How well do documented goals-of-care discussions for patients with stage IV cancer reflect communication best practices?

A conceptual model of the nurse's role as primary palliative care provider in goals of care communication

Objective

Nurses have opportunities to engage in goals of care conversations that can promote palliative care communication. The purpose of this study was to describe nurses' experiences in goals of care communication as summarized in the literature and to present a conceptual model of communication pathways for nurses.

Methods

An integrative review of the literature (2016-2022) addressing nurses' experiences in goals of care communication was conducted using PubMed, CINAHL, and PsychInfo databases. A total of 92 articles were retrieved. A total of 12 articles were included for this review after applying the inclusion and exclusion criteria.

Results

Of the 12 articles, the majority were qualitative studies (n = 8). Qualitative analysis of findings from all articles revealed three dominant themes: nurses' ambiguous role responsibilities, goals of care as end-of-life communication, and the need for nurse communication training.

Conclusion

This article suggests an innovative conceptual model for advancing nurse communication about goals of care to facilitate primary palliative care.

Innovation

The framework characterizes two communication pathways for Advanced Practice Nurses who direct goals of care discussions and Registered Nurses who support goals of care communication. The model informs future communication training aimed at supporting primary palliative care.

Long-Term Engagement of Patients With Advanced Cancer: Results From the EPAC Randomized Clinical Trial

Importance

The long-term effect of interventions that assist patients with establishing their end-of-life care preferences among patients with cancer remain relatively unknown.

Objective

To evaluate the association of a long-term intervention of a lay health worker-led advance care planning intervention among patients with advanced stages of cancer with overall survival and end-of-life health care use and costs.

Design, Setting, and Participants

This follow-up study of the EPAC randomized clinical trial conducted between August 2013 and February 2015 used data from 9.4 years after the first patient was enrolled with a data cut-off date of February 1, 2023. Overall, 213 participants with stage 3 or 4 or recurrent cancer in the US Veterans Affairs Palo Alto Health Care System were included.

Interventions

A 6-month lay health worker-led education and support intervention to assist patients with establishing their end-of-life preferences vs usual care.

Main Outcomes and Measures

The outcomes of interest were overall survival, risk of death, restricted mean survival time, and palliative care, hospice, and acute care use in the final 30 days before death for participants who died.

Results

Among 213 participants randomized and included in the intention-to-treat analysis, the mean (SD) age was 69.3 (9.1) years; 211 (99.1%) were male, 2 (0.90%) were female. There were no demographic or clinical characteristic imbalances at enrollment. As of February 1, 2023, 188 had died. The intervention group had a 25% reduction in risk of death (hazard ratio, 0.75; 95% CI, 0.56-0.98); more palliative care (44 [50.0%] vs 35 [35.0%]) and hospice use (64 [72.7%] vs 53 [53.0%]); and lower emergency department use (20 [22.7%] vs 47 [47.0%]), hospitalizations (17 [19.3%] vs 46 [46.0%]), and median (IQR) total health care costs (median [IQR], $1637 [$383-$9026] vs $18 520 [$4790-$50 729]) than control group participants.

Conclusions and Relevance

The effects of the lay health worker-led intervention remain durable, with nearly complete follow-up, supporting integration into routine cancer care.

Trial Registration

ClinicalTrials.gov Identifier: NCT02966509.

Using Performance Status to Identify Risk of Acute Care Transfer in Inpatient Cancer Rehabilitation

OBJECTIVE

To identify patient factors associated with acute care transfer (ACT) among cancer survivors admitted for inpatient medical rehabilitation.

DESIGN

An exploratory, observational design was used to analyze retrospective data from electronic medical records.

SETTING

Data were obtained from 3 separate inpatient rehabilitation hospitals within a private rehabilitation hospital system in the Northeast.

PARTICIPANTS

Medical records were reviewed and analyzed for a total of 416 patients with a confirmed oncologic diagnosis treated in 1 of the inpatient rehabilitation hospitals between January and December 2020.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The primary outcome measure was the incidence of an ACT. Covariates included the adapted Karnofsky Performance Scale (KPS) for inpatient rehabilitation, demographic information, admission date, re-admission status, discharge destination, and cancer-related variables, such as primary cancer diagnosis and presence/location of metastases.

RESULTS

One in 5 patients (21.2%) were transferred to acute care. Patients with hematologic cancer had a higher risk of ACT compared with those with central nervous system (CNS) cancer. Lower functional status, measured by the adapted KPS, was associated with a higher likelihood of ACT. Patients with an admission KPS score indicating the need for maximum assistance had the highest transfer rate (59.1%).

CONCLUSIONS

These findings highlight the medical complexity of this population and increased risk of an interrupted rehabilitation stay. Considering patients' performance status, cancer type, and extent of disease may be important when assessing the appropriateness of IRF admission relative to patient quality of life. Earlier and improved understanding of the patient's prognosis will allow the cancer rehabilitation program to meet the patient's unique needs and facilitate an appropriate discharge to the community in an optimal window of time.

Do goals of care documentation reflect the conversation?: Evaluating conversation-documentation accuracy

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.

What Matters Most: The Documented Goals, Values and Motivators of Advanced Cancer Patients

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.

The Use of Templates for Documenting Advance Care Planning Conversations: A Descriptive Analysis

CONTEXT

While professional societies and expert panels have recommended quality indicators related to advance care planning (ACP) documentation, including using structured documentation templates, it is unclear how clinicians document these conversations.

OBJECTIVE

To explore how clinicians document ACP, specifically, which components of these conversations are documented.

METHODS

A codebook was developed based on existing frameworks for ACP conversations and documentation. ACP documentation from a hospital medicine quality improvement project conducted from November 2019 to April 2021 were included and assessed. Documentation was examined for the presence or absence of each component within the coding schema. Clinician documented ACP using three different note types: template (only template prompts were used), template plus (authors added additional text to the template), and free text only. ACP note components were analyzed by note type and author department.

RESULTS

A total of 182 ACP notes were identified and reviewed. The most common note type was template plus (58%), followed by free text (28%) and template (14%). The most frequent components across all note types were: important relationships to patient (92%), and discussion of life-sustaining treatment preferences (87%). There was considerable heterogeneity in the components across note types. The presence of components focused on treatment decisions and legal paperwork differed significantly between note types (P < 0.05). Components on preference for medical information, emotional state, or spiritual support were rarely included across all note types.

CONCLUSION

This study provides a preliminary exploration of ACP documentation and found that templates may influence what information is documented after an ACP conversation.

Using Design Thinking to Promote Goals of Care Conversations With Seriously Ill Patients

BACKGROUND

Goals of care (GOC) conversations can improve serious illness outcomes such as pain and symptom management and patient satisfaction.

PROBLEM

However, we recognized that very few Duke Health patients who died had a GOC conversation documented in the designated electronic health record (EHR) tab. Therefore, in 2020, we set a target that all Duke Health patients who died should have had a GOC conversation documented in a designated EHR tab in the last 6 months of life.

INTERVENTION

In developing a strategy to promote GOC conversations, we used two interwoven approaches. The first was RE-AIM, a model for designing, reporting and evaluating health behavior research. The second was less of a model than a way of approaching problems, known as "design thinking."

OUTCOMES

We employed both of these approaches in a system-wide effort that achieved a 50% prevalence of GOC conversations in the last 6 months of life.

KEY MESSAGE

In combination, simple interventions can have a significant impact on behavior change in an academic health system.

LESSONS LEARNED

We found that design thinking techniques offered a useful bridge between RE-AIM strategy and clinical.

Guidelines for goals of care discussions in patients with gynecologic cancer

This article represents a distillation of literature to provide guidance for goals of care discussions with patients who have gynecologic malignancies. As clinicians who provide surgical care, chemotherapy, and targeted therapeutics, gynecologic oncology clinicians are uniquely positioned to form longitudinal relationships with patients that can enable patient-centered decision making. In this review, we describe optimal timing, components, and best practices for goals of care discussions in gynecologic oncology.

Self‐reported documentation of goals and outcomes of nutrition care – A cross‐sectional survey study of Scandinavian dietitians

BACKGROUND

The documentation of goals and outcomes of nutrition care in Electronic Health Records is insufficient making further exploration of this of particular interest. Identifying common features in documentation practice among Scandinavian dietitians might provide information that can support improvement in this area.

AIMS

To explore the associations between clinical dietitians' self-reported documentation of patients' goals and outcomes and demographic factors, self-reported implementation of the systematic framework the Nutrition Care Process 4th step (NCP) and its associated terminology, and factors associated with the workplace.

METHODS

Data from a cross-sectional study based on a previously tested web-based survey (INIS) disseminated in 2017 to dietitians in Scandinavia (n = 494) was used. Respondents were recruited through e-mail lists, e-newsletters and social media groups for dietitians. Associations between countries regarding the reported documentation of goals and outcomes, implementation levels of the NCP 4th step, demographic information and factors associated with the workplace were measured through Chi-square test. Associations between dependent- and independent variables were measured through logistic regression analysis.

RESULTS

Clinically practicing dietitians (n = 347) working in Scandinavia, Sweden (n = 249), Norway (n = 60), Denmark (n = 38), who had completed dietetic education participated. The reported documentation of goals and outcomes from nutrition intervention was highly associated with the reported implementation of NCP 4th step terminology (OR = 5.26; p = 0.009, OR = 3.56; p = 0.003), support from the workplace (OR = 4.0, p < 0.001, OR = 8.89, p < 0.001) and area of practice (OR = 2.02, p = 0.017). Years since completed dietetic training and educational level did not have any significant associations with documentation practice regarding goals and outcomes.

CONCLUSION

Findings highlight strong associations between the implementation of the NCP 4th step terminology and the documentation of goals and outcomes. Strategies to support dietitians in using standardized terminology and the development of tools for comprehensive documentation of evaluation of goals and outcome are required.

Assessing Quality in Advance Care Planning Documentation: A Survey of Current Methods

BACKGROUND

High-quality advance care planning (ACP) documentation facilitates the communication of patients' wishes as they progress in their disease course and travel between health care settings. No consensus exists regarding evaluation of documentation quality, and diverse strategies for assessing quality have been adopted in clinical ACP studies.

METHODOLOGY

We conducted a literature review in PubMed and via manual search to identify clinical studies that assessed ACP quality or completeness as an outcome measure over a 5-year period. Studies that treated ACP as a binary outcome variable (present or absent), studies that took place outside of the US, and studies in pediatric populations were excluded from review.

RESULTS

We identified 11 studies for inclusion in our review. Across study methodologies, the following 8 quality domains were identified: discussion frequency, documentation accessibility, discussion timing, health care proxy, health goals or values, scope of treatment/code status, prognosis/illness understanding, and end of life (EOL) care planning. Each study assessed between 2 and 6 domains. Divergent methods for assessing quality domains were utilized, including manual qualitative analysis and natural language processing techniques.

CONCLUSION

Defining and measuring the quality of documentation is critical to developing ACP programs that improve patient care. Our review provides an adaptable framework centered around quality domains.