Identifying the gap in goals of care communication across care settings in a flagship cancer research and treatment facility.

Abstract

180 Background: There is widespread recognition of the importance of having and documenting timely Goals of Care (GOC) conversations with seriously ill patients. Inpatient oncology teams at UPMC have noted the limited availability in the Electronic Medical Record (EMR) of documentation of patient preferences about end of life care. This project aims to identify the gaps in GOC communication across care settings for cancer patients at UPMC. Methods: We identified sources of information regarding goals of care available to inpatient oncology providers. Using the EMR we accessed the following for each patient of interest: CPR status, GOC documentation, scanned Advance Directives and/or POLST and last two available outpatient notes. Patients of interests were older than 65 years with metastatic cancer and 2 hospital admissions in the past year, or any cancer patient > 90 years. We reviewed outpatient notes for words suggesting that GOC conversations had occurred, and for a subset (50%), we did a detailed review identifying documentation of prognosis, treatment options, treatment decisions and patient values. Results: Of a total 114 high risk patients admitted over a 6-month period, 73 (64%) died within 6 months, with 52 (46%) dying within one month of their last hospitalization. Thirty nine (34%) patients had at least 5 admissions. Only 35% patients had GOC documented using the EMR template, and only 38% had a completed POLST. Rates of CPR status completion were high (95%). However, when tracking CPR status across multiple admissions, 73% of patients were full code on their first admission, with 31% of patients with five admissions remaining full code. The qualitative analysis of outpatient notes revealed that most documentation (87%) reflected continued treatment with minimal discussion of hospice or patient values. Conclusions: In a cohort of patients with advanced cancer, documentation of GOC discussions is limited in both inpatient and outpatient settings. Available documentation suggests minimal discussion of the limited benefits of medical interventions to prolong life. Future efforts will be designed to improve the quality and frequency of documentation of GOC conversations.