogate (37/40, 93%) and advance directives (36/40, 90%) were often documented completely. Almost 40% of goals and values (15/40, 38%) and half of end of life planning (19/40, 48%) were incomplete. Illness understanding was missing (13/40, 33%), not discussed (13/40, 33%), or incorrect (2/40, 5%). CONCLUSION Nurse and social worker led goals of care conversations discussed and documented most components of the goals of care communication guide. Further research may guide how best to determine the relative importance of accuracy, especially in the broad setting of incomplete, missing, and incorrect EHR documentation.
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Affiliation(s)
- Jessica E Ma
- Geriatric Research Education and Clinical Center, Durham VA Health System, Durham, North Carolina, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Marie Haverfield
- Department of Communication Studies, San José State University, San Jose, California, USA
| | | | - Allison Lange
- Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Kelly Blanchard
- VA Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Brianne Morgan
- VA Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - David B Bekelman
- VA Eastern Colorado Health Care System, Aurora, Colorado, USA
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
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Aller A, Hauser K, Pedell L, Martinez F, Lin A. Time is of the Essence: Why Goals-of-Care Conversations and Prognosis Documentation Matters in Advanced Cancer Patients in an Integrated Health System. Am J Hosp Palliat Care 2024; 41:634-640. [PMID: 37592901 DOI: 10.1177/10499091231188715] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023] Open
Abstract
Background: Advanced cancer patients benefit less from aggressive therapies and more from goal-directed palliative management. Early and clearly documented goals-of-care discussions, including end-of-life decision making, are essential in this patient population. Integrated healthcare systems are comprehensive care models associated with improved quality of care and lower mortality compared to other healthcare models. The role of advance care planning within our system is understudied. Methods: Patients 18 years and older with a diagnosis of advanced-stage cancer were identified over a 6-month period. Expert panel review was performed to evaluate medical appropriateness of the selected diagnostic workup and management. The role and extent of care planning was reviewed in association with the clinical context. Results: In a cohort of 82 patients, evidence-based and individualized appropriateness of medical management was found to be consistent for all patients. Eighty-two percent of patients elected for oncologic-based treatment, 5% pursued active surveillance, and 11% did not receive treatment. Seventy-three percent of patients were referred to palliative care. Fifty-six percent of patients had a full goals-of-care conversation documented; yet only 9% of goals-of-care conversations were documented by an oncologist. Prognosis was documented fully for only 22% of patients. At the end of the study period, 43 patients were deceased (52%), further indicating the critical importance of documentation. Conclusions: Within our integrated health system, we found consistent guideline- and patient-directed diagnosis and management, along with frequent integration of palliative care services. Goals-of-care conversation and prognosis documentation, especially by the oncologist, remains an area of needed improvement.
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Affiliation(s)
- Ashley Aller
- Department of Hematology/Oncology, The Permanente Medical Group, San Francisco, CA, USA
| | - Karen Hauser
- Department of Internal Medicine, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Leon Pedell
- Independent Consultant, West Bloomfield Township, MI, USA
| | - Francisco Martinez
- Department of Hematology/Oncology, The Permanente Medical Group, San Francisco, CA, USA
| | - Amy Lin
- Department of Hematology/Oncology, The Permanente Medical Group, San Francisco, CA, USA
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Wu YJ, Tang EK, Wu FZ. Evaluating Efficiency and Adherence in Asian Lung Cancer Screening: Comparing Self-paid and Clinical Study Approaches in Taiwan. Acad Radiol 2024; 31:2109-2117. [PMID: 38480076 DOI: 10.1016/j.acra.2024.01.045] [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: 12/21/2023] [Revised: 01/17/2024] [Accepted: 01/30/2024] [Indexed: 05/12/2024]
Abstract
RATIONALE AND OBJECTIVES This study aimed to assess how different screening methods, specifically self-paid screening versus participation in clinical studies, affect screening efficiency and adherence in a real-world Asian lung cancer screening population. MATERIALS AND METHODS This study collected 4166 participants from our hospital imaging database who underwent baseline low-dose computed tomography (LDCT) between January 2014 and August 2021. Adherence status was determined by counting CT scans, with one check indicating non-adherence and two or more checks indicating adherence. The primary objective was to investigate adherence to LDCT follow-up schedules among individuals with baseline pure ground-glass nodules (GGNs) based on different screening settings and to evaluate adherence status and CT follow-up clinical profiles. RESULTS Of the 4166 participants in the study, 3619 in the self-paid group and 547 in the clinical study group were men, with an average follow-up period of 4.5 years. Significant differences were observed in the proportions of Lung-RADS 4 lesions, subsolid nodules, and pure GGN lesions between the self-paid and clinical trial groups. A significant difference was found in adherence rates between the self-paid screening group (60.5%) and the clinical study group (84.8%) (p < 0.001). Adherence status rates significantly increased with larger GGN sizes across categories (p < 0.001). Multivariate logistic regression revealed that age (odds ratio [OR], 1.025; p = 0.012), smoking habits (OR, 1.744; p = 0.036), and clinical study screening type (OR, 3.097; p < 0.001) significantly influenced the adherence status. CONCLUSION The disparities in Asian lung cancer screening emphasize the need for increased efficacy, public awareness, and culturally sensitive approaches to mitigate overdiagnosis and enhance adherence among self-paying groups.
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Affiliation(s)
- Yun-Ju Wu
- Department of Radiology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - En-Kuei Tang
- Department of Surgery, Kaohsiung Veterans General Hospital, Kaohsiung 813414, Taiwan
| | - Fu-Zong Wu
- Department of Radiology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Institute of Education, National Sun Yat-sen University, 70, Lien-hai Road, Kaohsiung 80424, Taiwan; Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Faculty of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Pusa S, Baxter R, Andersson S, Fromme EK, Paladino J, Sandgren A. Core Competencies for Serious Illness Conversations: An Integrative Systematic Review. J Palliat Care 2024:8258597241245022. [PMID: 38557369 DOI: 10.1177/08258597241245022] [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: 04/04/2024]
Abstract
Objective: The Serious Illness Care Program was developed to support goals and values discussions between seriously ill patients and their clinicians. The core competencies, that is, the essential clinical conversation skills that are described as requisite for effective serious illness conversations (SICs) in practice, have not yet been explicated. This integrative systematic review aimed to identify core competencies for SICs in the context of the Serious Illness Care Program. Methods: Articles published between January 2014 and March 2023 were identified in MEDLINE, PsycINFO, CINAHL, and PubMed databases. In total, 313 records underwent title and abstract screening, and 96 full-text articles were assessed for eligibility. The articles were critically appraised using the Joanna Briggs Institute Critical Appraisal Guidelines, and data were analyzed using thematic synthesis. Results: In total, 53 articles were included. Clinicians' core competencies for SICs were described in 3 themes: conversation resources, intrapersonal capabilities, and interpersonal capabilities. Conversation resources included using the conversation guide as a tool, together with applying appropriate communication skills to support better communication. Intrapersonal capabilities included calibrating one's own attitudes and mindset as well as confidence and self-assurance to engage in SICs. Interpersonal capabilities focused on the clinician's ability to interact with patients and family members to foster a mutually trusting relationship, including empathetic communication with attention and adherence to patient and family members views, goals, needs, and preferences. Conclusions: Clinicians need to efficiently combine conversation resources with intrapersonal and interpersonal skills to successfully conduct and interact in SICs.
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Affiliation(s)
- Susanna Pusa
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
- Department of Nursing, Umeå University, Umeå, Sweden
| | - Rebecca Baxter
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
- Department of Nursing, Umeå University, Umeå, Sweden
| | - Sofia Andersson
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
- Department of Nursing, Umeå University, Umeå, Sweden
| | - Erik K Fromme
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Dana-Farber Cancer Institute, 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, Växjö, Sweden
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Sloss EA, McPherson JP, Beck AC, Guo JW, Scheese CH, Flake NR, Chalkidis G, Staes CJ. Patient and Caregiver Perceptions of an Interface Design to Communicate Artificial Intelligence-Based Prognosis for Patients With Advanced Solid Tumors. JCO Clin Cancer Inform 2024; 8:e2300187. [PMID: 38657194 PMCID: PMC11161249 DOI: 10.1200/cci.23.00187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 02/22/2024] [Accepted: 03/07/2024] [Indexed: 04/26/2024] Open
Abstract
PURPOSE Use of artificial intelligence (AI) in cancer care is increasing. What remains unclear is how best to design patient-facing systems that communicate AI output. With oncologist input, we designed an interface that presents patient-specific, machine learning-based 6-month survival prognosis information designed to aid oncology providers in preparing for and discussing prognosis with patients with advanced solid tumors and their caregivers. The primary purpose of this study was to assess patient and caregiver perceptions and identify enhancements of the interface for communicating 6-month survival and other prognosis information when making treatment decisions concerning anticancer and supportive therapy. METHODS This qualitative study included interviews and focus groups conducted between November and December 2022. Purposive sampling was used to recruit former patients with cancer and/or former caregivers of patients with cancer who had participated in cancer treatment decisions from Utah or elsewhere in the United States. Categories and themes related to perceptions of the interface were identified. RESULTS We received feedback from 20 participants during eight individual interviews and two focus groups, including four cancer survivors, 13 caregivers, and three representing both. Overall, most participants expressed positive perceptions about the tool and identified its value for supporting decision making, feeling less alone, and supporting communication among oncologists, patients, and their caregivers. Participants identified areas for improvement and implementation considerations, particularly that oncologists should share the tool and guide discussions about prognosis with patients who want to receive the information. CONCLUSION This study revealed important patient and caregiver perceptions of and enhancements for the proposed interface. Originally designed with input from oncology providers, patient and caregiver participants identified additional interface design recommendations and implementation considerations to support communication about prognosis.
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Affiliation(s)
| | - Jordan P. McPherson
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
- College of Pharmacy, University of Utah, Salt Lake City, UT
| | - Anna C. Beck
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Jia-Wen Guo
- College of Nursing, University of Utah, Salt Lake City, UT
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT
| | - Carolyn H. Scheese
- College of Nursing, University of Utah, Salt Lake City, UT
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT
| | - Naomi R. Flake
- Clinical & Translational Science Institute, University of Utah, Salt Lake City, UT
| | | | - Catherine J. Staes
- College of Nursing, University of Utah, Salt Lake City, UT
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT
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Hussein S, Lim CA, Manokaran T, Kassam S, Earp M, Tang PA, Karim S, Biondo P, Watanabe SM, Sinnarajah A, Tan A, Simon J. Colorectal Cancer Patients' Reported Frequency, Content, and Satisfaction with Advance Care Planning Discussions. Curr Oncol 2024; 31:1235-1245. [PMID: 38534925 PMCID: PMC10969091 DOI: 10.3390/curroncol31030092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 02/20/2024] [Accepted: 02/20/2024] [Indexed: 04/13/2024] Open
Abstract
(1) Background: This observational cohort study describes the frequency, content, and satisfaction with advance care planning (ACP) conversations with healthcare providers (HCPs), as reported by patients with advanced colorectal cancer. (2) Methods: The patients were recruited from two tertiary cancer centers in Alberta, Canada. Using the My Conversations survey with previously validated questions, the patients were asked about specific ACP elements discussed, with which HCPs these elements were discussed, their satisfaction with these conversations, and whether they had a goals of care designation (GCD) order. We surveyed and analyzed data from the following four time points: enrollment, months 1, 2, and 3. (3) Results: In total, 131 patients were recruited. At enrollment, 24% of patients reported discussing at least one ACP topic. From enrollment to month 3, patients reported a high frequency of discussions (80.2% discussed fears, 71.0% discussed prognosis, 54.2% discussed treatment preferences at least once); however, only 44.3% of patients reported discussing what is important to them in considering health care preferences. Patients reported having ACP conversations most often with their oncologists (84.7%) and cancer clinic nurses (61.8%). Patients reported a high level of satisfaction with their ACP conversations, with over 80% of patients reported feeling heard and understood. From enrollment to month 3, there was an increase in the number of patients with a GCD order from 53% to 74%. (4) Conclusions: Patients reported more frequent conversations compared to the literature and clinical documentation. While the satisfaction with these conversations is high, there is room for quality improvement, particularly in eliciting patients' personal goals for their treatment.
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Affiliation(s)
- Said Hussein
- Division of Palliative Medicine, Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada; (S.H.); (S.K.); (M.E.); (P.B.); (A.S.)
| | - Chloe Ahryung Lim
- Internal Medicine Residency Program, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada; (C.A.L.); (T.M.)
| | - Thulasie Manokaran
- Internal Medicine Residency Program, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada; (C.A.L.); (T.M.)
| | - Shireen Kassam
- Division of Palliative Medicine, Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada; (S.H.); (S.K.); (M.E.); (P.B.); (A.S.)
| | - Madalene Earp
- Division of Palliative Medicine, Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada; (S.H.); (S.K.); (M.E.); (P.B.); (A.S.)
| | - Patricia A. Tang
- Division of Medical Oncology, Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N2, Canada; (P.A.T.); (S.K.)
| | - Safiya Karim
- Division of Medical Oncology, Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N2, Canada; (P.A.T.); (S.K.)
| | - Patricia Biondo
- Division of Palliative Medicine, Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada; (S.H.); (S.K.); (M.E.); (P.B.); (A.S.)
| | - Sharon M. Watanabe
- Division of Palliative Care Medicine, Department of Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 1Z2, Canada;
| | - Aynharan Sinnarajah
- Division of Palliative Medicine, Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada; (S.H.); (S.K.); (M.E.); (P.B.); (A.S.)
| | - Amy Tan
- Division of Palliative Care, Department of Family Practice, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Jessica Simon
- Division of Palliative Medicine, Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada; (S.H.); (S.K.); (M.E.); (P.B.); (A.S.)
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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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Ko J, Roze des Ordons A, Ballard M, Shenkier T, Simon JE, Fyles G, Lefresne S, Hawley P, Chen C, McKenzie M, Sanders J, Bernacki R. Exploring the value of structured narrative feedback within the Serious Illness Conversation-Evaluation Exercise (SIC-Ex): a qualitative analysis. BMJ Open 2024; 14:e078385. [PMID: 38286701 PMCID: PMC10826582 DOI: 10.1136/bmjopen-2023-078385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 01/11/2024] [Indexed: 01/31/2024] Open
Abstract
OBJECTIVES The Serious Illness Conversation Guide (SICG) has emerged as a framework for conversations with patients with a serious illness diagnosis. This study reports on narratives generated from open-ended questions of a novel assessment tool, the Serious Illness Conversation-Evaluation Exercise (SIC-Ex), to assess resident-led conversations with patients in oncology outpatient clinics. DESIGN Qualitative study using template analysis. SETTING Three academic cancer centres in Canada. PARTICIPANTS 7 resident physicians (trainees), 7 patients from outpatient cancer clinics, 10 preceptors (raters) consisting of medical oncologists, palliative care physicians and radiation oncologists. INTERVENTIONS Each trainee conducted an SIC with a patient, which was videotaped. The raters watched the videos and evaluated each trainee using the novel SIC-Ex and the reference Calgary-Cambridge Guide (CCG) initially and again 3 months later. Two independent coders used template analysis to code the raters' narrative comments and identify themes/subthemes. OUTCOME MEASURES How narrative comments aligned with elements of the CCG and SICG. RESULTS Template analysis yielded four themes: adhering to SICG, engaging patients and family members, conversation management and being mindful of demeanour. Narrative comments identified numerous verbal and non-verbal elements essential to SICG. Some comments addressing general skills in engaging patients/families and managing the conversation (eg, setting agenda, introduction, planning, exploring, non-verbal communication) related to both the CCG and SICG, whereas other comments such as identifying substitute decision maker(s), affirming commitment and introducing Advance Care Planning were specific to the SICG. CONCLUSIONS Narrative comments generated by SIC-Ex provided detailed and nuanced insights into trainees' competence in SIC, beyond the numerical ratings of SIC-Ex and the general communication skills outlined in the CCG, and may contribute to a more fulsome assessment of SIC skills.
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Affiliation(s)
- Jenny Ko
- Department of Medical Oncology, BC Cancer Agency Abbostford Centre, Abbotsford, British Columbia, Canada
| | - Amanda Roze des Ordons
- Department of Critical Care Medicine and Division of Palliative Medicine; Department of Anesthesiology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Mark Ballard
- Department of Internal Medicine, Chilliwack General Hospital, Chilliwack, British Columbia, Canada
| | - Tamara Shenkier
- Department of Medical Oncology, BC Cancer Agency Vancouver Centre, Vancouver, British Columbia, Canada
| | - Jessica E Simon
- Department of Oncology and Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Gillian Fyles
- Pain and Symptom Management/Palliative Care Program, BC Cancer Agency Sindi Ahluwalia Hawkins Centre for the Southern Interior, Kelowna, British Columbia, Canada
| | - Shilo Lefresne
- Department of Radiation Oncology, BC Cancer Agency Vancouver Centre, Vancouver, British Columbia, Canada
| | - Philippa Hawley
- Department of Palliative Care, BC Cancer Agency, Vancouver, British Columbia, Canada
| | - Charlie Chen
- Department of Oncology and Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Michael McKenzie
- Department of Radiation Oncology, BC Cancer Agency Vancouver Centre, Vancouver, British Columbia, Canada
| | - Justin Sanders
- Department of Palliative Care, McGill University, Montreal, Quebec, Canada
| | - Rachelle Bernacki
- Department of Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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Staes CJ, Beck AC, Chalkidis G, Scheese CH, Taft T, Guo JW, Newman MG, Kawamoto K, Sloss EA, McPherson JP. Design of an interface to communicate artificial intelligence-based prognosis for patients with advanced solid tumors: a user-centered approach. J Am Med Inform Assoc 2023; 31:174-187. [PMID: 37847666 PMCID: PMC10746322 DOI: 10.1093/jamia/ocad201] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/18/2023] [Accepted: 10/02/2023] [Indexed: 10/19/2023] Open
Abstract
OBJECTIVES To design an interface to support communication of machine learning (ML)-based prognosis for patients with advanced solid tumors, incorporating oncologists' needs and feedback throughout design. MATERIALS AND METHODS Using an interdisciplinary user-centered design approach, we performed 5 rounds of iterative design to refine an interface, involving expert review based on usability heuristics, input from a color-blind adult, and 13 individual semi-structured interviews with oncologists. Individual interviews included patient vignettes and a series of interfaces populated with representative patient data and predicted survival for each treatment decision point when a new line of therapy (LoT) was being considered. Ongoing feedback informed design decisions, and directed qualitative content analysis of interview transcripts was used to evaluate usability and identify enhancement requirements. RESULTS Design processes resulted in an interface with 7 sections, each addressing user-focused questions, supporting oncologists to "tell a story" as they discuss prognosis during a clinical encounter. The iteratively enhanced interface both triggered and reflected design decisions relevant when attempting to communicate ML-based prognosis, and exposed misassumptions. Clinicians requested enhancements that emphasized interpretability over explainability. Qualitative findings confirmed that previously identified issues were resolved and clarified necessary enhancements (eg, use months not days) and concerns about usability and trust (eg, address LoT received elsewhere). Appropriate use should be in the context of a conversation with an oncologist. CONCLUSION User-centered design, ongoing clinical input, and a visualization to communicate ML-related outcomes are important elements for designing any decision support tool enabled by artificial intelligence, particularly when communicating prognosis risk.
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Affiliation(s)
- Catherine J Staes
- College of Nursing, University of Utah, Salt Lake City, UT 84112, United States
- Department of Biomedical Informatics, School of Medicine, University of Utah, Salt Lake City, UT 84108, United States
| | - Anna C Beck
- Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84112, United States
| | - George Chalkidis
- Healthcare IT Research Department, Center for Digital Services, Hitachi Ltd., Tokyo, Japan
| | - Carolyn H Scheese
- College of Nursing, University of Utah, Salt Lake City, UT 84112, United States
- Department of Biomedical Informatics, School of Medicine, University of Utah, Salt Lake City, UT 84108, United States
| | - Teresa Taft
- Department of Biomedical Informatics, School of Medicine, University of Utah, Salt Lake City, UT 84108, United States
| | - Jia-Wen Guo
- College of Nursing, University of Utah, Salt Lake City, UT 84112, United States
- Department of Biomedical Informatics, School of Medicine, University of Utah, Salt Lake City, UT 84108, United States
| | - Michael G Newman
- Department of Population Sciences, Huntsman Cancer Institute, Salt Lake City, UT 84112, United States
| | - Kensaku Kawamoto
- Department of Biomedical Informatics, School of Medicine, University of Utah, Salt Lake City, UT 84108, United States
| | - Elizabeth A Sloss
- College of Nursing, University of Utah, Salt Lake City, UT 84112, United States
| | - Jordan P McPherson
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT 84108, United States
- Department of Pharmacy, Huntsman Cancer Institute, Salt Lake City, UT 84112, United States
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12
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Pusa S, Baxter R, Sandgren A. Physicians' perceptions of the implementation of the serious illness care program: a qualitative study. BMC Health Serv Res 2023; 23:1401. [PMID: 38087357 PMCID: PMC10717999 DOI: 10.1186/s12913-023-10419-5] [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: 07/09/2023] [Accepted: 12/01/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Conversations about goals, values and priorities with patients that are seriously ill are associated with improved palliative healthcare. The Serious Illness Care Program is a multi-component program that can facilitate more, better, and earlier conversations between clinicians and seriously ill patients. For successful and sustainable implementation of the Serious Illness Care Program, it is important to consider how stakeholders perceive it. The aim of our study was to explore physicians' perceptions and experiences of implementing the Serious Illness Care Program. METHODS Data were collected through four focus group discussions with physicians (n = 14) working at a hospital where the Serious Illness Care program was in the process of being implemented. Data were analyzed with inductive thematic analysis. RESULTS Physicians' perceptions of the implementation encompassed three thematic areas: hovering between preparedness and unpreparedness, being impacted and being impactful, and picking pieces or embracing it at all. CONCLUSIONS This study identified key aspects related to the individual physician, the care team, the impact on the patient, and the organizational support that were perceived to influence the implementation and sustainable integration of the Serious Illness Care Program. Describing these aspects provides insight into how the Serious Illness Care Program is implemented in practice and indicates areas for future training and development. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Susanna Pusa
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden.
| | - Rebecca Baxter
- 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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13
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Salas A, Boanca K, Purdy J, De Lima B, Peterson M, Nerness R, Eckstrom E, Kwon A. Resident-led research: a quality improvement project to improve serious illness conversations. GERONTOLOGY & GERIATRICS EDUCATION 2023:1-6. [PMID: 37561638 DOI: 10.1080/02701960.2023.2246406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Skilled conversations regarding end-of-life (EOL) care reduce emotional suffering and increase goal-concordant care. The Ariadne Labs Serious Illness Conversation (SIC) framework is an effective tool for improving EOL communication, but research is lacking on use with resident physicians. This study led by internal medicine residents tested the feasibility and acceptability of training peers in SIC. In 2021, three resident project leaders recruited first and second year internal medicine residents at a single tertiary academic center to receive extracurricular training on the Ariadne Labs SIC Guide. Baseline and post-training surveys were conducted to determine attitudes, barriers, and confidence related to EOL discussions. Initial recruitment efforts were unsuccessful but participation increased from zero to seven after residency administrators approved protected time for SIC training. Six residents (85.7%) completed baseline and post-training surveys. Residents identified lack of time as the key barrier to initiating SIC. Self-reported comfort discussing EOL care and documenting the conversations improved after training. Both resident researchers and participants reported SIC training was valuable and successful. Institutional support with dedicated buy-in, strong faculty mentorship, and committed resident leaders all contribute to successfully implementing a resident-led project.
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Affiliation(s)
- Arinea Salas
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon, USA
| | - KerriAnn Boanca
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon, USA
| | - Johanna Purdy
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon, USA
| | - Bryanna De Lima
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon, USA
| | - Mara Peterson
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon, USA
| | - Reed Nerness
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon, USA
| | - Elizabeth Eckstrom
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon, USA
| | - Amy Kwon
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon, USA
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14
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Wreyford L, Gururajan R, Zhou X. When can cancer patient treatment nonadherence be considered intentional or unintentional? A scoping review. PLoS One 2023; 18:e0282180. [PMID: 37134109 PMCID: PMC10155980 DOI: 10.1371/journal.pone.0282180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 02/10/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Treatment nonadherence in cancer patients remains high with most interventions having had limited success. Most studies omit the multi-factorial aspects of treatment adherence and refer to medication adherence. The behaviour is rarely defined as intentional or unintentional. AIM The aim of this Scoping Review is to increase understanding of modifiable factors in treatment nonadherence through the relationships that physicians have with their patients. This knowledge can help define when treatment nonadherence is intentional or unintentional and can assist in predicting cancer patients at risk of nonadherence and in intervention design. The scoping review provides the basis for method triangulation in two subsequent qualitative studies: 1. Sentiment analysis of online cancer support groups in relation to treatment nonadherence; 2. A qualitative validation survey to refute / or validate claims from this scoping review. Thereafter, framework development for a future (cancer patient) online peer support intervention. METHODS A Scoping Review was performed to identify peer reviewed studies that concern treatment / medication nonadherence in cancer patients-published between 2000 to 2021 (and partial 2022). The review was registered in the Prospero database CRD42020210340 and follows the PRISMA-S: an extension to the PRISMA Statement for Reporting Literature Searches in Systematic Searches. The principles of meta-ethnography are used in a synthesis of qualitative findings that preserve the context of primary data. An aim of meta-ethnography is to identify common and refuted themes across studies. This is not a mixed methods study, but due to a limited qualitativevidence base and to broaden findings, the qualitative elements (author interpretations) found within relevant quantitative studies have been included. RESULTS Of 7510 articles identified, 240 full texts were reviewed with 35 included. These comprise 15 qualitative and 20 quantitative studies. One major theme, that embraces 6 sub themes has emerged: 'Physician factors can influence patient factors in treatment nonadherence'. The six (6) subthemes are: 1. Suboptimal Communication; 2. The concept of Information differs between Patient and Physician; 3.Inadequate time. 4. The need for Treatment Concordance is vague or missing from concepts; 5. The importance of Trust in the physician / patient relationship is understated in papers; 6. Treatment concordance as a concept is rarely defined and largely missing from studies. LINE OF ARGUMENT WAS DRAWN Treatment (or medication) nonadherence that is intentional or unintentional is often attributed to patient factors-with far less attention to the potential influence of physician communication factors. The differentation between intentional or unintentional nonadherence is missing from most qualitative and quantitative studies. The holistic inter-dimensional / multi-factorial concept of 'treatment adherence' receives scant attention. The main focus is on medication adherence / nonadherence in the singular context. Nonadherence that is unintentional is not necessarily passive behaviour and may overlap with intentional nonadherence. The absence of treatment concordance is a barrier to treatment adherence and is rarely articulated or defined in studies. CONCLUSION This review demonstrates how cancer patient treatment nonadherence is often a shared outcome. An equal focus on physican and patient factors can increase understanding of the two main types of nonadherence (intentional or unintentional). This differentation should help improve the fundamentals of intervention design.
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Affiliation(s)
- Leon Wreyford
- University of Southern Queensland (USQ), Toowoomba, Qld, Australia
| | - Raj Gururajan
- University of Southern Queensland (USQ), Toowoomba, Qld, Australia
| | - Xujuan Zhou
- University of Southern Queensland (USQ), Toowoomba, Qld, Australia
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15
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Porter AS, Woods C, Stall M, Baker JN, Mack JW, Kaye EC. Mismatch between Pediatric Oncologists' Private and Parent-Facing Prognostic Communication: Communication Patterns Used to Soften Prognostic Disclosure. J Palliat Med 2023; 26:210-219. [PMID: 35976087 DOI: 10.1089/jpm.2022.0265] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Purpose: Most parents of children with cancer desire honest prognostic communication, yet oncologists often avoid clear prognostic disclosure. This study explored differences between oncologists' private assessments of prognosis and their prognostic communication with patients and parents. Patients and Methods: In this prospective, longitudinal, mixed-methods study, we audio-recorded serial disease reevaluation conversations between children with advancing cancer, parents, and primary oncologists and separately surveyed and interviewed oncologists at disease progression time points. At time points when oncologists privately described curability as ≤10%, content analysis was used to compare prognostic language in recorded dialogue with private responses about prognosis. Results: Of 33 enrolled patient-parent dyads, 17 patients with high-risk cancer under the care of 6 primary oncologists experienced disease progression during the study period. In 95% of oncologist interviews at disease progression time points, oncologists either predicted curability to be ≤10% or incurable. In most interviews (82%), oncologists stated unequivocally that chances of cure were ≤10%, yet did not communicate these low odds during recorded discussions at the same time point. Analysis revealed three distinct communication patterns through which oncologists softened prognostic disclosure to patients and families: (1) space-holding for hope of cure: statements acknowledging difficult prognosis yet leaving room for possibility of cure; (2) vague warning: statements implying that cancer may progress without offering specifics; and (3) data without interpretation: statements describing disease progression findings in detail without explaining what this meant for the patient's future life or survival. Conclusion: Pediatric oncologists often temper their assessment of poor prognosis when speaking with patients and families. Future work should explore serious conversation guides and other clinical interventions aimed at encouraging person-centered prognostic disclosure for patients with advancing cancer and their families.
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Affiliation(s)
- Amy S Porter
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Cameka Woods
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Melanie Stall
- Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Justin N Baker
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jennifer W Mack
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Erica C Kaye
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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16
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Havis I, Coates T, Wyant KJ, Spears CC, Garwood M, Kotagal V. Isolated REM sleep behavior disorder in North American older adults in an integrated health care system. J Clin Sleep Med 2022; 18:2173-2178. [PMID: 35678069 PMCID: PMC9435338 DOI: 10.5664/jcsm.10066] [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: 10/26/2021] [Revised: 04/13/2022] [Accepted: 04/13/2022] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVE Identifying individuals with isolated rapid eye movement sleep behavioral disorder (iRBD) is an important clinical research priority for future synucleinopathy trials. Nevertheless, little is known about the breadth of clinical settings where diagnoses of iRBD are initially made. METHODS We conducted a retrospective cohort study using the electronic medical record system at the University of Michigan to identify patients aged ≥ 60 years with new diagnoses of iRBD between 2015 and 2020. We focused specifically on patients receiving primary care at the University of Michigan so that we might use the university's electronic medical record system to capture the full scope of their multispecialty care interactions and diagnoses in this integrated health care system. We used International Classification of Diseases, Ninth Revision and Tenth Revision, diagnosis codes to identify the time of initial clinical diagnosis. RESULTS We found that 62/105 (59.0%) diagnoses were made by a sleep specialist, 9 (8.6%) by neurologists, and 30 (29.5%) by generalists or primary care (29.5%) providers. In addition, 67/105 (63.8%) diagnoses were made in the context of having available polysomnography results, while the remainder was made on the basis of clinical symptoms alone. The prognostic implications of iRBD were documented in 40/105 (38.1%) encounter notes and were more likely to occur in sleep clinic settings (chi-square = 12.74; P < .001) than in other contexts. CONCLUSIONS Initial iRBD diagnoses occur in varied clinical settings in an integrated health care system and are often made without a confirmatory polysomnogram. Documented prognostic counseling is seen most often in sleep medicine clinics. Synucleinopathy prevention trials may be best designed around a sleep clinic-focused recruitment approach. CITATION Havis I, Coates T, Wyant KJ, Spears CC, Garwood M, Kotagal V. Isolated REM sleep behavior disorder in North American older adults in an integrated health care system. J Clin Sleep Med. 2022;18(9):2173-2178.
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Affiliation(s)
- Isabelle Havis
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Trinity Coates
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Kara J. Wyant
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | | | - Mark Garwood
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Vikas Kotagal
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
- Veterans Affairs Ann Arbor Healthcare System and Veterans Affairs Ann Arbor Healthcare System Geriatric Research Education and Clinical Center, Ann Arbor, Michigan
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17
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Morberg Jämterud S, Sandgren A. Health care professionals' perceptions of factors influencing the process of identifying patients for serious illness conversations: A qualitative study. Palliat Med 2022; 36:1072-1079. [PMID: 35729752 PMCID: PMC9247430 DOI: 10.1177/02692163221102266] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Serious Illness Care Programme enables patients to receive care that is in accordance with their priorities. However, despite clarity about palliative care needs, many barriers to and difficulties in identifying patients for serious illness conversations remain. AIM To explore healthcare professionals' perceptions about factors influencing the process of identifying patients for serious illness conversations. DESIGN Qualitative design. A thematic analysis of observations and semi-structured interviews was used. SETTING/PARTICIPANTS Twelve observations at team meetings in which physicians and nurses discussed the process of identifying the patients for serious illness conversations were conducted at eight different clinics in two hospitals. Semi-structured interviews were conducted with three physicians and two nurses from five clinics. RESULTS Identifying the right patient and doing so at the right time were key to identifying patients for serious illness conversations. The continuity of relations and continuity over time could facilitate the identification process, while attitudes towards death and its relation to hope could hinder the process. CONCLUSIONS The process of identifying patients for serious illness conversations is complex and may not be captured only by generic tools such as the surprise question. It is crucial to address existential and ethical obstacles that can hinder the identification of patients for serious illness conversations.
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Affiliation(s)
- Sofia Morberg Jämterud
- Department of Thematic Studies, Linköping University, Linköping, Sweden.,Center for Collaborative Palliative Care, Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
| | - Anna Sandgren
- Center for Collaborative Palliative Care, Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
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18
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King S, Douglas M, Javed S, Semenchuk J, Ghosh S, Dunne F, Moledina A, Fassbender K, Simon J. Content of Serious Illness Care conversation documentation is associated with goals of care orders-a quantitative evaluation in hospital. Palliat Care 2022; 21:116. [PMID: 35764991 PMCID: PMC9241276 DOI: 10.1186/s12904-022-01006-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 06/15/2022] [Indexed: 12/03/2022] Open
Abstract
Background The Serious Illness Care Program (SICP) increases quality of documentation about patients’ values and priorities, but it is not known whether patient characteristics and goals of care are associated with the elements documented. The purpose of this study was to explore for associations between the quantity and type of elements documented after SICP conversations with patient characteristics and goals of care order. Methods Documentation of SICP conversations by internal medicine physicians with hospitalized patients was evaluated in a retrospective chart review between March 2018 to December 2019. The conversations occurred after SICP implementation in a Tertiary Hospital, Medical teaching unit which uses “Goals of Care Designation” (GCD) medical orders to communicate a patient’s general intent, specific interventions, and preferred locations of care. A validated SICP codebook was used to determine the frequency of conversation elements documented for (1) Goals and Values; (2) Prognosis/illness understanding; (3) End-of-life care planning and (4) GCD/Life-sustaining treatment preferences. Univariate and multivariate generalized linear models were used to analyze associations between quantity of elements documented and patient characteristics (age, gender, frailty, language spoken and GCD). Results Of 175 SICP conversations documented, in the univariate analysis more goals and values were documented for patients who understand/speak English (0.89; 95% CI: 0.14 - 1.63) and more content was recorded for patients with a non-resuscitative GCD focus (“Medical”: 2.42; 95% CI: 1.51 – 3.33; “Comfort”: 1.06; 95% CI: 0.24 – 1.88) although not in all domains. In the multivariate analysis, controlling for age, gender, language and frailty, the association between content scores and GCD remained highly significant. Patients with a non-resuscitative GCD had higher total domain scores than those with a resuscitative GCD (“Medical”: 1.27 95% CI: 0.42–2.13; “Comfort”: 2.67, 95% CI:1.71–3.62). Conclusion The type of content documented by physicians after a SICP conversation is associated with the patient’s goals of care. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-01006-2.
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Affiliation(s)
- Seema King
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Maureen Douglas
- Covenant Health Palliative Care Institute, Edmonton, AB, Canada
| | - Sidra Javed
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | | | | | - Fiona Dunne
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Aliza Moledina
- Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Konrad Fassbender
- Covenant Health Palliative Care Institute, Edmonton, AB, Canada.,Department of Oncology, University of Alberta, Edmonton, AB, Canada
| | - Jessica Simon
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada. .,Department of Medicine, University of Calgary, Calgary, AB, Canada. .,Department of Oncology, Division of Palliative Medicine, University of Calgary, AB, T2N 4Z6, Calgary, Canada.
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19
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Daly J, Schmidt M, Thoma K, Xu Y, Levy B. How Well are Serious Illness Conversations Documented and What are Patient and Physician Perceptions of These Conversations? J Palliat Care 2022; 37:332-340. [PMID: 35341365 DOI: 10.1177/08258597221090387] [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: 11/15/2022]
Abstract
BACKGROUND The Serious Illness Care Program (SICP), developed in 2011 by Ariadne Labs, restructures care so that knowing and then honoring patients' wishes becomes part of routine care. OBJECTIVES 1) summarize patient perceptions of use of the Serious Illness Conversation Guide (SICG) components, 2) assess whether a serious illness conversation was documented in the electronic health record (EHR) and identify the SICG components that were included, 3) summarize clinician perceptions of use of the SICG components, and 4) assess the association of documented SICG components with the patient's perception of the SICG discussion. METHODS Clinicians at three family medicine offices were trained in serious illness conversations using the SICG. They documented their serious illness conversations in the medical record. Retrospective chart review for SICG components was conducted for patients. Patients and clinicians completed questionnaires about their experience with the SICG. Statistical analysis included the Pearson chi-square test for categorical variables and Cohen's kappa to determine agreement between clinician documentation and patient perception. RESULTS Eighty-nine patients consented and completed their baseline questionnaire. Mean age of the 89 patients was 72 years and 65 (73%) were female. Thirty (34%) medical records had one or more SICG components documented. Seventy-nine (89%) patients reported at least one individual component of the SICG being discussed. Clinicians reported they engaged in asking patients what is important to them at a mean of 5.9, with 7 being "all the time". There was slight agreement (kappa = .19) for patient perception and clinician documentation of discussing patient goals, but no agreement for any of the other SICG components. CONCLUSION Even among trained clinicians, only one-third of patients had documentation of at least one SICG component. Only slight agreement was found between clinician documentation of SICG in the medical record and patient perception of SICG discussion.
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Affiliation(s)
- Jeanette Daly
- Family Medicine, The University of Iowa, 200 Hawkins Drive, Iowa, USA
| | - Megan Schmidt
- Family Medicine, The University of Iowa, 200 Hawkins Drive, Iowa, USA
| | - Kate Thoma
- Family Medicine, The University of Iowa, 200 Hawkins Drive, Iowa, USA
| | - Yinghui Xu
- Family Medicine, The University of Iowa, 200 Hawkins Drive, Iowa, USA
| | - Barcey Levy
- Family Medicine, The University of Iowa, 200 Hawkins Drive, Iowa, USA
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Karim S, Levine O, Simon J. The Serious Illness Care Program in Oncology: Evidence, Real-World Implementation and Ongoing Barriers. Curr Oncol 2022; 29:1527-1536. [PMID: 35323328 PMCID: PMC8947515 DOI: 10.3390/curroncol29030128] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 02/22/2022] [Indexed: 11/16/2022] Open
Abstract
The Serious Illness Care Program (SICP), designed by Ariadne Labs, is a multicomponent intervention to improve conversations about values and goals for patients with a life-limiting illness. In oncology, implementation of the SICP achieved more, earlier, and better-quality conversations and reduced anxiety and depression among patients with advanced cancer. In this commentary, we describe the SICP, including results from the cluster-randomized trial, provide examples of real-world implementation of this program, and highlight ongoing challenges and barriers that are preventing widespread adoption of this intervention into routine practice. For the SICP to be successfully embedded into routine patient care, it will require significant effort, including ongoing leadership support and training opportunities, champions from all sectors of the interdisciplinary team, and adaptation of the program to a wider range of patients. Future research should also investigate how early conversations can be translated into personalized care plans for patients.
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Affiliation(s)
- Safiya Karim
- Department of Oncology, Faculty of Medicine, University of Calgary, Calgary, AB T2N 4N2, Canada;
- Correspondence: ; Tel.: +1-403-521-3166; Fax: +1-402-283-1651
| | - Oren Levine
- Department of Oncology, Faculty of Health Sciences, McMaster University, Hamilton, ON L8V 5C2, Canada;
| | - Jessica Simon
- Department of Oncology, Faculty of Medicine, University of Calgary, Calgary, AB T2N 4N2, Canada;
- Department of Community Health Services, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N2, Canada
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21
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Pennarola BW, Fry A, Prichett L, Beri AE, Shah NN, Wiener L. Mapping the Landscape of Advance Care Planning in Adolescents and Young Adults Receiving Allogeneic Hematopoietic Stem Cell Transplantation: A 5-Year Retrospective Review. Transplant Cell Ther 2022; 28:164.e1-164.e8. [PMID: 34936929 PMCID: PMC8923987 DOI: 10.1016/j.jtct.2021.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 12/03/2021] [Accepted: 12/05/2021] [Indexed: 12/17/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) carries significant risks of morbidity and mortality. Participation in advance care planning (ACP) is crucial to promote patient-centered care and has been shown to have positive impacts on patients, caregivers, and providers. Historically, both HSCT recipients and adolescents and young adults (AYAs) are significantly less likely to engage in ACP. We sought to characterize ACP utilization in AYAs undergoing HSCT by evaluating the frequency of different types of ACP documentation over time and identifying demographic and clinical factors associated with documentation of each type of ACP. We conducted a single-center retrospective review of the electronic health record (EHR) of AYAs (age 15 to 39 years) who underwent allogeneic HSCT between 2015 and 2020. EHR documents were screened for 3 predefined categories of ACP: (1) advance directives (ADs) or medical orders (MOs), which included proof of signed paper directives, expressions of preferred code status, and identification of a healthcare proxy; (2) goals of care (GOC) conversations, which included discussions of medical care in a specific situation informed by patients' priorities; and (3) other ACP conversations, which included more general discussions of patients' values regarding their care or legacy wishes. Documents were coded by 2 researchers, and discrepant categorizations were reviewed by a third researcher. Patients age <18 years on the day of transplantation were excluded in the analyses of AD/MO documentation. Univariate and multivariate logistic regression were used to test for associations between patient factors and documentation of each type of ACP. For deceased patients, Kaplan-Meier curves were created to illustrate the time-to-event relationship between days before death and documentation of each type of ACP. Sixty-eight thousand documents associated with 219 patients were reviewed, and 666 ACP documents associated with 190 patients were identified. Few of the 219 patients had documented GOC (n = 29; 13%) or other ACP conversations (n = 81; 37%). A subset of patients (n = 28; 13%) had no documented ACP. Most of the 201 patients age ≥18 years had a documented AD/MO (n = 172; 86%). No tested factors were significantly associated with documentation of ADs/MOs. GOC and other ACP conversations were more likely to occur in patients with a palliative care consult, and patients with a malignant diagnosis were also more likely to engage in GOC conversations. More than 50% of the documentation occurred in the subset of 39 deceased patients, with one-half of AD/MO documentation in the last 67 days of life, one-half of other ACP documentation in the last 20 days of life, and one-half of GOC documentation in the final 2 days of life. Although the majority of AYA patients receiving HSCT did have documentation of ADs/MOs, few patients had documented GOC or other ACP conversations. The bulk of all ACP conversations occurred in patients that ultimately died and who were very close to the end of life. Our results support ongoing efforts to improve the implementation of ACP in this vulnerable population, particularly for those undergoing HSCT for nonmalignant conditions.
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Affiliation(s)
- Brian W Pennarola
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Department of Pediatric Oncology, Johns Hopkins Hospital, Baltimore, Maryland.
| | - Abigail Fry
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Laura Prichett
- Johns Hopkins School of Medicine, Department of Pediatrics, Biostatistics, Epidemiology, and Data Management Core, Baltimore, Maryland
| | - Andrea E Beri
- National Institutes of Health Biomedical Translational Research Information System, Bethesda, Maryland
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Lori Wiener
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
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22
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Daly JM, Schmidt ME, Thoma KD, Levy BT. Trained Clinician's Documentation of Serious Illness Conversations and Use of Billing CPT 99497. J Palliat Care 2021; 37:323-331. [PMID: 34918568 DOI: 10.1177/08258597211049136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Advance care planning (ACP) involves patients and family members in discussions with clinicians about their values, goals, and preferences regarding future medical care. Objectives: To (1) assess whether an ACP conversation using the Serious Illness Conversation (SIC) was initiated and documented; (2) assess which components of SIC were documented; (3) determine how frequently clinicians trained to use the SIC guide used ACP billing codes during the study time period, (4) determine whether there was a significant difference in mortality risk score according to documentation of each component of the SIC. Methods; Thirteen clinicians at three family medicine offices were trained in the Serious Illness Care Program and asked to document SICs in the electronic medical record (EMR). A retrospective chart review of SIC components was conducted in the EMRs of patients who presumably had ACP conversations initiated by the trained clinicians. Patients were identified using the billing codes for ACP conversations and through referrals from another study that requires clinicians to have ACP conversations with their patients. Pearson chi-square test for categorical variables and t-tests for continuous variables were conducted. Results: A total of 157 patients were included in this study; 131 patients referred from another ACP study and an additional 26 patients using the billing codes of ACP conversations. Through retrospective chart review, the mean age of patients was 72 years and 54 were male. Sixty-two (40%) charts had one or more SIC components documented. "Explore key topics" was documented most frequently for 58 (38%) patients by the 13 participating clinicians. Mean mortality risk score was 10.7 and higher scores were significantly correlated with more SIC components documented (rp = 0.217, P = 0.007). Conclusion: Little use of the SIC guide among trained physicians was found in the EMR. It was expected that provision of an EMR template for documenting the SIC would have facilitated documentation of SICs.
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Affiliation(s)
- Jeanette M Daly
- University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Megan E Schmidt
- University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | | | - Barcey T Levy
- University of Iowa Carver College of Medicine, Iowa City, IA, USA.,University of Iowa, College of Public Health, Iowa City, IA, USA.,University of Iowa, Iowa City, IA, USA
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23
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Gloeckler S, Krones T, Biller-Andorno N. Advance care planning evaluation: a scoping review of best research practice. BMJ Support Palliat Care 2021:bmjspcare-2021-003193. [PMID: 34667065 DOI: 10.1136/bmjspcare-2021-003193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/11/2021] [Indexed: 11/04/2022]
Abstract
Various indicators have been used to evaluate advance care planning, including completion rates, type of care received, and satisfaction. Recent consensus suggests, though, that receiving care consistent with one's goals is the primary outcome of advance care planning and assessment should capture this metric. Goal concordant care is challenging to measure, and there is little clarity about how best to do so. The aim of this scoping review is to explore what methods have been used to measure goal concordant care in the evaluation of advance care planning. PubMed, Embase, PsycINFO, CINAHL and Cochrane were searched in September 2020 to identify studies that aimed to track whether advance care planning affected the likelihood of patients receiving care that matched their preferred care. 135 original studies were included for review. Studies used retrospective chart review (36%, n=49), questionnaire (36%, n=48) and interview (31%, n=42), focusing on both patients and proxies. Studies considered both actual care received (55%, n=74) and hypothetical scenarios anticipating possible future care (49%, n=66); some studies did both. While the reviewed studies demonstrate the possibility of working towards a solid methodology, there were significant weaknesses. Notably, studies often lacked enough reporting clarity to be reproducible and, relatedly, key concepts, such as end-of-life or preferred care, were left undefined. The recommendations that follow from these findings inform future research approaches, supporting the development of a strong evidence base to guide advance care planning implementation in practice.
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Affiliation(s)
- Sophie Gloeckler
- Institute for Biomedical Ethics and History of Medicine, Universität Zürich, Zurich, Switzerland
- School of Nursing, Columbia University, New York, New York, USA
| | - Tanja Krones
- Institute for Biomedical Ethics and History of Medicine, Universität Zürich, Zurich, Switzerland
- Clinical Ethics, UniversitätsSpital Zürich, Zurich, Switzerland
| | - Nikola Biller-Andorno
- Institute for Biomedical Ethics and History of Medicine, Universität Zürich, Zurich, Switzerland
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24
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Prater LC, O'Rourke B, Schnell P, Xu W, Li Y, Gustin J, Lockwood B, Lustberg M, White S, Happ MB, Retchin SM, Wickizer TM, Bose-Brill S. Examining the Association of Billed Advance Care Planning With End-of-Life Hospital Admissions Among Advanced Cancer Patients in Hospice. Am J Hosp Palliat Care 2021; 39:504-510. [PMID: 34427154 DOI: 10.1177/10499091211039449] [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: 11/17/2022] Open
Abstract
BACKGROUND Advance care planning (ACP), or the consideration and communication of care preferences for the end-of-life (EOL), is a critical process for improving quality of care for patients with advanced cancer. The incorporation of billed service codes for ACP allows for new inquiries on the association between systematic ACP and improved EOL outcomes. OBJECTIVE Using the IBM MarketScan® Database, we conducted a retrospective medical claims analysis for patients with an advanced cancer diagnosis and referral to hospice between January 2016 and December 2017. We evaluated the association between billed ACP services and EOL hospital admissions in the final 30 days of life. DESIGN This is a cross-sectional retrospective cohort study. PARTICIPANTS A total of 3,705 patients met the study criteria. MAIN MEASURES ACP was measured via the presence of a billed ACP encounter (codes 99497 and 99498) prior to the last 30 days of life; hospital admissions included a dichotomous indicator for inpatient admission in the final 30 days of life. KEY RESULTS Controlling for key covariates, patients who received billed ACP were less likely to experience inpatient hospital admissions in the final 30 days of life compared to those not receiving billed ACP (OR: 0.34; p < 0.001). CONCLUSION The receipt of a billed ACP encounter is associated with reduced EOL hospital admissions in a population of patients with advanced cancer on hospice care. Strategies for consistent, anticipatory delivery of billable ACP services prior to hospice referral may prevent potentially undesired late-life hospital admissions.
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Affiliation(s)
- Laura C Prater
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA.,Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Brian O'Rourke
- Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Patrick Schnell
- Division of Biostatistics, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Wendy Xu
- Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Yiting Li
- Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Jillian Gustin
- Division of Palliative Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Bethany Lockwood
- Division of Palliative Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Maryam Lustberg
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus OH, USA.,James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Susan White
- James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mary Beth Happ
- The Ohio State University College of Nursing, Columbus, OH, USA
| | - Sheldon M Retchin
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA.,Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Thomas M Wickizer
- Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Seuli Bose-Brill
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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25
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Ernecoff NC, Wessell KL, Wood WA, Winzelberg GS, Collichio FA, Hanson LC. How well do documented goals-of-care discussions for patients with stage IV cancer reflect communication best practices? BMC Palliat Care 2021; 20:41. [PMID: 33691683 PMCID: PMC7944465 DOI: 10.1186/s12904-021-00733-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 02/25/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Written clinical communication regarding patients' disease understanding and values may facilitate goal-concordant care, yet little is known about the quality of electronic health record (EHR) documentation. We sought to (1) describe frequency of communication best practices in EHR-documented goals-of-care discussions, and (2) assess whether templated notes improve quality of documentation. METHODS Researchers pulled text of EHR-documented goals-of-care discussions for hospitalized patients with Stage IV cancer from admission to 60-days follow-up. Text was included when in a single encounter the clinician addressed: (a) prognosis and/or illness understanding; and (b) goals and/or treatment options. Researchers qualitatively coded text based on guidelines for communication best practices, and noted if an EHR template was used. RESULTS Forty-two percent (206/492) of patients had EHR-documented goals-of-care discussions. Text frequently described communication of cancer progression (89%), though rarely included prognosis (22%). Text often included patients' goals and values (83%), and at least on specific treatment decision (82%). Communication about treatments was included for 98% of patients; common examples included cancer treatment (62%), hospice (62%), resuscitation (51%), or intensive care (38%). Clinicians documented making recommendations for 40% of patients. Text addressing patient emotional and spiritual concerns was uncommon (15%). Compared to free text, use of a template was associated with increased documentation of goals and values (80% vs. 61%, p < 0.01), but not other best practices. CONCLUSION Insights from the study can be used to guide future training and research to study and improve the quality of documentation about goal of care, and its impact on goal-concordant care.
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Affiliation(s)
- Natalie C Ernecoff
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, 3600 Forbes Avenue, 405.35 Iroquois Building, Pittsburgh, PA, 15213, USA.
| | - Kathryn L Wessell
- Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, USA
| | - William A Wood
- Department of Medicine, Division of Hematology/Oncology, University of North Carolina, Chapel Hill, USA
| | - Gary S Winzelberg
- Department of Medicine, Division of Geriatric Medicine and Palliative Care Program, University of North Carolina, Chapel Hill, USA
| | - Frances A Collichio
- Department of Medicine, Division of Hematology/Oncology, University of North Carolina, Chapel Hill, USA
| | - Laura C Hanson
- Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, USA
- Department of Medicine, Division of Geriatric Medicine and Palliative Care Program, University of North Carolina, Chapel Hill, USA
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