Abstract
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. To explore clinicians' experiences with the SICP 1 year after implementation. 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. The SICP includes clinician training, communication tools, and processes for system change. Clinicians' experiences with and perceptions of the SICP. 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. 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.
Highlights
Hospitalized patients with serious life-limiting illness often receive treatment incongruent with their preferences.[1,2,3] Unwanted interventions are associated with increased distress among patients and families, medical error, reduced quality of life, and lower satisfaction with care.[4,5,6] Clinicians experience moral distress when providing aggressive interventions for which they perceive no benefit.[7]
The 3 main themes were the ways in which the Serious Illness Care Program (SICP) (1) supported changes in clinician behavior, (2) shifted the focus of goals-ofcare conversations beyond discussion of code status, and (3) influenced clinicians personally and professionally
Concerns with the program included finding time to have conversations, building transient relationships, and limiting conversation fluidity. 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
Summary
Hospitalized patients with serious life-limiting illness often receive treatment incongruent with their preferences.[1,2,3] Unwanted interventions are associated with increased distress among patients and families, medical error, reduced quality of life, and lower satisfaction with care.[4,5,6] Clinicians experience moral distress when providing aggressive interventions for which they perceive no benefit.[7]. Multiple educational programs and tools have sought to enhance this communication.[13,16,17,18] The Serious Illness Care Program (SICP) uses a multifaceted system-change approach to build clinician capacity for more timely and person-centered conversations about the values and priorities of patients with serious illness.[19] In a cluster randomized clinical trial, the SICP achieved more, earlier, and better-quality conversations in an outpatient setting and reduced anxiety and depression among patients with advanced cancer.[20,21] less is known about the consequences of the SICP when applied in hospitals. The objective of this qualitative study was to understand clinicians’ experiences with the SICP 1 year after its implementation in the general internal medicine wards of 2 hospitals in Canada
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