Documented Goals Of Care Discussions Research Articles

Classification of Documented Goals of Care Among Hospitalized Patients with High Mortality Risk: a Mixed-Methods Feasibility Study.

The ability to classify patients' goals of care (GOC) from clinical documentation would facilitate serious illness communication quality improvement efforts and pragmatic measurement of goal-concordant care. Feasibility of this approach remains unknown. To evaluate the feasibility of classifying patients' GOC from clinical documentation in the electronic health record (EHR), describe the frequency and patterns of changes in patients' goals over time, and identify barriers to reliable goal classification. Retrospective, mixed-methods chart review study. Adults with high (50-74%) and very high (≥ 75%) 6-month mortality risk admitted to three urban hospitals. Two physician coders independently reviewed EHR notes from 6months before through 6months after admission to identify documented GOC discussions and classify GOC. GOC were classified into one of four prespecified categories: (1) comfort-focused, (2) maintain or improve function, (3) life extension, or (4) unclear. Coder interrater reliability was assessed using kappa statistics. Barriers to classifying GOC were assessed using qualitative content analysis. Among 85 of 109 (78%) patients, 338 GOC discussions were documented. Inter-rater reliability was substantial (75% interrater agreement; Cohen's kappa = 0.67; 95% CI, 0.60-0.73). Patients' initial documented goal was most frequently "life extension" (N = 37, 44%), followed by "maintain or improve function" (N = 28, 33%), "unclear" (N = 17, 20%), and "comfort-focused" (N = 3, 4%). Among the 66 patients whose goals' classification changed over time, most changed to "comfort-focused" goals (N = 49, 74%). Primary reasons for unclear goals were the observation of concurrently held or conditional goals, patient and family uncertainty, and limited documentation. Clinical notes in the EHR can be used to reliably classify patients' GOC into discrete, clinically germane categories. This work motivates future research to use natural language models to promote scalability of the approach in clinical care and serious illness research.

Abstract WP143: Towards What Goal? Palliative Care Utilization for the Post Endovascular Therapy Patient

Introduction: AHA Guidelines call for utilization of Palliative Care (PC) for all patients with serious, life-threatening stroke. The purpose of this study was to assess factors associated with change in Code Status and PC utilization for patients with large vessel occlusion undergoing EVT. Methods: We retrospectively reviewed prospectively collected data in an IRB-approved stroke registry at two large, academic Comprehensive Stroke Centers. Subjects who received EVT for acute ischemic stroke (AIS) between 2014-2022 were included. Patients were grouped by change in code status during hospitalization. Baseline demographics were compared between groups with frequencies, chi-squared or t-test as appropriate. A correlation matrix was constructed and regression was performed. Results: Of the 411 included patients, 88 had code status changes. There was a significant difference in age, history of diabetes, last known well to hospital arrival, groin puncture to recanalization, and sICH within 36 hours between groups (Table 1). Goals of care (GOC) discussion was documented in only 36% of patients, with a mean of 4 days from stroke onset to code status change. Code status change was significantly associated with female sex (p=0.04), history of diabetes (p=0.01), sICH at 36 hours post rt-PA (p<0.001), PC consult (p<0.001), and rt-PA treatment (p=0.004). Code status change was best predicted with a model including age, DM, Initial NIHSS, and sICH within 36 hours. Conclusions: Despite undergoing acute intervention, few AIS patients had documented GOC discussions or code status change during hospitalization. Biases must be addressed in utilizing PC in AIS to provide comprehensive care. Standardized GOC discussions result in caregivers being more informed of prognosis and ensuring that patient’s GOC are honored. Further research is needed to determine barriers to GOC discussions and PC utilization in AIS.

Virtual inpatient continuity visit to reduce readmissions, establish goals of care and engage palliative care: A feasibility pilot.

421 Background: Patients with solid tumors readmitted within 30 days (d) have a median overall survival of less than 90d. Decisions regarding goals of care (GOC), engagement with Palliative Care (PC) and further therapy are often deferred to the outpatient team leading to future readmissions. Methods: A pilot virtual continuity visit (VCV) program was developed using a video platform to arrange meetings with outpatient oncologists, inpatient teams, patients, families and PC providers during a hospital readmission within 30d. The intervention occurred on a single solid tumor oncology service at an academic medical center. Patients were included if discharged from the same hospital within 30d and not readmitted from hospice or SNF. Exclusion criteria included admission for scheduled therapy, curative-intent treatment, or acute side effects of new therapy. Orders were placed at the discretion of the inpatient team. Visits were scheduled only on weekdays. A structured discussion tool was used for prognostic awareness, GOC and availability of PC services. Results: From April 1, 2022 through March 31, 2023, 96 unique patients were eligible for VCVs. This represented 6% admissions to this floor. 15 VCV were completed, 23 were scheduled but not completed, 58 were not scheduled. Reason scheduled visits not completed included: in-person family meeting (7 ), physician unavailable (9), transfer off floor (1), conversation deferred to outpatient visit (4), not clinically necessary (2). Reason visits not scheduled: unable to schedule prior to D/C (37), deferred to outpatient (2) hospice D/C (3), not appropriate (5), in person visit (1). Of the 15 patients who completed VCV, 0% were readmitted within 30d, 100% had documented GOC discussion and 100% had PC engaged in the VCV. Of the 7 patients who had in person visits, 3 of 7 were readmitted, 1 of 7 in person visits had a documented GOC discussion. No PC engagement was present for the in-person meetings. 51/58 patients without scheduled VCV were readmitted, 22 within 30d. Conclusions: VCV are feasible via a video platform with the patient, primary oncologist, inpatient team and PC. The structured discussion provided clear documentation of prognostic awareness, GOC and engagement with PC. No patient who completed a VCV was readmitted.

Video Intervention and Goals-of-Care Documentation in Hospitalized Older Adults

Despite the benefits of goals-of-care (GOC) communication, many hospitalized individuals never communicate their goals or preferences to clinicians. To assess whether a GOC video intervention delivered by palliative care educators (PCEs) increased the rate of GOC documentation. This pragmatic, stepped-wedge cluster randomized clinical trial included patients aged 65 years or older admitted to 1 of 14 units at 2 urban hospitals in New York and Boston from July 1, 2021, to October 31, 2022. The intervention involved PCEs (social workers and nurses trained in GOC communication) facilitating GOC conversations with patients and/or their decision-makers using a library of brief, certified video decision aids available in 29 languages. Patients in the control period received usual care. The primary outcome was GOC documentation, which included any documentation of a goals conversation, limitation of life-sustaining treatment, palliative care, hospice, or time-limited trials and was obtained by natural language processing. A total of 10 802 patients (mean [SD] age, 78 [8] years; 51.6% male) were admitted to 1 of 14 hospital units. Goals-of-care documentation during the intervention phase occurred among 3744 of 6023 patients (62.2%) compared with 2396 of 4779 patients (50.1%) in the usual care phase (P < .001). Proportions of documented GOC discussions for Black or African American individuals (865 of 1376 [62.9%] vs 596 of 1125 [53.0%]), Hispanic or Latino individuals (311 of 548 [56.8%] vs 218 of 451 [48.3%]), non-English speakers (586 of 1059 [55.3%] vs 405 of 863 [46.9%]), and people living with Alzheimer disease and related dementias (520 of 681 [76.4%] vs 355 of 570 [62.3%]) were greater during the intervention phase compared with the usual care phase. In this stepped-wedge cluster randomized clinical trial of older adults, a GOC video intervention delivered by PCEs resulted in higher rates of GOC documentation compared with usual care, including among Black or African American individuals, Hispanic or Latino individuals, non-English speakers, and people living with Alzheimer disease and related dementias. The findings suggest that this form of patient-centered care delivery may be a beneficial decision support tool. ClinicalTrials.gov Identifier: NCT04857060.

Factors and Barriers to Goals-of-Care Conversations for Patients With Cancer and Inpatient Mortality.

Conversations about personal values and goals of care (GOC) at the end of life are essential in caring for patients with advanced cancer. However, GOC conversations may be influenced by patient and oncologist factors during transitions of care. We electronically administered surveys to medical oncologists of inpatients who died from May 1, 2020, to May 31, 2021. Primary outcomes included oncologists' knowledge of inpatient death, anticipation of patient death, and recollection of GOC discussions. Secondary outcomes, including GOC documentation and advance directives (ADs), were collected retrospectively from electronic health records. Outcomes were analyzed for association with patient, oncologist, and patient-oncologist relationship factors. For 75 patients who died, 104/158 (66%) surveys were completed by 40 inpatient and 64 outpatient oncologists. Eighty-one oncologists (77.9%) were aware of patients' deaths, 68 (65.4%) anticipated patients' deaths within 6 months, and 67 (64.4%) recalled having GOC discussions before or during the terminal hospitalization. Outpatient oncologists were more likely to report knowledge of patient death (P < .001), as were those with longer therapeutic relationships (P < .001). Inpatient oncologists were more likely to correctly anticipate patient death (P = .014). Secondary outcomes revealed 21.3% of patients had documented GOC discussions before admission and 33.3% had ADs; patients with a longer duration of cancer diagnosis were more likely to have ADs (P = .003). Oncologist-reported barriers to GOC included unrealistic expectations from patients or family (25%) and decreased patient participation because of clinical conditions (15%). Most oncologists recalled having GOC discussions for patients with inpatient mortality, yet documentation of serious illness conversations remained suboptimal. Further studies are needed to examine barriers to GOC conversations and documentation during transitions of care and across health care settings.

Goals-of-care and serious illness conversations for patients with cancer with inpatient mortality.

184 Background: Goals-of-care (GOC) and serious illness conversations are an integral part of personalized cancer care, particularly toward the end of life (EOL). Eliciting patients (pts)’ preferences and values facilitates informed decision-making throughout the disease course and enables oncologists to provide patient-centered care. Many aspects of GOC discussions and advance care planning (ACP) are inadequately understood, particularly during transitions of care when pts are hospitalized. Methods: We administered surveys to inpatient and outpatient medical oncologists of pts who died while hospitalized from 5/1/2020 to 5/31/2021. Survey items included oncologists’ knowledge of inpatient death, anticipation of pt death within six months of admission, recollection of GOC discussions taking place, and perceived barriers to GOC discussions. To better characterize EOL planning for these pts, retrospective data was collected to identify documentation of GOC discussions, advance directives, and hospice consideration in pts’ electronic health records. Results: For 75 cancer pts who died while hospitalized, 158 surveys were electronically administered with 104 responses (response rate: 66%). Pts characteristics: median age 62 (range 25-89); 63% men; 79% white; median length of hospital stay 7 days (range 1-45). Primary cancer disease type varied: 26.7% gastrointestinal, 18.7% non-small cell lung, 14.7% hematologic, 10.7% sarcoma, 9.3% genitourinary, and 19.9% other cancers. Of 104 completed surveys, responses were received from 40 inpatient and 64 outpatient oncologists. 81 oncologists (77.9%) were aware of the pt’s death prior to survey communication, 68 (65.4%) anticipated the pt’s death within six months of admission, and 67 (64.4%) recalled having a GOC discussion prior to or during the terminal hospitalization. Only 21.3% of pts had documented GOC discussions prior to admission, 33.3% had advance directives, and 22.7% had prior documentation of hospice consideration. Oncologist-reported barriers to GOC discussions included unrealistic expectations from pts or family (25%) and inability for pts to participate due to their clinical condition (15%). Oncologists commented on lack of time, lack of communication between inpatient and outpatient teams, and discordance among multiple inpatient providers as additional barriers. Conclusions: Most oncologists recalled having GOC discussions and anticipated six-month mortality for cancer pts who died while hospitalized. However, documentation of ACP and serious illness communication remained sub-optimal. Ongoing analyses are examining potential associations between patient, provider, and patient-provider relationship factors and oncologists’ survey responses. Addressing barriers to serious illness conversations across different healthcare settings is crucial to providing high-quality EOL care for cancer pts.

Critical decisions in the trauma intensive care unit: Are we practicing primary palliative care?

Devastating injuries require both urgent assessment by a trauma service and early attention to patients' goals of care (GOC). American College of Surgeons Trauma Quality Improvement Program (TQIP) guidelines recommend an initial palliative assessment within 24 hours of admission and family meeting, if needed, within 72 hours. We hypothesize that a primary palliative care-based practice improves adherence to TQIP guidelines in trauma patients. All adult trauma patients who died while inpatient from January 2014 to December 2018 were reviewed. Timing of GOC discussions, transition to comfort measures only (CMO), and the utilization of specialty palliative services were analyzed with univariate analysis. During the study period, 415 inpatients died. Median Injury Severity Score was 26 (interquartile range [IQR], 17-34), median age was 67 years (IQR, 51-81 years), and 72% (n = 299) transitioned to CMO before death. Documented GOC discussions increased from 77% of patients in 2014 to 95% of patients in 2018 (p < 0.001), and in 2018, the median time to the first GOC discussion was 15 hours (IQR, 7- 24 hours). Specialty palliative care was consulted in 7% of all patients. Of patients who had at least one GOC discussion, 98% were led by the trauma intensive care unit (TICU) team. Median time from admission to first GOC discussion was 27 hours (IQR, 6-91 hours). Median number of GOC discussions was 1 (IQR, 1-2). Median time to CMO after the final GOC discussion was 0 hours (IQR, 0-3). Median time to death after transition to CMO was 4 hours (IQR, 1-18 hours). Of those who died during index admission, we demonstrated significant improvement in adherence to American College of Surgeons TQIP palliative guidelines across the 5-year study period, with the TICU team guiding the majority of GOC discussions. Our TICU team has developed an effective primary palliative care approach, selectively consulting specialty palliative care only when needed. Therapeutic/care management, level III.

Mortality Risk for Patients With Stage IV Cancer and Acute Illness Hospitalization

ContextCancer prognosis data often come from clinical trials which exclude patients with acute illness. ObjectivesFor patients with Stage IV cancer and acute illness hospitalization to 1) describe predictors of 60-day mortality and 2) compare documented decision-making for survivors and decedents. MethodsInvestigators studied a consecutive prospective cohort of patients with Stage IV cancer and acute illness hospitalization. Structured health record and obituary reviews provided data on 60-day mortality (outcome), demographics, health status, and treatment; logistic regression models identified mortality predictors. ResultsFour hundred ninety-two patients with Stage IV cancer and acute illness hospitalization had median age of 60.2 (51% female, 38% minority race/ethnicity); 156 (32%) died within 60 days, and median survival for decedents was 28 days. Nutritional insufficiency (odds rato [OR] 1.83), serum albumin (OR 2.15 per 1.0 g/dL), and hospital days (OR 1.04) were associated with mortality; age, gender, race, cancer, and acute illness type were not predictive.On admission, 79% of patients had orders indicating Full Code. During 60-day follow-up, 42% of patients discussed goals of care. Documented goals of care discussions were more common for decedents than survivors (70% vs. 28%, P < 0.001), as were orders for do not resuscitate/do not intubate (68% vs. 24%, P < 0.001), stopping cancer-directed therapy (29% vs. 10%, P < 0.001), specialty Palliative Care (79% vs. 44%, P < 0.001), and Hospice (68% vs. 14%, P < 0.001). ConclusionAcute illness hospitalization is a sentinel event in Stage IV cancer. Short-term mortality is high; nutritional decline increases risk. For patients with Stage IV cancer, acute illness hospitalization should trigger goals of care discussions.

Risky Behavior: Hospital Transfers Associated with Early Mortality and Rates of Goals of Care Discussions.

IntroductionInter-hospital transfer (IHT) patients have higher in-hospital mortality, higher healthcare costs, and worse outcomes compared to non-transferred patients. Goals of care (GoC) discussions prior to transfer are necessary in patients at high risk for decline to ensure that the intended outcome of transfer is goal concordant. However, the frequency of these discussions is not well understood. This study was intended to assess the prevalence of GoC discussions in IHT patients with early mortality, defined as death within 72 hours of transfer, and prevalence of primary diagnoses associated with in-hospital mortality.MethodsThis was a retrospective study of IHT patients aged 18 and older who died within 72 hours of transfer to Wake Forest Baptist Medical Center between October 1, 2016-October 2018. Documentation of GoC discussions within the electronic health record (EHR) prior to transfer was the primary outcome. We also assessed charts for primary diagnosis associated with in-hospital mortality, code status changes prior to death, in-hospital healthcare interventions, and frequency of palliative care consults.ResultsWe included in this study a total of 298 patients, of whom only 10.1% had documented GoC discussion prior to transfer. Sepsis (29.9%), respiratory failure (28.2%), and cardiac arrest (27.5%) were the top three diagnoses associated with in-hospital mortality, and 73.2% of the patients transitioned to comfort measures prior to death. After transfer, 18.1% of patients had invasive procedures performed with 9.7% undergoing major surgery. Palliative care consultation occurred in only 4.4%.ConclusionThe majority (89.9%) of IHT patients with early mortality did not have GoC discussion documented within EHR prior to transfer, although most transitioned to comfort measures prior to their deaths, highlighting that additional work is needed in this area.

Retrospective study of the evaluation and management of febrile neutropenia in cancer patients in a tertiary center.

e19100 Background: Febrile neutropenia is a medical emergency often managed by internists, but adherence to guidelines has not been well-described. We aimed to describe care and outcomes of a retrospective cohort of patients hospitalized with febrile neutropenia at a single tertiary care hospital. Methods: We included adults ≥18 years old who had a cancer diagnosis and required hospital admission for a principal diagnosis of fever and neutropenia (ANC &lt; 500) from October 2015 - April 2019. We reviewed records to identify demographics, cancer diagnosis and stage, and outcomes, including death. Results: We included 193 patients; all were cared for by hospitalists. About half (52%) were classified as high risk [ &lt; 21 Multinational Association of Supportive Care in Cancer (MASCC)score], but only 1 patient had a documented MASCC score in hospital progress notes. The majority of patients were female (55%) and white (84%). Twenty-three percent had a stage IV diagnosis. Most (89.1%) patients were within their first chemotherapy cycle, and 23% received GCSF. Approximately half (47%) had solid tumors; the remainder had hematologic malignancies. About one quarter (27%) had positive blood cultures (of these, 43.4 % were gram positive cocci (GPC); 49.1% were gram negative rods (GNR)). Most patients received empiric coverage for GPC and GNR: 82% received cefepime and 42% received empiric MRSA coverage. Few patients had cultures positive for resistant organisms such as MRSA (n = 3) or pseudomonas (n = 4). Hematology/Oncology was consulted for most (82%) cases. Inpatient mortality occurred in 12% of patients. Compared to those who survived, patients who died had lower MASCC score 13.9 (vs. 19.1) and were more likely to receive critical care therapies during hospitalization (70% vs. 14%). Few patients (n = 24, 12%) had documented goals of care (GOC) discussions. Conclusions: Although MASCC is predictive of outcomes, internists caring for patients with fever and neutropenia do not document this score. Hospitalist-focused education efforts about MASCC score could improve care. Few patients had documented GOC discussions. Oncologists should maintain good communication with internal medicine colleagues, who may be hesitant to address GOC in patients receiving chemotherapy.

Goals of care designations in advanced pancreatic cancer patients undergoing palliative chemotherapy.

683 Background: Discussion of goals of care (GoC) is a key part of quality care for patients with palliative cancer. Numerous studies have shown that documentation of GoC in this population remains low. In 2014, Alberta Health Services launched a health-system wide initiative to provide patients with physical copies of their GoC designation intended to be available at all health-system interactions. Here we describe rates of GoC documentation in the period surrounding this initiative. Methods: This is a retrospective cohort analysis of 240 patients with locally advanced or metastatic pancreatic cancer treated with palliative chemotherapy from 2012-2015 in Alberta, Canada. Data were obtained from outpatient electronic medical record documentation and the provincial cancer registry. Results: 63.8% (153/240) of patients had a documented GoC discussion, with 60.4% (145/240) receiving a specific GoC designation. 59.6% (143/240) of patients were referred to palliative care, with 32.5% (78/240) seen by palliative care physician. Of 334 individual GoC discussions documented, 38.6% (129/334) were by medical oncologists, 2.3% (10/334) were by radiation oncologists, 27.2% (91/334) were by palliative care, and 19.2% (64/334) were by other inpatient physicians during hospital admissions. At least 9.6% (32/334) referenced discussions that occurred prior to initial consultation with an oncology physician. Conclusions: The majority of pancreatic cancer patients undergoing palliative chemotherapy had a documented GoC designation during the study period. Providing patients with physical copies of their GoC designation may therefore represent a simple but effective means of increasing GoC documentation in the outpatient oncology setting.

Evaluation of Palliative Care Coaching Sessions on Resident Physicians' Knowledge, Preparedness, and Frequency of Goals of Care Conversations (QI616)

•Describe a coaching intervention to improve resident physicians' palliative care skills.•Evaluate outcomes in resident preparedness, resident understanding of hospice and disposition options, and goals of care documentation resulting from palliative care coaching sessions. A previously developed coaching intervention increased resident physicians' preparedness in discussing palliative care (PC) topics and improved rates of documented goals of care (GOC) discussions. Based on resident feedback, we focused on prognostication and posthospital discharge options in PDSA cycle 2 of this quality improvement (QI) initiative. Evaluate whether short interactive PC coaching sessions increased residents' preparedness in discussing prognosis, knowledge of disposition options, and GOC discussion documentation with hospitalized patients. This prospective comparative QI initiative involved internal medical residents during their 4-week hospitalist rotation (three residents per cycle) at an urban medical center. A PC social worker led a brief didactic session about benefits of and requirements for home care, skilled nursing, and hospice. Two PC physicians led informal coaching sessions to build skills related to GOC conversations, prognostication, and any other PC topics residents raised. Both pre- and postrotation, residents completed surveys rating their preparedness on a five-point scale (from 1 “not well prepared” to 5 “very well prepared”) and a five-question multiple-choice test of disposition options. We measured GOC documentation in a patient population considered at-risk based on age, comorbid conditions, and frequent hospitalizations. We trained 30 residents over 10 months in thrice-weekly coaching sessions (average 18 minutes). Residents' preparedness increased most in evaluating appropriate hospice options (pre/post 3.2/4.0, change +0.8) and nonhospice disposition options (3.4/4.1, +0.7). Residents also reported increased confidence in communicating prognosis to patients/families (3.8/4.4, +0.6). Quiz scores did not differ pre- and post-rotation. Documented GOC discussions in at-risk patients increased from 21.1% prehospitalization to 87.4% by hospital discharge. Brief PC coaching sessions increased residents' preparedness in discussing PC topics including prognosis and disposition options, though an objective measure did not show increased knowledge of the latter. Coaching sessions increased the likelihood that residents facilitated GOC discussions with inpatients.

Goals of care discussions for patients with blood cancers: Association of person, place, and time with end-of-life care utilization.

Patients with blood cancers experience high-intensity medical care near the end of life (EOL) and low rates of hospice use; attributes of goals of care (GOC) discussions may partly explain these outcomes. By using a retrospective cohort of patients with blood cancer who received care at Dana-Farber Cancer Institute and died in 2014, the authors assessed the potential relationship between timing, location, and the involvement of hematologic oncologists in the first GOC discussion with intensity of care near the EOL and timely hospice use. Among 383 patients, 39.2% had leukemia/myelodysplastic syndromes, 37.1% had lymphoma, and 23.7% had myeloma. Overall, 65.3% of patients had a documented GOC discussion. Of the first discussions, 33.2% occurred >30days before death, 34.8% occurred in the outpatient setting, and 46.4% included a hematologic oncologist. In multivariable analyses, having the first discussion >30days before death (odds ratio [OR], 0.37; 95% CI, 0.17-0.81), in the outpatient setting (OR, 0.21; 95% CI, 0.09-0.50), and having a hematologic oncologist present (OR, 0.40; 95% CI, 0.21-0.77) were associated with lower odds of intensive care unit admission ≤30days before death. The presence of a hematologic oncologist at the first discussion (OR, 3.07; 95% CI, 1.58-5.96) also was associated with earlier hospice use (>3days before death). In this large cohort of blood cancer decedents, most initial GOC discussions occurred close to death and in the inpatient setting. When discussions were timely, outpatient, or involved hematologic oncologists, patients were less likely to experience intensive health care use near death and were more likely to enroll in hospice.

Goals of care discussion and hospice enrollment.

229 Background: When asked, many people wish to die at home. Yet, more than one third of cancer patients with poor prognosis die in hospital. Enrollment in hospice care is associated with reduced receipt of high-intensity care toward the end of life. Hospice is palliative care tailored to patients in the last 6 months of life. The ability to collect, organize, analyze and report documented Goals of Care (GOC) conversation data and the relationship to hospice enrollment is challenging. Seattle Cancer Care Alliance (SCCA) created a process to establish a sample baseline of documented GOC discussions, the healthcare setting in which they took place, and how this relates to hospice enrollment. Methods: We selected a sample of 50 decedent charts. Patients were verified as period of 6 months from date of death, documenting provider type, care setting that documented discussion took place and chart search terms. Results: Our sample consisted of 50 adult solid tumor cancer patients who died between March-May 2018. Using an SCCA created GOC discussion definition adapted from Ariadne Labs Serious Illness Care program, we found that 52% of patients had a GOC discussion in the last 6 months of life and of these, 92% discussed hospice with a provider, 77% received a hospice referral and 62% enrolled in hospice. 48% of our decedent sample did not have a GOC discussion. 46% had a hospice discussion of whom 100% enrolled in hospice. 46% received a hospice referral. 54% of patients did not discuss hospice of whom 30% enrolled in hospice. In looking at which providers talked with patients about hospice and in what care setting, we found that 44% discussed hospice with outpatient medical oncologist, 10% discussed hospice with an outpatient provider, 16% had a discussion while inpatient, and 30% had no hospice discussion at all. Conclusions: The majority of GOC discussions happened in the outpatient setting with medical oncologists. Many patients never had a discussion about hospice with their provider. Patients were most likely to enroll in hospice when it was specifically discussed, regardless of whether a GOC discussion took place.

Coaching Palliative Care Conversations: Evaluating the Impact on Resident Preparedness and Goals-of-Care Conversations.

Background: There is increasing need for nonspecialty physicians to deliver palliative care (PC) services to meet patient needs, but many physicians feel inadequately prepared. Objective: We aimed to improve the PC skills of resident physicians through a learner-centered, just-in-time coaching intervention. Design: Our quality improvement initiative consisted of two didactics and brief thrice-weekly coaching sessions that focused on real-time PC questions. Upper level internal medicine residents participated during an inpatient hospitalist rotation. Measurements: Residents completed pre/postrotation surveys of their preparedness in discussing PC topics. Electronic medical record data of documentation of goals-of-care (GOC) discussions and Physician Orders for Life-Sustaining Treatment (POLST) completion in at-risk hospitalized patients (age >65 with two or more hospitalizations in the past six months, or age >90) were obtained and compared with before hospitalization. These data were also compared with data from patients on the same resident hospitalist service during the six-month period before the intervention began. Results: During the 14-month intervention period, 42 residents cared for 232 at-risk patients. Among at-risk patients, 12.9% had a documented GOC discussion before hospitalization, which rose to 57.3% before discharge. Among at-risk patients preintervention, these rates were 5.2% and 25.0%, respectively. Residents reported their preparedness increased across many elements of GOC discussions and rated coaching sessions as useful and relevant to their training. Rates of POLST completion did not differ between preintervention and intervention groups. Conclusions: Brief coaching sessions can integrate PC education into a busy clinical service, improve residents' primary PC skills, and improve GOC documentation.

Goals of care designation associated with improved survival and indicators of quality end-of-life care in pancreatic cancer (PC) patients (pts) undergoing palliative chemotherapy.

11532 Background: Discussion of goals of care (GoC) is a key part of quality care for pts with palliative cancer. Numerous studies have shown that documentation of GoC in this population remains low. Here we describe changes in GoC documentation and other indicators of quality end-of-life care in PC pts undergoing palliative chemotherapy during a health-system wide initiative to improve advanced care planning (ACP). Methods: This is a retrospective cohort analysis of 106 pts with locally advanced or metastatic PC treated with palliative chemotherapy from 2012-2015 in Northern Alberta (Canada). In 2014, an initiative was launched to provide pts with hard copies of their GoC designation intended to be available at all health-system interactions. Data were obtained from outpatient medical oncology (MO) and palliative care (PAL) notes and the provincial cancer registry. Survival analysis used a multivariate Cox-regression. All other tests were Chi-squared. Results: 50% (53/106) of pts had a documented GoC discussion, with 45% (48/106) receiving a specific GoC designation. In 2012, 31% (6/19) of pts had a GoC designation, which increased to 61% (20/33) in 2015. Of 84 individual GoC discussions documented, 34% (29/84) were by MO, 62% (52/84) were by PAL, and at least 8% (7/84) referenced prior discussions with a family physician or discussion while admitted to hospital. Pts with a GoC designation had increased median overall survival (287 vs 216 days; HR = 0.62; p = 0.041), and were less likely to receive chemotherapy in the last two weeks of life (p = 0.016). Conclusions: Rates of GoC discussions for PC pts undergoing palliative chemotherapy increased during a health-system wide ACP initiative. Having a GoC designation was associated with greater overall survival and indicators of higher quality end-of-life care.

Coaching Palliative Care Conversations: Evaluating the Impact on Resident Preparedness and Goals of Care Conversations (QI735)

1.Describe a novel coaching intervention to improve palliative care skills of resident physicians.2.Identify positive outcomes in resident preparedness and goals of care documentation resulting from palliative care coaching sessions. Lectures alone are likely inadequate to prepare resident physicians for goals of care (GOC) discussions. Drawing on adult learning theories, we developed a real-time, learner-centered coaching intervention to improve palliative care (PC) skills of residents. Evaluate whether short interactive PC didactic and coaching sessions increased resident physicians’ preparedness in discussing PC topics and completion of GOC discussions with hospitalized patients. Prospective quality improvement study involving internal medical residents during their four-week hospitalist rotation at an urban medical center. Two PC physicians led the sessions. Brief didactics trained each three-person resident group in a GOC communication roadmap and appropriate documentation. Informal coaching sessions centered on building skills related to conducting GOC conversations and addressing other PC topics residents raised. Residents completed surveys addressing their level of preparedness on a 5-point scale (from 1 = not well prepared to 5 = very well-prepared) in issues related to discussing GOC pre/post-rotation. We measured GOC documentation in a defined patient population considered “at-risk” by the health system based on age, comorbid conditions, and frequent hospitalizations. We monitored data monthly and made small curricular adjustments during the year. We trained 39 residents over 12 months in thrice-weekly coaching sessions lasting on average 16 minutes. Residents’ level of preparedness increased across several GOC topics. The greatest increases were in eliciting patients’ fears for the end of life (pre/post 3.3/4.1, change +0.8) and helping patients talk with their families about the future (pre/post 3.4/4.2, change +0.8). Documented GOC discussions in at-risk patients increased from 17.4% pre-hospitalization to 53.9% by the end of hospitalization. Resident physicians rated coaching sessions as useful (4.5) and relevant (4.3) to their training. Brief coaching sessions can integrate PC education into a busy clinical service and improve the likelihood that residents will facilitate GOC discussions with hospitalized patients.

Impact of Timing and Location of Goals of Care Discussions for Patients with Blood Cancers

▪INTRODUCTION: Timely goals of care (GOC) discussions improve end-of-life (EOL) care for patients with solid malignancies. Although timely GOC discussions might also improve EOL care for patients with blood cancers, data are sparse regarding such discussions for this population. We studied the impact of timing and location of GOC discussions on quality of EOL care for a cohort of patients who died of blood cancers.METHODS: We assembled a retrospective cohort of blood cancer decedents from Dana-Farber Cancer Institute, Boston, MA. We included patients diagnosed with a blood cancer, who had ≥ 2 outpatient visits at the study institution, and who died between January 1 and December 31, 2014. Using the established definition from Mack et al, JCO 2012, we classified patients as having had a GOC discussion if there was any documentation in the medical record of a discussion involving resuscitation status, hospice, or preferred location of death. We abstracted content and location of the first documented GOC discussion. Next, we ascertained intensity of care near the EOL (i.e. chemotherapy ≤ 14 days before death, intensive care unit [ICU] admission ≤ 30 days before death, and hospital death) and hospice enrollment. Of note, decreased intensity of medical care and high rates of hospice enrollment are accepted indicators of quality EOL care. In univariable and multivariable models, we assessed the potential relationship between timing (> or ≤ 30 days before death) and location (outpatient or inpatient) of GOC discussions with intensity of medical care and hospice use near the EOL.RESULTS: Of the 384 eligible deceased patients, 39.1% had leukemia/myelodysplastic syndromes, 37.2% had lymphoma, and 23.7% had myeloma. 40.6% had undergone a hematopoietic stem cell transplant (HCT). Overall, 235 (61.2%) had a documented GOC discussion. The median time between first documented discussion and death was 15 days, with 33.2% of first discussions occurring > 30 days before death, and the minority (36.2%) occurring in the outpatient setting. The most commonly discussed topic was resuscitation preferences (82.6%), followed by hospice (30.6%); preferred location of death was rarely discussed (3.4%).Of the entire cohort, 16.9% received chemotherapy ≤ 14 days before death, 21.6% had at least one ICU admission ≤ 30 days before death, and 38.0% died in the hospital. 49.5% of the study population experienced at least one indicator of high-intensity medical care near the EOL. The rate of hospice use was 24.2%.In univariable analyses among those who had EOL discussions (n=235), having the first GOC discussion > 30 days before death was significantly associated with a lower likelihood of ICU admission ≤ 30 days before death (14.1% vs. 40.8%, p<0.001) and a lower likelihood of hospital death (37.2% vs. 63.1%, p=0.0002; Figure). Significant differences persisted in multivariable models controlling for sex, age, diagnosis, and HCT status. There were no significant differences in chemotherapy receipt close to death or hospice use by timing of GOC discussions in univariable or multivariable models. Having the first GOC discussion in an outpatient setting was significantly associated with a lower likelihood of ICU admission ≤ 30 days before death (9.4% vs. 44.7%, p<0.001), lower likelihood of hospital death (25.9% vs. 70.7%, p<0.001) but no significant difference in chemotherapy use near death (Figure). Outpatient location of first GOC discussion was also significantly associated with higher rates of hospice use (41.2% vs. 24.0%, p=0.006). Significant associations persisted in multivariable analyses.CONCLUSIONS: In this large cohort of patients who died of blood cancers, nearly 40% did not have a documented GOC discussion. For those who did, most GOC discussions occurred close to death and in the inpatient setting. Moreover, when patients had GOC discussions greater than a month before death and in the outpatient setting, they were more likely to experience high-quality EOL care. DisclosuresNo relevant conflicts of interest to declare.

202 Missed Opportunities: Integrating Palliative Care Into the Emergency Department for Older Adults Presenting as Level 1 Triage Priority from Long-Term Care Facilities

Early integration of palliative care from the emergency department (ED) has been identified as an underutilized modality of care with significant potential benefits, but few studies have addressed how to assess which patients are appropriate for such care. Our hypothesis is that patients 65 years of age or greater who present to the emergency department as a level 1 emergency severity index from a long-term care facility have prolonged hospitalizations with high resource utilization and significant mortality and therefore would benefit from early palliative care involvement. For the years of 2014 and 2015, we performed a retrospective chart review of all patients > 65 years of age that arrived in the emergency department of an academic suburban southeastern Level 1 trauma center from a long-term care facility and were triaged as a Level 1 triage priority, using the Emergency Severity Index. The ED course, hospital course, and final outcomes were analyzed and data collected included code status, mortality, length of stay, level of care, and presence of palliative care intervention. Of the 198 patients in the study population 54% were deceased 30 days after hospital discharge with only 25.7% alive at 15 months. Admitted patients had a mean hospital length of stay of 7 days with 73% requiring intensive care. 40.4% of the patients received a formal palliative care intervention during their hospitalization from either the palliative care consult service (12.1%) or by embedded supportive care nurses (28.3%). Formal palliative care interventions occurred a median of 3 days into hospitalization and often changed the direction of care with 85% of patients downgrading their advanced directive wishes and discharge occurring a median of 1 day after intervention. Few formal palliative care interventions began from the emergency department (9.1%). Interestingly, 47.1% of patients who did not receive any documented goals of care discussions or palliative care interventions were deceased at 15 months post-discharge. Elderly patients from long-term care facilities presenting with severe acute illness have high mortality and seldom receive early palliative care. Introduction of palliative care has the ability to change the course of treatment and improve end-of-life care in this vulnerable population and should be considered early in the hospitalization and where available, be initiated in the emergency department.

Establishing Goals of Care for Patients With Stroke and Feeding Problems: An Interdisciplinary Trigger-Based Continuous Quality Improvement Project

BackgroundFew patients with dysphagia because of stroke receive early palliative care (PC) to align treatment goals with their values, as called for by practice guidelines, particularly before enteral access procedures for artificial nutrition. MeasuresTo increase documented goals of care (GOC) discussions among acute stroke patients before feeding gastrostomy tube placement. InterventionWe undertook a rapid-cycle continuous quality improvement process with interdisciplinary planning, implementation, and performance review to operationalize an upstream trigger for PC referral prompted by the speech and language pathology evaluation. OutcomesDuring a six-month period, 21 patients underwent gastrostomy tube placement; 52% had preprocedure GOC discussions postintervention, with the rate of compliance increasing steadily from 13% (11/87, preintervention) to 100% (2/2) in the final two months. Conclusions/Lessons LearnedWe effectively increased documented GOC discussions before feeding gastrostomy tube placement among stroke patients. Systems-based tools and education will enhance this upstream trigger model to ensure early PC for stroke patients.