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Abbas M, Chua IS, Tabata-Kelly M, Bulger AL, Gershanik E, Sheu C, Kerr E, Ruan M, Dey T, Lakin JR, Bernacki RE. Racial and Ethnic Disparities in Serious Illness Conversation Quality during the COVID-19 Pandemic. J Pain Symptom Manage 2024; 68:205-213.e6. [PMID: 38782305 DOI: 10.1016/j.jpainsymman.2024.05.016] [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] [Received: 02/20/2024] [Revised: 05/03/2024] [Accepted: 05/14/2024] [Indexed: 05/25/2024]
Abstract
CONTEXT The COVID-19 pandemic disproportionately impacted non-Hispanic Black and Hispanic patients. However, little is known about the quality of serious illness communication in these communities during this time. OBJECTIVE We aimed to determine whether racial and ethnic disparities manifested in serious illness conversations during the pandemic. METHODS This was a retrospective, observational, cohort study of adult patients with a documented serious illness conversation from March 2020 to April 2021. Serious illness conversation documentation quality was assessed by counting the median number (IQR) of conversation domains and their elements included in the documentation. Domains included (1) values and goals, (2) prognosis and illness understanding, (3) end-of-life care planning, and (4) life-sustaining treatment preferences. A multivariable ordinal logistic regression analysis was conducted to assess associations between differences in serious illness documentation quality with patient race and ethnicity. RESULTS Among 291 patients, 149 (51.2%) were non-Hispanic White; 81 (27.8%) were non-Hispanic Black; and 61 (21.0%) were Hispanic patients. Non-Hispanic Black patients were associated with fewer domains (OR 0.46 [95% CI 0.25, 0.84]; P=.01) included in their serious illness conversation documentation compared to non-Hispanic White patients. Both non-Hispanic Black (OR 0.35 [95% CI 0.20, 0.62]; P<.001) and Hispanic patients (OR 0.29 [95% CI 0.14, 0.58]; P<.001) were associated with fewer elements in the values and goals domain compared to non-Hispanic White patients in their serious illness documentation. CONCLUSION During the COVID-19 pandemic, serious illness conversation documentation among non-Hispanic Black and Hispanic patients was less comprehensive compared to non-Hispanic White patients.
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Affiliation(s)
- Muhammad Abbas
- Department of General Surgery(M.A.), Rabin Medical Centre, Beilinson Hospital, Petah Tikva, Israel
| | - Isaac S Chua
- Division of General Internal Medicine and Primary Care(I.S.C., E.G.), Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Department of Psychosocial Oncology and Palliative Care(I.S.C., J.R.L., R.E.B.), Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School(I.S.C., J.L.R., R.E.B.), Boston, MA, USA.
| | - Masami Tabata-Kelly
- The Center for Surgery and Public Health(M.T.K., E.K., M.R., T.D., C.S.), Brigham and Women's Hospital, Boston, MA, USA; The Center for Geriatric Surgery(M.T.K., A.L.B., C.S., R.E.B.), Brigham and Women's Hospital, Boston, MA, USA; The Heller School for Social Policy and Management(M.T.K.), Waltham, MA, USA
| | - Amy L Bulger
- The Center for Geriatric Surgery(M.T.K., A.L.B., C.S., R.E.B.), Brigham and Women's Hospital, Boston, MA, USA; Department of Care Continuum Management(A.L.B.), Brigham and Women's Hospital, Boston, MA, USA
| | - Esteban Gershanik
- Division of General Internal Medicine and Primary Care(I.S.C., E.G.), Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School(I.S.C., J.L.R., R.E.B.), Boston, MA, USA
| | - Christina Sheu
- The Center for Surgery and Public Health(M.T.K., E.K., M.R., T.D., C.S.), Brigham and Women's Hospital, Boston, MA, USA; The Center for Geriatric Surgery(M.T.K., A.L.B., C.S., R.E.B.), Brigham and Women's Hospital, Boston, MA, USA
| | - Emma Kerr
- The Center for Surgery and Public Health(M.T.K., E.K., M.R., T.D., C.S.), Brigham and Women's Hospital, Boston, MA, USA
| | - Mengyuan Ruan
- The Center for Surgery and Public Health(M.T.K., E.K., M.R., T.D., C.S.), Brigham and Women's Hospital, Boston, MA, USA
| | - Tanujit Dey
- The Center for Surgery and Public Health(M.T.K., E.K., M.R., T.D., C.S.), Brigham and Women's Hospital, Boston, MA, USA
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care(I.S.C., J.R.L., R.E.B.), Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School(I.S.C., J.L.R., R.E.B.), Boston, MA, USA; Division of Palliative Medicine (J.R.L., R.E.B.), Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Rachelle E Bernacki
- Department of Psychosocial Oncology and Palliative Care(I.S.C., J.R.L., R.E.B.), Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School(I.S.C., J.L.R., R.E.B.), Boston, MA, USA; The Center for Geriatric Surgery(M.T.K., A.L.B., C.S., R.E.B.), Brigham and Women's Hospital, Boston, MA, USA; Division of Palliative Medicine (J.R.L., R.E.B.), Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Sanders JJ, Benotti E, Jaramillo C, Sihlongonyane B, Downey N, Mitchell S, Sterba KR, Carey EC, Meier D, Mohta NS, Fromme E, Paladino J. Implementing the Serious Illness Care Program in Safety Net Health Systems: A Qualitative Study. J Pain Symptom Manage 2024; 68:214-222.e6. [PMID: 38815729 DOI: 10.1016/j.jpainsymman.2024.05.017] [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] [Received: 01/31/2024] [Revised: 05/03/2024] [Accepted: 05/14/2024] [Indexed: 06/01/2024]
Abstract
CONTEXT Interventions to improve the quality of care for people affected by serious illness commonly fail to reach patients from marginalized and underserved communities, which include those characterized by racialized or indigenous identity, sexual and gender minority status, and rural living. Interventions to improve care through serious illness conversations have demonstrated benefit, but little is known about their implementation in health systems that predominantly serve these patient groups. OBJECTIVES The study aimed to understand factors influencing implementation of a serious illness communication-focused intervention-the Serious Illness Care Program in health systems who primarily provide care to marginalized and underserved communities. METHODS Qualitative interviews (16) and focus groups (3) were conducted with 19 interdisciplinary team members from six geographically diverse U.S. healthcare systems. Using a template analysis approach, investigators coded data inductively and deductively to identify themes. RESULTS Three themes emerged: patient factors, intervention elements, and health system contextual factors. Participants highlighted mission-driven efforts, creativity, interprofessional practice, and trainees as enablers of success. They identified weaknesses in the intervention's communication tool-the Serious Illness Conversation Guide as barriers to implementation of conversations. Resource constraints, socio-economic vulnerability, and mistrust in the health system were seen as additional barriers. CONCLUSIONS Health systems that provide care to underserved and marginalized communities face unique challenges implementing the Serious Illness Care Program. They also possess assets, some unique to these settings, that support program adoption. Findings suggest that implementation of similar programs in low-resource healthcare settings may help address unmet needs among marginalized populations.
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Affiliation(s)
- Justin J Sanders
- Ariadne Labs (J.J.S., E.B., C.J., B.S., N.D., N.S.M., E.F., J.P.), Boston, MA, USA; McGill University (J.J.S.), Montreal, QC, Canada.
| | - Emily Benotti
- Ariadne Labs (J.J.S., E.B., C.J., B.S., N.D., N.S.M., E.F., J.P.), Boston, MA, USA
| | - Carolina Jaramillo
- Ariadne Labs (J.J.S., E.B., C.J., B.S., N.D., N.S.M., E.F., J.P.), Boston, MA, USA; Harvard Medical School (C.J., N.S.M., E.F., J.P.), Boston, MA, USA
| | - Bukiwe Sihlongonyane
- Ariadne Labs (J.J.S., E.B., C.J., B.S., N.D., N.S.M., E.F., J.P.), Boston, MA, USA; Boston University (B.S.), Boston, MA, USA
| | - Nora Downey
- Ariadne Labs (J.J.S., E.B., C.J., B.S., N.D., N.S.M., E.F., J.P.), Boston, MA, USA
| | - Suzanne Mitchell
- University of Massachusetts Medical School (S.M.), Worcester, MA, USA
| | | | | | - Diane Meier
- Mt. Sinai School of Medicine (D.M.), New York, NY, USA
| | - Namita S Mohta
- Ariadne Labs (J.J.S., E.B., C.J., B.S., N.D., N.S.M., E.F., J.P.), Boston, MA, USA; Harvard Medical School (C.J., N.S.M., E.F., J.P.), Boston, MA, USA; Brigham and Women's Hospital (N.S.M.), Boston, MA, USA
| | - Erik Fromme
- Ariadne Labs (J.J.S., E.B., C.J., B.S., N.D., N.S.M., E.F., J.P.), Boston, MA, USA; Dana-Farber Cancer Institute (E.F.), Boston, MA, USA; Harvard Medical School (C.J., N.S.M., E.F., J.P.), Boston, MA, USA
| | - Joanna Paladino
- Ariadne Labs (J.J.S., E.B., C.J., B.S., N.D., N.S.M., E.F., J.P.), Boston, MA, USA; Harvard Medical School (C.J., N.S.M., E.F., J.P.), Boston, MA, USA; Massachusetts General Hospital (J.P.), Boston, MA, USA
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Wood GJ, Clepp RK, Lee J, Twaddle ML, Ogunseitan A, Neagle J, Szmuilowicz E. Outcomes of a Multisite Mentored Implementation Approach to Promoting Goals of Care Conversations. J Pain Symptom Manage 2024; 68:163-170.e2. [PMID: 38697406 DOI: 10.1016/j.jpainsymman.2024.04.024] [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] [Received: 01/27/2024] [Revised: 04/20/2024] [Accepted: 04/24/2024] [Indexed: 05/05/2024]
Abstract
CONTEXT The Preference-Aligned Communication and Treatment (PACT) Project is a multisite quality improvement effort that has been shown to increase the frequency of goals of care (GOC) conversations in hospitalized patients with serious illness. OBJECTIVES To evaluate the effect of PACT on goal-discordant care and resource utilization. METHODS Hospitals enrolled in a multiyear mentored implementation quality improvement initiative to facilitate GOC conversations for seriously ill hospitalized patients. The primary outcome was the percentage of patients with care discordant with stated preferences, assessed by comparing documented wishes to Medicare claims data for patients who were admitted to intervention units and died over the study period. Secondary outcomes evaluated end-of-life resource utilization by comparing Medicare claims data for intervention patients with propensity score-matched controls. RESULTS In the 9 hospitals included in the study, 1347 intervention group patients were compared to 4019 in the control group. Rates of discordance between wishes and care were generally low in the intervention group. Compared to the control group, patients in the intervention group had lower costs (-976.05 dollars, P = 0.010), were less likely to be admitted to the ICU (OR 0.9, P = 0.005), less likely to be on a ventilator or undergo CPR or cardioversion, more likely to enroll in hospice (OR 1.81, P < 0.001) and had a longer hospice stay (3.35 more days, P = 0.041). CONCLUSION A multisite mentored implementation quality improvement intervention for seriously ill hospitalized patients resulted in care aligned with goals and decreased resource utilization at the end of life.
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Affiliation(s)
- Gordon J Wood
- Division of Hospital Medicine (G.J.W., A.O., J.N., E.S.), Section of Palliative Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Department of Medical Education (G.J.W.), Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| | - Rebecca K Clepp
- Division of Pulmonary and Critical Care (R.K.C.), Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jungwha Lee
- Department of Preventive Medicine (J.L.), Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Martha L Twaddle
- Northwestern Lake Forest Hospital (M.L.T), Palliative Medicine and Supportive Care, Lake Forest, Illinois, USA
| | - Adeboye Ogunseitan
- Division of Hospital Medicine (G.J.W., A.O., J.N., E.S.), Section of Palliative Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jayson Neagle
- Division of Hospital Medicine (G.J.W., A.O., J.N., E.S.), Section of Palliative Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Eytan Szmuilowicz
- Division of Hospital Medicine (G.J.W., A.O., J.N., E.S.), Section of Palliative Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Gabbard JL, Brenes GA, Callahan KE, Dharod A, Bundy R, Foley KL, Moses A, Williamson JD, Pajewski NM. Promoting serious illness conversations in primary care through telehealth among persons living with cognitive impairment. J Am Geriatr Soc 2024. [PMID: 39041185 DOI: 10.1111/jgs.19100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 06/25/2024] [Accepted: 06/30/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND serious illness conversations (SIC), particularly for persons living with cognitive impairment (PLCI), inconsistently happen in primary care. Pragmatic, scalable strategies are needed to promote SIC for PLCI. DESIGN Pragmatic, prospective single-arm pilot study that occurred between July 1, 2021 and May 30, 2022 across seven primary care practices in North Carolina. PARTICIPANTS Community-dwelling patients aged 65 and older with known or probable mild cognitive impairment or dementia (with decision-making capacity) and their care partners (if available). INTERVENTION SIC telehealth intervention (TeleVoice) via video or telephone to assist PLCI in discussing their current goals, values, and future medical preferences, while facilitating documentation within the EHR. MAIN OUTCOMES Main feasibility outcomes included reach/enrollment, intervention completion, and adoption rates at the clinic and provider level. Primary effectiveness outcomes included SIC documentation and quality within the EHR and usage of advance care planning billing (ACP) codes. RESULTS Of the 163 eligible PLCI approached, 107 (66%) enrolled (mean age 83.7 years, 68.2% female, 16.8% Black, 22% living in a geographic area of high socioeconomic disadvantage) and 81 (76%) completed the SIC telehealth intervention; 45 care partners agreed to participate (mean age 71.5 years, 80% female). Adoption at clinic level was 50%, while 75% of providers within these clinics participated. Among PLCI that completed the intervention, SIC documentation and usage of ACP billing codes was 100% and 96%, respectively, with 96% (n = 78) having high-quality SIC documentation. No significant differences were observed between telephone and video visits. CONCLUSION These findings provide preliminary evidence to support the feasibility of conducting SICs through telehealth to specifically meet the needs of community-dwelling PLCI. Further investigation of the sustainability of the intervention and its long-term impact on patient and caregiver outcomes is needed.
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Affiliation(s)
- Jennifer L Gabbard
- Section of Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Gretchen A Brenes
- Section of Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Kathryn E Callahan
- Section of Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Division of Public Health Sciences, Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Ajay Dharod
- Division of Public Health Sciences, Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Section of General Internal Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Richa Bundy
- Division of Public Health Sciences, Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Section of General Internal Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Kristie L Foley
- Division of Public Health Sciences, Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Adam Moses
- Section of General Internal Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Jeff D Williamson
- Section of Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Nicholas M Pajewski
- Division of Public Health Sciences, Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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DeCourcey DD, Bernacki RE, Nava-Coulter B, Lach S, Xiong N, Wolfe J. Feasibility of a Serious Illness Communication Program for Pediatric Advance Care Planning. JAMA Netw Open 2024; 7:e2424626. [PMID: 39058485 PMCID: PMC11282445 DOI: 10.1001/jamanetworkopen.2024.24626] [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] [Indexed: 07/28/2024] Open
Abstract
Importance Pediatric advance care planning (ACP), which aims to ensure care is aligned with family goals and values, is associated with better end-of-life outcomes; however, ACP in pediatrics remains uncommon. Objectives To determine the feasibility and acceptability of the Pediatric Serious Illness Communication Program (PediSICP) and explore family-centered outcomes. Design, Setting, and Participants This cohort study was a single-group pilot study of the PediSICP in adolescents and young adults (AYAs; age ≥13 y) with serious illness, parents of seriously ill children, and interprofessional clinicians from April 2021 to March 2023 in a quaternary care pediatric hospital. Duration of follow-up was 1 month. Data were analyzed from January 2022 to March 2023. Exposure The PediSICP includes clinician training preceding an ACP communication occasion supported by communication guides and a template for electronic medical record documentation. Main Outcomes and Measures Outcomes of interest were parent, patient, and clinician experiences with and perceptions of the PediSICP. Feasibility was defined a priori as at least 70% clinician intervention completion rates. Results A total of 10 virtual trainings were conducted among 40 clinicians, including 27 physicians, 7 nurse practitioners, 5 nurses, and 1 respiratory therapist, and 30 trained clinicians (75%) conducted and documented 42 ACP conversations with 33 parents (median [IQR] age, 43 [35-51] years; 25 [76%] female) and 5 AYAs (median [IQR] age, 19 [17-19] years; 3 [60%] female) who completed the intervention. The median (IQR) conversation duration was 27 (10-45) minutes. Most clinicians (29 clinicians [97%]) agreed that they felt prepared for the conversation, and all clinicians recommended the PediSICP. Parents reported participation was worthwhile (27 parents [84%]), they felt listened to (31 parents [94%]), and would recommend the PediSICP (28 parents [85%]). Parents endorsed higher therapeutic alliance after the PediSICP intervention compared with before (The Human Connection scale mean [SD] score, 57.6 [6.4] vs 55.3 [7.8]; P = .03) and decreased anxiety immediately after the intervention (Generalized Anxiety Disorder-7-item mean [SD] score, 10.1 [7.3] vs 8.4 [6.9]; P = .003), which persisted at the 1-month follow-up (mean [SD] score, 7.7 [6.8]; P = .03). Conclusions and Relevance This pilot cohort study found that the PediSICP was feasible, acceptable, and highly valued by clinicians and parents of children with serious illness. These findings suggest that the PediSICP may empower interprofessional clinicians and improve ACP with families of children and AYAs who are seriously ill.
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Affiliation(s)
- Danielle D DeCourcey
- Department of Pediatrics, Division of Medical Critical Care, Boston Children's Hospital, Boston, Massachusetts
| | - Rachelle E Bernacki
- Division of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Brett Nava-Coulter
- Department of Pediatrics, Division of Medical Critical Care, Boston Children's Hospital, Boston, Massachusetts
| | - Sithya Lach
- Department of Pediatrics, Division of Medical Critical Care, Boston Children's Hospital, Boston, Massachusetts
| | - Niya Xiong
- Department of Data Science, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Joanne Wolfe
- Division of Supportive and Palliative Care, Mass General for Children, Boston, Massachusetts
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Calton B, Williams P, Jaramillo C, Corelli K, Carr K, Waldman L. "We're Onto Something Here!": Clinician Perspectives of a Pilot Program to Increase Palliative Care Access in an Urban Skilled Nursing Facility. J Am Med Dir Assoc 2024; 25:104907. [PMID: 38185467 DOI: 10.1016/j.jamda.2023.11.022] [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: 08/31/2023] [Revised: 11/30/2023] [Accepted: 11/30/2023] [Indexed: 01/09/2024]
Abstract
Many adults cycle between the hospital and skilled nursing facilities (SNFs) near the end of life. However, palliative care services, which can provide specialized support for patients with serious illness, are often limited at SNFs. The "3C's Palliative Care Program," a 5-month pilot, aimed to improve palliative care access for patients admitted to subacute rehabilitation at an SNF affiliated with an urban academic medical center. This manuscript focuses on the pilot's feasibility, acceptability based on SNF clinician feedback from interviews, and lessons learned. The 3C's Program featured primary palliative care skill coaching, virtual palliative care consultations, and continuity via referrals to home-based palliative care at discharge. Ninety percent of SNF clinicians surveyed recommended the continuation of the pilot. SNF clinicians felt the program improved their ability to identify patients for PC consultation, to understand the role and value of palliative care, and to appreciate their patients' illness trajectories. Lessons learned from this pilot suggest SNF-Palliative Care clinician relationship building and simple patient identification mechanisms for palliative care are key to the success of palliative care at SNF integration.
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Affiliation(s)
- Brook Calton
- Division of Palliative Care and Geriatric Medicine, The Massachusetts General Hospital, Boston, MA, USA; Massachusetts General Brigham Office of Population Health, Boston, MA, USA.
| | - Pamela Williams
- Division of Palliative Care and Geriatric Medicine, The Massachusetts General Hospital, Boston, MA, USA
| | | | - Kathryn Corelli
- Massachusetts General Brigham Office of Population Health, Boston, MA, USA; Division of General Internal Medicine, The Massachusetts General Hospital, Boston, MA, USA
| | - Katie Carr
- Massachusetts General Brigham Office of Population Health, Boston, MA, USA
| | - Louis Waldman
- Spaulding Rehabilitation, Boston, MA, USA; Division of Aging, Brigham and Women's Hospital, Boston, MA, USA
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Gonella S, Di Giulio P, Riva-Rovedda F, Stella L, Rivolta MM, Malinverni E, Paleologo M, Di Vella G, Dimonte V. Supporting health and social care professionals in serious illness conversations: Development, validation, and preliminary evaluation of an educational booklet. PLoS One 2024; 19:e0304180. [PMID: 38820471 PMCID: PMC11142603 DOI: 10.1371/journal.pone.0304180] [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: 02/14/2024] [Accepted: 05/08/2024] [Indexed: 06/02/2024] Open
Abstract
Serious illness conversations aim to align the care process with the goals and preferences of adult patients suffering from any advanced disease. They represent a challenge for healthcare professionals and require specific skills. Conversation guides consistent with task-centered instructional strategies may be particularly helpful to improve the quality of communication. This study aims to develop, validate, and preliminarily evaluate an educational booklet to support Italian social and healthcare professionals in serious illness conversations. A three-step approach, including development, validation, and evaluation, was followed. A co-creation process with meaningful stakeholders led to the development of the booklet, validated by 15 experts on clarity, completeness, coherence, and relevance. It underwent testing on readability (Gulpease index, 0 = lowest-100 = maximum) and design (Baker Able Leaflet Design criteria, 0 = worst to 32 = best). Twenty-two professionals with different scope of practice and care settings evaluated acceptability (acceptable if score ≥30), usefulness, feasibility to use (1 = not at all to 10 = extremely), and perceived acquired knowledge (1 = not at all to 5 = extremely). After four rounds of adjustments, the booklet scored 97% for relevance, 60 for readability, and 25/32 for design. In all, 18 (81.8%), 19 (86.4%) and 17 (77.3%) professionals deemed the booklet acceptable, moderate to highly useful, and feasible to use, respectively; 18/22 perceived gain in knowledge and all would recommend it to colleagues. The booklet has good readability, excellent design, high content validity, and a high degree of perceived usefulness and acquired knowledge. The booklet is tailored to users' priorities, mirrors their most frequent daily practice challenges, and offers 1-minute, 2-minute and 5-minute solutions for each scenario. The co-creation process ensured the development of an educational resource that could be useful regardless of the scope of practice and the care setting to support professionals in serious illness conversations.
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Affiliation(s)
- Silvia Gonella
- City of Health and Science University Hospital Turin, Turin, Italy
| | - Paola Di Giulio
- Department of Public Health and Pediatrics, University of Torino, Turin, Italy
| | | | - Luigi Stella
- Fondazione Assistenza e Ricerca Oncologica (F.A.R.O.), Turin, Italy
| | | | | | - Mario Paleologo
- City of Health and Science University Hospital Turin, Turin, Italy
| | - Giancarlo Di Vella
- Department of Public Health and Pediatrics, University of Torino, Turin, Italy
| | - Valerio Dimonte
- City of Health and Science University Hospital Turin, Turin, Italy
- Department of Public Health and Pediatrics, University of Torino, Turin, Italy
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Rotenstein L, Wang L, Zupanc SN, Penumarthy A, Laurentiev J, Lamey J, Farah S, Lipsitz S, Jain N, Bates DW, Zhou L, Lakin JR. Looking Beyond Mortality Prediction: Primary Care Physician Views of Patients' Palliative Care Needs Predicted by a Machine Learning Tool. Appl Clin Inform 2024; 15:460-468. [PMID: 38636542 PMCID: PMC11168809 DOI: 10.1055/a-2309-1599] [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: 12/13/2023] [Accepted: 04/17/2024] [Indexed: 04/20/2024] Open
Abstract
OBJECTIVES To assess primary care physicians' (PCPs) perception of the need for serious illness conversations (SIC) or other palliative care interventions in patients flagged by a machine learning tool for high 1-year mortality risk. METHODS We surveyed PCPs from four Brigham and Women's Hospital primary care practice sites. Multiple mortality prediction algorithms were ensembled to assess adult patients of these PCPs who were either enrolled in the hospital's integrated care management program or had one of several chronic conditions. The patients were classified as high or low risk of 1-year mortality. A blinded survey had PCPs evaluate these patients for palliative care needs. We measured PCP and machine learning tool agreement regarding patients' need for an SIC/elevated risk of mortality. RESULTS Of 66 PCPs, 20 (30.3%) participated in the survey. Out of 312 patients evaluated, 60.6% were female, with a mean (standard deviation [SD]) age of 69.3 (17.5) years, and a mean (SD) Charlson Comorbidity Index of 2.80 (2.89). The machine learning tool identified 162 (51.9%) patients as high risk. Excluding deceased or unfamiliar patients, PCPs felt that an SIC was appropriate for 179 patients; the machine learning tool flagged 123 of these patients as high risk (68.7% concordance). For 105 patients whom PCPs deemed SIC unnecessary, the tool classified 83 as low risk (79.1% concordance). There was substantial agreement between PCPs and the tool (Gwet's agreement coefficient of 0.640). CONCLUSIONS A machine learning mortality prediction tool offers promise as a clinical decision aid, helping clinicians pinpoint patients needing palliative care interventions.
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Affiliation(s)
- Lisa Rotenstein
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- School of Medicine, University of California, San Francisco, San Francisco, California, United States
| | - Liqin Wang
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - Sophia N. Zupanc
- School of Medicine, University of California, San Francisco, San Francisco, California, United States
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, United States
| | - Akhila Penumarthy
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, United States
| | - John Laurentiev
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Jan Lamey
- Brigham and Women's Physician Organization, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Subrina Farah
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts, United States
| | - Stuart Lipsitz
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - Nina Jain
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - David W. Bates
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - Li Zhou
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - Joshua R. Lakin
- Harvard Medical School, Boston, Massachusetts, United States
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, United States
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
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Serna MK, Yoon C, Fiskio J, Lakin JR, Schnipper JL, Dalal AK. The Association of Standardized Documentation of Serious Illness Conversations With Healthcare Utilization in Hospitalized Patients: A Propensity Score Matched Cohort Analysis. Am J Hosp Palliat Care 2024; 41:479-485. [PMID: 37385609 PMCID: PMC10983774 DOI: 10.1177/10499091231186818] [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] [Indexed: 07/01/2023] Open
Abstract
Background: Serious Illness Conversations (SICs) conducted during hospitalization can lead to meaningful patient participation in the decision-making process affecting medical management. The aim of this study is to determine if standardized documentation of a SIC within an institutionally approved EHR module during hospitalization is associated with palliative care consultation, change in code status, hospice enrollment prior to discharge, and 90-day readmissions. Methods: We conducted retrospective analyses of hospital encounters of general medicine patients at a community teaching hospital affiliated with an academic medical center from October 2018 to August 2019. Encounters with standardized documentation of a SIC were identified and matched by propensity score to control encounters without a SIC in a ratio of 1:3. We used multivariable, paired logistic regression and Cox proportional-hazards modeling to assess key outcomes. Results: Of 6853 encounters (5143 patients), 59 (.86%) encounters (59 patients) had standardized documentation of a SIC, and 58 (.85%) were matched to 167 control encounters (167 patients). Encounters with standardized documentation of a SIC had greater odds of palliative care consultation (odds ratio [OR] 60.10, 95% confidence interval [CI] 12.45-290.08, P < .01), a documented code status change (OR 8.04, 95% CI 1.54-42.05, P = .01), and discharge with hospice services (OR 35.07, 95% CI 5.80-212.08, P < .01) compared to matched controls. There was no significant association with 90-day readmissions (adjusted hazard ratio [HR] .88, standard error [SE] .37, P = .73). Conclusions: Standardized documentation of a SIC during hospitalization is associated with palliative care consultation, change in code status, and hospice enrollment.
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Affiliation(s)
- Myrna K. Serna
- Division of General Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Catherine Yoon
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA, USA
| | - Julie Fiskio
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA, USA
| | - Joshua R. Lakin
- Harvard Medical School, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA, USA
| | - Jeffrey L. Schnipper
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Anuj K. Dalal
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Kaplan A, Ladin K, Junna S, Lindenberger E, Ufere NN. Serious Illness Communication in Cirrhosis Care: Tools to Improve Illness Understanding, Prognostic Understanding, and Care Planning. GASTRO HEP ADVANCES 2024; 3:634-645. [PMID: 38873184 PMCID: PMC11175167 DOI: 10.1016/j.gastha.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
Patients with cirrhosis frequently experience an unpredictable illness trajectory, with frequent hospitalizations and complications. Along with the uncertain nature of the disease, the possibility of a lifesaving and curative transplant often makes prognostic discussions and future care decisions challenging. Serious illness communication (SIC) refers to supportive communication whereby clinicians assess patients' illness understanding, share prognostic information according to patients' preferences, explore patients' goals, and make recommendations for care that align with these goals. SIC includes 3 key components: (1) illness understanding; (2) prognostic understanding; and (3) care planning. In this piece, we explore current barriers to early implementation of SIC in cirrhosis care and share possible solutions, including adopting a multidisciplinary approach, delivering culturally competent care, and training clinicians in SIC core skills. By use of a case example, we aim to demonstrate SIC in action and to provide clinicians with tools and skills that can be used in practice.
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Affiliation(s)
- Alyson Kaplan
- Department of Gastroenterology, Department of Surgery, Transplant Institute, Tufts University Medical Center, Boston, Massachusetts
| | - Keren Ladin
- Department of Community Health, Tufts University, Boston, Massachusetts
| | - Shilpa Junna
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Elizabeth Lindenberger
- Department of Geriatrics and Palliative Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Nneka N. Ufere
- Department of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
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Walkner T, Karr DW, Murray S, Heeren A, Berry-Stoelzle M. Participation in Advance Care Planning Among Medically At-Risk Rural Veterans: Protocol for a Personalized Engagement Model. JMIR Res Protoc 2024; 13:e55080. [PMID: 38608267 PMCID: PMC11053389 DOI: 10.2196/55080] [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: 12/01/2023] [Revised: 01/26/2024] [Accepted: 01/31/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Many of the challenges in advanced care planning (ACP) conversations are linked to the waxing and waning progress of serious illnesses. Conversations with patients about future medical care decisions by a surrogate decision maker have historically been left until late in the patient's disease trajectory. These conversations often happen at a time when the patient is already very ill. The challenge in effective early ACP and serious illness conversations is to create a situation where patients appreciate the link between current and future medical care. Setting the stage to make these conversations more accessible includes using telehealth to have conversations at the patient's place of choice. The personalization used includes addressing the current medical and social needs of the patient and ensuring that expressed needs are addressed as much as possible. Engaging patients in these conversations allows the documentation of patient preferences in the electronic health record (EHR), providing guidelines for future medical care. OBJECTIVE The objective of our telehealth serious illness care conversations program was to successfully recruit patients who lacked up-to-date documentation of ACP in their EHR. Once these patients were identified, we engaged in meaningful, structured conversations to address the veterans' current needs and concerns. We developed a recruitment protocol that increased the uptake of rural veterans' participation in serious illness care conversations and subsequent EHR documentation. METHODS The recruitment protocol outlined herein used administrative data to determine those patients who have not completed or updated formal ACP documentation in the EHR and who are at above-average risk for death in the next 3-5 years. The key features of the telehealth serious illness care conversations recruitment protocol involve tailoring the recruitment approach to address current patient concerns while emphasizing future medical decision-making. RESULTS As of September 2022, 196 veterans had completed this intervention. The recruitment method ensures that the timing of the intervention is patient driven, allowing for veterans to engage in ACP at a time and place convenient for them and their identified support persons. CONCLUSIONS The recruitment protocol has been successful in actively involving patients in ACP conversations, leading to an uptick in completed formal documentation of ACP preferences within the EHR for this specific population. This documentation is then available to the medical team to guide future medical care. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR1-10.2196/55080.
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Affiliation(s)
- Tammy Walkner
- Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, IA, United States
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, United States
| | - Daniel W Karr
- Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, IA, United States
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, United States
| | - Sarah Murray
- Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, IA, United States
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, United States
| | - Amanda Heeren
- Iowa City VA Health Care System, Iowa City, IA, United States
- Department of Psychiatry, Carver College of Medicine, Unviersity of Iowa, Iowa City, IA, United States
| | - Maresi Berry-Stoelzle
- Veterans Rural Health Resource Center, Iowa City VA Health Care System, Iowa City, IA, United States
- Vaughan Institute, Tippie College of Business, University of Iowa, Iowa City, IA, United States
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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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Serna MK, Yoon C, Fiskio J, Lakin JR, Schnipper JL, Dalal AK. A Mixed Methods Analysis of Standardized Documentation of Serious Illness Conversations Within an Electronic Health Record Module During Hospitalization. Am J Hosp Palliat Care 2024:10499091241228269. [PMID: 38334010 DOI: 10.1177/10499091241228269] [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: 02/10/2024] Open
Abstract
BACKGROUND Analysis of documented Serious Illness Conversations (SICs) in the inpatient setting can help clinicians align management to address patient and caregiver needs. METHODS We conducted a mixed methods analysis of the first instance of standardized documentation of a SIC within a structured module among hospitalized general medicine patients from 2018 to 2019. Percentage of documentations that included a description of patient or family understanding of the patient's medical condition and use of radio buttons to answer the "prognostic information shared," "hopes," and "worries" modules are reported. Using grounded theory approach, physicians analyzed free text entries to: "What is important to the patient/family?" and "Recommendations or next steps planned." RESULTS Out of 5142 patients, 59 patients had a documented SIC. Patient or family understanding of the medical condition(s) was reported in 56 (95%). For "prognostic information shared," the most frequently selected radio buttons were: 49 (83%) incurable disease and 28 (48%) prognosis of weeks to months while those for "hopes" were: 52 (88%) be comfortable and 27 (46%) be at home and for "worries" were: 49 (83%) other physical suffering and 36 (61%) pain. Themes generated from entries to "What's important to patient/family?" included being with loved ones; comfort; mentally and physically present; and reliable care while those for "Recommendations" were coordinating support services; symptom management; and support and communication. CONCLUSIONS SIC content indicated concern about pain and reliable care suggesting the complex, intensive nature of caring for seriously ill patients and the need to consider SICs earlier in the life course of patients.
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Affiliation(s)
- Myrna Katalina Serna
- Division of General Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Catherine Yoon
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Julie Fiskio
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Joshua R Lakin
- Harvard Medical School, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jeffrey L Schnipper
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Anuj K Dalal
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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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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Paladino J, Fromme EK, Kilpatrick L, Dingfield L, Teuteberg W, Bernacki R, Jackson V, Sanders JJ, Jacobsen J, Ritchie C, Mitchell S. Lessons Learned About System-Level Improvement in Serious Illness Communication: A Qualitative Study of Serious Illness Care Program Implementation in Five Health Systems. Jt Comm J Qual Patient Saf 2023; 49:620-633. [PMID: 37537096 DOI: 10.1016/j.jcjq.2023.06.013] [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: 02/09/2023] [Revised: 06/26/2023] [Accepted: 06/26/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Serious illness communication is a key element of high-quality care, but it is difficult to implement in practice. The Serious Illness Care Program (SICP) is a multifaceted intervention that contributes to more, earlier, and better serious illness conversations and improved patient outcomes. This qualitative study examined the organizational and implementation factors that influenced improvement in real-world contexts. METHODS The authors performed semistructured interviews of 30 health professionals at five health systems that adopted SICP as quality improvement initiatives to investigate the organizational and implementation factors that appeared to influence improvement. RESULTS After SICP implementation across the organizations studied, approximately 4,661 clinicians have been trained in serious illness communication and 56,712 patients had had an electronic health record (EHR)-documented serious illness conversation. Facilitators included (1) visible support from leaders, who financially invested in an implementation team and champions, expressed the importance of serious illness communication as an institutional priority, and created incentives for training and documenting serious illness conversations; (2) EHR and data infrastructure to foster performance improvement and accountability, including an accessible documentation template, a reporting system, and customized data feedback for clinicians; and (3) communication skills training and sustained support for clinicians to problem-solve communication challenges, reflect on communication experiences, and adapt the intervention. Inhibitors included leadership inaction, competing priorities and incentives, variable clinician acceptance of EHR and data tools, and inadequate support for clinicians after training. CONCLUSION Successful implementation appeared to rely on multilevel organizational strategies to prioritize, reward, and reinforce serious illness communication. The insights derived from this research may function as an organizational road map to guide implementation of SICP or related quality initiatives.
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Carter C, Mohammed S, Upshur R, Kontos P. "I don't see the whole picture of their health": a critical ethnography of constraints to interprofessional collaboration in end-of-life conversations in primary care. BMC PRIMARY CARE 2023; 24:225. [PMID: 37898764 PMCID: PMC10612350 DOI: 10.1186/s12875-023-02171-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 10/04/2023] [Indexed: 10/30/2023]
Abstract
CONTEXT Interprofessional collaboration is recommended in caring for frail older adults in primary care, yet little is known about how interprofessional teams approach end-of-life (EOL) conversations with these patients. OBJECTIVE To understand the factors shaping nurses' and allied health clinicians' involvement, or lack of involvement in EOL conversations in the primary care of frail older adults. METHODS/SETTING A critical ethnography of a large interprofessional urban Family Health Team in Ontario, Canada. Data production included observations of clinicians in their day-to-day activities excluding direct patient care; one-to-one semi-structured interviews with clinicians; and document review. Analysis involved coding data using an interprofessional collaboration framework as well as an analysis of the normative logics influencing practice. PARTICIPANTS Interprofessional clinicians (n = 20) who cared for mildly to severely frail patients (Clinical Frailty Scale) at the Family Health Team. RESULTS Findings suggest primary care nurses and allied health clinicians have the knowledge, skills, and inclination to engage frail older adults in EOL conversations. However, the culture of the clinic prioritizes biomedical care, and normalizes nurses and allied health clinicians providing episodic task-based care, which limits the possibility for these clinicians' engagement in EOL conversations. The barriers to nurses' and allied health clinicians' involvement in EOL conversations are rooted in neoliberal-biomedical ideologies that shapes the way primary care is governed and practiced. CONCLUSIONS Our findings help to explain why taking an individual-level approach to addressing the challenge of delayed or avoided EOL conversations, is unlikely to result in practice change. Instead, primary care teams can work to critique and redevelop quality indicators and funding models in ways that promote meaningful interprofessional practice that recognize the expertise of nursing and allied health clinicians in providing high quality primary care to frail older patients, including EOL conversations.
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Affiliation(s)
- Celina Carter
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
| | - Shan Mohammed
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Ross Upshur
- Department of Family and Community Medicine and Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Pia Kontos
- KITE Research Institute, Toronto Rehabilitation Institute - University Health Network, Toronto, Canada
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Sanders JJ, Durieux BN, Cannady K, Johnson KS, Ford DW, Block SD, Paladino J, Sterba KR. Acceptability of a Serious Illness Conversation Guide to Black Americans: Results from a focus group and oncology pilot study. Palliat Support Care 2023; 21:788-797. [PMID: 36184937 DOI: 10.1017/s1478951522001298] [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] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Serious illness conversations (SICs) can improve the experience and well-being of patients with advanced cancer. A structured Serious Illness Conversation Guide (SICG) has been shown to improve oncology patient outcomes but was developed and tested in a predominantly White population. To help address disparities in advanced cancer care, we aimed to assess the acceptability of the SICG among African Americans with advanced cancer and their clinicians. METHODS A two-phase study conducted in Charleston, SC, included focus groups to gather perspectives on the SICG in Black Americans and a single-arm pilot study of a revised SICG with surveys and qualitative exit interviews to evaluate patient and clinician perspectives. We used descriptive analysis of survey results and thematic analysis of qualitative data. RESULTS Community-based and patient focus group participants (N = 20) reported that a simulated conversation using an adapted SICG built connection, promoted control, and fostered consideration of religious faith and family. Black patients with advanced cancer (N = 23) reported that SICG-guided conversations were acceptable, helpful, and promoted conversations with loved ones. Oncologists found conversations feasible to implement and skill-building, and also identified opportunities for training and implementation that could support meeting the needs of their patients with low health literacy. An adapted SICG includes language to assess the strength and affirm the clinician-patient relationship. SIGNIFICANCE OF RESULTS An adapted structured communication tool to facilitate SIC, the SICG, appears acceptable to Black Americans with advanced cancer and seems feasible for use by oncology clinicians working with this population. Further testing in other marginalized populations may address disparities in advanced cancer care.
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Affiliation(s)
- Justin J Sanders
- Department of Family Medicine, McGill University, Montreal, QC, Canada
- Ariadne Labs, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Brigitte N Durieux
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Kimberly Cannady
- Department of Medicine (Ford) Department of Public Health Sciences (Cannady and Sterba), Medical University of South Carolina, Charleston, SC, USA
| | - Kimberly S Johnson
- Department of Medicine, Division of Geriatrics, Duke University School of Medicine, Durham, NC, USA
- Geriatrics Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Dee W Ford
- Department of Medicine (Ford) Department of Public Health Sciences (Cannady and Sterba), Medical University of South Carolina, Charleston, SC, USA
| | - Susan D Block
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Joanna Paladino
- Ariadne Labs, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Katherine R Sterba
- Department of Medicine (Ford) Department of Public Health Sciences (Cannady and Sterba), Medical University of South Carolina, Charleston, SC, USA
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Mandel EI, Maloney FL, Pertsch NJ, Gass JD, Sanders JJ, Bernacki RE, Block SD. A Pilot Study of the Serious Illness Conversation Guide in a Dialysis Clinic. Am J Hosp Palliat Care 2023; 40:1106-1113. [PMID: 36708263 DOI: 10.1177/10499091221147303] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Clinician-led conversations about future care priorities occur infrequently with end-stage renal disease (ESRD) patients on dialysis. This was a pilot study of structured serious illness conversations using the Serious Illness Conversation Guide (SICG) in a single dialysis clinic to assess acceptability of the approach and explore conversation themes and potential outcomes among patients with ESRD. Twelve individuals with ESRD on dialysis from a single outpatient dialysis clinic participated in this study. Participants completed a baseline demographics survey, engaged in a clinician-led structured serious illness conversation, and completed an acceptability questionnaire. Conversations were recorded, transcribed and thematically analyzed. The average age of participants was 68.8 years. The conversations averaged 20:53 in length. Ten participants (83%) felt that the conversation was held at the right time in their clinical course and eleven participants (91%) felt that it was worthwhile. Most participants (73%) reported neutral feelings about clinician use of a printed guide. Eleven participants (91%) reported no change in anxiety about their illness following the conversation, and five participants (42%) reported that the conversation increased their hopefulness about future quality of life. Thematic analysis revealed common perspectives on dialysis including that participants view in-center hemodialysis as temporary, compartmentalize their kidney disease, perceive narrowed life experiences and opportunities, and believe dialysis is their only option. This pilot study suggests that clinician-led structured serious illness conversations may be acceptable to patients with ESRD on dialysis. The themes identified can inform future serious illness conversations with dialysis patients.
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Affiliation(s)
- Ernest I Mandel
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Ariadne Labs, Brigham and Women's Hospital and Harvard TH Chan School of Public Health, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Francine L Maloney
- Ariadne Labs, Brigham and Women's Hospital and Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Nathan J Pertsch
- Ariadne Labs, Brigham and Women's Hospital and Harvard TH Chan School of Public Health, Boston, MA, USA
| | | | - Justin J Sanders
- Department of Family Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Rachelle E Bernacki
- Ariadne Labs, Brigham and Women's Hospital and Harvard TH Chan School of Public Health, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Adult Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Susan D Block
- Ariadne Labs, Brigham and Women's Hospital and Harvard TH Chan School of Public Health, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Departments of Psychiatry and Medicine, Brigham and Women's Hospital, Boston, MA, USA
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20
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Rosa WE, Levoy K, Doyon K, McDarby M, Ferrell BR, Parker PA, Sanders JJ, Epstein AS, Sullivan DR, Rosenberg AR. Integrating evidence-based communication principles into routine cancer care. Support Care Cancer 2023; 31:566. [PMID: 37682354 PMCID: PMC10805358 DOI: 10.1007/s00520-023-08020-x] [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: 05/22/2023] [Accepted: 08/25/2023] [Indexed: 09/09/2023]
Abstract
PURPOSE The global incidence of cancer and available cancer-directed therapy options is increasing rapidly, presenting patients and clinicians with more complex treatment decisions than ever before. Despite the dissemination of evidence-based communication training tools and programs, clinicians cite barriers to employing effective communication in cancer care (e.g., discomfort of sharing serious news, concern about resource constraints to meet stated needs). We present two composite cases with significant communication challenges to guide clinicians through an application of evidence-based approaches to achieve quality communication. METHODS Composite cases, communication skills blueprint, and visual conceptualization. RESULTS High-stakes circumstances in each case are described, including end-of-life planning, advanced pediatric illness, strong emotions, and health inequities. Three overarching communication approaches are discussed: (1) content selection and delivery; (2) rapport development; and (3) empathic connection. The key takeaways following each case provide succinct summaries of challenges encountered and approaches used. A communication blueprint from the Memorial Sloan Kettering Cancer Center Communication Skills Training Program and Research Laboratory has been adapted and is comprised of strategies, skills, process tasks, and sample talking points. A visually concise tool - the Communication Blueprint Traffic Circle - illustrates these concepts and demonstrates the iterative, holistic, and agile considerations inherent to effective communication. CONCLUSION Evidence-based communication is foundational to person-centeredness, associated with improved clinician and patient/caregiver outcomes, and can be integrated throughout routine oncology care. When used by clinicians, evidence-based communication can improve patient and caregiver experiences and assist in ensuring goal-concordant cancer care delivery.
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Affiliation(s)
- William E Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Kristin Levoy
- School of Nursing, Indiana University, Indianapolis, IN, USA
- Indiana University Center for Aging Research (IUCAR), Regenstrief Institute, Indianapolis, IN, USA
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis, IN, USA
| | | | - Meghan McDarby
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Patricia A Parker
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Justin J Sanders
- Department of Family Medicine, McGill University, Montreal, QC, Canada
| | - Andrew S Epstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, Cornell University, New York, NY, USA
| | - Donald R Sullivan
- Division of Pulmonary, Allergy, and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
- Center to Improve Veteran Involvement in Care (CIVIC), Portland-Veterans Affairs Medical Center, Portland, OR, USA
| | - Abby R Rosenberg
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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21
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Izumi SS, Caron D, Guay-Bélanger S, Archambault P, Michaels L, Heinlein J, Dorr DA, Totten A, Légaré F. Development and Evaluation of Serious Illness Conversation Training for Interprofessional Primary Care Teams. J Palliat Med 2023; 26:1198-1206. [PMID: 37040304 DOI: 10.1089/jpm.2022.0268] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023] Open
Abstract
Background: Early advance care planning (ACP) conversations are essential to deliver patient-centered care. While primary care is an ideal setting to initiate ACP, such as Serious Illness Conversations (SICs), many barriers exist to implement such conversations in routine practice. An interprofessional team approach holds promises to address barriers. Objective: To develop and evaluate SIC training for interprofessional primary care teams (IP-SIC). Design: An existing SIC training was adapted for IP-SIC and then implemented and evaluated for acceptability and effectiveness. Setting/Context: Interprofessional teams in 15 primary care clinics in five US states. Measures: Acceptability of the IP-SIC training and participants' self-reported likelihood to engage in ACP after the training. Results: The 156 participants were a mix of physicians and advanced practice providers (APPs) (44%), nurses and social workers (31%), and others (25%). More than 90% of all participants rated the IP-SIC training positively. While nurse/social worker and other groups were less likely than physician and APP group to engage in ACP before training (4.4, 3.7, and 6.4 on a 1-10 scale, respectively), all groups showed significant increase in likelihood to engage in ACP after the IP-SIC training (8.5, 7.7, and 9.2, respectively). Both physician/APP and nurse/social worker groups showed significant increase in likelihood to use the SIC Guide after the IP-SIC training, whereas an increase in likelihood to use SIC Guide among other groups was not statistically significant. Conclusion: The new IP-SIC training was well accepted by interprofessional team members and effective to improve their likelihood to engage in ACP. Further research exploring how to facilitate collaboration among interprofessional team members to maximize opportunities for more and better ACP is warranted. ClinicalTrials.gov ID: NCT03577002.
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Affiliation(s)
- Shigeko Seiko Izumi
- School of Nursing, Oregon Health and Science University, Portland, Oregon, USA
| | - Danielle Caron
- VITAM-Centre de Recherche en Santé Durable, Centre Intégré Universitaire de Santé et Services Sociaux de la Capitale-Nationale, Quebec City, Quebec, Canada
| | - Sabrina Guay-Bélanger
- VITAM-Centre de Recherche en Santé Durable, Centre Intégré Universitaire de Santé et Services Sociaux de la Capitale-Nationale, Quebec City, Quebec, Canada
| | - Patrick Archambault
- VITAM-Centre de Recherche en Santé Durable, Centre Intégré Universitaire de Santé et Services Sociaux de la Capitale-Nationale, Quebec City, Quebec, Canada
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
- Centre de Recherche, Centre Intégré en Santé et Services Sociaux de Chaudière-Appalaches, Lévis, Quebec, Canada
| | - LeAnn Michaels
- Oregon Rural Practice-Based Research Network, Oregon Health and Science University, Portland, Oregon, USA
| | - Julia Heinlein
- Oregon Rural Practice-Based Research Network, Oregon Health and Science University, Portland, Oregon, USA
| | - David A Dorr
- Oregon Rural Practice-Based Research Network, Oregon Health and Science University, Portland, Oregon, USA
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, USA
| | - Annette Totten
- Oregon Rural Practice-Based Research Network, Oregon Health and Science University, Portland, Oregon, USA
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, USA
| | - France Légaré
- VITAM-Centre de Recherche en Santé Durable, Centre Intégré Universitaire de Santé et Services Sociaux de la Capitale-Nationale, Quebec City, Quebec, Canada
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
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22
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Gonella S, Dimonte V, Arnone Y, Albanesi B, Berchialla P, Di Giulio P, van der Steen JT. Interventions to Promote End-of-Life Conversations: A Systematic Review and Meta-Analysis. J Pain Symptom Manage 2023; 66:e365-e398. [PMID: 37164151 DOI: 10.1016/j.jpainsymman.2023.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/26/2023] [Accepted: 05/02/2023] [Indexed: 05/12/2023]
Abstract
CONTEXT Although several interventions aimed to promote end-of-life conversations are available, it is unclear whether and how these affect delivery of end-of-life conversations. Measuring the processes associated with high-quality end-of-life care may trigger improvement. OBJECTIVES To estimate the effect of interventions aimed to promote end-of-life conversations in clinical encounters with patients with advanced chronic or terminal illness or their family, on process indicators of end-of-life conversations. METHODS Systematic review with meta-analysis (PROSPERO no. CRD42021289471). Four databases (PubMed, CINAHL, PsycINFO, and Scopus) were searched up to September 30, 2021. The primary outcomes were any process indicators of end-of-life conversations. Results of pairwise meta-analyses were presented as Risk Ratio (RR) for occurrence, standardized mean difference (SMD) for quality and ratio of means (ROM) for duration. Meta-analysis was not performed when fewer than four studies were available. RESULTS A total of 4,663 articles were scanned. Eighteen studies were included in the systematic review and 16 entered at least one meta-analysis: documented occurrence (n = 8), patient-reported occurrence (n = 4), patient-reported-quality (n = 4), duration (n = 4). There was significant variability in settings, patients' clinical conditions, and professionals. No significant effect of interventions on documented occurrence (RR 1.54, 95% CI 0.84-2.84; I2 91%), patient-reported occurrence (RR 1.52, 95% CI 0.80-2.91; I2 95%), patient-reported quality (SMD 0.83, 95% CI -1.06 to 2.71; I2 99%), or duration (ROM 1.20, 95% CI 0.95-1.51; I2 65%) of end-of-life conversations was found. Data on frequency were conflicting. Interventions targeting multiple stakeholders promoted earlier and more comprehensive conversations. CONCLUSION Heterogeneity was considerable, but findings suggest no significant effect of interventions on occurrence, patient-reported quality and duration of end-of-life conversations. Nevertheless, we found indications for interventions targeting multiple stakeholders to promote earlier and more comprehensive conversations.
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Affiliation(s)
- Silvia Gonella
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino (S.G.), Torino, Italy.
| | - Valerio Dimonte
- Department of Public Health and Pediatrics (B.A., P.DG., V.D., Y.A.), University of Torino, Torino, Italy
| | - Ylenia Arnone
- Department of Public Health and Pediatrics (B.A., P.DG., V.D., Y.A.), University of Torino, Torino, Italy
| | - Beatrice Albanesi
- Department of Public Health and Pediatrics (B.A., P.DG., V.D., Y.A.), University of Torino, Torino, Italy
| | - Paola Berchialla
- Department of Clinical and Biological Sciences (P.B.), University of Torino, Torino, Italy
| | - Paola Di Giulio
- Department of Public Health and Pediatrics (B.A., P.DG., V.D., Y.A.), University of Torino, Torino, Italy
| | - J T van der Steen
- Department of Public Health and Primary Care (J.T.S.), Leiden University Medical Center, Leiden, The Netherlands; Department of Primary and Community Care (J.T.S.), Radboud University Medical Center, Radboudumc Alzheimer Center, Nijmegen. The Netherlands
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23
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Paladino J, Sanders JJ, Fromme EK, Block S, Jacobsen JC, Jackson VA, Ritchie CS, Mitchell S. Improving serious illness communication: a qualitative study of clinical culture. BMC Palliat Care 2023; 22:104. [PMID: 37481530 PMCID: PMC10362669 DOI: 10.1186/s12904-023-01229-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 07/17/2023] [Indexed: 07/24/2023] Open
Abstract
OBJECTIVE Communication about patients' values, goals, and prognosis in serious illness (serious illness communication) is a cornerstone of person-centered care yet difficult to implement in practice. As part of Serious Illness Care Program implementation in five health systems, we studied the clinical culture-related factors that supported or impeded improvement in serious illness conversations. METHODS Qualitative analysis of semi-structured interviews of clinical leaders, implementation teams, and frontline champions. RESULTS We completed 30 interviews across palliative care, oncology, primary care, and hospital medicine. Participants identified four culture-related domains that influenced serious illness communication improvement: (1) clinical paradigms; (2) interprofessional empowerment; (3) perceived conversation impact; (4) practice norms. Changes in clinicians' beliefs, attitudes, and behaviors in these domains supported values and goals conversations, including: shifting paradigms about serious illness communication from 'end-of-life planning' to 'knowing and honoring what matters most to patients;' improvements in psychological safety that empowered advanced practice clinicians, nurses and social workers to take expanded roles; experiencing benefits of earlier values and goals conversations; shifting from avoidant norms to integration norms in which earlier serious illness discussions became part of routine processes. Culture-related inhibitors included: beliefs that conversations are about dying or withdrawing care; attitudes that serious illness communication is the physician's job; discomfort managing emotions; lack of reliable processes. CONCLUSIONS Aspects of clinical culture, such as paradigms about serious illness communication and inter-professional empowerment, are linked to successful adoption of serious illness communication. Further research is warranted to identify effective strategies to enhance clinical culture and drive clinician practice change.
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Affiliation(s)
- Joanna Paladino
- Massachusetts General Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- Ariadne Labs, Joint Innovation Center at Brigham & Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, MA, USA.
- Mongan Institute Center for Aging and Serious Illness, Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, USA.
| | | | - Erik K Fromme
- Harvard Medical School, Boston, MA, USA
- Ariadne Labs, Joint Innovation Center at Brigham & Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Dana Farber Cancer Institute, Boston, MA, USA
| | - Susan Block
- Harvard Medical School, Boston, MA, USA
- Dana Farber Cancer Institute, Boston, MA, USA
| | - Juliet C Jacobsen
- Massachusetts General Hospital, Boston, MA, USA
- Lund University, Lund, Sweden
| | - Vicki A Jackson
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Christine S Ritchie
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Mongan Institute Center for Aging and Serious Illness, Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, USA
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24
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Streid JL, Lee KC, Bader AM, Jarman MP, Rosenthal RA, Cooper Z, Lindvall C. Shared Decision Making in the Geriatric Surgery Verification Program: Assessing Baseline Performance. J Pain Symptom Manage 2023; 65:510-520.e3. [PMID: 36736861 DOI: 10.1016/j.jpainsymman.2023.01.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 01/19/2023] [Accepted: 01/24/2023] [Indexed: 02/04/2023]
Abstract
CONTEXT As part of the launch of the Geriatric Surgery Verification program in 2019, the American College of Surgeons issued care standards for older patients, including requirements for preoperative documentation of patients' goals. Hospital performance on these standards prior to the Geriatric Surgery Verification program is unknown. OBJECTIVES To assess baseline performance of the Geriatric Surgery Verification (GSV) standard for documentation of preoperative goals for older patients, and to determine factors associated with standard adherence. METHODS Using natural language processing, this study examines the electronic health records of patients aged 65 years or older who underwent coronary artery bypass grafts (CABG) or colectomies in 2017 or 2018 at three hospitals. The primary outcome was adherence to at least one of the three components of GSV Standard 5.1, which requires preoperative documentation of overall health goals, treatment goals, and patient-centered outcomes. RESULTS A total of 2630 operations and 2563 patients were included. At least one component of the standard was met in 307 (11.7%) operations and all three components were met in 5 (0.2%). Higher likelihood of meeting the standard was demonstrated for patients who were female (odds ratio [OR] 1.30; 95% CI 1.00-1.68), undergoing colectomy (OR 2.82; 95% CI 2.15-3.72), or with more comorbidities (Charlson scores >3 [OR 1.55; 95% CI 1.14-2.09]). CONCLUSION Before GSV program implementation, clinicians for two major operations almost never met the GSV standard for preoperative discussion of patient goals. Interdisciplinary teams will need to adjust clinical practice to meet best-practice communication standards for older patients.
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Affiliation(s)
- Jocelyn L Streid
- Center for Surgery and Public Health (J.L.S., K.C.L., A.M.B., M.P.J., Z.C.), Brigham and Women's Hospital, Boston, Massachusetts; Department of Anesthesiology, Perioperative and Pain Medicine (J.L.S., A.M.B.), Brigham and Women's Hospital, Boston, Massachusetts.
| | - Katherine C Lee
- Center for Surgery and Public Health (J.L.S., K.C.L., A.M.B., M.P.J., Z.C.), Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery (K.C.L.), University of California, San Diego, La Jolla, California
| | - Angela M Bader
- Center for Surgery and Public Health (J.L.S., K.C.L., A.M.B., M.P.J., Z.C.), Brigham and Women's Hospital, Boston, Massachusetts; Department of Anesthesiology, Perioperative and Pain Medicine (J.L.S., A.M.B.), Brigham and Women's Hospital, Boston, Massachusetts
| | - Molly P Jarman
- Center for Surgery and Public Health (J.L.S., K.C.L., A.M.B., M.P.J., Z.C.), Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Zara Cooper
- Center for Surgery and Public Health (J.L.S., K.C.L., A.M.B., M.P.J., Z.C.), Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery (Z.C.), Brigham and Women's Hospital, Boston, Massachusetts
| | - Charlotta Lindvall
- Division of Palliative Medicine, Department of Medicine (C.L.), Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute (C.L.), Boston, Massachusetts
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25
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Rosa WE, Izumi S, Sullivan DR, Lakin J, Rosenberg AR, Creutzfeldt CJ, Lafond D, Tjia J, Cotter V, Wallace C, Sloan DE, Cruz-Oliver DM, DeSanto-Madeya S, Bernacki R, Leblanc TW, Epstein AS. Advance Care Planning in Serious Illness: A Narrative Review. J Pain Symptom Manage 2023; 65:e63-e78. [PMID: 36028176 PMCID: PMC9884468 DOI: 10.1016/j.jpainsymman.2022.08.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/16/2022] [Accepted: 08/18/2022] [Indexed: 02/03/2023]
Abstract
CONTEXT Advance care planning (ACP) intends to support person-centered medical decision-making by eliciting patient preferences. Research has not identified significant associations between ACP and goal-concordant end-of-life care, leading to justified scientific debate regarding ACP utility. OBJECTIVE To delineate ACP's potential benefits and missed opportunities and identify an evidence-informed, clinically relevant path ahead for ACP in serious illness. METHODS We conducted a narrative review merging the best available ACP empirical data, grey literature, and emergent scholarly discourse using a snowball search of PubMed, Medline, and Google Scholar (2000-2022). Findings were informed by our team's interprofessional clinical and research expertise in serious illness care. RESULTS Early ACP practices were largely tied to mandated document completion, potentially failing to capture the holistic preferences of patients and surrogates. ACP models focused on serious illness communication rather than documentation show promising patient and clinician results. Ideally, ACP would lead to goal-concordant care even amid the unpredictability of serious illness trajectories. But ACP might also provide a false sense of security that patients' wishes will be honored and revisited at end-of-life. An iterative, 'building block' framework to integrate ACP throughout serious illness is provided alongside clinical practice, research, and policy recommendations. CONCLUSIONS We advocate a balanced approach to ACP, recognizing empirical deficits while acknowledging potential benefits and ethical imperatives (e.g., fostering clinician-patient trust and shared decision-making). We support prioritizing patient/surrogate-centered outcomes with more robust measures to account for interpersonal clinician-patient variables that likely inform ACP efficacy and may better evaluate information gleaned during serious illness encounters.
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Affiliation(s)
- William E Rosa
- Department of Psychiatry and Behavioral Sciences (W.E.R.), Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Shigeko Izumi
- School of Nursing (S.I.), Oregon Health and Science University, Portland, Oregon
| | - Donald R Sullivan
- Division of Pulmonary and Critical Care Medicine (D.R.S.), School of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Joshua Lakin
- Department of Psychosocial Oncology and Palliative Care (J.L., R.B.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Abby R Rosenberg
- Division of Hematology-Oncology, Department of Pediatrics (A.R.R.), University of Washington School of Medicine, Seattle, Washington; Palliative Care and Resilience Lab (A.R.R.), Seattle Children's Research Institute, Seattle, Washington
| | | | - Debbie Lafond
- Pediatric and Neonatal Needs Advanced (PANDA) Education Consultants (D.L.)
| | - Jennifer Tjia
- Chan Medical School, University of Massachusetts (J.T.), Worcester, Massachusetts
| | - Valerie Cotter
- School of Nursing, Johns Hopkins University (V.C.), Baltimore, Maryland; School of Medicine, Johns Hopkins University (V.C.), Baltimore, Maryland
| | - Cara Wallace
- College for Public Health and Social Justice (C.W.), Saint Louis University, St. Louis, Missouri
| | - Danetta E Sloan
- Department of Health (D.E.S.), Behavior and Society, Johns Hopkins University, Baltimore, Maryland
| | - Dulce Maria Cruz-Oliver
- Geriatric Medicine and Gerontology (D.M.C.O.), Beacham Center for Geriatric Medicine, Johns Hopkins Medicine, Baltimore, Maryland
| | | | - Rachelle Bernacki
- Department of Psychosocial Oncology and Palliative Care (J.L., R.B.), Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Thomas W Leblanc
- Department of Medicine (T.W.L.), Duke University School of Medicine, Durham, North Carolina
| | - Andrew S Epstein
- Department of Medicine (A.S.E.), Memorial Sloan Kettering Cancer Center, New York, New York
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26
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Lin M, Sayeed S, DeCourcey DD, Wolfe J, Cummings C. The Case for Advance Care Planning in the NICU. Pediatrics 2022; 150:189893. [PMID: 36321383 DOI: 10.1542/peds.2022-057824] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2022] [Indexed: 11/06/2022] Open
Abstract
Many NICUs have reached an inflection point where infant deaths following limitation of life-sustaining treatments outnumber those following unsuccessful resuscitations, and many infants who survive continue to require intensive supports. Families of such infants with serious illness may benefit from a standardized, process-oriented approach in decisional-support. Advance care planning (ACP), or communication that supports patients, or their surrogate decision-makers, in sharing values, goals, and preferences for future medical care, is recognized as a valuable strategy in supporting adults with serious and chronic illness. Although the role of ACP in older children and adolescents is evolving, its utility has not been systematically explored in the perinatal context. This article builds a case for formalizing a role for ACP in the NICU by defining ACP and appraising recent outcomes research, reviewing the current state of parental needs for decisional support and serious illness in the NICU, and describing how ACP may address current limitations in primary and specialty pediatric palliative care and challenges for decision-making in the newborn period.
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Affiliation(s)
- Matthew Lin
- Pediatric Palliative Care Program, Children's National Medical Center, Washington, District of Columbia
| | | | | | - Joanne Wolfe
- Departments of Psychosocial Oncology and Palliative Care and Pediatrics, Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, Massachusetts
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27
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Bowman JK, Aaronson EL, Petrillo LA, Jacobsen JC. Goals of Care Conversations Documented by an Embedded Emergency Department-Palliative Care Team during COVID. J Palliat Med 2022; 26:662-666. [PMID: 36378862 DOI: 10.1089/jpm.2022.0314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: There has been growing interest around integrating palliative care (PC) into emergency department (ED) practice but concern about feasibility and impact. In 2020, as the COVID pandemic was escalating, our hospital's ED and PC leadership created a new service of PC clinicians embedded in the ED. Objectives: To describe the clinical work of the embedded ED-PC team, in particular what was discussed during goals of care conversations. Design: Prospective patient identification followed by retrospective electronic health record chart extraction and analysis. Settings/Subjects: Adult ED patients in an academic medical center in the United States. Measurements/Results: The embedded ED-PC team saw 159 patients, whose mean age was 77.5. Nearly all patients were admitted, 48.0% had confirmed or presumed COVID, and overall mortality was 29.1%. Of the patients seen, 58.5% had a serious illness conversation documented as part of the consult. The most common topics addressed were patient (or family) illness understanding (96%), what was most important (92%), and a clinical recommendation (91%). Clinicians provided a prognostic estimate in 57/93 (61.3%) of documented discussions. In the majority of cases where prognosis was discussed, it was described as poor. Conclusion: Specialist PC clinicians embedded in the ED can engage in high-quality goals of care conversations that have the potential to align patients' hospital trajectory with their preferences.
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Affiliation(s)
- Jason K. Bowman
- Department of Emergency Medicine and Brigham & Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Brigham & Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Emily L. Aaronson
- Department of Emergency Medicine and Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Laura A. Petrillo
- Department of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Juliet C. Jacobsen
- Department of Palliative Care and Geriatric Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Lund University Institute for Palliative Care, Lund, Sweden
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Zehm A, Scott E, Schaefer KG, Nguyen PL, Jacobsen J. Improving Trainees' Confidence and Participation in Serious Illness Communication: Testing the Serious Illness Care Program With Early Learners. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:S150. [PMID: 37838882 DOI: 10.1097/acm.0000000000004854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Affiliation(s)
- April Zehm
- Author affiliations: A. Zehm, Medical College of Wisconsin; E. Scott, The Ohio State University College of Medicine; K.G. Schaefer, J. Jacobsen, Harvard Medical School; P.L. Nguyen, Massachusetts General Hospital
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Chua IS, Shi SM, Jia Z, Leiter R, Rodriguez JA, Sivashanker K, Yeh IM, Bernacki R, Levine DM. Differences in End-of-Life Care between COVID-19 Inpatient Decedents with English Proficiency and Limited English Proficiency. J Palliat Med 2022; 25:1629-1638. [PMID: 35575745 PMCID: PMC9836680 DOI: 10.1089/jpm.2021.0541] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2022] [Indexed: 01/22/2023] Open
Abstract
Background: Patients with limited English proficiency (LEP) experience lower quality end-of-life (EOL) care. This inequity may have been exacerbated during the COVID-19 pandemic. Objective: Compare health care utilization, EOL, and palliative care outcomes between COVID-19 decedents with and without LEP during the pandemic's first wave in Massachusetts. Methods: Retrospective cohort study of adult inpatients who died from COVID-19 between February 18, 2020 and May 18, 2020 at two academic and four community hospitals within a greater Boston health care system. We performed multivariable regression adjusting for patient sociodemographic variables and hospital characteristics. Primary outcome was place of death (intensive care unit [ICU] vs. non-ICU). Secondary outcomes included hospital and ICU length of stay and time to initial palliative care consultation. Results: Among 337 patients, 89 (26.4%) had LEP and 248 (73.6%) were English proficient. Patients with LEP were less often white (24 [27.0%] vs. 193 [77.8%]; p < 0.001); were more often Hispanic or Latinx (40 [45.0%] vs. 13 [5.2%]; p < 0.001); and less often had a medical order for life-sustaining treatment (MOLST) on admission (15 [16.9%] vs. 120 [48.4%]; p < 0.001) versus patients with English proficiency. In the multivariable analyses, LEP was not independently associated with ICU death, ICU length of stay, or time to palliative care consultation, but was independently associated with increased hospital length of stay (mean difference 4.12 days; 95% CI, 1.72-6.53; p < 0.001). Conclusions: Inpatient COVID-19 decedents with LEP were not at increased risk of an ICU death, but were associated with an increased hospital length of stay versus inpatient COVID-19 decedents with English proficiency.
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Affiliation(s)
- Isaac S. Chua
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Sandra M. Shi
- Harvard Medical School, Boston, Massachusetts, USA
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Zhimeng Jia
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Temmy Latner Centre for Palliative Care, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Richard Leiter
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Jorge A. Rodriguez
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | | | - Irene M. Yeh
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Rachelle Bernacki
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - David M. Levine
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Serna MK, Fiskio J, Yoon C, Plombon S, Lakin JR, Schnipper JL, Dalal AK. Who Gets (and Who Should Get) a Serious Illness Conversation in the Hospital? An Analysis of Readmission Risk Score in an Electronic Health Record. Am J Hosp Palliat Care 2022:10499091221129602. [PMID: 36154485 DOI: 10.1177/10499091221129602] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Serious Illness Conversations (SICs) explore patients' prognostic awareness, hopes, and worries, and can help establish priorities for their care during and after hospitalization. While identifying patients who benefit from an SIC remains a challenge, this task may be facilitated by use of validated prediction scores available in most commercial electronic health records (EHRs), such as Epic's Readmission Risk Score (RRS). We identified the RRS on admission for all hospital encounters from October 2018 to August 2019 and measured the area under the receiver operating characteristic (AUROC) curve to determine whether RRS could accurately discriminate post discharge 6-month mortality. For encounters with standardized SIC documentation matched in a 1:3 ratio to controls by sex and age (±5 years), we constructed a multivariable, paired logistic regression model and measured the odds of SIC documentation per every 10% absolute increase in RRS. RRS was predictive of 6-month mortality with acceptable discrimination (AUROC .71) and was significantly associated with SIC documentation (adjusted OR 1.42, 95% CI 1.24-1.63). An RRS >28% used to identify patients with post discharge 6-month mortality had a high specificity (89.0%) and negative predictive value (NPV) (97.0%), but low sensitivity (25.2%) and positive predictive value (PPV) (7.9%). RRS may serve as a practical EHR-based screen to exclude patients not requiring an SIC, thereby leaving a smaller cohort to be further evaluated for SIC needs using other validated tools and clinical assessment.
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Affiliation(s)
- Myrna K Serna
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, 1861Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Julie Fiskio
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, 1861Brigham and Women's Hospital, Boston, MA, USA
| | - Catherine Yoon
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, 1861Brigham and Women's Hospital, Boston, MA, USA
| | - Savanna Plombon
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, 1861Brigham and Women's Hospital, Boston, MA, USA
| | - Joshua R Lakin
- Harvard Medical School, Boston, MA, USA.,Department of Psychosocial Oncology and Palliative Care, 1855Dana Farber Cancer Institute, Boston, MA, USA
| | - Jeffrey L Schnipper
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, 1861Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Anuj K Dalal
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, 1861Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Integrating Narrative Goals of Care in the Medical Intensive Care Unit: Impact on Educational and Clinical Outcomes. ATS Sch 2022; 3:449-459. [PMID: 36312808 PMCID: PMC9585691 DOI: 10.34197/ats-scholar.2022-0003in] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 04/29/2022] [Indexed: 11/18/2022] Open
Abstract
Background High-quality goals of care (GOC) communication is fundamental to providing excellent critical care. Objective Educate medical intensive care unit (MICU) clinicians, design and implement workflows relating to GOC communication, and measure the impact on communication proficiency and rate of GOC documentation. Methods Guided by Lean Six Sigma principles, an interprofessional team from palliative and critical care tailored a multicomponent intervention—the 3-Act Model communication training and workflow modification—to equip and empower the pulmonary and critical care medicine (PCCM) fellow as the clinical lead for GOC discussions. Fellows’ education included in-person narrative reflection, asynchronous online didactic and demonstration videos of the 3-Act Model, online roleplays, and direct observation leading GOC discussions in the ICU. PCCM fellows were objectively evaluated for proficiency using the Goals of Care Assessment Tool. To evaluate the impact of our intervention on documented GOC conversations, we performed a retrospective chart review over two 3-month periods (before and after intervention) when the MICU cared exclusively for critically ill patients with coronavirus disease (COVID-19). Results All PCCM fellows demonstrated proficiency in GOC communication via online simulated roleplays, as well as in observed bedside GOC communication. Per chart review of patients with a minimum of 7 consecutive days in the MICU, documented GOC conversations were found for 5.55% (2/36) of patients during the preintervention period and for 28.89% (13/45) of patients in the postintervention period. Palliative care consults increased in the pre- versus postintervention period: for all patients, 4.85% versus 14.52% (P < 0.05); for patients age ⩾80 years, 3.54% versus 29.41% (P < 0.05); and for patients with MICU length of stay ⩾7 days, 2.78% versus 24.44% (P < 0.05). Conclusion Combining 3-Act Model education for PCCM fellows with Lean Six Sigma quality improvement resulted in effective GOC communication training and improved palliative care integration in the ICU.
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Ryan RE, Connolly M, Bradford NK, Henderson S, Herbert A, Schonfeld L, Young J, Bothroyd JI, Henderson A. Interventions for interpersonal communication about end of life care between health practitioners and affected people. Cochrane Database Syst Rev 2022; 7:CD013116. [PMID: 35802350 PMCID: PMC9266997 DOI: 10.1002/14651858.cd013116.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Communication about end of life (EoL) and EoL care is critically important for providing quality care as people approach death. Such communication is often complex and involves many people (patients, family members, carers, health professionals). How best to communicate with people in the period approaching death is not known, but is an important question for quality of care at EoL worldwide. This review fills a gap in the evidence on interpersonal communication (between people and health professionals) in the last year of life, focusing on interventions to improve interpersonal communication and patient, family member and carer outcomes. OBJECTIVES To assess the effects of interventions designed to improve verbal interpersonal communication about EoL care between health practitioners and people affected by EoL. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL from inception to July 2018, without language or date restrictions. We contacted authors of included studies and experts and searched reference lists to identify relevant papers. We searched grey literature sources, conference proceedings, and clinical trials registries in September 2019. Database searches were re-run in June 2021 and potentially relevant studies listed as awaiting classification or ongoing. SELECTION CRITERIA This review assessed the effects of interventions, evaluated in randomised and quasi-randomised trials, intended to enhance interpersonal communication about EoL care between patients expected to die within 12 months, their family members and carers, and health practitioners involved in their care. Patients of any age from birth, in any setting or care context (e.g. acute catastrophic injury, chronic illness), and all health professionals involved in their care were eligible. All communication interventions were eligible, as long as they included interpersonal interaction(s) between patients and family members or carers and health professionals. Interventions could be simple or complex, with one or more communication aims (e.g. to inform, skill, engage, support). Effects were sought on outcomes for patients, family and carers, health professionals and health systems, including adverse (unintended) effects. To ensure this review's focus was maintained on interpersonal communication in the last 12 months of life, we excluded studies that addressed specific decisions, shared or otherwise, and the tools involved in such decision-making. We also excluded studies focused on advance care planning (ACP) reporting ACP uptake or completion as the primary outcome. Finally, we excluded studies of communication skills training for health professionals unless patient outcomes were reported as primary outcomes. DATA COLLECTION AND ANALYSIS Standard Cochrane methods were used, including dual review author study selection, data extraction and quality assessment of the included studies. MAIN RESULTS Eight trials were included. All assessed intervention effects compared with usual care. Certainty of the evidence was low or very low. All outcomes were downgraded for indirectness based on the review's purpose, and many were downgraded for imprecision and/or inconsistency. Certainty was not commonly downgraded for methodological limitations. A summary of the review's findings is as follows. Knowledge and understanding (four studies, low-certainty evidence; one study without usable data): interventions to improve communication (e.g. question prompt list, with or without patient and physician training) may have little or no effect on knowledge of illness and prognosis, or information needs and preferences, although studies were small and measures used varied across trials. Evaluation of the communication (six studies measuring several constructs (communication quality, patient-centredness, involvement preferences, doctor-patient relationship, satisfaction with consultation), most low-certainty evidence): across constructs there may be minimal or no effects of interventions to improve EoL communication, and there is uncertainty about effects of interventions such as a patient-specific feedback sheet on quality of communication. Discussions of EoL or EoL care (six studies measuring selected outcomes, low- or very low-certainty evidence): a family conference intervention may increase duration of EoL discussions in an intensive care unit (ICU) setting, while use of a structured serious illness conversation guide may lead to earlier discussions of EoL and EoL care (each assessed by one study). We are uncertain about effects on occurrence of discussions and question asking in consultations, and there may be little or no effect on content of communication in consultations. Adverse outcomes or unintended effects (limited evidence): there is insufficient evidence to determine whether there are adverse outcomes associated with communication interventions (e.g. question prompt list, family conference, structured discussions) for EoL and EoL care. Patient and/or carer anxiety was reported by three studies, but judged as confounded. No other unintended consequences, or worsening of desired outcomes, were reported. Patient/carer quality of life (four studies, low-certainty evidence; two without useable data): interventions to improve communication may have little or no effect on quality of life. Health practitioner outcomes (three studies, low-certainty evidence; two without usable data): interventions to improve communication may have little or no effect on health practitioner outcomes (satisfaction with communication during consultation; one study); effects on other outcomes (knowledge, preparedness to communicate) are unknown. Health systems impacts: communication interventions (e.g. structured EoL conversations) may have little or no effect on carer or clinician ratings of quality of EoL care (satisfaction with care, symptom management, comfort assessment, quality of care) (three studies, low-certainty evidence), or on patients' self-rated care and illness, or numbers of care goals met (one study, low-certainty evidence). Communication interventions (e.g. question prompt list alone or with nurse-led communication skills training) may slightly increase mean consultation length (two studies), but other health service impacts (e.g. hospital admissions) are unclear. AUTHORS' CONCLUSIONS Findings of this review are inconclusive for practice. Future research might contribute meaningfully by seeking to fill gaps for populations not yet studied in trials; and to develop responsive outcome measures with which to better assess the effects of communication on the range of people involved in EoL communication episodes. Mixed methods and/or qualitative research may contribute usefully to better understand the complex interplay between different parties involved in communication, and to inform development of more effective interventions and appropriate outcome measures. Co-design of such interventions and outcomes, involving the full range of people affected by EoL communication and care, should be a key underpinning principle for future research in this area.
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Affiliation(s)
- Rebecca E Ryan
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Michael Connolly
- School of Nursing, Midwifery and Health Systems, University College Dublin and Our Lady's Hospice and Care Services, Dublin, Ireland
| | - Natalie K Bradford
- Centre for Children's Health Research, Cancer and Palliative Care Outcomes at Centre for Children's Health Research, Queensland University of Technology (QUT), South Brisbane, Australia
| | - Simon Henderson
- Department of Aviation, The University of New South Wales, Sydney, Australia
| | - Anthony Herbert
- Paediatric Palliative Care Service, Children's Health Queensland, Hospital and Health Service, South Brisbane, Australia
- Centre for Children's Health Research, Queensland University of Technology, South Brisbane, Australia
| | - Lina Schonfeld
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Jeanine Young
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Sippy Downs, Australia
| | | | - Amanda Henderson
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Sippy Downs, Australia
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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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Chang AA, Siropaides CH, Chou CL. Improving Communication Skills: A Roadmap for Humanistic Health Care. Med Clin North Am 2022; 106:727-737. [PMID: 35725237 DOI: 10.1016/j.mcna.2022.01.011] [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: 10/18/2022]
Abstract
This article outlines frameworks that enable health care providers to take steps to improve their health care communication skills, including not only outward-facing conversational tools but also personal awareness. Such awareness includes recognition of bias and emotional reactions, their behavioral consequences, and how to intervene when necessary. The authors describe the intrinsic and extrinsic motivators to improving communication skills, followed by a review of foundational communication microskills and suggestions on how to improve them through the perspectives of the clinician as a self-learner, the clinician with external coaching, and the administrator/leader.
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Affiliation(s)
- Andrew A Chang
- Department of Medicine, State University of New York Downstate, NYC Health + Hospitals/Kings County, 451 Clarkson Avenue, E Building 7th Floor Adult Primary Care, Brooklyn, NY 11203, USA.
| | - Caitlin H Siropaides
- Department of Internal Medicine, Section of Supportive and Palliative Care, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Calvin L Chou
- Department of Medicine, University of California and Veterans Affairs Healthcare System, VA Medical Center, 4150 Clement St (136MP), San Francisco, CA 94121, USA
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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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Anaka M, Lee M, Lim E, Ghosh S, Cheung WY, Spratlin J. Changing Rates of Goals of Care Designations in Patients With Advanced Pancreatic Cancer During a Multifactorial Advanced Care Planning Initiative: A Real-World Evidence Study. JCO Oncol Pract 2022; 18:e869-e876. [PMID: 35108030 DOI: 10.1200/op.21.00649] [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: 09/03/2021] [Revised: 11/03/2021] [Accepted: 01/10/2022] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Goals of care (GoC) designations are an important part of advanced care planning (ACP) for patients with incurable cancers. Studies of outpatient oncology records show that most patients do not have GoC documented. We performed a retrospective analysis of changes in GoC designations in patients with advanced pancreatic cancer in Northern Alberta, Canada, during a system-wide ACP quality improvement initiative. METHODS Four hundred seventy-one patients with newly diagnosis of advanced, non-neuroendocrine pancreatic cancer between 2010 and 2015 in Northern Alberta, Canada, were included. The ACP initiation launched April 2014, and included educational materials for patients and families, and a coded system of GoC designations describing care philosophies and preferences for resuscitation and medical interventions. Data sources included the Alberta Cancer Registry and oncology-specific electronic medical records. RESULTS 25.5% of patients had a documented GoC, which increased over the study period (Mantel-Haenszel test-of-trend P < .001; increased from 7.8% in 2010 to 50.0% in 2015). GoC designations occurred later in patients who received palliative chemotherapy versus those who did not (median 130 days from diagnosis [95% CI, 76.019 to 183.981] v 36 days [95% CI, 28.107 to 43.893]; P < .001), and coincided with the end of treatment (median 4.5 days from last treatment). 64.8% of GoC designations were documented by palliative care physicians, but the proportion documented by medical oncologists increased with time (Mantel-Haenszel test-of-trend P = .020; increased from 0% in 2010 to 52.1% in 2015). CONCLUSION GoC documentation increased in the outpatient records of patients with advanced pancreatic cancer during the system-wide, multifactorial ACP initiative. GoC documentation by medical oncologists also increased. These data provide real-world evidence supporting the impact of a specific ACP initiative to improve rates of GoC designation in patients with advanced cancer.
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Affiliation(s)
| | - Minji Lee
- University of Alberta, Edmonton, AB, Canada
| | - Elisa Lim
- Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
| | - Sunita Ghosh
- Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | - Winson Y Cheung
- Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
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Andersson S, Sandgren A. Organizational readiness to implement the Serious Illness Care Program in hospital settings in Sweden. BMC Health Serv Res 2022; 22:539. [PMID: 35459204 PMCID: PMC9026003 DOI: 10.1186/s12913-022-07923-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 04/08/2022] [Indexed: 11/29/2022] Open
Abstract
Background The Serious Illness Care Program (SICP) is a model developed for structured communication, identifying patients, and training physicians to use a structured guide for conversations with patients and family members. However, there is a lack of knowledge regarding the sustainable implementation of this conversation model. Therefore, the aim of this study was to identify barriers and enablers during the implementation of the SICP in hospital settings. Methods The SICP was implemented at 20 units in two hospitals in Sweden. During the implementation process, seven individual interviews and two group interviews were conducted with seven facilitators (five physicians, one behavioral therapist, and one administrator). Data were analyzed using qualitative content analysis, first inductively, and then deductively using the organizational readiness for change as a theoretical framework. Result The analysis resulted in three factors acting as enablers and eight factors acting as enablers and/or barriers during the implementation of the SICP. The three factors considered as enablers were preliminaries, identifying patients, and facilitator’s role. The eight factors considered as enablers and/or barriers were broad implementation, leadership, time, confidence, building foundation, motivation to work change, motivation for training in serious illness conversations, and attitudes. Conclusion This study indicates limited readiness to implement the SICP in hospital settings due to considerable variation in organizational contextual factors, change efficacy, and change commitment. The identified enablers and barriers for implementation of the SICP could guide and support future implementations to be sustainable over time. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07923-5.
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Affiliation(s)
- Sofia Andersson
- 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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Durieux BN, Berrier A, Catzen HZ, Gray TF, Lakin JR, Cunningham R, Morris SE, Tulsky JA, Sanders JJ. " I think that she would have wanted. . .": Qualitative interviews with bereaved caregivers reveal complexity in measuring goal-concordant care at the end of life. Palliat Med 2022; 36:742-750. [PMID: 35164612 DOI: 10.1177/02692163221078472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Experts consider goal-concordant care an important healthcare outcome for individuals with serious illness. Despite their relationship to the patient and knowledge about the patient's wishes and values, little is known about bereaved family caregivers' perceptions of how end-of-life care aligns with patient goals and preferences. AIM To understand caregivers' perceptions about patients' care experiences, the extent to which care was perceived as goal-concordant, and the factors that contextualized the end-of-life care experience. DESIGN Qualitative interview study employing a semi-structured interview guide based on the National Health and Aging Trends Survey end-of-life planning module. Template analysis was used to identify themes. SETTING/PARTICIPANTS Nineteen recently bereaved family caregivers of people with serious illness in two academic medical centers in the Northeastern United States. RESULTS Most caregivers reported goal-concordant care, though many also recalled experiences of goal discordance. Three themes characterized care perceptions and related to perceived quality: communication, relationships and humanistic care, and care transitions. Within communication, caregivers described the importance of clear communication, inadequate prognostic communication, and information gaps that undermined caregiver confidence in decision making. Patient-clinician relationships enriched care and were considered higher-quality when felt to be humanistic. Finally, care transitions impacted goal discordance when marked by logistical barriers, a need to establish relationships with new providers, inadequate information transfer, and poor care coordination. CONCLUSIONS Bereaved caregivers commonly rated care as goal-concordant while also identifying areas of disappointing and low-quality care. Communication, relationships and humanistic care, and care transitions are modifiable quality improvement targets for patients with advanced cancer.
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Affiliation(s)
| | - Anna Berrier
- Dana-Farber Cancer Institute, Boston, MA, USA.,Gillings School of Global Public Health at The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Tamryn F Gray
- Dana-Farber Cancer Institute, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Joshua R Lakin
- Dana-Farber Cancer Institute, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Rebecca Cunningham
- Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Sue E Morris
- Dana-Farber Cancer Institute, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - James A Tulsky
- Dana-Farber Cancer Institute, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Justin J Sanders
- Dana-Farber Cancer Institute, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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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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40
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Arney J, Gray C, Clark JA, Smith D, Swank A, Matlock DD, Melcher J, Kanwal F, Naik AD. Prognosis conversations in advanced liver disease: A qualitative interview study with health professionals and patients. PLoS One 2022; 17:e0263874. [PMID: 35180233 PMCID: PMC8856527 DOI: 10.1371/journal.pone.0263874] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 01/31/2022] [Indexed: 12/16/2022] Open
Abstract
Advanced Liver Disease (AdvLD) is common, morbid, and associated with high likelihood of death. Patients may not fully understand their prognosis and are often unprepared for the course of illness. Little is known about how and when to deliver prognosis-related information to patients with AdvLD, who should participate, and what should be discussed. We conducted in-depth interviews with a multi-profession sample of Hepatology clinicians and patients with AdvLD. Participants were drawn from three geographically diverse facilities (New England, Texas, California). We used inductive and deductive qualitative data analysis approaches to identify themes related to AdvLD prognosis discussions. Thematic analysis focused on content, timing, and participants’ roles in prognosis discussions. In total, 31 patients with AdvLD and 26 multi-profession clinicians completed interviews. Most participants provided a broad conceptualization of prognosis beyond predictions of survival, including expectations about illness course, ways to manage or avoid complications and a need to address patients’ emotions. Patients favored initiating discussions early in the AdvLD course and welcomed a multi-profession approach to conducting discussions. Clinicians favored a larger role for specialty physicians. All participants recognized that AdvLD prognosis discussions occur infrequently and favored a structured, standardized approach to broadly discussing prognosis. Patients with AdvLD and their clinicians favored a multifaceted approach to prognosis conversations including discussions of life expectancy, predictions about likely course of liver disease, and expected changes in function and capabilities over time. Structured and early prognosis discussions should be part of routine AdvLD care.
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Affiliation(s)
- Jennifer Arney
- VA Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, United States of America
- Department of Sociology, University of Houston-Clear Lake, Houston, Texas, United States of America
| | - Caroline Gray
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California, United States of America
| | - Jack A. Clark
- Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Donna Smith
- VA Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, United States of America
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, United States of America
| | - Annie Swank
- Department of Sociology, University of Houston-Clear Lake, Houston, Texas, United States of America
| | - Daniel D. Matlock
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, Colorado
| | - Jennifer Melcher
- VA Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, United States of America
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, United States of America
| | - Fasiha Kanwal
- VA Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, United States of America
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, United States of America
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, United States of America
| | - Aanand D. Naik
- VA Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, United States of America
- Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, United States of America
- Department of Medicine, Section of Geriatrics and Palliative Medicine, Baylor College of Medicine, Houston, Texas, United States of America
- Department of Management, Policy, and Community Health, School of Public Health, University of Texas Health Science Center, Houston, Texas, Colorado
- * E-mail:
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41
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Jindal SK, Karamourtopoulos M, Jacobson AR, Pinheiro A, Smith AK, Hamel MB, Schonberg MA. Strategies for discussing long‐term prognosis when deciding on cancer screening for adults over age 75. J Am Geriatr Soc 2022; 70:1734-1744. [DOI: 10.1111/jgs.17723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/12/2022] [Accepted: 02/06/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Shivani K. Jindal
- New England Geriatrics Research Education, and Clinical Center, VA Boston Health Care System Boston Massachusetts USA
- Section of Geriatrics, Department of Medicine Boston University School of Medicine Boston Massachusetts USA
| | - Maria Karamourtopoulos
- Division of General Medicine and Primary Care, Department of Medicine Harvard Medical School, Beth Israel Deaconess Medical Center Boston Massachusetts USA
| | | | - Adlin Pinheiro
- Division of General Medicine and Primary Care, Department of Medicine Harvard Medical School, Beth Israel Deaconess Medical Center Boston Massachusetts USA
| | - Alexander K. Smith
- Division of Geriatrics, Department of Medicine University of California San Francisco California USA
| | - Mary Beth Hamel
- Division of General Medicine and Primary Care, Department of Medicine Harvard Medical School, Beth Israel Deaconess Medical Center Boston Massachusetts USA
| | - Mara A. Schonberg
- Division of General Medicine and Primary Care, Department of Medicine Harvard Medical School, Beth Israel Deaconess Medical Center Boston Massachusetts USA
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Xu L, Sommer RK, Nyeko L, Michael C, Traeger L, Jacobsen J. Patient Perspectives on Serious Illness Conversations in Primary Care. J Palliat Med 2022; 25:940-944. [PMID: 35196134 DOI: 10.1089/jpm.2021.0420] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: The Serious Illness Care Program has been shown to improve quality and feasibility of value-based end-of-life conversations in primary care. Objectives: To elicit patients' perspectives on serious illness conversations conducted by primary care clinicians. Subjects and Methods: Telephone interviews were conducted with patients at an academic center in the United States, who had a recent serious illness conversation with their primary care clinician. Interviews were audio-recorded and qualitatively analyzed using thematic analysis. Results: A total of eleven patients were enrolled. We identified three major themes: (1) positive emotional experiences are facilitated by established patient-clinician relationships and/or clinicians' skills in navigating emotional challenges, (2) patients appreciate a personalized conversation, and (3) clinicians should orchestrate the experience of the conversation, from preparation through follow-up. Conclusion: Patients appreciate having serious illness conversations in the primary care setting. Future efforts can be focused on improving clinicians' skills in navigating emotional challenges during conversations and implementing system changes to optimize orchestration.
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Affiliation(s)
- Luyi Xu
- Division of Pulmonary, Critical Care and Sleep Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Robert K Sommer
- Department of Educational and Psychological Studies, University of Miami, Coral Gables, Florida, USA
| | - Liza Nyeko
- Office of Patient Experience and Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians Organization, Boston, Massachusetts, USA
| | - Carol Michael
- Massachusetts General Hospital Patient and Family Advisory Council, Boston, Massachusetts, USA
| | - Lara Traeger
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Juliet Jacobsen
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Paladino J, Sanders J, Kilpatrick LB, Prabhakar R, Kumar P, O'Connor N, Durieux B, Fromme EK, Benjamin E, Mitchell S. Serious Illness Care Programme-contextual factors and implementation strategies: a qualitative study. BMJ Support Palliat Care 2022:bmjspcare-2021-003401. [PMID: 35168931 DOI: 10.1136/bmjspcare-2021-003401] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/24/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES The Serious Illness Care Programme (SICP) is a multicomponent evidence-based intervention that improves communication about patients' values and goals in serious illness. We aim to characterise implementation strategies for programme delivery and the contextual factors that influence implementation in three 'real-world' health system SICP initiatives. METHODS We employed a qualitative thematic framework analysis of field notes collected during the first 1.5 years of implementation and a fidelity survey. RESULTS Analysis revealed empiric evidence about implementation and institutional context. All teams successfully implemented clinician training and an electronic health record (EHR) template for documentation of serious illness conversations. When training was used as the primary strategy to engage clinicians, however, clinician receptivity to the programme and adoption of conversations remained limited due to clinical culture-related barriers (eg, clinicians' attitudes, motivations and practice environment). Visible leadership involvement, champion facilitation and automated EHR-based data feedback on documented conversations appeared to improve adoption. Implementing these strategies depended on contextual factors, including leadership support at the specialty level, champion resources and capacity, and EHR capabilities. CONCLUSIONS Health systems need multifaceted implementation strategies to move beyond the limited impact of clinician training in driving improvement in serious illness conversations. These include EHR-based data feedback, involvement of specialty leaders to message the programme and align incentives, and local champions to problem-solve frontline challenges longitudinally. Implementation of these strategies depended on a favourable institutional context. Greater attention to the influence of contextual factors and implementation strategies may enable sustained improvements in serious illness conversations at scale.
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Affiliation(s)
- Joanna Paladino
- Ariadne Labs, Brigham & Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Justin Sanders
- Ariadne Labs, Brigham & Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Family Medicine, Palliative Care, McGill University, Montreal, Québec, Canada
| | - Laurel B Kilpatrick
- Division of Supportive and Palliative Care, Baylor Scott and White Health, Temple, Texas, USA
| | | | | | | | | | - Erik K Fromme
- Ariadne Labs, Brigham & Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Evan Benjamin
- Ariadne Labs, Brigham & Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Suzanne Mitchell
- Ariadne Labs, Brigham & Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, MA, USA
- UMass Memorial Health Care, Worcester, Massachusetts, USA
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Bloom JR, Marshall DC, Rodriguez-Russo C, Martin E, Jones JA, Dharmarajan KV. Prognostic disclosure in oncology - current communication models: a scoping review. BMJ Support Palliat Care 2022; 12:167-177. [PMID: 35144938 DOI: 10.1136/bmjspcare-2021-003313] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 01/08/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Prognostic disclosure is essential to informed decision making in oncology, yet many oncologists are unsure how to successfully facilitate this discussion. This scoping review determines what prognostic communication models exist, compares and contrasts these models, and explores the supporting evidence. METHOD A protocol was created for this study using the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols extension for Scoping Reviews. Comprehensive literature searches of electronic databases MEDLINE, EMBASE, PsycINFO and Cochrane CENTRAL were executed to identify relevant publications between 1971 and 2020. RESULTS In total, 1532 articles were identified, of which 78 met inclusion criteria and contained 5 communication models. Three of these have been validated in randomised controlled trials (the Serious Illness Conversation Guide, the Four Habits Model and the ADAPT acronym) and have demonstrated improved objective communication measures and patient reported outcomes. All three models emphasise the importance of exploring patients' illness understanding and treatment preferences, communicating prognosis and responding to emotion. CONCLUSION Communicating prognostic estimates is a core competency skill in advanced cancer care. This scoping review highlights available communication models and identifies areas in need of further assessment. Such areas include how to maintain learnt communication skills for lifelong practice, how to assess patient and caregiver understanding during and after these conversations, and how to best scale these protocols at the institutional and national levels.
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Affiliation(s)
- Julie Rachel Bloom
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Carlos Rodriguez-Russo
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emily Martin
- Palliative Care Program, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Joshua Adam Jones
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kavita Vyas Dharmarajan
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Grossoehme DH, Thienprayoon R, Sawnani H, Jenkins R, Rossman I, Mosher K, Friebert S. Assessment of the relationship between disease progression and goals of care by individuals with Duchenne Muscular Dystrophy and their caregivers. Muscle Nerve 2022; 65:646-651. [PMID: 35119694 DOI: 10.1002/mus.27514] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 01/24/2022] [Accepted: 01/29/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION/AIMS Most patients with Duchenne muscular dystrophy (DMD) in the US are diagnosed at about age 5 years. Some adolescents and young adults (AYAs) with DMD are now living into their fourth decade, yet AYAs and caregivers are frequently unprepared to address changes in goals of care due to disease progression. The hypothesis-generating research question was how AYAs with DMD and their caregivers understand the relationship between physical changes and the need to change goals of care. METHODS Grounded theory design using data from N = 30 semi-structured interviews (n = 13 AYA; n = 17 caregivers) from two sites. RESULTS AYAs with DMD frequently defer considering and/or reconsidering goals of care based on (1) delays in diagnosis; (2) gradual, rather than episodic, disease progression; and (3) orientation to living in the present. Desire for autonomy motivates advance care planning and end-of-life treatment preferences for some. DISCUSSION Routine inquiry into AYA and caregiver goals for living may normalize goals of care conversations, maximizing patients' ability to process information, reflect on preferences, and articulate wishes. Discussing present-day goals and abilities may invite conversation about future preferences. Framing conversations in terms of AYA autonomy may increase motivation to engage in such discussions. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Daniel H Grossoehme
- Haslinger Family Pediatric Palliative Care Center, Akron Children's Hospital, Akron, OH
| | - Rachel Thienprayoon
- Division of Palliative Care, Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Hemant Sawnani
- Department of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Rachel Jenkins
- Haslinger Family Pediatric Palliative Care Center, Akron Children's Hospital, Akron, OH
| | - Ian Rossman
- Neurdevelopmental Science Center, Akron Children's Hospital, Akron, OH
| | - Kathryn Mosher
- Neurdevelopmental Science Center, Akron Children's Hospital, Akron, OH
| | - Sarah Friebert
- Haslinger Family Pediatric Palliative Care Center, Akron Children's Hospital, Akron, OH
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Zehm A, Scott E, Schaefer KG, Nguyen PL, Jacobsen J. Improving Serious Illness Communication: Testing the Serious Illness Care Program with Trainees. J Pain Symptom Manage 2022; 63:e252-e259. [PMID: 34743012 DOI: 10.1016/j.jpainsymman.2021.10.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/19/2021] [Accepted: 10/27/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Early conversations about patients' goals and values improve care, but clinicians struggle to conduct them. The systems-based Serious Illness Care Program (SICP) helps clinicians have more, better, and earlier conversations. Central to this approach is a clinician conversation guide for patient encounters. While the SICP works for practicing clinicians, it has not been tested with medical trainees. INTERVENTION We adapted the SICP training to emphasize assessing prognostic awareness and responding to emotion. We developed a 2.5-hour SICP workshop for medical students and medical interns that included large- and small-group work, practice with an actor, and interdisciplinary clinician facilitators. We trained 81 students and 156 interns and obtained anonymous quantitative and qualitative feedback. OUTCOMES Eighty-six percent of students and 91% of residents rated the session as "very good" or "excellent" and >90% of all learners would either recommend this training or intended to apply this to their practice. Post-session learner confidence increased in all communication skills. Learners said the training provided a helpful framework and useful language for these conversations. Resident documentation of serious illness conversations in the medical record increased dramatically during the year following training commencement. CONCLUSIONS Grounded in principles of adult learning theory, this training was rated highly by trainees and resulted in demonstrable practice change. These early learners were more flexible and willing to try this approach than practicing clinicians who tend to resist or revert to old habits. A Guide represents a new paradigm for teaching communication skills and is valued by early learners.
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Affiliation(s)
- April Zehm
- Medical College of Wisconsin (A.Z.), Milwaukee, Wisconsin, USA.
| | - Erin Scott
- The Ohio State University College of Medicine (E.S.), Columbus, Ohio, USA
| | | | - Phuong L Nguyen
- Massachusetts General Hospital (P.L.N., J.J.), Boston, Massachusetts, USA
| | - Juliet Jacobsen
- Harvard Medical School (K.G.S., J.J.), Boston, Massachusetts, USA; Massachusetts General Hospital (P.L.N., J.J.), Boston, Massachusetts, USA
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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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48
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Smith GM, Radigan NJ, Maloney FL, Hawrusik R, Paquette E, Takahashi K, Downey N, Paladino J, Bernacki RE. Development, Implementation, and Outcomes of a Serious Illness Care Community of Practice. J Pain Symptom Manage 2022; 63:e160-e167. [PMID: 34371136 DOI: 10.1016/j.jpainsymman.2021.07.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/23/2021] [Accepted: 07/28/2021] [Indexed: 11/30/2022]
Abstract
CONTEXT Communities of Practice (CoP) can help geographically separated individuals who share a joint enterprise, mutual engagement, and a repertoire of tools to gain, maintain, and implement new skills, including serious illness communication. OBJECTIVES To investigate the health system uptake, implementation and outcomes of the Serious Illness Community of Practice (SICoP). METHODS Participants included members of the online SICoP, including participants from all 50 states in the United States and 44 countries, interested in implementation of the Serious Illness Care Program. Yearly surveys asked members about their program's composition, completed trainings, number of serious illness conversations, and utilization of the online SICoP tools and resources. RESULTS Over four years, membership in the SICoP increased from 429 to 1,912, with an estimated 17,785 clinicians trained and 38,945 serious illness conversations conducted. Members have continued to utilize and modify the SICoP resources. CONCLUSIONS Utilizing a CoP has contributed to improving the health care system implementation and process outcomes of serious illness communication training. KEY MESSAGE This article describes the implementation and health system outcomes of a Community of Practice developed to support serious illness communication. The results indicate that the membership of the community grew and that the community supported growth in the number of trained clinicians and the number of serious illness conversations conducted.
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Affiliation(s)
- Grant M Smith
- Section of Palliative Medicine, Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Palo Alto, California, USA
| | - Nicholas J Radigan
- University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Francine L Maloney
- Ariadne Labs, Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Rebecca Hawrusik
- Ariadne Labs, Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Elodie Paquette
- Ariadne Labs, Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Kaeng Takahashi
- Ariadne Labs, Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Nora Downey
- Ariadne Labs, Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Joanna Paladino
- Ariadne Labs, Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA; Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Rachelle E Bernacki
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Adult Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA.
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49
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Schonberg MA, Hamel MB, Davis RB, Karamourtopoulos M, Pinheiro A, Hayes MC, Wee CC, Kistler C. Primary Care Providers’ Perceptions of the Acceptability, Appropriateness, and Feasibility of a Mammography Decision Aid for Women Aged 75 and Older. MDM Policy Pract 2022; 7:23814683221074310. [PMID: 35097217 PMCID: PMC8796098 DOI: 10.1177/23814683221074310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 12/16/2021] [Indexed: 11/16/2022] Open
Abstract
Background. Clinicians need to find decision aids (DAs) useful for their successful implementation. Therefore, we aimed to conduct an exploratory study to learn primary care clinicians’ (PCPs) perspectives on a mammography DA for women ≥75 to inform its implementation. Methods. We sent a cross-sectional survey to 135 PCPs whose patients had participated in a randomized trial of the DA. These PCPs practiced at 1 of 11 practices in Massachusetts or North Carolina. PCPs were asked closed-ended and open-ended questions on shared decision making (SDM) around mammography with women ≥75 and on the DA’s acceptability, appropriateness, and feasibility. Results. Eighty PCPs participated (24 [30%] from North Carolina). Most (n = 69, 86%) thought that SDM about mammography with women ≥75 was extremely/very important and that they engaged women ≥75 in SDM around mammography frequently/always (n = 49, 61%). Regarding DA acceptability, 60% felt the DA was too long. Regarding appropriateness, 70 (89%) thought it was somewhat/very helpful and that it would help patients make more informed decisions; 55 (70%) would recommend it. Few (n = 6, 8%) felt they had other resources to support this decision. Regarding feasibility, 53 (n = 67%) thought it would be most feasible for patients to receive the DA before a visit from medical assistants rather than during or after a visit or from health educators. Most (n = 62, 78%) wanted some training to use the DA. Limitations. Sixty-nine percent of PCPs in this small study practiced in academic settings. Conclusions. Although PCPs were concerned about the DA’s length, most found it helpful and informative and felt it would be feasible for medical assistants to deliver the DA before a visit. Implications. Study findings may inform implementation of this and other DAs.
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Affiliation(s)
- Mara A. Schonberg
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Mary Beth Hamel
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Roger B. Davis
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Maria Karamourtopoulos
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Adlin Pinheiro
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Michelle C. Hayes
- Division of Geriatric Medicine and Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Christina C. Wee
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christine Kistler
- Division of Geriatric Medicine and Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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50
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Murthy S, Clapp JT, Burson RC, Fleisher LA, Neuman MD. Physicians' perspectives of prognosis and goals of care discussions after hip fracture. J Am Geriatr Soc 2022; 70:1487-1494. [PMID: 34990017 PMCID: PMC9106823 DOI: 10.1111/jgs.17642] [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: 08/11/2021] [Revised: 12/10/2021] [Accepted: 12/17/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hip fracture often represents a major transition in patients' health, with a 1-year mortality rate between 25% and 30% and a challenging recovery course. Caring for hip fracture patients presents opportunities for goals of care discussions that include prognostic information and guidance about functional dependence. METHODS We conducted qualitative, semi-structured interviews with 23 attending physicians involved with the care of hip fracture patients, including orthopedic surgeons, anesthesiologists, internists, and geriatricians, across 13 health systems in the United States and Canada. Questions addressed knowledge and interpretation of prognosis, discussing prognosis and goals of care, and timing and prioritization of surgery. Interviews were analyzed using a constructivist grounded theory approach to identify themes and develop a coding taxonomy. RESULTS Physicians agreed that hip fracture had a considerable 1-year mortality, felt that it was important to discuss prognostic outcomes and the recovery process, wanted to elucidate patients' priorities, and often promoted timely surgery. Physicians perceived challenges when discussing mortality data with new patients in an acute setting. They more easily discussed outcomes related to functional dependence and quality of life. Some physicians used iterative communication as a strategy to have in-depth conversations in a busy perioperative setting. CONCLUSION Providing timely, compassionate care for hip fracture patients is challenging. There are opportunities to study iterative communication to encourage dialogue at key points of patient care to better discuss prognosis and recovery and bolster coordinated multidisciplinary care that focuses on patients' goals and values.
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Affiliation(s)
- Sushila Murthy
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Justin T Clapp
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Randall C Burson
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lee A Fleisher
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Clinical Standards and Quality, Centers for Medicare and Medicaid Services, Baltimore, Maryland, USA
| | - Mark D Neuman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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