Documented Goals Of Care Discussions Research Articles

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.

Urgent versus elective inpatient anticancer therapy in patients with metastatic solid tumors: Analysis of admission characteristics and posthospitalization clinical outcomes.

12 Background: Palliative chemotherapy is used urgently in the hospital due to rapid disease progression, risk of toxicity, or other cancer-related acute medical diagnoses. Our primary objective was to characterize the utilization of urgent anticancer therapy (antiCT) in metastatic solid tumor patients. Secondary objectives were to compare time to next treatment (TTNT) and overall survival (OS) between those who received antiCT during urgent and elective admissions, and to further characterize if goals of care (GOC) or prognosis discussions were included in the decision process. Methods: This was a single-center observational cohort study of patients with advanced solid tumors treated with antiCT during urgent versus elective inpatient admissions at Huntsman Cancer Institute from June 1, 2014 to June 30, 2016. Line of therapy, ICU utilization, readmission rate, palliative care (PC) consultation, and documentation of GOC and prognosis discussions were evaluated for patients who received urgent antiCT. Results: 265 patients were included. The majority were treated during urgent admissions (63.7%). Patients receiving urgent antiCT were older (57.6 ± 14.2 vs 54.9 ± 14.9 years, p < 0.001) with more advanced cancer at diagnosis (56.8% vs 37.5%, p = 0.009). Urgent antiCT was associated with both decreased median TTNT (3.5 vs 15.7 months; p < 0.001) and median OS (4.7 vs 31.4 months; p < 0.001) as compared to elective antiCT. Of those who received urgent antiCT, 47.9% were started on a new antiCT during admission. First-line therapy accounted for 58% of urgent antiCT, and 27.2% was third-line or higher. ICU care was utilized for 20.7% of these patients, and 23.1% were readmitted ≤30 days after discharge. PC was consulted for 37.9% during admission. Less than half (41.4%) had a documented GOC discussion; only 32.5% had a documented prognosis discussion. Conclusions: Urgent inpatient antiCT is associated with suboptimal advance care planning despite high risk of mortality in the 5 months following admission. Efforts to identify predictors of early mortality after urgent antiCT and incorporate earlier GOC and prognosis discussions are warranted.

293 Goals of Care Determination Prior to Transfer: A Missed Opportunity

To determine the prevalence of goals of care discussion documentation by sending institutions among adults transferred to our tertiary care medical center who died within the first 48 hours of their transfer. We performed a retrospective chart review of patients 18 years and older transferred from outlying hospital emergency departments and inpatient units to our rural tertiary medical center as either floor level or critical care level patients from October 2011 through April 2016 who died within 48 hours of arriving. Data was abstracted from both the referring hospital’s documentation provided upon transfer and our electronic medical record. Physiologic and laboratory data was abstracted from the referring facilities chart or our electronic medical record reflecting the patient’s condition at the time of transfer; this was used to calculate the Charlson Age-Comorbidity Index. The presence of documented goals of care was specifically determined through review transfer documentation accompanying the patient. Data was analyzed using STATA 10 statistical software. A total of 181 patients met the inclusion criteria. The average age was 69.3 years and 47.5% were female. 76% of the referring hospitals were critical access hospitals. 45 % came from emergency departments, 55% from inpatient units. The mean Charlson Age-Comorbidity Index score was 5.5±2.7. Mode of transfer to our facility was local EMS 52.5% of the time, critical care helicopter 32%, and critical care ground transport 15.5%. The cause of death was septic shock for 24.9%, cerebrovascular accident for 14.4%, and acute myocardial infarction or cardiogenic shock for 12.7%. Documented goals of care discussion was available in 18 of 181 (10%) of transfer records. Our chart review revealed 22 (12%) instances of initial goals of care discussion taking place on admission to the hospital which resulted in the decision to transition to a comfort-based end-of-life care upon arrival. Care was transitioned to a comfort-based care within the first 24 hours for 88 (49%) of the patients. While transfer to a higher level of care is often necessary, the sought after care should be in line with the patient’s goals. In this single center review of critically ill patients, it was striking that only 1 in 10 patients who were critically ill had a discussion about their goals of care addressed and documented prior to transfer. Although the decision to transfer a critically ill patient must often be made with in information, these results suggest an opportunity to improve on the current state. The 12% of patients transitioned to comfort-based care upon arrival to our hospital suggests an opportunity to improve patient care while also decreasing unnecessary transfer. Addressing goals of care along with aggressive medical interventions is important to providing a therapy consistent with our patients’ goals and avoiding costly and invasive treatments that do not align with their goals of care.

The Relationship Between Frailty and the Subjective Decision to Conduct a Goals of Care Discussion With Burned Elders.

Best practices are to conduct an early discussion of goals of care (GoC) after injury in the elderly, but this intervention is inconsistently applied. We hypothesized that a frail appearance was a factor in the decision to conduct a GoC discussion after thermal injury. A retrospective review was performed of all burn survivors aged ≥ 65 years at our American Burn Association (ABA)-verified level 1 burn center between April 02, 2009, and December 30, 2014. Demographic information included age, gender, mechanism of injury, percentage TBSA burned, revised Baux score, patient/physician racial discordance, documented GoC discussion (as defined within the electronic medical record), length of stay (LOS), and disposition. One rater retrospectively assigned clinical frailty scores to patients using the Canadian Study of Health and Aging Criteria, which ranged from 1 (very fit) to 7 (severely frail). Ordinal logistic regression was performed. Demographics for the cohort of 126 subjects were (mean ± SD): age = 75.5 ± 7.7 years, %TBSA burned = 11.9% ± 7.2, revised Baux = 87.8 ± 10.2, hospital LOS (days) = 14.9 ± 13.7, Intensive Care Unit (ICU) LOS (days) = 6.2 ± 1.2, frailty score = 4.1 ± 1.1. Overall, 72% of geriatric survivors had a favorable discharge disposition. GoC discussions occurred in 25% of patients. GoC discussion (OR, 3.42; 95% CI, 1.54-7.60) and an unfavorable disposition (OR, 9.01; 95% CI, 3.91-20.78) were associated with greater predicted odds of receiving a higher ordered frailty score. Our results suggest that, even in the absence of a formal diagnosis, a frail appearance may influence a provider's decision to perform GoC discussions after severe thermal injury.

Categorization of survival and death after cardiac arrest

BackgroundMost cardiac arrest (CA) patients remain comatose post-resuscitation, prompting goals-of-care (GOC) conversations. The impact of these conversations on patient outcomes has not been well described. MethodsPatients (n=385) treated for CA in Columbia University ICUs between 2008–2015 were retrospectively categorized into various modes of survival and death based on documented GOC discussions. Patients were deemed “medically unstable” if there was evidence of hemodynamic instability at the time of discussion. Cerebral performance category (CPC) greater than 2 was defined as poor outcome at discharge and one-year post-arrest. ResultsThe survival rate was 31% (n=118); most commonly after early recovery without any discussions (57%, n=67), followed by survival due to family wishes despite physicians predicting poor neurological prognosis (20%, n=24), and then survival after physician/family agreement of favorable prognosis (17%, n=20). The survivors due to family wishes had significantly worse outcomes compared to the early recovery group (discharge: p=0.01; one-year: p=0.06) and agreement group (p<0.001; p<0.001), though 2 patients did achieve favorable recovery. Among nonsurvivors (n=267), withdrawal of life-sustaining therapy (WLST) while medically unstable was most common (31%; n=83), followed by death after care was capped (24%, n=65), then WLST while medically stable (17%, n=45). Death despite full support, brain death and WLST due to advanced directives were less common causes. ConclusionsMost survivors due to family wishes despite poor neurological prognosis die or have poor outcomes at one-year. However, a small number achieve favorable recovery, demonstrating limitations with current prognostication methods. Among nonsurvivors, most WLST occurs while medically unstable, suggesting an overestimation of WLST due to unfavorable neurological prognosis.

Palliative care consultation and advance care planning for adults with poor-risk leukemia admitted to an academic medical center.

13 Background: Despite high mortality for certain patients with hematologic malignancies, integration of palliative care (PC) and documentation of advance care planning (ACP) is lacking. Our primary objective was to determine the frequency of PC consultation and ACP for inpatients with poor-risk leukemia at our institution. Our secondary objectives were to describe the content of goals of care (GOC) discussions and to characterize PC and end-of-life quality measures. Methods: Chart reviews were conducted for patients with poor risk leukemia (acute leukemia ≥ 65 years or relapsed leukemia &gt; 18 years) admitted to the University of North Carolina from October 1, 2015 to March 31, 2016. The following was abstracted from the chart: demographic data, disease characteristics, presence of a PC consultation, frequency and content of ACP (written advance directive, documented GOC discussion, identified surrogate decision maker), PC quality measures (assessment of pain, dyspnea, nausea, constipation), and end-of-life quality measures (chemotherapy within 14 days of death, ICU stay within 30 days of death, hospice referral less than 3 days prior to death). Results: Thirty-eight subjects were identified. Fifty percent of patients were over age 65 with a new diagnosis of acute leukemia and 50% had relapsed leukemia. The majority of patients (66%) reported pain and 45% reported dyspnea on admission. Sixteen percent of patients died within 30 days of discharge. Eleven percent of patients received PC consultation and 16% had all elements of ACP documented in the chart. GOC discussions without a surrogate decision maker were documented for 37%; content included discussion of values (11%), prognosis (37%), treatment choices (21%), life sustaining preferences (16%), and hospice (21%). Conclusions: In this descriptive study of inpatients with poor-risk leukemia, we found that despite a poor prognosis and high symptom burden, only 11% of patients received PC consultation and 16% had all elements of ACP present in the chart. While our data are limited by documentation, we believe this represents missed opportunities for the delivery of high-quality care.