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Allen MB, Reich A, Collins P, Chahal K, Moustaqim-Barrette M, Bernacki RE, Cooper Z, Bader AM. Provider Perceptions Regarding Cardiopulmonary Resuscitation in Surgical Patients with Frailty. Ann Surg 2024:00000658-990000000-00749. [PMID: 38258581 DOI: 10.1097/sla.0000000000006214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
OBJECTIVE To characterize the perceptions of surgeons, anesthesiologists, and geriatricians regarding perioperative CPR in surgical patients with frailty. SUMMARY BACKGROUND DATA The population of patients undergoing surgery is growing older and more frail. Despite a growing focus on goal-concordant care, frailty assessment, and debate regarding the appropriateness of cardiopulmonary resuscitation (CPR) in patients with frailty, providers' views regarding frailty and perioperative CPR are unknown. METHODS We performed qualitative thematic analysis of transcripts from semi-structured interviews of anesthesiologists (8), surgeons (10), and geriatricians (9) who care for high-risk surgical patients at two academic medical centers in Boston, MA. The interview guide elicited clinicians' understanding of frailty, approach to decision-making regarding perioperative CPR, and perceptions of perioperative CPR in frail surgical patients. RESULTS We identified 5 themes: perceptions of perioperative CPR in patients with frailty vary by provider specialty; judgments regarding appropriateness of CPR in surgical patients with frailty are typically multifactorial and include patient goals, age, comorbidities, and arrest etiology; resuscitation in patients with frailty is sometimes associated with moral distress; biases such as ableism and ageism may skew clinicians' perceptions of appropriateness of perioperative CPR in patients with frailty; and evidence to guide risk stratification for patients with frailty undergoing perioperative CPR is inadequate. CONCLUSIONS Anesthesiologists, surgeons, and geriatricians offer different accounts of frailty's relevance to judgments regarding CPR in surgical patients. Divergent views regarding frailty and perioperative CPR may impede efforts to deliver goal-concordant care and suggest a need for research to inform risk stratification, predict patient-centered outcomes, and understand the role of potential biases such as ageism and ableism.
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Affiliation(s)
- Matthew B Allen
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Amanda Reich
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Patrick Collins
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Karen Chahal
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Maria Moustaqim-Barrette
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Anesthesiology and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Rachelle E Bernacki
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Angela M Bader
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Lehto HR, Jain N, Bernacki RE, Landzberg MJ, Desai AS, Orkaby AR. Feasibility of frailty screening among patients with advanced heart failure. BMJ Open Qual 2023; 12:e002430. [PMID: 37857523 PMCID: PMC10603494 DOI: 10.1136/bmjoq-2023-002430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 09/21/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Frailty is common among patients with advanced heart failure (HF), and screening for frailty to guide care is recommended. Although multiple tools are available to screen for frailty, the feasibility of routinely incorporating frailty screening into daily clinical practice among hospitalised advanced HF patients has not been rigorously tested. METHODS This was a prospective, single-centre, quality improvement study. Two brief frailty screening tools were incorporated into palliative care consultations for all patients ≥50 years from August 2021 to October 2022. In the first phase, the Clinical Frailty Scale (CFS) was implemented, followed by the Study of Osteoporotic Fracture (SOF) tool or a modified SOF (mSOF) version in the second phase. The primary outcome was feasibility (%) of performing frailty screenings for this high-risk population. RESULTS A total of 212 patients (mean age 69±10 years, 69% male, 79% white, 30% with ischaemic HF) were referred for palliative care consultation during the study period. Overall, frailty screens were completed in 86% (n=183) of patients. CFS and mSOF reached >80% of adoption, while SOF adoption was 54%. Altogether, 52% of the population screened frail by use of CFS and 52% also by mSOF. All clinicians (n=6) participating in the study reported that frailty screening tools were useful and acceptable, and 83% reported plans for continued utilisation in future clinical practice. CONCLUSIONS Frailty screening with CFS or mSOF tools was feasible in hospitalised patients with advanced HF. Tools that require physical assessment were more challenging to implement. These data support the feasibility of incorporating questionnaire-based frailty screening in a busy hospital setting.
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Affiliation(s)
- Hanna-Riikka Lehto
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Nelia Jain
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Rachelle E Bernacki
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Michael J Landzberg
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Akshay S Desai
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ariela R Orkaby
- Harvard Medical School, Boston, Massachusetts, USA
- New England GRECC, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, 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] [What about the content of this article? (0)] [Affiliation(s)] [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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4
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Allen MB, Orkaby AR, Justice S, Hall DE, Hu FY, Cooper Z, Bernacki RE, Bader AM. Frailty and Outcomes Following Cardiopulmonary Resuscitation for Perioperative Cardiac Arrest. JAMA Netw Open 2023; 6:e2321465. [PMID: 37399014 DOI: 10.1001/jamanetworkopen.2023.21465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/04/2023] Open
Abstract
Importance Frailty is associated with mortality following surgery and cardiopulmonary resuscitation (CPR) for in-hospital cardiac arrest. Despite the growing focus on frailty as a basis for preoperative risk stratification and concern that CPR in patients with frailty may border on futility, the association between frailty and outcomes following perioperative CPR is unknown. Objective To determine the association between frailty and outcomes following perioperative CPR. Design, Setting, and Participants This longitudinal cohort study of patients used the American College of Surgeons National Surgical Quality Improvement Program, including more than 700 participating hospitals in the US, from January 1, 2015, through December 31, 2020. Follow-up duration was 30 days. Patients 50 years or older undergoing noncardiac surgery who received CPR on postoperative day 0 were included; patients were excluded if data required to determine frailty, establish outcome, or perform multivariable analyses were missing. Data were analyzed from September 1, 2022, through January 30, 2023. Exposures Frailty defined as Risk Analysis Index (RAI) of 40 or greater vs less than 40. Outcomes and Measures Thirty-day mortality and nonhome discharge. Results Among the 3149 patients included in the analysis, the median age was 71 (IQR, 63-79) years, 1709 (55.9%) were men, and 2117 (69.2%) were White. Mean (SD) RAI was 37.73 (6.18), and 792 patients (25.9%) had an RAI of 40 or greater, of whom 534 (67.4%) died within 30 days of surgery. Multivariable logistic regression adjusting for race, American Society of Anesthesiologists physical status, sepsis, and emergency surgery demonstrated a positive association between frailty and mortality (adjusted odds ratio [AOR], 1.35 [95% CI, 1.11-1.65]; P = .003). Spline regression analysis demonstrated steadily increasing probability of mortality and nonhome discharge with increasing RAI above 37 and 36, respectively. Association between frailty and mortality following CPR varied by procedure urgency (AOR for nonemergent procedures, 1.55 [95% CI, 1.23-1.97]; AOR for emergent procedures, 0.97 [95% CI, 0.68-1.37]; P = .03 for interaction). An RAI of 40 or greater was associated with increased odds of nonhome discharge compared with an RAI of less than 40 (AOR, 1.85 [95% CI, 1.31-2.62]; P < .001). Conclusions and Relevance The findings of this cohort study suggest that although roughly 1 in 3 patients with an RAI of 40 or greater survived at least 30 days following perioperative CPR, higher frailty burden was associated with increased mortality and greater risk of nonhome discharge among survivors. Identifying patients who are undergoing surgery and have frailty may inform primary prevention strategies, guide shared decision-making regarding perioperative CPR, and promote goal-concordant surgical care.
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Affiliation(s)
- Matthew B Allen
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ariela R Orkaby
- New England Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Samuel Justice
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel E Hall
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, Veteran Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- GRECC, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Frances Y Hu
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Zara Cooper
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rachelle E Bernacki
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Angela M Bader
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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5
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Godage S, Rowe K, Hu FY, Bader AM, Cooper Z, Bernacki RE, Hepner DL, Allen MB. Preoperative Code Status Discussion Workflows: Targets for Improvement in Multidisciplinary Pathways. J Pain Symptom Manage 2023; 66:e35-e43. [PMID: 37023833 DOI: 10.1016/j.jpainsymman.2023.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/22/2023] [Accepted: 03/26/2023] [Indexed: 04/08/2023]
Abstract
CONTEXT Discussion of perioperative code status is an important element of preoperative care and a component of the American College of Surgeons' Geriatric Surgery Verification (GSV) program. Evidence suggests code status discussions (CSDs) are not routinely performed and are inconsistently documented. OBJECTIVES Because preoperative decision making is a complex process spanning multiple providers, this study aims to utilize process mapping to highlight challenges associated with CSDs and inform efforts to improve workflows and implement elements of the GSV program. METHODS Using process mapping, we detailed workflows relating to (CSDs) for patients undergoing thoracic surgery and a possible workflow for implementing GSV standards for goals and decision-making. RESULTS We generated process maps for outpatient and day-of-surgery workflows relating to CSDs. In addition, we generated a process map for a potential workflow to address limitations and integrate GSV Standards for Goals and Decision Making. CONCLUSION Process mapping highlighted challenges associated with the implementation of multidisciplinary care pathways and indicated a need for centralization and consolidation of perioperative code status documentation.
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Affiliation(s)
- Sashini Godage
- Harvard Medical School (S.G., K.R.), Boston, Massachusetts, USA
| | - Katie Rowe
- Harvard Medical School (S.G., K.R.), Boston, Massachusetts, USA; Harvard Business School (K.R.), Boston, Massachusetts, USA
| | - Frances Y Hu
- Department of Surgery (F.Y.H., Z.C.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Angela M Bader
- Center for Surgery and Public Health (A.M.B., Z.C.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Anesthesiology (A.M.B., D.L.H., M.B.A), Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Zara Cooper
- Department of Surgery (F.Y.H., Z.C.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Center for Surgery and Public Health (A.M.B., Z.C.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rachelle E Bernacki
- Department of Psychosocial Oncology and Palliative Care (R.E.B), Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA; Division of Palliative Medicine, Department of Medicine (R.E.B), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David L Hepner
- Department of Anesthesiology (A.M.B., D.L.H., M.B.A), Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew B Allen
- Department of Anesthesiology (A.M.B., D.L.H., M.B.A), Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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6
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Hu FY, Tabata-Kelly M, Johnston FM, Walling AM, Lindvall C, Bernacki RE, Pusic AL, Cooper Z. Surgeon-reported Factors Influencing Adoption of Quality Standards for Goal-concordant Care in Patients With Advanced Cancer: A Qualitative Study. Ann Surg 2023; 277:e1000-e1005. [PMID: 35766368 PMCID: PMC9797615 DOI: 10.1097/sla.0000000000005441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE This study explored surgical oncologists' perspectives on factors influencing adoption of quality standards in patients with advanced cancer. BACKGROUND The American College of Surgeons Geriatric Surgery Verification Program includes communication standards designed to facilitate goal-concordant care, yet little is known about how surgeons believe these standards align with clinical practice. METHODS Semistructured video-based interviews were conducted from November 2020 to January 2021 with academic surgical oncologists purposively sampled based on demographics, region, palliative care certification, and years in practice. Interviews addressed: (1) adherence to standards documenting care preferences for life-sustaining treatment, surrogate decision-maker, and goals of surgery; and (2) factors influencing their adoption into practice. Interviews were audio-recorded, transcribed, qualitatively analyzed, and conducted until thematic saturation was reached. RESULTS Twenty-six surgeons participated (57.7% male, 8.5 mean years in practice, 19.2% palliative care board-certified). Surgeons reported low adherence to documenting care preferences and surrogate decision-maker and high adherence to discussing, but not documenting, goals of surgery. Participants held conflicting views about the relevance of care preferences to preoperative conversations and surrogate decision-maker documentation by the surgeon and questioned the direct connection between documentation of quality standards and higher value patient care. Key themes regarding factors influencing adoption of quality standards included organizational culture, workflow, and multidisciplinary collaboration. CONCLUSIONS Although surgeons routinely discuss goals of surgery, documentation is inconsistent; care preferences and surrogate decision-makers are rarely discussed or documented. Adherence to these standards would be facilitated by multidisciplinary collaboration, institutional standardization, and evidence linking standards to higher value care.
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Affiliation(s)
- Frances Y Hu
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Masami Tabata-Kelly
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
| | | | - Anne M Walling
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
| | - Rachelle E Bernacki
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
| | - Andrea L Pusic
- Department of Surgery, Brigham and Women's Hospital, Boston, MA
- Brigham and Women's Hospital, Patient-Reported Outcomes, Value & Experience (PROVE) Center, Boston, MA
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA
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7
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Jain N, Bernacki RE, Lee KA, Siegel JH, Yenulevich EG, Lally KM. Adaptations within Palliative Care Delivery Models Due to the COVID-19 Pandemic at a Tertiary Care Hospital. J Palliat Med 2023; 26:544-547. [PMID: 36719991 DOI: 10.1089/jpm.2022.0398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Background: Since the onset of the COVID-19 pandemic, all facets of palliative care provision for patients with serious illness have faced unparalleled challenges. Methods: We describe our palliative care program's response to the increased clinical volume associated with the pandemic by adapting workflows for inpatient and outpatient palliative care teams caring for oncology and nononcology populations. Results: During the initial surge, the demand for palliative care consultation for patients affected by SARS-CoV-2 was high, accounting for 75% of all inpatient palliative care referral requests for oncology and nononcology patients. Furthermore, our ambulatory clinic experienced a 40% increase in visits for complex oncology patients between February and December of 2020. Discussion: This article highlights transformations in palliative care delivery implemented in response to the pandemic and reflects on how these transformations have shaped our current care delivery models. We further delineate our intentional reliance on key population health principles to drive ongoing innovation in palliative care provision across our clinical teams.
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Affiliation(s)
- Nelia Jain
- Department of Psychosocial Oncology and Palliative Care and Dana-Farber Cancer Institute, 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
- Department of Psychosocial Oncology and Palliative Care and Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Kathleen A Lee
- Harvard Medical School, Boston, Massachusetts, USA.,Section of Palliative Care, Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jocelyn H Siegel
- Department of Psychosocial Oncology and Palliative Care and Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Eric G Yenulevich
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Kate M Lally
- Department of Psychosocial Oncology and Palliative Care and Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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8
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Hu FY, Rowe KA, O'Mara LM, Bulger A, Bleday R, Groff MW, Cooper Z, Bernacki RE. Evaluation of interdisciplinary care pathway implementation in older elective surgery patients. J Am Geriatr Soc 2023; 71:1310-1322. [PMID: 36705068 DOI: 10.1111/jgs.18244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 12/14/2022] [Accepted: 12/23/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND The American College of Surgeons Geriatric Surgery Verification Program outlines best practices for surgical care in older adults. These recommendations have guided institutions to create workflows to better support needs specific to older surgical patients. This qualitative study explored clinician experiences to understand influences on implementation of frailty screening and an interdisciplinary care pathway in older elective colorectal surgery and neurosurgery patients. STUDY DESIGN Semi-structured in-person and video-based interviews were conducted from July 2021 to March 2022 with clinicians caring for patients ≥70 years on the colorectal surgery and neurosurgery services. Interviews addressed familiarity with and beliefs about the intervention, intervention alignment with routine workflow and workflow adaptations, and barriers and facilitators to performing the intervention. Interviews were analyzed using the consolidated framework for implementation research (CFIR) to find themes related to ongoing implementation. RESULTS Thirty-two clinicians participated (56.3% female, 58.8% White). Fifteen relevant CFIR constructs were identified. Key themes to implementation success included strong participant belief in effectiveness of the intervention and its advantage over standard care; the importance of training, reference materials, and champions; and the need for institution-level investment in resources to amplify the impact of the intervention on patients and expand the capacity to address their needs. CONCLUSION Systematic evaluation found implementation of frailty screening and an interdisciplinary care pathway in elective colorectal surgery and neurosurgery patients to be supported by participating clinicians, yet sustainability of the intervention and further adoption across surgical services to better meet the needs of older patients would necessitate organizational resource allocation.
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Affiliation(s)
- Frances Y Hu
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Katherine A Rowe
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lynne M O'Mara
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Division of Aging, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Amy Bulger
- Department of Nursing, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ronald Bleday
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael W Groff
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Rachelle E Bernacki
- Department of Medicine, Division of Aging, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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9
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Hu FY, O'Mara L, Tulebaev S, Orkaby AR, Cooper Z, Bernacki RE. Geriatric surgical service interventions in older emergency general surgery patients: Preliminary results. J Am Geriatr Soc 2022; 70:2404-2414. [PMID: 35670490 DOI: 10.1111/jgs.17916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/21/2022] [Accepted: 05/01/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Older adults comprise an increasing proportion of emergency general surgery (EGS) admissions and face high morbidity and mortality. We created a geriatric surgical service with geriatric and palliative expertise to mitigate risks of hospitalization most hazardous to older patients. We sought to identify geriatric surgical service interventions most relevant to EGS patients. METHODS We prospectively identified patients ≥75 years admitted to the EGS service at an urban tertiary care hospital from January 2020-March 2021 who screened positive for frailty (FRAIL score ≥3 [scale 0-5, higher being worse]) or with cognitive impairment. A pilot geriatric surgical service, led by a dually-board certified geriatric and palliative care specialist, conducted a comprehensive geriatric assessment and modified Rockwood Frailty Index calculation for each eligible patient. Patient, hospital admission, and geriatric consultation characteristics were collected via chart review. RESULTS Fifty consecutive patients (median age 82 years [IQR 78-90], 56% female) received geriatric consultation (median time 3 days [IQR 1-6] from admission). The most common admission diagnosis was bowel obstruction (32%). Sixty-four percent of patients underwent ≥1 surgical procedure. Using the Frailty Index, 64% were moderately or severely frail. Interventions most frequently performed by the geriatric team included delirium prevention and management (66%), consideration of swallowing function (52%), individualized pain management (50%), and facilitation of serious illness conversations (58%). CONCLUSIONS Geriatric service involvement addresses a high burden of both geriatric and palliative care needs in older EGS patients. Geriatric recommendations may direct interventions for surgical education in fundamental geriatric and palliative care knowledge to maximize geriatric resources for the most high-risk patients.
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Affiliation(s)
- Frances Y Hu
- Center for Surgery and Public Health, Brigham and Woman's Hospital, Boston, Massachusetts, USA.,Department of Surgery, Brigham and Woman's Hospital, Boston, Massachusetts, USA
| | - Lynne O'Mara
- Department of Surgery, Brigham and Woman's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Division of Aging, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Samir Tulebaev
- Department of Medicine, Division of Aging, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ariela R Orkaby
- Department of Medicine, Division of Aging, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Woman's Hospital, Boston, Massachusetts, USA.,Department of Surgery, Brigham and Woman's Hospital, Boston, Massachusetts, USA
| | - Rachelle E Bernacki
- Department of Medicine, Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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10
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Hu FY, Sokas C, Jarman MP, Bader A, Bernacki RE, Cooper Z. Which Geriatric Variables Most Strongly Inform Discharge Disposition After Emergency Surgery? J Surg Res 2022; 274:224-231. [DOI: 10.1016/j.jss.2021.12.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 08/30/2021] [Accepted: 12/27/2021] [Indexed: 01/12/2023]
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11
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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12
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Sokas CM, Hu FY, Dalton MK, Jarman MP, Bernacki RE, Bader A, Rosenthal RA, Cooper Z. Understanding the role of informal caregivers in postoperative care transitions for older patients. J Am Geriatr Soc 2021; 70:208-217. [PMID: 34668189 DOI: 10.1111/jgs.17507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/18/2021] [Accepted: 09/05/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Older adults may have new care needs and functional limitations after surgery. Many rely on informal caregivers (unpaid family or friends) after discharge but the extent of informal support is unknown. We sought to examine the role of informal postoperative caregiving on transitions of care for older adults undergoing routine surgical procedures. MATERIALS AND METHODS We performed a retrospective cohort study using ACS NSQIP Geriatric Pilot Project data, 2014-2018. Patients were ≥65 years and underwent an inpatient surgical procedure. Patients who lived at home alone were compared with those who lived with support from informal caregivers (family and/or friends). Primary outcomes were discharge destination (home vs. post-acute care) and readmission within 30 days. Multivariable logistic regression was used to determine the association between support at home, discharge destination, and readmission. RESULTS Of 18,494 patients, 25% lived alone before surgery. There was no difference in loss of independence (decline in functional status or new use of mobility aid) after surgery between patients who lived alone or with others (18.7% vs. 19.5%, p = 0.24). Nevertheless, twice as many patients who lived alone were discharged to a non-home location (10.2% vs. 5.1%; OR: 2.24, CI: 1.93-2.56). Patients who lived alone and were discharged home with new informal caregivers had increased odds of readmission (OR: 1.43, CI: 1.09-1.86). CONCLUSION Living alone independently predicts discharge to post-acute care, and patients who received new informal caregiver support at home have higher odds of readmission. These findings highlight opportunities to improve discharge planning and care.
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Affiliation(s)
- Claire M Sokas
- Center for Surgery and Public Health, Brigham and Woman's Hospital, Boston, Massachusetts, USA
| | - Frances Y Hu
- Center for Surgery and Public Health, Brigham and Woman's Hospital, Boston, Massachusetts, USA
| | - Michael K Dalton
- Center for Surgery and Public Health, Brigham and Woman's Hospital, Boston, Massachusetts, USA
| | - Molly P Jarman
- Center for Surgery and Public Health, Brigham and Woman's Hospital, Boston, Massachusetts, USA
| | - Rachelle E Bernacki
- Department of Medicine, Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Angela Bader
- Department of Anesthesia, Brigham & Women's Hospital, Boston, Massachusetts, USA
| | | | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Woman's Hospital, Boston, Massachusetts, USA.,Department of Surgery, Brigham and Woman's Hospital, Boston, Massachusetts, USA
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13
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Lagrotteria A, Swinton M, Simon J, King S, Boryski G, Ma IWY, Dunne F, Singh J, Bernacki RE, You JJ. Clinicians' Perspectives After Implementation of the Serious Illness Care Program: A Qualitative Study. JAMA Netw Open 2021; 4:e2121517. [PMID: 34406399 PMCID: PMC8374609 DOI: 10.1001/jamanetworkopen.2021.21517] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Discussions about goals of care with patients who are seriously ill typically occur infrequently and late in the illness trajectory, are of low quality, and focus narrowly on the patient's resuscitation preferences (ie, code status), risking provision of care that is inconsistent with patients' values. The Serious Illness Care Program (SICP) is a multifaceted communication intervention that builds capacity for clinicians to have earlier, more frequent, and more person-centered conversations. OBJECTIVE To explore clinicians' experiences with the SICP 1 year after implementation. DESIGN, SETTING, AND PARTICIPANTS This qualitative study was conducted at 2 tertiary care hospitals in Canada. The SICP was implemented at Hamilton General Hospital (Hamilton, Ontario) from March 1, 2017, to January 19, 2018, and at Foothills Medical Centre (Calgary, Alberta) from March 1, 2018, to December 31, 2020. A total of 45 clinicians were invited to participate in the study, and 23 clinicians (51.1%) were enrolled and interviewed. Semistructured interviews of clinicians were conducted between August 2018 and May 2019. Content analysis was used to evaluate information obtained from these interviews between May 2019 and May 2020. EXPOSURES The SICP includes clinician training, communication tools, and processes for system change. MAIN OUTCOMES AND MEASURES Clinicians' experiences with and perceptions of the SICP. RESULTS Among 23 clinicians interviewed, 15 (65.2%) were women. The mean (SD) number of years in practice was 14.6 (9.1) at the Hamilton site and 12.0 (6.9) at the Calgary site. Participants included 19 general internists, 3 nurse practitioners, and 1 social worker. The 3 main themes were the ways in which the SICP (1) supported changes in clinician behavior, (2) shifted the focus of goals-of-care conversations beyond discussion of code status, and (3) influenced clinicians personally and professionally. Changes in clinician behavior were supported by having a unit champion, interprofessional engagement, access to copies of the Serious Illness Conversation Guide, and documentation in the electronic medical record. Elements of the program, especially the Serious Illness Conversation Guide, shifted the focus of goals-of-care conversations beyond discussion of code status and influenced clinicians on personal and professional levels. Concerns with the program included finding time to have conversations, building transient relationships, and limiting conversation fluidity. CONCLUSIONS AND RELEVANCE In this qualitative study, hospital clinicians described components of the SICP as supporting changes in their behavior and facilitating meaningful patient interactions that shifted the focus of goals-of-care conversations beyond discussion of code status. The perceived benefits of SICP implementation stimulated uptake within the medical units. These findings suggest that the SICP may prompt hospital culture changes in goals-of-care dialogue with patients and the care of hospitalized patients with serious illness.
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Affiliation(s)
- Andrew Lagrotteria
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marilyn Swinton
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jessica Simon
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Seema King
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Irene Wai Yan Ma
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Fiona Dunne
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Japteg Singh
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Rachelle E. Bernacki
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - John J. You
- Division of General Internal and Hospitalist Medicine, Department of Medicine, Trillium Health Partners, Credit Valley Hospital, Mississauga, Ontario, Canada
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14
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Affiliation(s)
- Zara Cooper
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Rachelle E Bernacki
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
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15
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Sokas C, Yeh IM, Bernacki RE, Rangel EL, Kaafarani H, Mitchell SL, Bader AM, Ladin K, Palmer JA, Tulsky JA, Cooper Z. Older adults' perspectives 3 months after emergency general surgery highlight opportunities to improve care. J Am Geriatr Soc 2021; 69:2023-2025. [PMID: 33797750 DOI: 10.1111/jgs.17152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 03/14/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Claire Sokas
- Brigham and Woman's Hospital, Center for Surgery and Public Health, Boston, Massachusetts, USA
| | - Irene M Yeh
- Division of Palliative Medicine, 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
| | - Rachelle E Bernacki
- Division of Palliative Medicine, 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
| | - Erika L Rangel
- Department of Surgery, Brigham and Woman's Hospital, Boston, Massachusetts, USA
| | - Haytham Kaafarani
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Susan L Mitchell
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA
| | - Angela M Bader
- Brigham and Woman's Hospital, Center for Surgery and Public Health, Boston, Massachusetts, USA.,Department of Anesthesia, Brigham and Woman's Hospital, Boston, Massachusetts, USA
| | - Keren Ladin
- Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts, USA
| | - Jennifer A Palmer
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research, Boston, Massachusetts, USA.,Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - James A Tulsky
- Division of Palliative Medicine, 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
| | - Zara Cooper
- Brigham and Woman's Hospital, Center for Surgery and Public Health, Boston, Massachusetts, USA.,Department of Surgery, Brigham and Woman's Hospital, Boston, Massachusetts, USA
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16
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Lakin JR, Arnold CG, Catzen HZ, Rangarajan A, Berger RS, Brannen EN, Cunningham RJ, Schaffer AC, Lamey J, Baker O, Bernacki RE. Early serious illness communication in hospitalized patients: A study of the implementation of the Speaking About Goals and Expectations (SAGE) program. Healthc (Amst) 2021; 9:100510. [PMID: 33517037 DOI: 10.1016/j.hjdsi.2020.100510] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 11/23/2020] [Accepted: 12/11/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Early conversations about patients' goals and values in advancing serious illness (serious illness conversations) can drive better healthcare. However, these conversations frequently happen during acute illness, often near death, without time to realize benefits of early communication. METHODS The Speaking About Goals and Expectations (SAGE) Program, adapted from the Serious Illness Care Program, is a multicomponent intervention designed to foster earlier and more comprehensive serious illness conversations for patients admitted to the hospital. We present a quality improvement study of the SAGE Program assessing older adults admitted to a general medicine service at the Brigham & Women's Hospital in Boston, Massachusetts. Our primary outcomes included the proportion of patients with at least one documented conversation, the timing between first conversation documented and death, the quality of conversations, and their interprofessional nature. Secondary outcomes assessed evaluations of the training and hospital utilization. RESULTS We trained 37 clinicians and studied 133 patients split between the SAGE intervention and a comparison population. Intervention patients were more likely to have documented serious illness conversations (89.1% vs. 26.1%, p < 0.001); these conversations occurred earlier (mean of 598.9 vs. 180.8 days before death, p < 0.001) and included more key elements of conversation (mean of 6.56 vs. 1.78, p < 0.001). CONCLUSIONS This study demonstrated significant differences in the frequency and quality of serious illness conversations completed earlier in the illness course for hospitalized patients. IMPLICATIONS Programs designed to drive serious illness conversations earlier in the hospital may be an effective way to improve care for patients not reached in the ambulatory setting. LEVEL OF EVIDENCE Prospectively designed trial, non-randomized sample.
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Affiliation(s)
- Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | | | | | | | - Rebecca S Berger
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Elise N Brannen
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Rebecca J Cunningham
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Brigham & Women's Physician Organization, Boston, MA, USA
| | - Adam C Schaffer
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Jan Lamey
- Brigham & Women's Physician Organization, Boston, MA, USA
| | - Olesya Baker
- Center for Clinical Investigation, Brigham and Women's Hospital, Boston, MA, USA
| | - Rachelle E Bernacki
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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17
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Affiliation(s)
- Joshua R Lakin
- Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston Massachusetts (J.R.L., J.A.T., R.E.B.)
| | - James A Tulsky
- Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston Massachusetts (J.R.L., J.A.T., R.E.B.)
| | - Rachelle E Bernacki
- Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston Massachusetts (J.R.L., J.A.T., R.E.B.)
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18
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Abstract
This essay describes timely and targeted actions that clinicians can take during the COVID-19 pandemic to support fellow clinicians.
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19
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Leiter RE, Pu CT, Mazzola E, Gallagher J, Wright J, Manigault S, Moore ST, Bernacki RE. Engaging Hospices in Quality Measurement and Improvement: Early Experiences of a Large Integrated Health Care System. J Pain Symptom Manage 2020; 60:866-873.e4. [PMID: 32512046 DOI: 10.1016/j.jpainsymman.2020.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/28/2020] [Accepted: 05/29/2020] [Indexed: 10/24/2022]
Abstract
The quality of hospice care remains highly variable in the U.S. Patients, providers, and health care systems lack a comprehensive method of measuring the quality of care provided by an individual hospice. Partners HealthCare sought to assess hospice quality based on objective and quantitative criteria obtained directly from hospices and through public reporting. Here, we describe the process of creating and administering this assessment and the initial creation of a collaborative network with high-quality hospices. A multidisciplinary advisory council developed criteria and a scoring system, focusing on organizational information (e.g., nursing turnover), clinical care quality indicators (e.g., visit hours before death), and training (e.g., medical director certification) and satisfaction (e.g., patient and family surveys). All Medicare-certified hospices in good standing in Massachusetts were eligible to participate in a request for information (RFI) process. We blinded data before scoring and invited hospices scoring above the 15th percentile to join the initial collaborative. Of 72 eligible hospices, most (53%) responded to the RFI, and 32% (n = 23) submitted completed surveys. Hospices could receive up to 23.75 points, and scores ranged from 2.25 to 19.5. The median score was 13.62 (interquartile range 10.5-16.75). For hospices scoring above the 15th percentile (n = 19), scores ranged from 10.0 to 19.5 (median 14). The hospice RFI process is one health care system's attempt to evaluate hospice quality. Further research will determine whether the scoring system proves to be a sensitive, specific, and reproducible measure of hospice quality, and whether the collaborative can foster quality improvement over time.
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Affiliation(s)
- Richard E Leiter
- Harvard Medical School, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
| | - Charles T Pu
- Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA; Center for Population Health, Partners Healthcare, Boston, Massachusetts, USA
| | - Emanuele Mazzola
- Division of Biostatistics, Department of Data Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Julia Gallagher
- Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jennifer Wright
- Population Health Management, Newton-Wellesley Hospital, Boston, Massachusetts, USA
| | - Shekinah Manigault
- Center for Population Health, Partners Healthcare, Boston, Massachusetts, USA
| | - Susan T Moore
- Case Management Department, Spaulding Rehabilitation Network, Boston, Massachusetts, USA
| | - Rachelle E Bernacki
- Harvard Medical School, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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20
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Marie Sokas C, Coogan K, Bernacki RE, Cooper Z. “I Had No Choice”: Older Patients’ Perspectives on Shared Decision-Making During Acute Surgical Emergencies. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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21
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Cooper L, Abbett SK, Feng A, Bernacki RE, Cooper Z, Urman RD, Frain LN, Edwards AF, Blitz JD, Javedan H, Bader AM. Launching a Geriatric Surgery Center: Recommendations from the Society for Perioperative Assessment and Quality Improvement. J Am Geriatr Soc 2020; 68:1941-1946. [DOI: 10.1111/jgs.16681] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/03/2020] [Accepted: 06/04/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Lisa Cooper
- Division of Aging, Department of Medicine Brigham and Womenʼs Hospital Boston Massachusetts USA
| | - Sarah K. Abbett
- Department of Anesthesiology, Perioperative and Pain Medicine Brigham and Womenʼs Hospital Boston Massachusetts USA
| | - Aiden Feng
- Department of Anesthesiology, Perioperative and Pain Medicine Brigham and Womenʼs Hospital Boston Massachusetts USA
| | - Rachelle E. Bernacki
- Department of Psychosocial Oncology and Palliative Care Dana‐Farber Cancer Institute Boston Massachusetts USA
| | - Zara Cooper
- Department of Surgery Brigham and Womenʼs Hospital Boston Massachusetts USA
| | - Richard D. Urman
- Department of Anesthesiology, Perioperative and Pain Medicine Brigham and Womenʼs Hospital Boston Massachusetts USA
| | - Laura N. Frain
- Division of Aging, Department of Medicine Brigham and Womenʼs Hospital Boston Massachusetts USA
| | - Angela F. Edwards
- Department of Anesthesiology Wake Forest School of Medicine Winston‐Salem North Carolina USA
| | - Jeanna D. Blitz
- Department of Anesthesiology Duke University School of Medicine Durham North Carolina USA
| | - Houman Javedan
- Division of Aging, Department of Medicine Brigham and Womenʼs Hospital Boston Massachusetts USA
| | - Angela M. Bader
- Department of Anesthesiology, Perioperative and Pain Medicine Brigham and Womenʼs Hospital Boston Massachusetts USA
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22
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Geerse OP, Lamas DJ, Bernacki RE, Sanders JJ, Paladino J, Berendsen AJ, Hiltermann TJN, Lindvall C, Fromme EK, Block SD. Adherence and Concordance between Serious Illness Care Planning Conversations and Oncology Clinician Documentation among Patients with Advanced Cancer. J Palliat Med 2020; 24:53-62. [PMID: 32580676 DOI: 10.1089/jpm.2019.0615] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Serious illness conversations are part of advance care planning (ACP) and focus on prognosis, values, and goals in patients who are seriously ill. To be maximally effective, such conversations must be documented accurately and be easily accessible. Objectives: The two coprimary objectives of the study were to assess concordance between written documentation and recorded audiotaped conversations, and to evaluate adherence to the Serious Illness Conversation Guide questions. Methods: Data were obtained as part of a trial in patients with advanced cancer. Clinicians were trained to use a guide to conduct and document serious illness conversations. Conversations were audiotaped. Two researchers independently compared audiorecordings with the corresponding documentation in an electronic health record (EHR) template and free-text progress notes, and rated the degree of concordance and adherence. Results: We reviewed a total of 25 audiorecordings. Clinicians addressed 87% of the conversation guide elements. Prognosis was discussed least frequently, only in 55% of the patients who wanted that information. Documentation was fully concordant with the conversation 43% of the time. Concordance was best when documenting family matters and goals, and least frequently concordant when documenting prognostic communication. Most conversations (64%) were documented in the template, a minority (28%) only in progress notes and two conversations (8%) were not documented. Concordance was better when the template was used (62% vs. 28%). Conclusion: Clinicians adhered well to the conversation guide. However, key information elicited was documented and fully concordant less than half the time. Greater concordance was observed when clinicians used a prespecified template. The combined use of a guide and EHR template holds promise for ACP conversations.
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Affiliation(s)
- Olaf P Geerse
- Ariadne Labs at Brigham and Women's Hospital and the Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | - Daniela J Lamas
- Ariadne Labs at Brigham and Women's Hospital and the Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Rachelle E Bernacki
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Justin J Sanders
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Joanna Paladino
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Annette J Berendsen
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | - Thijo J N Hiltermann
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Erik K Fromme
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Susan D Block
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Lakin JR, Neal BJ, Maloney FL, Paladino J, Vogeli C, Tumblin J, Vienneau M, Fromme E, Cunningham R, Block SD, Bernacki RE. A systematic intervention to improve serious illness communication in primary care: Effect on expenses at the end of life. Healthc (Amst) 2020; 8:100431. [PMID: 32553522 DOI: 10.1016/j.hjdsi.2020.100431] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 04/26/2020] [Accepted: 04/29/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND At a population level, conversations between clinicians and seriously ill patients exploring patients' goals and values can drive high-value healthcare, improving patient outcomes and reducing spending. METHODS We examined the impact of a quality improvement intervention to drive better communication on total medical expenses in a high-risk care management program. We present our analysis of secondary expense outcomes from a prospective implementation trial of the Serious Illness Care Program, which includes clinician training, coaching, tools, and system interventions. We included patients who died between January 2014 and September 2016 who were selected for serious illness conversations, using the "Surprise Question," as part of implementation of the program in fourteen primary care clinics. RESULTS We evaluated 124 patients and observed no differences in total medical expenses between intervention and comparison clinic patients. When comparing patients in intervention clinics who did and did not have conversations, we observed lower average monthly expenses over the last 6 ($6297 vs. $8,876, p = 0.0363) and 3 months ($7263 vs. $11,406, p = 0.0237) of life for patients who had conversations. CONCLUSIONS Possible savings observed in this study are similar in magnitude to previous studies in advance care planning and specialty palliative care but occur earlier in the disease course and in the context of documented conversations and a comprehensive, interprofessional case management program. IMPLICATIONS Programs designed to drive more, earlier, and better serious illness communication hold the potential to reduce costs. LEVEL OF EVIDENCE Prospectively designed trial, non-randomized sample, analysis of secondary outcomes.
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Affiliation(s)
- Joshua R Lakin
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Department of Medicine, Brigham & Women's Hospital, Boston, MA, USA.
| | - Brandon J Neal
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Francine L Maloney
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Joanna Paladino
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Christine Vogeli
- Harvard Medical School, Boston, MA, USA; Partners Healthcare, Boston, MA, USA; Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Erik Fromme
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Rebecca Cunningham
- Harvard Medical School, Boston, MA, USA; Department of Medicine, Brigham & Women's Hospital, Boston, MA, USA
| | - Susan D Block
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Department of Medicine, Brigham & Women's Hospital, Boston, MA, USA; Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
| | - Rachelle E Bernacki
- Ariadne Labs, Brigham and Women's Hospital & Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Department of Medicine, Brigham & Women's Hospital, Boston, MA, USA
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24
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Abstract
Clinicians working with seriously ill patients need the skills to effectively communicate with patients and their families throughout the trajectory of illness. Common communication tasks that arise in the care of seriously ill patients include advance care planning, delivering serious news, discussing prognosis, eliciting values, and medical decision making. Clinicians often use goals of care conversations to facilitate these tasks. Similar to other procedures, goals of care conversations require a systematic, evidence-based approach to ensure quality and value. This article provides a framework that clinicians can follow to effectively communicate with seriously ill patients and families and promote patient-centered care.
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Affiliation(s)
- Nelia Jain
- Adult Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, 450 Brookline Avenue, JF 805D, Boston, MA 02215, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02215, USA.
| | - Rachelle E Bernacki
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02215, USA; Adult Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, JF 821, Boston, MA 02215, USA; Serious Illness Care Program, Ariadne Labs, 401 Park Drive, 3rd floor, Boston, MA 02215, USA. https://twitter.com/rbernack
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25
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Leiter RE, Pu CT, Mazzola E, Bernacki RE. A HOSPICE COLLABORATIVE NETWORK TO IMPROVE SERIOUS ILLNESS CARE IN A LARGE HEALTHCARE SYSTEM. Innov Aging 2019. [PMCID: PMC6845968 DOI: 10.1093/geroni/igz038.481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
The quality of hospice care in the United States varies significantly, yet healthcare systems lack methods to comprehensively evaluate and stimulate quality improvement in organizations that serve their patients. Partners HealthCare, an integrated healthcare system located in Eastern Massachusetts, sought to create a high-quality hospice collaborative network based on objective and quantitative criteria obtained from public reporting as well as the hospice itself. Through a modified Delphi procedure, clinicians, administrators, and data scientists developed a set of criteria and a scoring system focused on three areas: organizational information, clinical care quality indicators, and training and satisfaction. All Medicare-certified hospices in good-standing in Massachusetts were eligible to participate in a request for information (RFI) process. We blinded all hospice data prior to scoring and invited hospices scoring above the 15th percentile to join the collaborative for a 2-year initial term. Of 72 eligible hospices, the majority (53%) responded to the RFI, of which 60% submitted completed surveys. Hospices could receive up to 23.75 points with scores ranging from 2.25 to 19.5. The median score was 13.62 (IQR: 10.5-16.75). For the 19 hospices scoring above the 15th percentile, scores ranged from 10.0-19.5 (median: 14, IQR: 11.1-16.9). There was no association between quality score and continuous (Spearman’s correlation 0.24, p=0.27) or dichotomous (Wilcoxon rank sum test p=0.13) measures of hospice size. The hospice collaborative network is one healthcare system’s initial attempt to effectively leverage its influence and relationships to improve hospice quality for the benefit of its seriously ill patients and their families.
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Affiliation(s)
- Richard E Leiter
- Dana-Farber Cancer Institute, Boston, Massachusetts, United States
| | - Charles T Pu
- Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Emanuele Mazzola
- Dana-Farber Cancer Institute, Boston, Massachusetts, United States
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26
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Chen EE, Pu CT, Bernacki RE, Ragland J, Schwartz JH, Mutchler JE. Surrogate Preferences on the Physician Orders for Life-Sustaining Treatment Form. Gerontologist 2019; 59:811-821. [PMID: 29788197 DOI: 10.1093/geront/gny042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The purpose of this study is to compare treatment preferences of patients to those of surrogates on the Physician Orders for Life-Sustaining Treatment (POLST) forms. RESEARCH DESIGN AND METHODS Data were collected from a sequential selection of 606 Massachusetts POLST (MOLST) forms at 3 hospitals, and corresponding electronic patient health records. Selections on the MOLST forms were categorized into All versus Limit Life-Sustaining Treatment. Multivariable mixed effects (grouped by clinician) logistic regression models estimated the impact of using a surrogate decision maker on choosing All Treatment, controlling for patient characteristics (age, severity of illness, sex, race/ethnicity), clinician (physician vs non-physician), and hospital (site). RESULTS Surrogates signed 253 of the MOLSTs (43%). A multivariable logistic regression model taking into consideration patient, clinician, and site variables showed that surrogate decision makers were 60% less likely to choose All Treatment than patients who made their own decisions (odds ratio = 0.39 [95% confidence interval = 0.24-0.65]; p < .001). This model explained 44% of the variation in the dependent variable (Pseudo-R2 = 0.442; p < .001); mixed effects logistic regression grouped by clinician showed no difference between the models (LR test = 4.0e-13; p = 1.00). DISCUSSION AND IMPLICATIONS Our study took into consideration variation at the patient, clinician, and site level, and showed that surrogates had a propensity to limit life-sustaining treatment. Surrogate decision makers are frequently needed for hospitalized patients, and nearly all states have adopted the POLST. Researchers may want study decision-making processes for patients versus surrogates when the POLST paradigm is employed.
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Affiliation(s)
| | | | - Rachelle E Bernacki
- Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
| | | | | | - Jan E Mutchler
- Gerontology Department and Institute, University of Massachusetts Boston
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27
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Lakin JR, Brannen EN, Bernacki RE, Jones E. A Curriculum in Quality Improvement for Interprofessional Palliative Care Trainees. Am J Hosp Palliat Care 2019; 37:41-45. [PMID: 31096756 DOI: 10.1177/1049909119850794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION A structured and intentional approach to quality improvement is critical for clinicians specializing in palliative care and is a required component of training programs. METHODS We present a multimodal, comprehensive curriculum for teaching quality improvement to interdisciplinary trainees in palliative care. RESULTS The curriculum consists of 4 sessions, one and half hours long a piece, that focus on the purpose and practice of quality improvement and guide learners through a team-based project implementation experience. Course assessments demonstrate satisfaction with the course and improvement in targeted skills, knowledge, and attitudes. DISCUSSION Several key learnings stand out from our experience with this curriculum as central to the experience of students: project work completed as interdisciplinary teams, varying teaching methodologies over a longitudinal curriculum, and the opportunity for formal presentation of their work.
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Affiliation(s)
- Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.,Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Elise N Brannen
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Rachelle E Bernacki
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.,Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Emma Jones
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Pediatric Advanced Care Team (PACT), Boston Children's Hospital, Boston, MA, USA
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28
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Leung KM, Blatt C, Ravid S, Bilchik B, Bakken K, McGrath DR, Bernacki RE, Schaefer KG, Lee-Lewis D. A PILOT STUDY OF ADVANCE CARE PLANNING IN THE OUTPATIENT CARDIOLOGY SETTING: PRELIMINARY FEASIBILITY AND STUDY DESIGN. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)33617-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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29
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Geerse OP, Lamas DJ, Sanders JJ, Paladino J, Kavanagh J, Henrich NJ, Berendsen AJ, Hiltermann TJN, Fromme EK, Bernacki RE, Block SD. A Qualitative Study of Serious Illness Conversations in Patients with Advanced Cancer. J Palliat Med 2019; 22:773-781. [PMID: 30724693 DOI: 10.1089/jpm.2018.0487] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background: Conversations with seriously ill patients about their values and goals have been associated with reduced distress, a better quality of life, and goal-concordant care near the end of life. Yet, little is known about how such conversations are conducted. Objective: To characterize the content of serious illness conversations and identify opportunities for improvement. Design: Qualitative analysis of audio-recorded, serious illness conversations using an evidence-based guide and obtained through a cluster randomized controlled trial in an outpatient oncology setting. Setting/Measurements: Clinicians assigned to the intervention arm received training to use the "Serious Illness Conversation Guide" to have a serious illness conversation about values and goals with advanced cancer patients. Conversations were de-identified, transcribed verbatim, and independently coded by two researchers. Key themes were analyzed. Results: A total of 25 conversations conducted by 16 clinicians were evaluated. The median conversation duration was 14 minutes (range 4-37), with clinicians speaking half of the time. Thematic analyses demonstrated five key themes: (1) supportive dialogue between patients and clinicians; (2) patients' openness to discuss emotionally challenging topics; (3) patients' willingness to articulate preferences regarding life-sustaining treatments; (4) clinicians' difficulty in responding to emotional or ambiguous patient statements; and (5) challenges in discussing prognosis. Conclusions: Data from this exploratory study suggest that seriously ill patients are open to discussing values and goals with their clinician. Yet, clinicians may struggle when disclosing a time-based prognosis and in responding to patients' emotions. Such skills should be a focus for additional training for clinicians caring for seriously ill patients.
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Affiliation(s)
- Olaf P Geerse
- 1 Serious Illness Care Program, Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,2 Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Daniela J Lamas
- 1 Serious Illness Care Program, Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,3 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,4 Division of Palliative Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Justin J Sanders
- 1 Serious Illness Care Program, Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,4 Division of Palliative Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,5 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joanna Paladino
- 1 Serious Illness Care Program, Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,4 Division of Palliative Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jane Kavanagh
- 1 Serious Illness Care Program, Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,5 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Natalie J Henrich
- 1 Serious Illness Care Program, Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Annette J Berendsen
- 6 Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Thijo J N Hiltermann
- 2 Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Erik K Fromme
- 1 Serious Illness Care Program, Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,4 Division of Palliative Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,5 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Rachelle E Bernacki
- 1 Serious Illness Care Program, Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,4 Division of Palliative Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,5 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Susan D Block
- 1 Serious Illness Care Program, Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,4 Division of Palliative Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,5 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,7 Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts
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30
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Miranda SP, Bernacki RE, Paladino JM, Norden AD, Kavanagh JE, Palmor MC, Block SD. A Descriptive Analysis of End-of-Life Conversations With Long-Term Glioblastoma Survivors. Am J Hosp Palliat Care 2017; 35:804-811. [PMID: 29121789 DOI: 10.1177/1049909117738996] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Early, high-quality serious illness (SI) conversations are critical for patients with glioblastoma (GBM) but are often mistimed or mishandled. OBJECTIVE To describe the prevalence, timing, and quality of documented SI conversations and evaluate their focus on patient goals/priorities. DESIGN/PARTICIPANTS Thirty-three patients with GBM enrolled in the control group of a randomized controlled trial of a communication intervention and were followed for 2 years or until death. At baseline, all patients answered a validated question about preferences for life-extending versus comfort-focused care and completed a Life Priorities Survey about their goals/priorities. In this secondary analysis, retrospective chart review was performed for 18 patients with GBM who died. Documented SI conversations were systematically identified and evaluated using a codebook reflecting 4 domains: prognosis, goals/priorities, end-of-life planning, and life-sustaining treatments. Patient goals/priorities were compared to documentation. MEASUREMENTS/RESULTS At baseline, 16 of 24 patients preferred life-extending care. In the Life Priorities Survey, goals/priorities most frequently ranked among the top 3 were "Live as long as possible," "Be mentally aware," "Provide support for family," "Be independent," and "Be at peace." Fifteen of 18 patients had at least 1 documented SI conversation (range: 1-4). Median timing of the first documented SI conversation was 84 days before death (range: 29-231; interquartile range: 46-119). Fifteen patients had documentation about end-of-life planning, with "hospice" and "palliative care" most frequently documented. Five of 18 patients had documentation about their goals. CONCLUSION Patients with GBM had multiple goals/priorities with potential treatment implications, but documentation showed SI conversations occurred relatively late and infrequently reflected patient goals/priorities.
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Affiliation(s)
- Stephen P Miranda
- 1 Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,2 Ariadne Labs, Brigham and Women's Hospital and Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Rachelle E Bernacki
- 2 Ariadne Labs, Brigham and Women's Hospital and Harvard T. H. Chan School of Public Health, Boston, MA, USA.,3 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.,4 Harvard Medical School Center for Palliative Care, Boston, MA, USA.,5 Harvard Medical School, Boston, MA, USA.,6 Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Joanna M Paladino
- 2 Ariadne Labs, Brigham and Women's Hospital and Harvard T. H. Chan School of Public Health, Boston, MA, USA.,3 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Andrew D Norden
- 5 Harvard Medical School, Boston, MA, USA.,7 Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA.,8 Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jane E Kavanagh
- 2 Ariadne Labs, Brigham and Women's Hospital and Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Marissa C Palmor
- 2 Ariadne Labs, Brigham and Women's Hospital and Harvard T. H. Chan School of Public Health, Boston, MA, USA.,5 Harvard Medical School, Boston, MA, USA
| | - Susan D Block
- 2 Ariadne Labs, Brigham and Women's Hospital and Harvard T. H. Chan School of Public Health, Boston, MA, USA.,3 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.,5 Harvard Medical School, Boston, MA, USA.,6 Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,9 Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
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31
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Lakin JR, Koritsanszky LA, Cunningham R, Maloney FL, Neal BJ, Paladino J, Palmor MC, Vogeli C, Ferris TG, Block SD, Gawande AA, Bernacki RE. A Systematic Intervention To Improve Serious Illness Communication In Primary Care. Health Aff (Millwood) 2017; 36:1258-1264. [DOI: 10.1377/hlthaff.2017.0219] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Joshua R. Lakin
- Joshua R. Lakin ( ) is a palliative care physician at the Dana-Farber Cancer Institute and Brigham and Women’s Hospital and an associate faculty member at Ariadne Labs, all in Boston, Massachusetts
| | | | - Rebecca Cunningham
- Rebecca Cunningham is medical director of the Integrated Care Management Program at Brigham and Women’s Hospital and an assisant professor of medicine at Harvard Medical School, both in Boston
| | | | | | - Joanna Paladino
- Joanna Paladino is a palliative care physician at Dana-Farber Cancer Institute and the assistant director of implementation for the Serious Illness Care Program at Ariadne Labs
| | | | - Christine Vogeli
- Christine Vogeli is an assistant professor of medicine at Massachusetts General Hospital and Harvard Medical School and director of evaluation and research at the Center for Population Health, Partners HealthCare, in Boston
| | - Timothy G. Ferris
- Timothy G. Ferris is senior vice president of population health at Massachusetts General Hospital and Partners Healthcare and an associate professor of medicine at Harvard Medical School
| | - Susan D. Block
- Susan D. Block is director of the Serious Illness Care Program at Ariadne Labs; founding chair of the Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Brigham and Women’s Hospital; and a professor of psychiatry and medicine, Harvard Medical School
| | - Atul A. Gawande
- Atul A. Gawande is executive director of Ariadne Labs; a surgeon at Brigham and Women’s Hospital; and a professor at the Harvard T. H. Chan School of Public Health and Harvard Medical School
| | - Rachelle E. Bernacki
- Rachelle E. Bernacki is director of quality initiatives for palliative care at the Dana-Farber Cancer Institute and associate director of the Serious Illness Care Program at Ariadne Labs
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32
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Lamas DJ, Owens RL, Nace RN, Massaro AF, Pertsch NJ, Moore ST, Bernacki RE, Block SD. Conversations About Goals and Values Are Feasible and Acceptable in Long-Term Acute Care Hospitals: A Pilot Study. J Palliat Med 2017; 20:710-715. [DOI: 10.1089/jpm.2016.0485] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Daniela J. Lamas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Ariadne Labs at Brigham and Women's Hospital and Harvard T.H. Chen School of Public Health, Boston, Massachusetts
| | - Robert L. Owens
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, San Diego, California
| | - R. Nicholas Nace
- Department of Medicine, Spaulding Hospital for Continuing Medical Care, Cambridge, Massachusetts
| | - Anthony F. Massaro
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Nathan J. Pertsch
- Ariadne Labs at Brigham and Women's Hospital and Harvard T.H. Chen School of Public Health, Boston, Massachusetts
| | - Susan T. Moore
- Department of Medicine, Spaulding Hospital for Continuing Medical Care, Cambridge, Massachusetts
| | - Rachelle E. Bernacki
- Ariadne Labs at Brigham and Women's Hospital and Harvard T.H. Chen School of Public Health, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Susan D. Block
- Ariadne Labs at Brigham and Women's Hospital and Harvard T.H. Chen School of Public Health, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts
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33
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Abstract
Dialysis-dependent ESRD is a serious illness with high disease burden, morbidity, and mortality. Mortality in the first year on dialysis for individuals over age 75 years old approaches 40%, and even those with better prognoses face multiple hospitalizations and declining functional status. In the last month of life, patients on dialysis over age 65 years old experience higher rates of hospitalization, intensive care unit admission, procedures, and death in hospital than patients with cancer or heart failure, while using hospice services less. This high intensity of care is often inconsistent with the wishes of patients on dialysis but persists due to failure to explore or discuss patient goals, values, and preferences in the context of their serious illness. Fewer than 10% of patients on dialysis report having had a conversation about goals, values, and preferences with their nephrologist, although nearly 90% report wanting this conversation. Many nephrologists shy away from these conversations, because they do not wish to upset their patients, feel that there is too much uncertainty in their ability to predict prognosis, are insecure in their skills at broaching the topic, or have difficulty incorporating the conversations into their clinical workflow. In multiple studies, timely discussions about serious illness care goals, however, have been associated with enhanced goal-consistent care, improved quality of life, and positive family outcomes without an increase in patient distress or anxiety. In this special feature article, we will (1) identify the barriers to serious illness conversations in the dialysis population, (2) review best practices in and specific approaches to conducting serious illness conversations, and (3) offer solutions to overcome barriers as well as practical advice, including specific language and tools, to implement serious illness conversations in the dialysis population.
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Affiliation(s)
- Ernest I. Mandel
- Renal Division, Department of Medicine and
- Ariadne Laboratories, Brigham and Women’s Hospital and Harvard TH Chan School of Public Health, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts; and
| | - Rachelle E. Bernacki
- Ariadne Laboratories, Brigham and Women’s Hospital and Harvard TH Chan School of Public Health, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts; and
- Division of Adult Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Susan D. Block
- Departments of Psychiatry and Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Ariadne Laboratories, Brigham and Women’s Hospital and Harvard TH Chan School of Public Health, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts; and
- Division of Adult Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
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34
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Lakin JR, Robinson MG, Bernacki RE, Powers BW, Block SD, Cunningham R, Obermeyer Z. Estimating 1-Year Mortality for High-Risk Primary Care Patients Using the "Surprise" Question. JAMA Intern Med 2016; 176:1863-1865. [PMID: 27695853 PMCID: PMC5755589 DOI: 10.1001/jamainternmed.2016.5928] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts2Ariadne Labs, Brigham and Women's Hospital and Harvard School of Public Health, Boston, Massachusetts
| | - Margaret G Robinson
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Rachelle E Bernacki
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts2Ariadne Labs, Brigham and Women's Hospital and Harvard School of Public Health, Boston, Massachusetts
| | - Brian W Powers
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts4Francis Weld Peabody Society, Harvard Medical School, Boston, Massachusetts
| | - Susan D Block
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts5Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts
| | - Rebecca Cunningham
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ziad Obermeyer
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts7Departments of Emergency Medicine and Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Lakin JR, Block SD, Billings JA, Koritsanszky LA, Cunningham R, Wichmann L, Harvey D, Lamey J, Bernacki RE. Improving Communication About Serious Illness in Primary Care: A Review. JAMA Intern Med 2016; 176:1380-7. [PMID: 27398990 DOI: 10.1001/jamainternmed.2016.3212] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The Institute of Medicine recently called for systematic improvements in clinician-led conversations about goals, values, and care preferences for patients with serious and life-threatening illnesses. Studies suggest that these conversations are associated with improved outcomes for patients and their families, enhanced clinician satisfaction, and lower health care costs; however, the role of primary care clinicians in driving conversations about goals and priorities in serious illness is not well defined. OBJECTIVE To present a review of a structured search of the evidence base about communication in serious illness in primary care. EVIDENCE REVIEW MEDLINE was searched, via PubMed, on January 19, 2016, finding 911 articles; 126 articles were reviewed and selected titles were added from bibliography searches. FINDINGS Review of the literature informed 2 major topic areas: the role of primary care in communication about serious illness and clinician barriers and system failures that interfere with effective communication. Literature regarding the role that primary care plays in communication focused primarily on the ambiguity about whether primary care clinicians or specialists are responsible for initiating conversations, the benefits of primary care clinicians and specialists conducting conversations, and the quantity and quality of discussions. Timely and effective communication about serious illness in primary care is hampered by key clinician barriers, which include deficits in knowledge, skills, and attitudes; discomfort with prognostication; and lack of clarity about the appropriate timing and initiation of conversations. Finally, system failures in coordination, documentation, feedback, and quality improvement contribute to lack of conversations. CONCLUSIONS AND RELEVANCE Clinician and system barriers will challenge primary care clinicians and institutions to meet the needs of patients with serious illness. Ensuring that conversations about goals and values occur at the appropriate time for seriously ill patients will require improved training, validation, and dissemination of patient selection tools, systems for conducting and revisiting conversations, accessible documentation, and incentives for measurement, feedback, and continuous improvement.
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Affiliation(s)
- Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts2Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts3Ariadne Labs, Brigham and Women's Hospital, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts4Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Susan D Block
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts2Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts3Ariadne Labs, Brigham and Women's Hospital, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts4Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts5Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts
| | - J Andrew Billings
- Ariadne Labs, Brigham and Women's Hospital, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts6Division of Palliative Care, Department of Medicine, Massachusetts General Hospital, Boston
| | - Luca A Koritsanszky
- Ariadne Labs, Brigham and Women's Hospital, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Rebecca Cunningham
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lisa Wichmann
- Department of Care Coordination, Brigham and Women's Hospital, Boston, Massachusetts
| | - Doreen Harvey
- Department of Care Coordination, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jan Lamey
- Department of Medical Management, Brigham and Women's Physicians Organization, Boston, Massachusetts
| | - Rachelle E Bernacki
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts2Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts3Ariadne Labs, Brigham and Women's Hospital, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts4Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts9Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Cauley CE, Block SD, Koritsanszky LA, Gass JD, Frydman JL, Nurudeen SM, Bernacki RE, Cooper Z. Surgeons' Perspectives on Avoiding Nonbeneficial Treatments in Seriously Ill Older Patients with Surgical Emergencies: A Qualitative Study. J Palliat Med 2016; 19:529-37. [PMID: 27105058 DOI: 10.1089/jpm.2015.0450] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Clinical decisions for seriously ill older patients with surgical emergencies are highly complex. Measuring the benefits of burdensome treatments in this context is fraught with uncertainty. Little is known about how surgeons formulate treatment decisions to avoid nonbeneficial surgery, or engage in preoperative conversations about end-of-life (EOL) care. OBJECTIVE We sought to describe how surgeons approach such discussions, and to identify modifiable factors to reduce nonbeneficial surgery near the EOL. DESIGN Purposive and snowball sampling were used to recruit a national sample of emergency general surgeons. Semistructured interviews were conducted between February and May 2014. MEASUREMENTS Three independent coders performed qualitative coding using NVivo software (NVivo version 10.0, QSR International). Content analysis was used to identify factors important to surgical decision making and EOL communication. RESULTS Twenty-four surgeons were interviewed. Participants felt responsible for conducting EOL conversations with seriously ill older patients and their families before surgery to prevent nonbeneficial treatments. However, wide differences in prognostic estimates among surgeons, inadequate data about postoperative quality of life (QOL), patients and surrogates who were unprepared for EOL conversations, variation in perceptions about the role of palliative care, and time constraints are contributors to surgeons providing nonbeneficial operations. Surgeons reported performing operations they knew would not benefit the patient to give the family time to come to terms with the patient's demise. CONCLUSIONS Emergency general surgeons feel responsible for having preoperative discussions about EOL care with seriously ill older patients to avoid nonbenefical surgery. However, surgeons identified multiple factors that undermine adequate communication and lead to nonbeneficial surgery.
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Affiliation(s)
- Christy E Cauley
- 1 Ariadne Labs , Boston, Massachusetts.,3 Department of Surgery, Massachusetts General Hospital , Boston, Massachusetts
| | - Susan D Block
- 1 Ariadne Labs , Boston, Massachusetts.,4 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts.,5 Department of Psychiatry, Brigham and Women's Hospital , Boston, Massachusetts.,6 Department of Medicine, Brigham and Women's Hospital , Boston, Massachusetts
| | | | | | | | - Suliat M Nurudeen
- 1 Ariadne Labs , Boston, Massachusetts.,2 Department of Surgery, Brigham and Women's Hospital , Boston, Massachusetts
| | - Rachelle E Bernacki
- 1 Ariadne Labs , Boston, Massachusetts.,4 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts
| | - Zara Cooper
- 1 Ariadne Labs , Boston, Massachusetts.,2 Department of Surgery, Brigham and Women's Hospital , Boston, Massachusetts.,8 Center for Surgery and Public Health, Brigham and Women's Hospital , Boston, Massachusetts
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Dy SM, Herr K, Bernacki RE, Kamal AH, Walling AM, Ersek M, Norton SA. Methodological Research Priorities in Palliative Care and Hospice Quality Measurement. J Pain Symptom Manage 2016; 51:155-62. [PMID: 26596877 DOI: 10.1016/j.jpainsymman.2015.10.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 10/17/2015] [Accepted: 10/22/2015] [Indexed: 11/26/2022]
Abstract
Quality measurement is a critical tool for improving palliative care and hospice, but significant research is needed to improve the application of quality indicators. We defined methodological priorities for advancing the science of quality measurement in this field based on discussions of the Technical Advisory Panel of the Measuring What Matters consensus project of the American Academy of Hospice and Palliative Medicine and Hospice and Palliative Nurses Association and a subsequent strategy meeting to better clarify research challenges, priorities, and quality measurement implementation strategies. In this article, we describe three key priorities: 1) defining the denominator(s) (or the population of interest) for palliative care quality indicators, 2) developing methods to measure quality from different data sources, and 3) conducting research to advance the development of patient/family-reported indicators. We then apply these concepts to the key quality domain of advance care planning and address relevance to implementation of indicators in improving care. Developing the science of quality measurement in these key areas of palliative care and hospice will facilitate improved quality measurement across all populations with serious illness and care for patients and families.
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Affiliation(s)
- Sydney Morss Dy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | - Keela Herr
- University of Iowa College of Nursing, Iowa City, Iowa, USA
| | - Rachelle E Bernacki
- Division of Adult Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Ariadne Labs, Boston, Massachusetts, USA; Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard School of Public Health, Boston, Massachusetts, USA
| | - Arif H Kamal
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Anne M Walling
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California, USA; David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Mary Ersek
- Corporal Michael J. Crescenz VA Medical Center-Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA; School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sally A Norton
- University of Rochester School of Nursing, Rochester, New York, USA
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Cooper Z, Mitchell SL, Lipsitz S, Harris MB, Ayanian JZ, Bernacki RE, Jha AK. Mortality and Readmission After Cervical Fracture from a Fall in Older Adults: Comparison with Hip Fracture Using National Medicare Data. J Am Geriatr Soc 2015; 63:2036-42. [PMID: 26456855 DOI: 10.1111/jgs.13670] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES To examine the prevalence of cervical spine fractures after falls in older Americans, to show changes in recent years, and to compare 12-month outcomes between individuals with cervical and hip fracture after falls. DESIGN Retrospective study of Medicare data from 2007 to 2011. SETTING Acute care hospitals. PARTICIPANTS Individuals aged 65 and older with cervical or hip fracture after a fall. MEASUREMENTS Cervical fracture rate, 12-month mortality, and readmission rate after injury. RESULTS Rates of cervical fracture increased from 4.6 per 10,000 in 2007 to 5.3 per 10,000 in 2011; rates of hip fracture decreased from 77.3 per 10,000 in 2007 to 63.5 per 10,000 in 2011. Participants with cervical fracture with and without spinal cord injury (SCI) were more likely than those with hip fracture to receive treatment at large hospitals (59.4% and 54.1% vs 28.1%, P < .001), teaching hospitals (49.3% and 40.0% vs 13.4%, P < .001), and regional trauma centers (46.3% and 38.5% vs 13.0%, P < .001). Participants with cervical fracture without (24.7%) and with SCI (41.7%) had greater risk-adjusted mortality at 1 year than those with hip fracture (22.7%) (P < .001). By 1 year, 73.4% of participants with cervical fracture with and 59.5% without SCI and 59.3% of those with hip fracture had died or were readmitted to the hospital (P < .001). CONCLUSION Cervical spinal fractures occur in one of every 2,000 Medicare beneficiaries annually and appear to be increasing over time. Participants with cervical fracture had greater mortality than those with hip fracture. Given the increasing prevalence and the poor outcomes in this population, hospitals need to develop processes to improve care for these vulnerable individuals.
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Affiliation(s)
- Zara Cooper
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.,Medical School of Medicine, Harvard University, Boston, Massachusetts
| | - Susan L Mitchell
- Medical School of Medicine, Harvard University, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Stuart Lipsitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Mitchel B Harris
- Medical School of Medicine, Harvard University, Boston, Massachusetts.,Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - John Z Ayanian
- Division of General Medicine, University of Michigan, Ann Arbor, Michigan.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Rachelle E Bernacki
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Ariadne Labs, Boston, Massachusetts
| | - Ashish K Jha
- T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
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Abstract
An understanding of patients' care goals in the context of a serious illness is an essential element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early discussions about goals of care are associated with better quality of life, reduced use of nonbeneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs. Existing evidence does not support the commonly held belief that communication about end-of-life issues increases patient distress. However, conversations about care goals are often conducted by physicians who do not know the patient, do not routinely address patients' nonmedical goals, and often fail to provide patients with sufficient information about prognosis to allow appropriate decisions; in addition, they tend to occur so late in the patient's illness that their impact on care processes is reduced. This article (1) reviews the evidence and describes best practices in conversations about serious illness care goals and (2) offers practical advice for clinicians and health care systems about developing a systematic approach to quality and timing of such communication to assure that each patient has a personalized serious illness care plan. Best practices in discussing goals of care include the following: sharing prognostic information, eliciting decision-making preferences, understanding fears and goals, exploring views on trade-offs and impaired function, and wishes for family involvement. Several interventions hold promise in systematizing conversations with patients about serious illness care goals: better education of physicians; systems to identify and trigger early discussions for appropriate patients; patient and family education; structured formats to guide discussions; dedicated, structured sections in the electronic health record for recording information; and continuous measurement. We conclude that communication about serious illness care goals is an intervention that should be systematically integrated into our clinical care structures and processes.
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Affiliation(s)
- Rachelle E Bernacki
- Division of Adult Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts2Ariadne Labs, Brigham and Women's Hospital & Harvard School of Public Health, Boston, Massachusetts3Division of
| | - Susan D Block
- Division of Adult Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts2Ariadne Labs, Brigham and Women's Hospital & Harvard School of Public Health, Boston, Massachusetts4Center for
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Affiliation(s)
- Rachelle E Bernacki
- Director of quality initiatives in the Department of Psychosocial Oncology and Palliative Care at Dana Farber Cancer Institute and jointly appointed in the Division of Aging at Brigham and Women's Hospital, and principal investigator of the Serious Illness Communication Checklist at Harvard School of Public Health's Ariadne Labs in Boston
| | - Susan D Block
- Chair of the Department of Psychosocial Oncology and Palliative Care at Dana-Farber Cancer Institute and Brigham and Women's Hospital, co-director of the Harvard Medical School Center for Palliative Care, a professor of psychiatry and medicine at Harvard Medical School, and director of the End of Life Program at Harvard School of Public Health's Ariadne Labs in Boston
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Bernacki RE, Ko DN, Higgins P, Whitlock SN, Cullinan A, Wilson R, Jackson V, Dahlin C, Abrahm J, Mort E, Scheer KN, Block S, Billings JA. Improving access to palliative care through an innovative quality improvement initiative: an opportunity for pay-for-performance. J Palliat Med 2012; 15:192-9. [PMID: 22304680 DOI: 10.1089/jpm.2011.0301] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Improving access to palliative care is an important priority for hospitals as they strive to provide the best care and quality of life for their patients. Even in hospitals with longstanding palliative care programs, only a small proportion of patients with life-threatening illnesses receive palliative care services. Our two well-established palliative care programs in large academic hospitals used an innovative quality improvement initiative to broaden access to palliative care services, particularly to noncancer patients. METHODS The initiative utilized a combination of electronic and manual screening of medical records as well as intensive outreach efforts to identify two cohorts of patients with life-threatening illnesses who, according to University HealthSystems Consortium (UHC) benchmarking criteria, would likely benefit from palliative care consultation. Given the differing cultures and structure of the two institutions, each service developed a unique protocol for identifying and consulting on suitable patients. RESULTS Consultation rates in the target populations tripled following the initiative: from 16% to 46% at one hospital and from 15% to 48% at the other. Although two different screening and identification processes were developed, both successfully increased palliative care consultations in the target cohorts. CONCLUSION Quality improvement strategies that incorporate pay-for-performance incentives can be used effectively to expand palliative care services to underserved populations.
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Affiliation(s)
- Rachelle E Bernacki
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Institute, Boston, MA, USA
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Abstract
This article describes the range of cancer patients in longterm care and provides a framework for clinical decision making. The benefits and burdens of providing standard therapy to a vulnerable population are discussed. To give more specific guidelines for advocates of treatment, skeptics, and others, the authors present best estimates of the current burden of cancer in the long-term care population and current screening guidelines that apply to the elderly under long-term care. Experience-based suggestions are offered for oncologists and clinicians involved in long-term care to help them respond to patient and family concerns about limitations of cancer care.
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Affiliation(s)
- Beatriz Korc-Grodzicki
- Geriatrics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.
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Cooper Z, Bernacki RE, Divo M. In Brief. Curr Probl Surg 2011. [DOI: 10.1067/j.cpsurg.2010.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Bernacki RE. Use of healthcare resources in the last six months of life: how doctors learn may explain results. BMJ 2004; 328:1202; author reply 1202. [PMID: 15142940 PMCID: PMC411113 DOI: 10.1136/bmj.328.7449.1202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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