Earlier Goals-of-Care Conversations Improve Patient Outcomes

TON January 2016 Vol 9 No 1 - Palliative Care
Meg Barbor, MPH

Boston, MA-An intervention called the Serious Illness Care Program uses a systematic approach to train and support clinicians in conducting conversations about goals of care with their patients, thereby improving patient outcomes, according to Rachelle Bernacki, MD, MS, who presented the preliminary results of the study at the recent Palliative Care in Oncology Symposium.

Less than a third of patients with end-stage medical diagnoses discuss end-of-life preferences with their physicians. As a result, patients regularly receive treatments that are not aligned with their goals.

"High-quality communication is associated with better serious illness care," said Dr Bernacki, Director of Quality Initiatives and Psychosocial Oncology and Palliative Care Senior Physician at the Dana-Farber Cancer Institute in Boston, MA. "However, these types of conversations often occur very late or not at all."

Earlier conversations about patient goals and priorities in serious illness are associated with enhanced goal-concordant care, improved quality of life, higher patient satisfaction, more and earlier hospice care, better patient and family coping, eased burden of decision-making for families, and improved bereavement outcome.

"Palliative care, with a strong emphasis on quality communication, is a high-value intervention," she said. "However, we do not and will not have enough palliative care clinicians to reach all patients who would benefit."

To expand access to these serious illness conversations, Dr Bernacki and her colleagues designed an intervention targeted at nonpalliative care clinicians.

Study Design

Investigators sought to evaluate clinician adoption and acceptability of both the training program and the Serious Illness Conversation Guide (a 7-question open-ended guide within the intervention) to determine the frequency, timing, and quality of goals-of-care documentation before death.

A cluster-randomized trial is currently under way, including oncology clinicians and their high-risk patients. The intervention group receives a patient-centered discussion about values and priorities conducted by trained oncology clinicians utilizing the conversation guide. The control group receives usual oncology care.

The intervention includes clinician identification of high-risk patients through the use of "The Surprise Question," a 2.5-hour clinician training on the Serious Illness Conversation Guide, an e-mail trigger reminding clinicians to have these conversations with their patients, and, finally, electronic health record (EHR) documentation.

Widespread Acceptability Demonstrated

Ninety oncology clinicians were randomized in clusters to the intervention group (n = 47) or the control group (n = 43). Of the 47 intervention clinicians, 46 have been trained and have rated the training as effective (4.3/5). Of the trained clinicians who have been e-mail-triggered, 97% have completed at least 1 conversation, and the conversation guide has been established as acceptable (4.2/5). Additionally, the trigger system was found to stimulate discussions in 90% of patients within 2 visits.

A total of 331 patients are enrolled in the study (163 intervention; 168 control). A preliminary chart review revealed more goals-of-care conversations occurred before death in patients receiving intervention compared with controls (92% vs 70%; P = .0037); intervention conversations also took place 4 months earlier than in the control group (median of 143 days vs 63 days; P = .0008).

Conversations in the intervention group were found to be more patient-centered (95% vs 45%; P < .0001), more readily retrievable in the EHR (68% vs 28%; P < .0001), and far fewer of them used code status only (5% vs 55%; P < .0001).

Based on preliminary data, the intervention was found to be feasible and acceptable to both patients and clinicians, also resulting in more patient-centered and comprehensive EHR documentation.

"The Serious Illness Care Program results in more, earlier, and better conversations about serious illness care values and goals," said Dr Bernacki.

Reference

Bernacki R, Paladino J, Lamas D, et al. Delivering more, earlier, and better goals-of-care conversations to seriously ill oncology patients. Presented at: 2015 Palliative Care in Oncology Symposium; October 9-10, 2015; Boston, MA. Abstract 39.

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Last modified: February 16, 2016