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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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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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West LJ, Tomko C, Sessanna L, Paplham P, Austin-Ketch T. Perceived Needs Among Healthcare Providers Caring for Seriously Ill Adults Regarding Electronic Health Record Triggers for Palliative Care Referral. Comput Inform Nurs 2023; 41:853-860. [PMID: 37562432 DOI: 10.1097/cin.0000000000001021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Many healthcare facilities in the United States currently utilize electronic health record triggers to promote and facilitate palliative care referral. The purpose of this study was to explore perceived needs regarding electronic health record trigger criteria for palliative care referral among healthcare providers caring for seriously ill adult hospitalized patients in a teaching hospital in New York State. A qualitative descriptive approach was utilized with use of individual semistructured interviews. Braun and Clarke's Reflexive Thematic Analysis method was used to analyze data. Data analysis generated one overarching theme, I'm in Favor of an Electronic Health Record Automatic Trigger for Palliative Care , and three key themes, Build a Checklist Screening Tool Into Epic With Predefined Conditions and a Palliative Consult in the Admission Order Set , If Providers Call a Palliative Care Consult Sooner, We Give Patients a Better Quality of Life , and Providers Need to Be Aware of the Different Facets of What Palliative Care Actually Does. Findings revealed that all participants supported incorporating electronic health record palliative care triggers. Future research is needed exploring provider palliative care education approaches to promote understanding of palliative care services and to address personal and/or professional bias.
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Affiliation(s)
- Lori-Jeanne West
- Author Affiliations: Upstate Medical University College of Nursing, Syracuse (Drs West, Tomko, and Austin-Ketch); and University at Buffalo, School of Nursing, Buffalo (Drs Sessanna and Paplham), NY
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Hu FY, Streiter S, O'Mara L, Sison SM, Theou O, Bernacki R, Orkaby A. Frailty and Survival After In-Hospital Cardiopulmonary Resuscitation. J Gen Intern Med 2022; 37:3554-3561. [PMID: 34981346 PMCID: PMC9585129 DOI: 10.1007/s11606-021-07199-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 10/01/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Older adults face high mortality following resuscitation efforts for in-hospital cardiac arrest. Less is known about the role of frailty in survival to discharge after in-hospital cardiopulmonary resuscitation. OBJECTIVE To investigate whether frailty, measured by the Clinical Frailty Scale, is associated with mortality after cardiopulmonary resuscitation following in-hospital cardiac arrest in older adults in the USA. DESIGN Retrospective cohort study. PARTICIPANTS Patients ≥ 65 years who had undergone cardiopulmonary resuscitation during an inpatient admission at two urban academic hospitals and three suburban community hospitals within a Boston area healthcare system from January 2018-January 2020. Patients with Clinical Frailty Scale scores 1-3 were considered not frail, 4-6 were considered very mildly, mildly, and moderately frail, respectively, and 7-9 were considered severely frail. MAIN MEASURES In-hospital mortality after cardiopulmonary resuscitation. KEY RESULTS Among 324 patients who underwent cardiopulmonary resuscitation following in-hospital cardiac arrest, 73.1% experienced in-hospital mortality. Patients with a Clinical Frailty Scale score of 1-3 had 54% in-hospital mortality, which increased to 66%, 78%, 84%, and 84% for those with a Clinical Frailty Scale score of 4, 5, 6, and 7-9, respectively (p = 0.001). After adjusting for age, sex, race, and Charlson Comorbidity Index, higher frailty scores were significantly associated with higher odds of in-hospital mortality. Compared to those with a Clinical Frailty Scale score of 1-3, odds ratios (95% CI) for in-hospital mortality for patients with a Clinical Frailty Scale score of 4, 5, 6, and 7-9 were 1.6 (0.8-3.3), 3.0 (1.3-7.1), 4.4 (1.9-9.9), and 4.6 (1.8-11.8), respectively (p = 0.001). CONCLUSIONS Higher levels of frailty are associated with increased mortality after in-hospital cardiopulmonary resuscitation in older adults. Clinicians may consider using the Clinical Frailty Scale to help guide goals of care conversations, including discussion of code status, in this patient population.
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Affiliation(s)
- Frances Y Hu
- Department of Surgery, Brigham & Women's Hospital, 1620 Tremont Street, Suite 2-016, Boston, MA, 02120, USA.
| | - Shoshana Streiter
- Department of Medicine, Division of Aging, Brigham & Women's Hospital, Boston, MA, USA
| | - Lynne O'Mara
- Department of Surgery, Brigham & Women's Hospital, 1620 Tremont Street, Suite 2-016, Boston, MA, 02120, USA
| | - Stephanie M Sison
- Department of Medicine, Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Olga Theou
- School of Physiotherapy and Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Rachelle Bernacki
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, USA
| | - Ariela Orkaby
- Department of Medicine, Division of Aging, Brigham & Women's Hospital, Boston, MA, USA
- Department of Medicine, VA Boston Healthcare System, Boston, MA, USA
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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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Patient Identification for Serious Illness Conversations: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19074162. [PMID: 35409844 PMCID: PMC8998898 DOI: 10.3390/ijerph19074162] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/24/2022] [Accepted: 03/29/2022] [Indexed: 02/04/2023]
Abstract
Serious illness conversations aim to align medical care and treatment with patients’ values, goals, priorities, and preferences. Timely and accurate identification of patients for serious illness conversations is essential; however, existent methods for patient identification in different settings and population groups have not been compared and contrasted. This study aimed to examine the current literature regarding patient identification for serious illness conversations within the context of the Serious Illness Care Program and/or the Serious Illness Conversation Guide. A scoping review was conducted using the Joanna Briggs Institute guidelines. A comprehensive search was undertaken in four databases for literature published between January 2014 and September 2021. In total, 39 articles met the criteria for inclusion. This review found that patients were primarily identified for serious illness conversations using clinical/diagnostic triggers, the ’surprise question’, or a combination of methods. A diverse assortment of clinicians and non-clinical resources were described in the identification process, including physicians, nurses, allied health staff, administrative staff, and automated algorithms. Facilitators and barriers to patient identification are elucidated. Future research should test the efficacy of adapted identification methods and explore how clinicians inform judgements surrounding patient identification.
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Jacobsen J, Jackson V, Asfaw S, Greenwald JL, Slavin P. One Hospital's Response to the Institute of Medicine Report, "Dying in America". J Pain Symptom Manage 2022; 63:e182-e187. [PMID: 34756956 DOI: 10.1016/j.jpainsymman.2021.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/05/2021] [Accepted: 10/22/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND In response to the Institute of Medicine (IOM) report, Dying in America, we undertook an institution wide effort to improve the experience of patients and families facing serious illness by engaging leadership and developing a program to promote the practice of generalist palliative care. MEASURES The impact of the program was measured with process measures related to its' three parts. INTERVENTION We developed a three-part generalist palliative care program that focuses on 1) instructional design, 2) advance care planning, and 3) engagement. OUTCOMES Over four years, the program trained 51 interprofessional clinicians in a two-week intensive palliative care course and 1,541 interprofessional clinicians in a 90-150 min skills-based training. Clinicians documented 15,791 serious illness conversations. Zoom community engagement sessions were attended by 411 live viewers, and subsequently, 1918 YouTube views. Additionally, we report on the impact of the COIVD-19 crisis on our efforts. Early in the pandemic, over two months, 464 interprofessional clinicians documented 5,168 conversations with patients. CONCLUSION/LESSONS LEARNED A broad based strategy resulted wide institutional engagement with serious illness care.
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Affiliation(s)
- Juliet Jacobsen
- Harvard Medical School (J.J., V.J., J.L.G.), Massachusetts General Hospital, Boston, Massachusetts, USA.
| | - Vicki Jackson
- Harvard Medical School (J.J., V.J., J.L.G.), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shae Asfaw
- Massachusetts General Hospital (S.A.), Boston, Massachusetts, USA
| | - Jeffrey L Greenwald
- Harvard Medical School (J.J., V.J., J.L.G.), Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Peter Slavin
- Department of Health Care Policy (P.S.), Harvard Medical School; President, Massachusetts General Hospital, Boston, Massachusetts, USA
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Cox CE, Ashana DC, Haines KL, Casarett D, Olsen MK, Parish A, O’Keefe YA, Al-Hegelan M, Harrison RW, Naglee C, Katz JN, Frear A, Pratt EH, Gu J, Riley IL, Otis-Green S, Johnson KS, Docherty SL. Assessment of Clinical Palliative Care Trigger Status vs Actual Needs Among Critically Ill Patients and Their Family Members. JAMA Netw Open 2022; 5:e2144093. [PMID: 35050358 PMCID: PMC8777568 DOI: 10.1001/jamanetworkopen.2021.44093] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
IMPORTANCE Palliative care consultations in intensive care units (ICUs) are increasingly prompted by clinical characteristics associated with mortality or resource utilization. However, it is not known whether these triggers reflect actual palliative care needs. OBJECTIVE To compare unmet needs by clinical palliative care trigger status (present vs absent). DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study was conducted in 6 adult medical and surgical ICUs in academic and community hospitals in North Carolina between January 2019 and September 2020. Participants were consecutive patients receiving mechanical ventilation and their family members. EXPOSURE Presence of any of 9 common clinical palliative care triggers. MAIN OUTCOMES AND MEASURES The primary outcome was the Needs at the End-of-Life Screening Tool (NEST) score (range, 0-130, with higher scores reflecting greater need), which was completed after 3 days of ICU care. Trigger status performance in identifying serious need (NEST score ≥30) was assessed using sensitivity, specificity, positive and negative likelihood ratios, and C statistics. RESULTS Surveys were completed by 257 of 360 family members of patients (71.4% of the potentially eligible patient-family member dyads approached) with a median age of 54.0 years (IQR, 44-62 years); 197 family members (76.7%) were female, and 83 (32.3%) were Black. The median age of patients was 58.0 years (IQR, 46-68 years); 126 patients (49.0%) were female, and 88 (33.5%) were Black. There was no difference in median NEST score between participants with a trigger present (45%) and those with a trigger absent (55%) (21.0; IQR, 12.0-37.0 vs 22.5; IQR, 12.0-39.0; P = .52). Trigger presence was associated with poor sensitivity (45%; 95% CI, 34%-55%), specificity (55%; 95% CI, 48%-63%), positive likelihood ratio (1.0; 95% CI, 0.7-1.3), negative likelihood ratio (1.0; 95% CI, 0.8-1.2), and C statistic (0.50; 95% CI, 0.44-0.57). CONCLUSIONS AND RELEVANCE In this cohort study, clinical palliative care trigger status was not associated with palliative care needs and no better than chance at identifying the most serious needs, which raises questions about an increasingly common clinical practice. Focusing care delivery on directly measured needs may represent a more person-centered alternative.
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Affiliation(s)
- Christopher E. Cox
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Deepshikha Charan Ashana
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Krista L. Haines
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, Duke University, Durham, North Carolina
| | - David Casarett
- Section of Palliative Care and Hospice Medicine, Duke University, Durham, North Carolina
| | - Maren K. Olsen
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | | | - Mashael Al-Hegelan
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Robert W. Harrison
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Colleen Naglee
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Jason N. Katz
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Allie Frear
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Elias H. Pratt
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Jessie Gu
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Isaretta L. Riley
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Kimberly S. Johnson
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
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