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Haimovich AD, Burke RC, Nathanson LA, Rubins D, Taylor RA, Kross EK, Ouchi K, Shapiro NI, Schonberg MA. Geriatric End-of-Life Screening Tool Prediction of 6-Month Mortality in Older Patients. JAMA Netw Open 2024; 7:e2414213. [PMID: 38819823 PMCID: PMC11143461 DOI: 10.1001/jamanetworkopen.2024.14213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 03/31/2024] [Indexed: 06/01/2024] Open
Abstract
Importance Emergency department (ED) visits by older adults with life-limiting illnesses are a critical opportunity to establish patient care end-of-life preferences, but little is known about the optimal screening criteria for resource-constrained EDs. Objectives To externally validate the Geriatric End-of-Life Screening Tool (GEST) in an independent population and compare it with commonly used serious illness diagnostic criteria. Design, Setting, and Participants This prognostic study assessed a cohort of patients aged 65 years and older who were treated in a tertiary care ED in Boston, Massachusetts, from 2017 to 2021. Patients arriving in cardiac arrest or who died within 1 day of ED arrival were excluded. Data analysis was performed from August 1, 2023, to March 27, 2024. Exposure GEST, a logistic regression algorithm that uses commonly available electronic health record (EHR) datapoints and was developed and validated across 9 EDs, was compared with serious illness diagnoses as documented in the EHR. Serious illnesses included stroke/transient ischemic attack, liver disease, cancer, lung disease, and age greater than 80 years, among others. Main Outcomes and Measures The primary outcome was 6-month mortality following an ED encounter. Statistical analyses included area under the receiver operating characteristic curve, calibration analyses, Kaplan-Meier survival curves, and decision curves. Results This external validation included 82 371 ED encounters by 40 505 unique individuals (mean [SD] age, 76.8 [8.4] years; 54.3% women, 13.8% 6-month mortality rate). GEST had an external validation area under the receiver operating characteristic curve of 0.79 (95% CI, 0.78-0.79) that was stable across years and demographic subgroups. Of included encounters, 53.4% had a serious illness, with a sensitivity of 77.4% (95% CI, 76.6%-78.2%) and specificity of 50.5% (95% CI, 50.1%-50.8%). Varying GEST cutoffs from 5% to 30% increased specificity (5%: 49.1% [95% CI, 48.7%-49.5%]; 30%: 92.2% [95% CI, 92.0%-92.4%]) at the cost of sensitivity (5%: 89.3% [95% CI, 88.8-89.9]; 30%: 36.2% [95% CI, 35.3-37.1]). In a decision curve analysis, GEST outperformed serious illness criteria across all tested thresholds. When comparing patients referred to intervention by GEST with serious illness criteria, GEST reclassified 45.1% of patients with serious illness as having low risk of mortality with an observed mortality rate 8.1% and 2.6% of patients without serious illness as having high mortality risk with an observed mortality rate of 34.3% for a total reclassification rate of 25.3%. Conclusions and Relevance The findings of this study suggest that both serious illness criteria and GEST identified older ED patients at risk for 6-month mortality, but GEST offered more useful screening characteristics. Future trials of serious illness interventions for high mortality risk in older adults may consider transitioning from diagnosis code criteria to GEST, an automatable EHR-based algorithm.
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Affiliation(s)
- Adrian D. Haimovich
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Ryan C. Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Larry A. Nathanson
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - David Rubins
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - R. Andrew Taylor
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Erin K. Kross
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle
- Cambia Palliative Care Center of Excellence at UW Medicine, Seattle, Washington
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Nathan I. Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Mara A. Schonberg
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Ouchi K, Prachanukool T, Aaronson EL, Lakin JR, Higuchi M, Liu SW, Kennedy M, Revette AC, Chary AN, Kaithamattam J, Lee B, Neville TH, Hasdianda MA, Sudore R, Schonberg MA, Tulsky JA, Block SD. The differences in code status conversation approaches reported by emergency medicine and palliative care clinicians: A mixed-method study. Acad Emerg Med 2024; 31:18-27. [PMID: 37814372 PMCID: PMC10794002 DOI: 10.1111/acem.14818] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/21/2023] [Accepted: 10/03/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND During acute health deterioration, emergency medicine and palliative care clinicians routinely discuss code status (e.g., shared decision making about mechanical ventilation) with seriously ill patients. Little is known about their approaches. We sought to elucidate how code status conversations are conducted by emergency medicine and palliative care clinicians and why their approaches are different. METHODS We conducted a sequential-explanatory, mixed-method study in three large academic medical centers in the Northeastern United States. Attending physicians and advanced practice providers working in emergency medicine and palliative care were eligible. Among the survey respondents, we purposefully sampled the participants for follow-up interviews. We collected clinicians' self-reported approaches in code status conversations and their rationales. A survey with a 5-point Likert scale ("very unlikely" to "very likely") was used to assess the likelihood of asking about medical procedures (procedure based) and patients' values (value based) during code status conversations, followed by semistructured interviews. RESULTS Among 272 clinicians approached, 206 completed the survey (a 76% response rate). The reported approaches differed greatly (e.g., 91% of palliative care clinicians reported asking about a patient's acceptable quality of life compared to 59% of emergency medicine clinicians). Of the 206 respondents, 118 (57%) agreed to subsequent interviews; our final number of semistructured interviews included seven emergency medicine clinicians and nine palliative care clinicians. The palliative care clinicians stated that the value-based questions offer insight into patients' goals, which is necessary for formulating a recommendation. In contrast, emergency medicine clinicians stated that while value-based questions are useful, they are vague and necessitate extended discussions, which are inappropriate during emergencies. CONCLUSIONS Emergency medicine and palliative care clinicians reported conducting code status conversations differently. The rationales may be shaped by their clinical practices and experiences.
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Affiliation(s)
- Kei Ouchi
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Thidathit Prachanukool
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Emily L. Aaronson
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joshua R. Lakin
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Masaya Higuchi
- Division of Palliative Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shan W. Liu
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Maura Kennedy
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Anna C. Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Anita N. Chary
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jenson Kaithamattam
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Brandon Lee
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Thanh H. Neville
- Division of Pulmonary and Critical Care, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Mohammad A. Hasdianda
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Rebecca Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, USA
| | - Mara A. Schonberg
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - James A. Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Susan D. Block
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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Stanich J, Sunga K, Loprinzi-Brauer C, Ginsburg A, Ingram C, Bellolio F, Cabrera D. Teaching Palliative Care to Emergency Medicine Residents Using Gamified Deliberate Practice-Based Simulation: Palliative Gaming Simulation Study. JMIR MEDICAL EDUCATION 2023; 9:e43710. [PMID: 37585258 PMCID: PMC10468704 DOI: 10.2196/43710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 03/07/2023] [Accepted: 05/09/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND Emergency departments (EDs) care for many patients nearing the end of life with advanced serious illnesses. Simulation training offers an opportunity to teach physicians the interpersonal skills required to manage end-of-life care. OBJECTIVE We hypothesized a gaming simulation of an imminently dying patient using the LIVE. DIE. REPEAT (LDR) format, would be perceived as an effective method to teach end-of-life communication and palliative care management skills. METHODS This was a gaming simulation replicating the experience of caring for a dying patient with advanced serious illness in the ED. The scenario involved a patient with pancreatic cancer presenting with sepsis and respiratory distress, with a previously established goal of comfort care. The gaming simulation game was divided into 4 stages, and at each level, learners were tasked with completing 1 critical action. The gaming simulation was designed using the LDR serious game scheme in which learners are allowed infinite opportunities to progress through defined stages depicting a single patient scenario. If learners successfully complete the predetermined critical actions of each stage, the game is paused, and there is a debriefing to reinforce knowledge or skills before progressing to the next stage of the gaming simulation. Conversely, if learners do not achieve the critical actions, the game is over, and learners undergo debriefing before repeating the failed stage with an immediate transition into the next. We used the Simulation Effectiveness Tool-Modified survey to evaluate perceived effectiveness in teaching end-of-life management. RESULTS Eighty percent (16/20) of residents completed the Simulation Effectiveness Tool-Modified survey, and nearly 100% (20/20) either strongly or somewhat agreed that the gaming simulation improved their skills and confidence at the end of life in the following dimensions: (1) better prepared to respond to changes in condition, (2) more confident in assessment skills, (3) teaching patients, (4) reporting to the health care team, (5) empowered to make clinical decisions, and (6) able to prioritize care and interventions. All residents felt the debriefing contributed to learning and provided opportunities to self-reflect. All strongly or somewhat agree that they felt better prepared to respond to changes in the patient's condition, had a better understanding of pathophysiology, were more confident on their assessment skills, and had a better understanding of the medications and therapies after the gaming simulation. A total of 88% (14/16) of them feel more empowered to make clinical decisions. After completing the gaming simulation, 88% (14/16) of residents strongly agreed that they would feel more confident communicating with a patient and prioritizing care interventions in this context. CONCLUSIONS This palliative gaming simulation using the LDR format was perceived by resident physicians to improve confidence in end-of-life communication and palliative care management.
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Affiliation(s)
- Jessica Stanich
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States
| | - Kharmene Sunga
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States
| | | | - Alexander Ginsburg
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States
| | - Cory Ingram
- Division of Palliative, Department of Medicine, Mayo Clinic, Rochester, MN, United States
| | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States
- Department of Health Science Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, United States
| | - Daniel Cabrera
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States
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Montori VM, Ruissen MM, Hargraves IG, Brito JP, Kunneman M. Shared decision-making as a method of care. BMJ Evid Based Med 2023; 28:213-217. [PMID: 36460328 PMCID: PMC10423463 DOI: 10.1136/bmjebm-2022-112068] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2022] [Indexed: 12/04/2022]
Affiliation(s)
- Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
| | - Merel M Ruissen
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
- Department of Biomedical Data Sciences, Section of Medical Decision Making, Leiden University Medical Center, Leiden, Netherlands
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, Netherlands
| | - Ian G Hargraves
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
| | - Juan P Brito
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
| | - Marleen Kunneman
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
- Department of Biomedical Data Sciences, Section of Medical Decision Making, Leiden University Medical Center, Leiden, Netherlands
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Seidenfeld J, Bellolio F, Vashi A, Van Houtven C, Hastings S. Shared Disposition Decision-Making in the Emergency Department for Persons Living with Dementia. JOURNAL OF GERIATRIC EMERGENCY MEDICINE 2023; 4. [PMID: 39246803 PMCID: PMC11378982 DOI: 10.17294/2694-4715.1057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/10/2024]
Affiliation(s)
- Justine Seidenfeld
- ADAPT HSR&D Center of Innovation and Department of Emergency Medicine, Durham VA Health Care System, Durham, NC; Department of Emergency Medicine, Duke University School of Medicine, Durham, NC
| | - Fernanda Bellolio
- Department of Emergency Medicine, Department of Medicine (Geriatrics), and Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN
| | - Anita Vashi
- Center for Innovation to Implementation and Department of Emergency Medicine, Palo Alto VA Medical Center, Palo Alto, CA; Department of Emergency Medicine, Stanford University, Stanford, CA
| | - Courtney Van Houtven
- ADAPT HSR&D Center of Innovation, Durham VA Health Care System, Durham, NC; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Susan Hastings
- ADAPT HSR&D Center of Innovation, Durham VA Health Care System, Durham, NC; Department of Medicine (Geriatrics) and Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
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Breslin M. Conversations as care. J Hosp Med 2022. [PMID: 36353969 DOI: 10.1002/jhm.12997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 10/23/2022] [Accepted: 10/25/2022] [Indexed: 11/11/2022]
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