Care Conversations Research Articles

Older Migrant Patients and Health Care Professionals' Experiences With Digital Translation Tools in Care Interactions: A Qualitative Literature Review.

Finding solutions to communicate difficulties in care interactions between health care professionals and older migrant patients may be facilitated by the use of digital translation tools. The aim was to explore older migrant patients' and health professionals' experiences using digital translation tools in transcultural care. A systematic qualitative literature review, based on nine quality assessed articles published 2009 to 2024 from five databases, and analyzed using thematic analysis. Three themes and eight subthemes emerged: advantages of using translation tools describes the benefits experienced using such tools; limitations and challenges highlights the problems identified in their use; and improvement suggestions for the functions of the translation apps describes adjustments and developments of the translation tools. Digital translation used in basic care, may enhance relationships and equity of care, but should not substitute human interpreters in complex care conversations. Translation tools need to be developed according to older users' abilities.

Goals of care conversations and advance care planning for paediatric patients living with serious illness.

Goals of care discussions and advance care planning aim to align the values and wishes of patients and their families with the care received. All paediatric health care practitioners who care for fetuses, infants, children or adolescents with serious illnesses have an ethical responsibility to educate themselves about these aspects of care. This statement assists care providers with important conversations. Effective communication is essential to clarify the goals of care and establish agreement on appropriate treatments for achieving those goals, including resuscitative and palliative measures.

Implementing and Evaluating a Pilot Interprofessional Training Program to Engage Health Care Teams in Cost of Care Conversations.

This study evaluated the impact of Financial and Insurance Navigation Assistance-Training - a pilot interprofessional training program to facilitate cost of care (CoC) conversations and address health-harming social determinants of health in a pediatric hematology-oncology clinic. A pre-post study design was used to evaluate the impact of Financial and Insurance Navigation Assistance-Training on an interprofessional health care team's (clinicians, social workers, financial navigator, and legal advocates) knowledge, attitudes, and behaviors related to CoC conversations and screening, referring, and collaborating with interprofessional team members. Data were collected via surveys administered at baseline/pretraining, immediate post-training, and 12-month post-training. Most health care team members (n= 21) reported improvement in their knowledge of available financial (66.7%) and legal resources (86.7%) and ability to address social needs (93.3%), financial needs (93.3%), and facilitate CoC conversations with patients and caregivers (66.7%). Improvements in attitudes and behaviors toward engaging in CoC conversations, screenings, and referrals were relatively improved as a result of the training. However, there was a lower positive rate for actual behaviors around routine screening and initiating discussions on out-of-pocket costs, suggesting a need to address barriers. Study findings highlight the importance of interprofessional education in helping health care teams address social determinants of health through effective CoC conversations.

Creating and implementing a medical consultation recording app: Improving health information recall and shared decision-making with My Care Conversations.

Research indicates that recording medical consultations benefits patients by helping them recall information pertinent to their care. Cancer Care Alberta set out to develop a mobile recording app to enable patients to safely and securely record appointments and take notes. Stakeholder engagement was conducted with patients, healthcare providers, and the Alberta Health Services Legal & Privacy team. App testing was completed with patient and family advisors. The app was piloted in a clinic to assess workflow impacts before moving to a public launch. The app launched in late November 2018 and continues to be used by patients in the cancer program and beyond. Earlier in 2024, the app underwent additional testing with advisors and user-friendly improvements were made based on feedback and previous user reviews. This article summarizes the development, implementation, and sustainment of the My Care Conversations app. Implementation challenges and effective strategies are highlighted.

Hospice Administrators' and Providers' Perspectives on Providing Upstream Palliative Care: Facilitators, Barriers, and Policy Prescriptions.

Background: Among patients with serious illness, palliative care before hospice enrollment is associated with improved quality of life, reduced symptom burden, and earlier transitions to hospice. However, fewer than half of eligible patients receive specialty palliative care referrals. As most hospice clinicians and administrators have experience in specialty palliative care, several emerging programs propose engaging hospice clinicians to provide early palliative care. Objective: We sought to identify barriers and facilitators to upstream palliative care. Design: We conducted a key informant qualitative study among hospice administrators and clinicians. Setting/Subjects: We conducted semi-structured interviews with 23 hospice administrators and clinicians in eight states from March to August 2022. We identified participants using snowball and purposive sampling using states that participate in Medicare Advantage's value-based insurance design Model. Results: Respondents indicated that barriers to early palliative care included inadequate staffing and reimbursement. Hospice clinicians providing community-based palliative care can address access barriers and improve transitions to hospice. Respondents expressed desire for payer guidance in identifying eligible patients but were cautious about payers acting as direct palliative care providers. However, payers could facilitate uptake by broadening and specifying coverage of services to include goals of care conversations and symptom management. Routine referrals initiated by objective measures could potentially increase access. Conclusions: Utilizing hospice providers to provide upstream palliative care can increase access, improve outcomes, and ease the transition to hospice.

Missed Opportunities for use of Advanced Care Planning and Palliative Care in Open Aortic Surgery

Major vascular surgery, including open aortic procedures, is associated with having a 30-day mortality rate greater than 6% and a perioperative complication rate greater than 50%. Published literature suggests that patients undergoing high-risk procedures benefit from having a care plan in place to not only maximize quality of life but also to ensure medical interventions align with care goals. Currently, there is a paucity of published data on the prevalence of goals of care conversations, advance care planning documentation, and palliative care evaluations in patients undergoing high-risk vascular operations. A retrospective chart review of all patients who underwent open aortic surgery at a tertiary care academic medical center from July 2014 to March 2023 was performed. Patient demographics, comorbidities, type and timing of advanced care planning (ACP), palliative care evaluations, and clinical outcomes during the periprocedural period were recorded. For patients who died during the study period, the use of palliative care prior to death were noted. Patients who received ACP or palliative care were compared with those who did not. The cohort consisted of 192 patients who underwent major open aortic surgery. The mean age was 63 years (SD 12.3) and the majority of patients were male (73.4%) and white (64.1%). Thirty-nine (20.6%) operations were classified as emergent. At the time of their operation, 16.7% (n=32) of patients had an ACP document on file. Of the 38 documents on file, most were durable power of attorney (DPOA) (86.8%) documents while a smaller percentage were physician orders for life-sustaining treatment (POLST) (13.2%). There were no patients with Do Not Resuscitate and/or Intubate (DNR/DNI), living will, or organ/tissue donation orders noted in their chart prior to surgery. One percent (n=2) of patients had a palliative evaluation prior to their operation. During the perioperative period, an additional 2 (1%) of patients had advanced care planning documentation and 7 (3.7%) of patients underwent palliative care evaluation. Fifteen percent of patients (n=28) died during the perioperative period and an additional 21 patients died by the end of the study period for a total mortality of 25.2% in the study population. Among patients that died during the perioperative period, 28.6% (n=8 out of 28) received palliative care. Overall, 28.6% of all study patients that died (n=14 out of 49) received a palliative care evaluation prior to or during their terminal hospitalization. Patients who had ACP documents or who received palliative care consultations prior to surgery were older (p=0.01), more likely to be on Medicare or Medicaid (p=0.004), and more likely to have a history of solid organ malignancy (p=0.03). The median interval between surgery and receiving palliative care was 20 (IQR 3-71) days. The median interval between palliative care and death was 5 (IQR 2-13) days. Patients who utilized ACP or PC were more likely to die at home (p=0.05). Despite a high mortality and morbidity rate, ACP documentation is poor for patients undergoing major open aortic surgery. Palliative care interventions tend to be performed closer to the end of life, suggesting a missed opportunity to define goals of care.

Impact of the Charlson Comorbidity Index on Delirium Outcomes.

Introduction Delirium is a significant inpatient healthcare challenge and has a greater incidence among older adults with adverse healthcare outcomes. Yet there are limited established models for risk stratification. The objective is to determine the effectiveness of implementing the Charlson comorbidity index (CCI) score, which is calculated based on the assigned weight for various disease conditions, and to analyze the healthcare outcomes in older hospitalized adults with delirium. Methodology A retrospective cohort study of 214 elderly hospitalized patients between January 1, 2015, and December 31, 2016, with the diagnosis of delirium, was analyzed by grouping based on the severity of diseases as defined in CCI. The primary analysis outcome was to analyze all-cause inpatient mortality, length of hospital stay (in days), 30-day readmissions, and discharge destination in patients with delirium based on CCI scores using regression analysis and nonparametric tests. Secondary analysis included the prevalence and characteristics of delirium patients in different severity levels of CCI. Results Patients with the severe CCI category (with a total score of five and above) spent 10 days longer in the hospital than those who were categorized with mild delirium (p = 0.011). There is a strong association between in-hospital mortality and the severe CCI category (odds ratio (OR), 4.566; 95% CI, 1.17- 1.86 (p = 0.035)). Also, patients with severe CCI scores were 4.6 times more likely to die during hospitalization compared to patients with less severe comorbidities. There were no significant differences found for discharge destination (OR, 0.702; 95% CI, 371- 1.328 (p = 0.277)) and readmission risk (OR, 1.660; 95% CI, 0.664- 4.149 (p = 0.278)) among different CCI groups. Conclusions Length of stay and inpatient mortality were significantly higher among the severe CCI category compared to the mild category. Our study suggests that CCI can help clinicians, patients, and their families in prognostication and better understanding of goals of care conversations.

Timing and content of serious illness conversations for patients with advanced heart failure in a specialty-aligned palliative care service

BackgroundPatients with advanced heart failure (AHF) desire communication around values and goals prior to treatment decisions. ObjectivesTo evaluate the timing and content of the first serious illness communication (SI conversation) for patients with AHF after referral to a specialist palliative care (PC) team (HeartPal). MethodsIn this retrospective cohort study, we used electronic health records to identify patients referred to HeartPal and their first SI conversations at a tertiary care hospital between October 2018 and September 2021. We used natural language processing and predetermined codes to quantify prevalence of prior goals of care conversations by the cardiology team within six months preceding the HeartPal consultation and the prevalence of hopes, fears, and seven conversation content codes. Consecutive SI conversations and patient outcomes were followed until March 2022. ResultsOf 468 patients (mean age: 64 years, 72 % male, 66 % referred for goals of care conversation), 25.2 % had prior documented goals of care conversations preceding the HeartPal consultation. During the study period, 206 (44.0 %) patients died (median time from initial SI conversation to death: 65 days, IQR 206) and 43.2 % engaged in multiple SI conversations before death. SI conversation analysis (n = 324) revealed that patients hoped to “be at home” (74.1 %, n = 240), “be independent” (65.7 %, n = 213) and “live as long as possible” (53.4 %, n = 173). Conversation content included goals of care (83.0 %), strengths (83.0 %), decision-making (79.3 %), spirituality (71.0 %), coping (52.2 %), and prognostic communication (43.5 %). ConclusionSpecialist PC service provides documentation of goals and values and offers longitudinal follow-up for patients with AHF.

Communication processes in an advance care planning initiative: A socio-ecological perspective for service evaluation.

Advance care planning initiatives are becoming more widespread, increasing expectations for providers to engage in goals of care conversations. However, less is known about how providers communicate advance care planning within and throughout a health care system. To explore perspectives of communication processes in the rollout of an advance care planning initiative. Theoretically informed secondary analysis of 31 semi-structured interviews. Key partners in a Veterans Health Administration goals of care initiative. Using the constant comparative approach followed by qualitative mapping of themes to the layers of the Socio-Ecological Model, four themes and corresponding Socio-Ecological layers were identified: Goals of Care Communication Training (Policy, Community, and Institutional) requires more resources across sites and better messaging to reduce provider misconceptions and promote an institutional culture invested in advance care planning; Interprofessional Communication (Interpersonal) suggests care team coordination is needed to facilitate continuity in goals of care messaging; Communication in Documentation (Institutional, Interpersonal, and Intrapersonal) highlights the need for capturing the context for goals of care preferences; and Patient/Family Communication (Interpersonal and Intrapersonal) encourages offering materials and informational resources early to facilitate rapport building and readiness to determine goals of care. Findings support the need for initiatives to incorporate an evaluation of how goals of care are discussed beyond the interpersonal exchange between patient and provider and signal opportunities for applying the Socio-Ecological Model to better understand goals of care communication processes, including opportunities to improve initiation and documentation of goals of care.

Curriculum Innovations: Enhancing Skills in Serious Illness Communication in Neurology Residents Using Simulation: A Pilot Study.

Patients with acute ischemic stroke are faced with prognostic uncertainty, progressive decline, and early mortality. Many neurologists report a lack of education and experience in providing palliative care. We developed a simulation-based curriculum to improve residents' confidence and comfort with conducting late-stage goals of care (GOC) conversations. To assess and improve neurology residents' self-reported confidence and comfort around GOC discussions, prognostication, and hospice; encourage neurology residents to conduct GOC conversations early in the illness; introduce neurology residents to a structured framework for conducting GOC conversations; facilitate the residents to build rapport and convey a mindful presence during GOC conversations; provide direct, real-time feedback and an opportunity for redo and practice; and identify gaps for education. The 3-hour experience included a didactic session followed by an interactive simulation and debriefing. The residents' objectives were to deliver difficult news, discuss prognosis, explore goals, navigate treatment options, and discuss end-of-life care including hospice. The faculty observed each interaction and called time-outs to allow the residents to self-assess and obtain feedback. Residents and faculty debriefed to identify take-home points and to reflect on their emotions, self-care, and sense of purpose in medicine. Twenty-six neurology residents filled out an anonymous presurvey to self-assess their confidence and comfort surrounding GOC conversations. More than 50% of residents reported being confident in conducting GOC discussions, whereas only 42% reported adequate prior training. Postsession, more than 90% of residents reported that training was relevant, helpful, organized, and clear. Faculty identified that residents had difficulty addressing prognosis, assessing goals, planning treatment, and using silence, responding to emotion, and displaying empathy. Fifteen residents filled out a postsurvey that revealed improved comfort with delivering prognosis, discussing hospice, and initiating early GOC discussions. Our project uniquely focuses on late-stage GOC conversations and builds on existing literature that supports a structured program with both didactic and simulation components to improve residents' abilities to effectively navigate GOC conversations with patients and families. Future work will focus on reinforcement and reassessment of communication skills.

Telehealth for Goals of Care Conversations in Advanced CKD: A Mixed-Methods Pilot Study of US Veterans and Their Clinicians

Telehealth for Goals of Care Conversations in Advanced CKD: A Mixed-Methods Pilot Study of US Veterans and Their Clinicians

Testing the transferability of Machine Learning techniques for determining photometric redshifts of galaxy catalogue populations

Abstract In this work the random forest algorithm GALPRO is implemented to generate photometric redshift posteriors, and its performance when trained and then applied to data from another survey is investigated. The algorithm is initially calibrated using a truth dataset compiled from the DESI Legacy survey. We find that the testing and training datasets must have very similar redshift distributions, with the range of their photometric data overlapping by at least 90% in the appropriate photometric bands in order for the training data to be applicable to the testing data. GALPRO is again trained using the DESI dataset and then applied to a sample drawn from the PanSTARRS survey, to explore whether GALPRO can be trained using a trusted dataset and applied to an entirely new survey, albeit one that uses a different magnitude system for its photometric bands, thus requiring careful conversion of the measured magnitudes. The results of this further test indicate that GALPRO does not produce accurate photometric redshift posteriors for the new survey, even where the distribution of redshifts for the two datasets overlaps by over 90%. We conclude that the photometric redshifts generated by GALPRO are not suitable for generating estimates of photometric redshifts and their posterior distribution functions when applied to an entirely new survey, particularly one that uses a different magnitude system. However, our results demonstrate that GALPRO is a useful tool for inferring photometric redshift estimates in the case where a spectroscopic galaxy survey is nearly complete, but missing some spectroscopic redshift values.

Increasing goals of care conversations in primary care: Study protocol for a cluster randomized, pragmatic, sequential multiple assignment randomized trial

BackgroundGoals of care conversations explore seriously ill patients' values to guide medical decision making and often inform decisions about life sustaining treatments. Ideally, conversations occur before a health crisis between patients and clinicians in the outpatient setting. In the United States Veterans Affairs (VA) healthcare system, most conversations still occur in the inpatient setting. Strategies are needed to improve implementation of outpatient, primary care goals of care conversations. MethodsWe plan a cluster randomized (clinician-level) sequential, multiple assignment randomized trial to evaluate the effectiveness of patient implementation strategies on the outcome of goals of care conversation documentation when delivered in combination with clinician implementation strategies. Across three VA healthcare system sites, we will enroll primary care clinicians with low rates of goals of care conversations and their patients with serious medical illness in the top 10th percentile of risk of hospitalization or death. We will compare the effectiveness of sequences of implementation strategies and explore how patient and site factors modify implementation strategy effects. Finally, we will conduct a mixed-methods evaluation to understand implementation strategy success or failure. The design includes two key innovations: (1) strategies that target both clinicians and patients and (2) sequential strategies with increased intensity for non-responders. ConclusionThis study aims to determine the effect of different sequences and combinations of implementation strategies on primary care documentation of goals of care conversations. Study partners, including the VA National Center for Ethics in Health Care and Office of Primary Care, can consider policies based on study findings.

Challenges in Prognostication of an Older Adult with Severe Obesity and End-Stage Heart Failure: A Case Study.

In this report, we present the case of an older adult with severe obesity and multiple comorbidities, including heart failure with preserved ejection fraction (HFpEF), who experienced a prolonged decline complicated by recurrent hospitalizations and skilled nursing facility stays during the two years preceding death. This case highlights challenges in prognostication attributed to severe obesity complicated by HFpEF, which likely delayed goals of care conversations, and access to palliative care and hospice, despite high symptom burden. We discuss prognostic uncertainty among those with severe obesity and outline potential future directions.

Observations about Holistic Care from the Experience of a Medical Student Shadowing a Chaplain

The project was initiated when a medical student expressed interest in shadowing a chaplain during their third-year clinical rotations. The Hospital Library Service supported this inquiry by providing readings about intentional programs and a medical practitioner spiritual screening for both the chaplain and student to review. By coordinating with the student’s medical supervision, different times were found throughout the day such that a variety of pastoral care instances could be observed. As part of the welcome extended to each patient, the chaplain introduced the medical student and obtained consent for them to be present during the care conversations that followed. These visits occurred over two months in the spring of 2024. This experience provided an opportunity for both the chaplain and student to reflect on the process of acknowledging, confirming, affirming, and encouraging patients and their families. Additionally, through these visits and subsequent conversations, a holistic health and wellness model was used to emphasize compassionate and spiritual patient care.

End of life care in a level IV outborn neonatal intensive care unit.

Describe care surrounding the end of life (EOL) in the neonatal intensive care unit (NICU). Retrospective chart review of 208 infants who died in a level IV referral-only NICU over 5 years. A goals of care (GOC) conversation was documented before the day of death for 63% of infants. 73% died following withdrawal of life-sustaining treatment (WD); 13% died in a code. The median age at death was 17.5 days. 72% were held by a parent at EOL. 94% of families desired formal memory-making. We identified associations with mode of death and parental holding at death, including: WD was associated with palliative care consultation, early GOC conversations, and increased unit-specific length of stay. Holding was associated with chaplain visits, memory-making, and increased home-to-hospital distance. We present a detailed description of EOL care in an outborn NICU, including novel data on parental holding and memory-making.

Implementation of kidney palliative care-lessons learned from the US Department of Veterans Affairs.

Advanced kidney disease is a progressive life-limiting illness associated with high symptom burden, disability, and highly intensive care near the end of life. There is growing interest in integrating palliative care principles into the care of patients with advanced kidney disease to improve care and outcomes for these patients. The United States (US) Department of Veterans Affairs (VA) has been a leader in advancing palliative care initiatives across its health system and whose experience and approach may be instructive to other health systems seeking to develop kidney palliative care (KPC) services. Herein, we review current KPC programs in the VA and highlight the different models of care that programs have been adopted and how key components of goals of care conversations and advance care planning, symptom management, multidisciplinary care, patient selection, and quality improvement have been implemented across programs. VA KPC programs have adopted "parallel", "merged", and "embedded" models of KPC that reflect the different configurations of partnerships between nephrology and palliative care providers to deliver KPC. A primary service of VA KPC programs is providing goals of care conversations and advance care planning to referred patients and systematically documenting the outcomes of these discussions in standardized note templates in the electronic medical record. Symptom management is delivered by KPC providers through regular shared or sequential visits with patients' nephrology providers and is guided by patient responses to validated symptom surveys. Programs are staffed by allied health professionals, such as chaplains, pharmacists, social workers, and dieticians, to provide whole-person care and regularly huddle with nephrology staff to reach a shared understanding of each patient's care needs and plan. KPC programs implement champions who select patients in greatest need of KPC using a combination of clinical events that trigger referral for KPC and validated mortality risk prediction scores that are automatically generated in each patient's medical record. KPC programs also routinely collect clinical, patient-reported, process, and care quality measures to assess its services. The experiences of the VA highlight novel approaches that strive to close the care gaps in meeting the KPC needs of patients with advanced kidney disease.

Exploring perceptions of online calculators for identifying community-dwelling older people at risk of dying: A qualitative study

ObjectivesThis study aimed to assess the acceptability, value, and perceived barriers of using electronic risk calculators for predicting and communicating the risk of death in community-dwelling older adults. MethodsOne focus group and eight interviews were conducted with 16 participants with experience caring for patients or family members at end of life. A prototype mortality risk tool was used to anchor discussions. Data were analysed using a qualitative content analysis approach. ResultsFive themes emerged: acceptability, communication, barriers to use, broadening the circle of care, and tool limitations. Participants found the tool helpful for preparation, planning, and providing care, but disagreed on its community availability. Personalized risk estimates were valued for facilitating early goals of care conversations and normalizing discussions about death. However, concerns were raised about the tool's interpretation for individuals with different language, cultural, or educational backgrounds. ConclusionsWhile electronic risk calculators were found to be acceptable, balancing autonomy with varying preferences for receiving the information and potential need for support is crucial. InnovationProviding patient-oriented life-expectancy estimates can enhance decisional capacity and facilitate shared decision-making between patients, their families, and healthcare professionals. Further research is needed to explore effective communication of personalized risk tools and additional benefits, harms, and barriers to implementation.

Does "Dr. Google" improve discussion and decisions in small animal practice? Dog and cat owners use of internet resources to find medical information about their pets in three European countries.

Modern dog and cat owners increasingly use internet resources to obtain information on pet health issues. While access to online information can improve owners' knowledge of patient care and inform conversations with their veterinarian during consultations, there is also a risk that owners will misinterpret online information or gain a false impression of current standards in veterinary medicine. This in turn can cause problems or tensions, for example if the owner delays consulting their veterinarian about necessary treatment, or questions the veterinarian's medical advice. Based on an online questionnaire aimed at dog and cat owners in Austria, Denmark and the United Kingdom (N = 2117) we investigated the use of internet resources to find veterinary medical information, the type of internet resources that were used, and whether owner beliefs explain how often they used the internet to find medical information about their pet. Approximately one in three owners reported that they never used internet resources prior to (31.7%) or after (37.0%) a consultation with their veterinarian. However, when owners do make use of the internet, our results show that they were more likely to use it before than after the consultation. The most common internet resources used by owners were practice websites (35.0%), veterinary association websites (24.0%), or 'other' websites providing veterinary information (55.2%). Owners who believe that the use of internet resources enables them to have a more informed discussion with their veterinarians more often use internet resources prior to a consultation, whereas owners who believed that internet resources help them to make the right decision for their animal more often use internet resources after a consultation. The results suggest that veterinarians should actively ask pet owners if they use internet resources, and what resources they use, in order to facilitate open discussion about information obtained from the internet. Given that more than a third of pet owners use practice websites, the findings also suggest that veterinarians should actively curate their own websites where they can post information that they consider accurate and trustworthy.

Feasibility and Effectiveness of Virtual Group Advance Care Planning Visits During the COVID-19 Pandemic.

The COVID-19 pandemic necessitated the transition from in person to virtual advance care planning (ACP) engagement efforts. This pilot initiative evaluated virtual group visits (GVs) and in-person GVs for ACP to determine their feasibility and effectiveness. Participants included patients in a Geriatric Medicine clinic who were referred by their primary care physician to an ACP GVs intervention. The ACP GVs had 2 sessions, led by clinicians with ACP expertise who facilitated a discussion on patients' values, goals, and preferences. Participants were provided with technical assistance to support use of the virtual platform. Evaluation included an ACP readiness survey, post-session feedback, GV observations, and electronic health record review at baseline and a 6month follow-up for goals of care documentation and advance directives. Seventy patients attended 46 ACP GVs from August 2019 to February 2022, including 16 in-person GVs and 54 virtual GVs. At a 6month follow-up, for virtual GVs participants (n = 54), goals of care documentation increased from 31% to 93%, and advance directives increased from 22% to 30%. For in-person GVs participants (n = 16), goals of care documentation increased from 25% to 100%, and advance directives increased from 69% to 75%. All surveyed patients in both formats would recommend ACP GVs. ACP GVs are feasible and effective for supporting ACP, demonstrating an increase in both goals of care conversations and advance directives completion.