Association of goals of care meetings for hospitalized cancer patients at risk for critical care with patient outcomes

Impact of an Interdisciplinary Goals-of-Care Program Among Medical Inpatients at a Comprehensive Cancer Center During the COVID-19 Pandemic: A Propensity Score Analysis

PURPOSE

Many hospitals have established goals-of-care programs in response to the coronavirus disease 2019 pandemic; however, few have reported their outcomes. We examined the impact of a multicomponent interdisciplinary goals-of-care program on intensive care unit (ICU) mortality and hospital outcomes for medical inpatients with cancer.

METHODS

This single-center study with a quasi-experimental design included consecutive adult patients with cancer admitted to medical units at the MD Anderson Cancer Center, TX, during the 8-month preimplementation (May 1, 2019-December 31, 2019) and postimplementation period (May 1, 2020-December 31, 2020). The primary outcome was ICU mortality. Secondary outcomes included ICU length of stay, hospital mortality, and proportion/timing of care plan documentation. Propensity score weighting was used to adjust for differences in potential covariates, including age, sex, cancer diagnosis, race/ethnicity, and Sequential Organ Failure Assessment score.

RESULTS

This study involved 12,941 hospitalized patients with cancer (pre n = 6,977; post n = 5,964) including 1,365 ICU admissions (pre n = 727; post n = 638). After multicomponent goals-of-care program initiation, we observed a significant reduction in ICU mortality (28.2% v 21.9%; change -6.3%, 95% CI, -9.6 to -3.1; P = .0001). We also observed significant decreases in length of ICU stay (mean change -1.4 days, 95% CI, -2.0 to -0.7; P < .0001) and in-hospital mortality (7% v 6.1%, mean change -0.9%, 95% CI, -1.5 to -0.3; P = .004). The proportion of hospitalized patients with an in-hospital do-not-resuscitate order increased significantly from 14.7% to 19.6% after implementation (odds ratio, 1.4; 95% CI, 1.3 to 1.5; P < .0001), and do-not-resuscitate order was established earlier (mean difference -3.0 days, 95% CI, -3.9 to -2.1; P < .0001).

CONCLUSION

This study showed improvement in hospital outcomes and care plan documentation after implementation of a system-wide, multicomponent goals-of-care intervention.

The Financial Impact of Palliative Care and Aggressive Cancer Care on End-of-Life Health Care Costs

BACKGROUND

Medicare cancer expenditures in the last month of life have increased. Aggressive cancer care at the end-of-life (ACEOL) is considered poor quality care. We used Geisinger Health Plan (GHP) last month's costs for cancer patients who died in 2018 and 2019 to determine the costs of and influence of Palliative Care (PC) on ACEOL.

METHOD

Patients with GHP ages 18-99 who died in 2018 and 2019 were included. Demographic, clinical characteristics, and Charlson Comorbid Index were compared across care groups defined as no ACEOL indicator, 1 or more than 1 indicator. Differences between groups were compared with Kruskal-Wallis tests and one-way ANOVA for 3 groups. Median two-sample tests and independent t-tests compared groups of 2. A P-value </= .05 indicated statistical significance.

RESULTS

Of 608 eligible patients; 261 had no indicator, 133 had 1 and 214 > 1. There were incremental cost increases with each additional ACEOL indicator (p = < .0001). Palliative Care <90 days before death was associated with increased costs while consultations >90 days before death lowered cost (P < .0001) due to reduced chemotherapy in the last month. Completed ADs reduced cost by $4000.

DISCUSSION

ACEOL indicators multiply costs during the last month of life. Palliative care instituted >90 days before death reduces chemotherapy in the last month of life and AD reduces health care costs.

CONCLUSION

Cancer health care costs increase with indicators of ACEOL. Palliative care consultations >90 days before death; ADs reduce cancer health care costs.

Serious Illness Conversation Training for Inpatient Medical Oncology Advanced Practice Providers: A Quality Improvement Project

Background

Hospitalized advanced cancer patients and their families are inadequately informed about their cancer diagnosis and prognosis, which limits educated and reasonable decision-making for their care and end-of-life planning.

Objectives

The primary objective of this evidence-based project was to enhance serious illness conversations (SICs) with advanced cancer patients by providing advanced practice providers (APP) training and to increase the frequency of SIC documentation in the electronic medical record (EMR).

Methods

SIC training included a 45-minute Zoom video recording and 30-minute discussion groups. Advanced practice providers' beliefs and self-efficacy were measured pre- and post-training via a survey. Prior training was queried in the pre-survey. Data from APP discussion groups were summarized and themes identified. Serious illness conversation documentation frequency was measured. Pre- and post-survey differences were assessed using Wilcoxon rank sum tests.

Findings

19 inpatient medical oncology nurse practitioners and 6 physician assistants participated. Many reported little formal training yet are engaging in SICs regularly. Scores on both the belief and self-efficacy survey sections were high prior to training and did not significantly change following training. Despite the high pre-survey scores, many of the APPs verbalized the need for more training to improve their confidence and to learn SIC communication skills. Training significantly improved the APP's ability to manage their own emotions and be present. This indicates a trend toward improved APP comfort with SICs. Accessible documentation in the EMR increased with training.

Evaluation of the 'Talking Together' simulation communication training for 'goals of patient care' conversations: a mixed-methods study in five metropolitan public hospitals in Western Australia

INTRODUCTION

In partnership with Cancer Council Western Australia (WA), the East Metropolitan Health Service in Perth, WA has developed a clinical simulation training programme 'Talking Together' using role play scenarios with trained actors as patients/carers. The aim of the training is to improve clinicians' communication skills when having challenging conversations with patients, or their carers, in relation to goals of care in the event of clinical deterioration.

METHODS AND ANALYSIS

A multisite, longitudinal mixed-methods study will be conducted to evaluate the impact of the communication skills training programme on patient, family/carer and clinician outcomes. Methods include online surveys and interviews. The study will assess outcomes in three areas: evaluation of the 'Talking Together' workshops and their effect on satisfaction, confidence and integration of best practice communication skills; quality of goals of patient care conversations from the point of view of clinicians, carers and family/carers; and investigation of the nursing/allied role in goals of patient care.

ETHICS AND DISSEMINATION

This study has received ethical approval from the Royal Perth Hospital, St John of God and Curtin University Human Research Ethics Committees. The outputs from this project will be a series of research papers and conference presentations.

Goals of care communication and higher-value care for patients with advanced-stage cancer: A systematic review of the evidence

CONTEXT

Goals-of-care communication (GOCC) is recommended to increase the value of cancer care near the end of life (EOL).

OBJECTIVES

Conduct a systematic review of the evidence that GOCC is associated with higher-value care.

METHODS

We searched PubMed, Scopus, Ovid MEDLINE, EMBASE, EMB Reviews, CINAHL, and PsycInfo from inception to July 2019. We analyzed the population,design, and results and the authors' definitions of GOCC. Risk of bias was assessed.

RESULTS

Thirty-two articles were selected. Ten articles reported results from 8 interventions; 17 characterized participants' perspectives; and 5 were retrospective The topics, behaviors, timing, and anticipated outcomes of GOCC varied significantly and were indistinguishable from practices such as advance care planning. GOCC typically focused on treatment outcomes rather than patients' goals. Four of 5 interventions increased evidence of GOCC after clinician training. Only one reported improved patient outcomes.

CONCLUSION

No consensus exists about what GOCC entails. There is limited evidence that GOCC increases the value of EOL care.

PRACTICE IMPLICATIONS

Future studies should focus on how to engage patients in conversations about their personal goals and integrate their goals into care planning. Clinicians can encourage GOCC by explaining how patients' goals influence decisions especially as treatment options become limited.

Characterizing uncertainty in goals-of-care discussions among black and white patients: a qualitative study

BACKGROUND

Uncertainty has been associated with distress and poorer quality of life in patients with advanced cancer. Prior studies have focused on prognostic uncertainty; little is known about other types of uncertainty that patients and family members experience when discussing goals of care. Understanding the types of uncertainty expressed and differences between Black and White patients can inform the development of uncertainty management interventions.

METHODS

This study sought to characterize the types of uncertainty expressed by Black and White patients and family members within the context of information needs during inpatient goals-of-care discussions. We performed a secondary analysis of transcripts from 62 recorded goals-of-care discussions that occurred between 2012 and 2014 at an urban, academic medical center in the United States. We applied an adapted taxonomy of uncertainty to data coded as describing information needs and used an inductive qualitative analysis method to analyze the discussions. We report the types of uncertainty expressed in these discussions.

RESULTS

Fifty discussions included patient or family expressions of information needs. Of these, 40 discussions (n=16 Black and n=24 White) included statements of uncertainty. Black and White patients and families most frequently expressed uncertainty related to processes and structures of care (system-centered uncertainty) and to treatment (scientific uncertainty). Statements of prognostic uncertainty focused on quantitative information among Whites and on qualitative information and expectations for the future among Blacks.

CONCLUSIONS

Black and White patients and families frequently expressed system-centered uncertainty, suggesting this may be an important target for intervention. Addressing other sources of uncertainty, such as prognostic uncertainty, may need more tailored approaches.

Effect of Palliative Care Curriculum on Serious Illness Conversation Preparedness

Background

A shortage of palliative pare (PC) specialists underscores the necessity that all clinicians feel comfortable with serious illness conversations (SICs).

Objective

To assess the effect of an intensive PC curriculum with multiple teaching modalities on Internal Medicine residents’ confidence with SICs and advance care planning documentation.

Methods

Twelve PC modules consisting of didactic lectures, role-playing, and online interactive modules were integrated as continuing education during academic year 2018–2019. Surveys were administered precurriculum and at 3 and 6 months postcurriculum to measure the primary outcome of increasing resident preparedness for SICs. A retrospective chart review was used to analyze secondary outcomes of advance care planning documentation for patients cared for by residents exposed to the curriculum versus residents from the previous year who received monthly didactic PC lectures.

Results

Postintervention surveys demonstrated statistically significant improvement in resident confidence. An increase in patient code status confirmation rates (odds ratio, 1.81; 95% confidence interval, 1.12–2.94; P = 0.02) and a decrease in PC consultation (odds ratio, 0.56; 95% confidence interval, 0.33–0.97; P = 0.04) was observed when compared with the previous year.

Conclusion

Among residents, the incorporation of an intensive PC curriculum that uses multiple teaching modalities improves confidence in SICs, which we believe is integral to the practice of goal-concordant patient care.

Evaluating the Outcomes of an Organizational Initiative to Expand End-of-Life Resources in Intensive Care Units With Palliative Support Tools and Floating Hospice

BACKGROUND

There is evidence that palliative care and floating (inpatient) hospice can improve end-of-life experiences for patients and their families in the intensive care unit (ICU). However, both palliative care and hospice remain underutilized in the ICU setting.

OBJECTIVES

This study examined palliative consultations and floating hospice referrals for ICU patients during a phased launch of floating hospice, 2 palliative order sets, and general education to support implementation of palliative care guidelines.

METHODS

This descriptive, retrospective study was conducted at a level I trauma and academic medical center. Electronic medical records of 400 ICU patients who died in the hospital were randomly selected. These electronic medical records were reviewed to determine if patients received a palliative consult and/or a floating hospice referral, as well as whether the new palliative support tools were used during the course of care. The numbers of floating hospice referrals and palliative consults were measured over time.

RESULTS

Although not significant, palliative consults increased over time (P = .055). After the initial introduction of floating hospice, 27% of the patients received referrals; however, referrals did not significantly increase over time (P = .807). Of the 68 patients who received a floating hospice referral (24%), only 38 were discharged to floating hospice. There was a trend toward earlier palliative care consults, although this was not statistically significant (P = .285).

CONCLUSION

This study provided the organization with vital information about their initiative to expand end-of-life resources. Utilization and timing of palliative consults and floating hospice referrals were lower and later than expected, highlighting the importance of developing purposeful strategies beyond education to address ICU cultural and structural barriers.

Associations Among End-of-Life Discussions, Health-Care Utilization, and Costs in Persons With Advanced Cancer: A Systematic Review

BACKGROUND

Aggressive end-of-life (EOL) care is associated with lower quality of life and greater regret about treatment decisions. Higher EOL costs are also associated with lower quality EOL care. Advance care planning and goals-of-care conversations ("EOL discussions") may influence EOL health-care utilization and costs among persons with cancer.

OBJECTIVE

To describe associations among EOL discussions, health-care utilization and place of death, and costs in persons with advanced cancer and explore variation in study measures.

METHODS

A systematic review was conducted using PubMed, Embase, and CINAHL. Twenty quantitative studies published between January 2012 and January 2019 were included.

RESULTS

End-of-life discussions are associated with lower health-care costs in the last 30 days of life (median US$1048 vs US$23482; P < .001); lower likelihood of acute care at EOL (odds ratio [(OR] ranging 0.43-0.69); lower likelihood of intensive care at EOL (ORs ranging 0.26-0.68); lower odds of chemotherapy near death (ORs 0.41, 0.57); lower odds of emergency department use and shorter length of hospital stay; greater use of hospice (ORs ranging 1.79 to 6.88); and greater likelihood of death outside the hospital. Earlier EOL discussions (30+ days before death) are more strongly associated with less aggressive care outcomes than conversations occurring near death.

CONCLUSIONS

End-of-life discussions are associated with less aggressive, less costly EOL care. Clinicians should initiate these discussions with patients having cancer earlier to better align care with preferences.

Facilitators and Barriers to Oncologists’ Conduct of Goals of Care Conversations

Introduction:

Goals of care (GoC) conversations optimally begin early in the course of cancer care, yet most happen near the end of life. We sought to describe oncologist-reported facilitators of and barriers to GoC conversations with patients who have advanced cancer.

Methods and Materials:

We conducted individual, semistructured qualitative interviews with oncologists from 4 academic, community, municipal, and rural hospitals in New York and Connecticut. Interview topics included approach to GoC conversations, facilitators, barriers, and organizational influences. We analyzed data using interpretive description. We collected demographic and practice information and surveyed oncologists on their communication skills training. We calculated descriptive statistics for quantitative data.

Results:

Oncologists (n = 21) had a mean age of 46 years (range: 34-68), 67% were male, 71% were White, 24% were Asian, 10% were Hispanic, and 5% were Black. They reported an average of 20 years in practice (range: 8-42), and 62% had received training on having GoC conversations. Facilitators included patient’s poor functional status, patient’s high health literacy, family understanding and acceptance, oncologist’s practice experience, and a supportive practice environment. Barriers included certain patient demographic and clinical characteristics, patient religion and culture, patient’s denial, and lack of time.

Conclusion:

GoC conversations may be facilitated by enabling oncologists to conduct these conversations despite difficult circumstances and emotional reactions by activating patients and family via increased health literacy and by advancing palliative-informed practice environments.

Common Items on a Bucket List

BACKGROUND

To provide preference-sensitive care, we propose that clinicians might routinely inquire about their patients' bucket-lists and discuss the impact (if any) of their medical treatments on their life goals.

METHODS

This cross-sectional, mixed methods online study explores the concept of the bucket list and seeks to identify common bucket list themes. Data were collected in 2015-2016 through an online survey, which was completed by a total of 3056 participants across the United States. Forty participants who had a bucket list were identified randomly and used as the development cohort: their responses were analyzed qualitatively using grounded theory methods to identify the six key bucket list themes. The responses of the remaining 3016 participants were used for the validation study. The codes identified from the development cohort were validated by analyses of responses from 50 randomly drawn subjects from the validation cohort. All the 3016 validation cohort transcripts were coded for presence or absence of each of the six bucket list themes.

RESULTS

Around 91.2% participants had a bucket list. Age and spirituality influence the patient's bucket-list. Participants who reported that faith/religion/spirituality was important to them were most likely (95%) to have a bucket list compared with those who reported it to be unimportant (68.2%), χ² = 37.67. Six primary themes identified were the desire to travel (78.5%), desire to accomplish a personal goal (78.3%), desire to achieve specific life milestones (51%), desire to spend quality time with friends and family (16.7%), desire to achieve financial stability (24.3%), and desire to do a daring activity (15%).

CONCLUSIONS

The bucket list is a simple framework that can be used to engage patients about their healthcare decision making. Knowing a patient's bucket list can aid clinicians in relating each treatment option to its potential impact (if any) on the patient's life and life goals to promote informed decision making.

Palliative Care Communication in the ICU: Implications for an Oncology-Critical Care Nursing Partnership

OBJECTIVES

To describe the development, launch, implementation, and outcomes of a unique multisite collaborative (ie, IMPACT-ICU [Integrating Multidisciplinary Palliative Care into the ICU]) to teach ICU nurses communication skills specific to palliative care. To identify options for collaboration between oncology and critical care nurses when integrating palliation into nursing care planning.

DATA SOURCES

Published literature and collective experiences of the authors in the provision of onco-critical-palliative care.

CONCLUSION

While critical care nurses were the initial focus of education, oncology, telemetry, step-down, and medical-surgical nurses within five university medical centers subsequently participated in this learning collaborative. Participants reported enhanced confidence in communicating with patients, families, and physicians, offering emotional support and involvement in family meetings.

IMPLICATIONS FOR NURSING PRACTICE

Communication education is a vital yet missing element of undergraduate nursing education. Programs should be offered in the work setting to address this gap in needed nurse competency, particularly within the context of onco-critical-palliative care.

No Exit: Identifying Avoidable Terminal Oncology Intensive Care Unit Hospitalizations

PURPOSE

Terminal oncology intensive care unit (ICU) hospitalizations are associated with high costs and inferior quality of care. This study identifies and characterizes potentially avoidable terminal admissions of oncology patients to ICUs.

METHODS

This was a retrospective case series of patients cared for in an academic medical center's ambulatory oncology practice who died in an ICU during July 1, 2012 to June 30, 2013. An oncologist, intensivist, and hospitalist reviewed each patient's electronic health record from 3 months preceding terminal hospitalization until death. The primary outcome was the proportion of terminal ICU hospitalizations identified as potentially avoidable by two or more reviewers. Univariate and multivariate analysis were performed to identify characteristics associated with avoidable terminal ICU hospitalizations.

RESULTS

Seventy-two patients met inclusion criteria. The majority had solid tumor malignancies (71%), poor performance status (51%), and multiple encounters with the health care system. Despite high-intensity health care utilization, only 25% had documented advance directives. During a 4-day median ICU length of stay, 81% were intubated and 39% had cardiopulmonary resuscitation. Forty-seven percent of these hospitalizations were identified as potentially avoidable. Avoidable hospitalizations were associated with factors including: worse performance status before admission (median 2 v 1; P = .01), worse Charlson comorbidity score (median 8.5 v 7.0, P = .04), reason for hospitalization (P = .006), and number of prior hospitalizations (median 2 v 1; P = .05).

CONCLUSION

Given the high frequency of avoidable terminal ICU hospitalizations, health care leaders should develop strategies to prospectively identify patients at high risk and formulate interventions to improve end-of-life care.

Epidemiology of in-hospital mortality in acute patients admitted to a tertiary-level hospital

BACKGROUND

Healthcare professionals may have difficulty in recognising the dying patient in acute care settings, and yet, this is essential if timely end-of-life care is to be provided. While approximately one-third of patients who pass away in-hospital are reviewed by the rapid response team (RRT), there is limited available research on other factors associated with mortality within the hospital setting.

AIMS

To describe the epidemiology of in-hospital mortality within a tertiary-level hospital, particularly in the context of RRT activation.

METHODS

We utilised the database extraction of demographic, admission and RRT activation data on acute patients discharged from an Australian acute tertiary hospital between 1 January 2009 and 31 December 2013. Analyses included simple descriptors, Chi-squared and non-parametric Kruskal-Wallis tests as appropriate.

RESULTS

Of the 44,297 patients discharged from our hospital, 1603 died during admission. The general medical, haematology/oncology and intensive care teams provided care for the majority of the patients who died. A small number of diagnoses had in-patient mortality rates of greater than 25%. These included respiratory failure, alcoholic liver disease, vascular disorders of the intestine, sepsis and aspiration pneumonia. Over 75% of patients who received a RRT call survived to hospital discharge; however, patients who received four or more RRT calls during admission had an in-hospital mortality rate of over 40%.

CONCLUSION

Acute in-patient mortality is unequally distributed throughout the hospital, and a small number of diagnoses has large associated in-patient mortality rates. Repeated involvement of the RRT is associated with in-patient mortality.

Team Leadership and Cancer End-of-Life Decision Making

End-of-life decision making in cancer can be a complicated process. Patients and families encounter multiple providers throughout their cancer care. When the efforts of these providers are not well coordinated in teams, opportunities for high-quality, longitudinal goals of care discussions can be missed. This article reviews the case of a 55-year-old man with lung cancer, illustrating the barriers and missed opportunities for end-of-life decision making in his care through the lens of team leadership, a key principle in the science of teams. The challenges demonstrated in this case reflect the importance of the four functions of team leadership: information search and structuring, information use in problem solving, managing personnel resources, and managing material resources. Engaging in shared leadership of these four functions can help care providers improve their interactions with patients and families concerning end-of-life care decision making. This shared leadership can also produce a cohesive care plan that benefits from the expertise of the range of available providers while reflecting patient needs and preferences. Clinicians and researchers should consider the roles of team leadership functions and shared leadership in improving patient care when developing and studying models of cancer care delivery.

'Rapid discharge': issues for hospital-based nurses in discharging cancer patients home to die

AIMS AND OBJECTIVES

To explore issues for hospital-based nurses in arranging rapid home discharge for imminently dying cancer patients in a Singapore acute hospital.

BACKGROUND

Dying at home is an important measure of a 'good death'. For hospitalised terminally ill patients, achieving home death can be of paramount importance to them and their family. Nurses experience many challenges in discharging imminently dying cancer patients home, due to time limitations and complex needs of patients and their families.

DESIGN

Qualitative interpretive description.

METHOD

Using purposive sampling, 14 registered nurses from an oncology ward in a Singapore hospital were recruited to participate in individual, semi-structured interviews.

RESULTS

Nursing issues in facilitating rapid discharge fell into three categories: time, discharge processes and family preparation. Decisions to die at home appeared solely family/patient driven, and were made when death appeared imminent. Discharge then became time-critical, as nurses needed to complete multiple tasks within short timeframes. Stress was further exacerbated by nurses' inexperience and the infrequent occurrence of rapid discharge, as well as absence of standardised discharge framework for guidance. Together, the lack of time and discharge processes to enable smooth hospital-to-home transition potentially affected nurses' capacity to adequately prepare families, and may contribute to caregiver anxiety.

CONCLUSION

Rapid discharge processes are needed as sudden patient/family decisions to die at home will continue. Earlier involvement of palliative care and implementation of a discharge pathway can potentially help nurses address their multiple responsibilities to ensure a successful transition from hospital to home.

RELEVANCE TO CLINICAL PRACTICE

Recognition of nursing issues and challenges during rapid discharge has implications for clinical improvements in supporting nurses during this challenging situation. Results of this study can be used to inform the conceptualisation of clinical interventions to facilitate urgent discharges of imminently dying patients.