Goals Of Care Conversations Research Articles

Improved Palliative Care Practices Through Machine-Learning Prediction of 90-Day Risk of Mortality Following Hospitalization

Summary Patients and families rely on clinicians to provide candid, transparent, and accurate data-driven prognostic information to make informed, value-based decisions about serious illness. In this realm, there has been a proliferation of the use of machine-learning algorithms within health care systems because of an overall desire to develop and validate predictive models for short- and long-term mortality and to provide optimal patient care across a range of modifiable conditions and clinical populations. In this study, the authors describe the use of machine-learning algorithms that are embedded into the University of Pittsburgh Medical Center (UPMC) electronic health record system to generate 90-day mortality risk classifications for hospitalized patients. The system automatically triggers clinician alerts for intermediate- and high-risk groups of patients so that the care team can provide goals-of-care (GOC) conversations and palliative care consultations. The machine-learning study population included 611,543 unique patients 18 years of age and older hospitalized in the UPMC system between January 1, 2015, and December 31, 2019. The development and validation of the predictive model for the 90-day risk of mortality from the date of hospital admission included iterative engagement with UPMC clinicians and health system stakeholders and gradient boosting decision tree–based supervised machine learning. Prior to deployment in July 2021, an average of 78 GOC conversations took place each month with patients deemed to be at moderate or high risk for 90-day mortality. After deployment, that number more than doubled to an average of 166 per month and has been sustained for more than a year. The authors also provide analytical and operational recommendations based on their approach.

A QUALITY INITIATIVE TO INCREASE HOSPICE REFERRALS FOR STARS PATIENTS DURING THE SECOND COVID SURGE

Abstract Background CMS uses the Overall Hospital Quality Star Rating program to stratify hospitals based on specific quality criteria (e.g., 30-day readmissions of older adults with pneumonia). “STARS patients” experience more readmissions, longer LOS and often have more complex discharge plans. During the second surge of COVID we implemented a program to increase hospice referrals through early identification and implementation of goals of care (GOC) conversations. Methods Electronic Medical Records reviewed for STARS patients from pre- (1/2019-7/2020) and post (3/2021–2/2022) program implementation. Location: 2 community-based hospitals. Data collected: demographics, hospital outcomes, discharge disposition. Data compared with Student’s t tests and Chi square. Results 459 patients, 177 pre-program and 282 post-program were included. Groups were similar in age (83.0 vs 83.6), LACE score (13.0 vs 12.8), principal diagnoses (PNA: 41.5% vs 46.0%, HF/COPD/AMI: 58.5% vs 54.0%), and mortality (3.5 vs. 4.0%). LOS increased 4.9 days vs. 6.1 days (p < 0.01), readmission rates unchanged: 12.6% vs 13.0% (p=0.90). GOC conversations increased, 48.6% to 75.0% (p < 0.01), DNR from 24% to 44% (p < 0.01), and comfort measures from 0.5% to 5% (p < 0.01). Hospice referrals increased from 0.5% to 11.2% (p < 0.01). Discussion: Early identification of STARS patients increased GOC conversations, DNR, comfort measures and hospice referral. Patients across time periods were similar in age, LACE and admitting diagnoses. LOS increased by a day, likely reflecting time needed to arrange discharge disposition. Increased hospice at end-of-life is associated with better quality care and patient/family satisfaction. This program may be adapted to larger, academic medical centers within the health system.

PATIENTS’ SPIRITUAL CONCERNS AND NEEDS DURING GOALS OF CARE CONVERSATIONS: HEALTHCARE CHAPLAINS’ PERSPECTIVES

Abstract Healthcare chaplains are critical members of interdisciplinary healthcare teams and routinely facilitate advance care planning (ACP) and goals of care conversations with patients with serious illnesses. These conversations involve discussion of one’s deeply held personal values and beliefs as well as uncertainty, fears, and hopes for current and future health care needs. However, there is limited empirical data on how patients’ spiritual concerns and needs are addressed during these conversations. An online survey of 563 board-certified chaplains was conducted from March to July 2020 to identify chaplains’ roles in facilitating goals of care conversations and included three open-ended questions about patients’ hopes and fears and how chaplains addressed them. Quantitative data and written qualitative responses from 244 chaplains were analyzed using descriptive analysis and content analysis, respectively. Majority of participants were white (83.6%), female (59%), Protestant (63.1%), employed full-time (82%), and worked in community hospital settings (45.5%) or academic medical centers (32.8%). Six major themes emerged from chaplains’ qualitative responses: (1) the utility of ACP; (2) focus on the present moment; (3) achieving a personally defined "good death"; (4) spiritual and religious matters and beliefs; (5) caring for and connection with family; and (6) how to address hopes and fears during ACP. ACP and goals of care conversations reflect profound human desires and needs; they require deeper listening and engagement by interdisciplinary team members to provide adequate spiritual and psychosocial support in addition to providing medical information to fulfill the intended meaning and purpose of ACP.

Replace the advance directive with a patient activation approach to serious illness communication.

Replace the advance directive with a patient activation approach to serious illness communication.

1279: EARLY GOALS-OF-CARE DISCUSSION IN GERIATRIC TRAUMA IS ASSOCIATED WITH INCREASED CODE STATUS CHANGES

Introduction: The Trauma Quality Improvement Program guidelines recommend early goals of care (GOC) discussions within 72 hours of admission for geriatric trauma patients. Despite this recommendation family meetings and GOC conversations are often performed in a delayed fashion. We hypothesized that early GOC discussions are associated with higher incidence of goal concordant care manifested as code status changes and implementation of comfort measures only (CMO), as well as shorter hospital length of stay (LOS). Methods: A retrospective chart review was performed on patients aged ≥65 years admitted to Hartford Hospital intensive care units (ICU) with a trauma diagnosis between January 2020 and December 2021. Demographics, timing of GOC discussion, and clinical outcomes were collected. Results: Of 273 identified patients, 78% were male, and median age was 79 years (interquartile range, IQR 71 – 86). Median injury severity scale (ISS) was 13 (IQR 9 – 21), and the most common mechanism of injury was falls (77%). Only 51 (19%) had a GOC discussion documented in the chart within 72 hours of admission. In a logistic regression model adjusting for significant variables, early GOC discussion was associated with higher likelihood for changing code status (adjusted odds ratio, OR 6.0; p< 0.001) and transitioning to CMO (OR 3.4; p=0.008), compared to having GOC discussion after 72 hours or not at all. Among those who had GOC discussion during hospitalization, early GOC discussion was associated with shorter ICU LOS (β=-7.4; p=0.014) and hospital LOS (β=-10.9; p=0.008), adjusting for significant variables identified on the univariable analysis. Patients who had GOC discussion within 72 hours were at significantly lower odds of undergoing invasive procedures (OR 0.41; p=0.02). Conclusions: Early GOC discussion within 72 hours of admission is associated with higher likelihood of code status change and election of CMO in geriatric trauma patients. Interventions to increase adherence to the early GOC meeting recommendation should be emphasized at an institutional level.

Goals of Care Conversations Documented By an Embedded Emergency Department-Palliative Care Team During COVID.

Background: There has been growing interest around integrating palliative care (PC) into emergency department (ED) practice but concern about feasibility and impact. In 2020, as the COVID pandemic was escalating, our hospital's ED and PC leadership created a new service of PC clinicians embedded in the ED. Objectives: To describe the clinical work of the embedded ED-PC team, in particular what was discussed during goals of care conversations. Design: Prospective patient identification followed by retrospective electronic health record chart extraction and analysis. Settings/Subjects: Adult ED patients in an academic medical center in the United States. Measurements/Results: The embedded ED-PC team saw 159 patients, whose mean age was 77.5. Nearly all patients were admitted, 48.0% had confirmed or presumed COVID, and overall mortality was 29.1%. Of the patients seen, 58.5% had a serious illness conversation documented as part of the consult. The most common topics addressed were patient (or family) illness understanding (96%), what was most important (92%), and a clinical recommendation (91%). Clinicians provided a prognostic estimate in 57/93 (61.3%) of documented discussions. In the majority of cases where prognosis was discussed, it was described as poor. Conclusion: Specialist PC clinicians embedded in the ED can engage in high-quality goals of care conversations that have the potential to align patients' hospital trajectory with their preferences.

A Qualitative Assessment of Patient Experience following Systematic Implementation of Goals of Care Conversations in the Ambulatory Gynecologic Oncology Setting.

Although skilled goals of care (GOC) conversations are known to reduce aggressive futile end-of-life care, they have not been widely implemented nor standardized in the care of gynecologic malignancies. Clinicians express concern regarding patient readiness and willingness to participate in these conversations, which may be a barrier to GOC discussions. This is a qualitative study, conducted at an academic institution in the United States, of patients with gynecologic malignancies at high risk of death within six months and who had recently completed a GOC discussion with their oncology clinician during an ambulatory visit. Within 10 days of this conversation, patients were approached for potential participation in an hour-long semistructured interview. Patients enrolled in hospice or who were non-English speaking were excluded. Participants were enrolled until thematic saturation was reached. Interviews were transcribed and coded using the five-stage thematic approach. Ten women were consented and participated in semistructured interviews, which occurred a median of 4 (range 1-18) days after the index GOC discussion. The median age was 64 (range 37-78), and the most common diagnosis (50%) was recurrent platinum-resistant ovarian cancer. Four themes were identified: (1) delivery of the GOC conversation, (2) importance of prioritizing individual values, (3) involving family in decision making, and (4) openness to discussing discontinuation of anticancer treatment and hospice. Patients generally felt these GOC conversations were useful, providing a space to express their values and did not compromise the patient-clinician relationship. Patients seemed willing to engage in GOC conversations and were appreciative of their clinicians' communication skills. Often, they used this conversation as an opportunity to convey personal values affecting their care.

What matters most: Qualitative investigation of goals and values in a diverse sample of patients with advanced cancer.

252 Background: Goals of care conversations (GOCC) are a complex part of patient-focused care. Current understanding of GOCC content is limited to post-hoc patient satisfaction surveys and focus groups evaluating end-of-life advance care planning physician-patient interactions, and documentation. We investigated patient goals and values through standardized GOCC documentation by oncologists in patients with advanced cancer. Methods: This pilot qualitative analysis of patient goals and values included all adult patients &gt; 18 years with advanced recurrent or stage IV cancer seen at Kaiser Permanente San Francisco with an oncologist documented GOCC between 1/1/2022 to 5/14/22. Our team developed a templated GOCC automated phrase (Smartphrase) within our electronic medical record (EMR), with a selection tab that included a listing of common patient goals and values and an option to add free text. Team members reviewed each patient’s initial GOCC content was reviewed for frequently occurring themes consistent with goals and values. Results: A total of 178 patients had EMR documented GOCC, with a mean of 1.8 GOCC per patient. These patients were 51% (n = 94) female, with a median age of 68.5 years old. The population was racially diverse with 46% identifying as White, 32% Asian/Pacific Islander, 13% Black, 8% Hispanic/Latino, and 1% Other. The most common cancer types included breast (19%, n = 34), lower GI (16%, n = 29), and thoracic (14%, n = 25). Family members were present in 35% (n = 63) of GOCC. Table summarizes thematically grouped goals and values. Conclusions: Our findings highlight the importance of GOCC in routine oncology visits. Our standardized documentation tool for GOCC prompted medical oncologists to identify what matters most to patients with advanced or recurrent cancer regarding their values and goals related to care and quality of life. Among the wide range of responses, we identified that the most important goals and values to our patients include avoiding pain and suffering, physical independence, and living as long as possible. In contrast, patients rarely identified comfort-only treatment as a priority. This tool can guide goal-concordant care at initial onset of the cancer journey and be revisited as these conversations evolve over time. Future investigation is needed to understand how GOCC goals and values identified early impact patient satisfaction, change over time, influence treatment decisions, and potentially lead to an evolution in standard for goal-concordant care.[Table: see text]

Triggering goals of care conversations in heart failure patients.

Goals of care conversations (GoCCs) are essential discussions, for those with chronic diseases, to identify a health care surrogate, initiate and review advance directives, and refer for palliative care. Prognosis with pulmonary hypertension (PH) related to heart failure (HF) remains challenging due to variation in trajectory of disease progression. The Gagne Combined Comorbidity score, an electronic prognostication score (E-Gagne), can be used to identify patients with high (>10%) 1-year mortality. Implementation of E-Gagne tool to identify HF patients with high 1-year mortality risk and trigger GoCCs. Plan-Do-Study-Act cycles were used throughout nine-week pre- and postintervention in an outpatient setting. Descriptive statistics and Chi-square analysis were used to compare GoCCs pre and post intervention. Using the E-Gagne tool, PH patients with high mortality risk were identified, within 1 week of their scheduled appointments. GoCCs education was provided to all stakeholders. Medical records were reviewed for four aspects of GoCCs: presence and review of advanced directive, documented health care surrogates, and referral for palliative care. Documentation of GoCCs was greater postintervention compared with preintervention (0%, n = 0/47 and 88%, n = 35/40 respectively, p < .001). Documentation of each of the four aspects of GoCCs was variable with the greatest improvement in documentation of health care surrogate and review of advance directives. There were no referrals for palliative care (0%, n = 0/47 and 0%, n = 0/40). Implementation of the E-Gagne tool, an electronic prognostication tool, identified high-risk PH HF patients and was effective in increasing documentation of GoCCs.

I-DO GOC: Improving documentation in oncology with goals of care.

314 Background: Goals of Care (GOC) discussions are part of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early GOC discussions are associated with better quality of life, reduced use of futile medical care, and enhanced goal-concordant care. In order to increase GOC documentation within the electronic medical record (EMR), the Kaiser Permanente San Francisco medical oncology practice began an ASCO Quality Training Program initiative in January 2022 to increase oncologist discussion and documentation of GOC in advanced cancer patients. Methods: Baseline data on the frequency of GOC discussions was obtained through a structured chart review with a historical cohort of stage IV or recurrent cancer patients &gt; 18 years old between 1/1/2020-6/1/2020. The project aimed to improve accessible GOC documentation from a baseline of 0% to a goal of 25% among stage IV or recurrent cancer patients seen by an oncologist between 1/2022 and 5/14/2022. Patients with hematologic malignancies were excluded. Oncologists were instructed to use a templated GOC automated phrase (Smartphrase) that consolidated content into a visible, centralized EMR location. The frequency of GOC Smartphrase usage among oncologists was tracked monthly through a customized dashboard. Plan-Do-Study-Act cycles included education on GOC documentation and monthly feedback for oncologists on performance. Results: Review of the 2020 historical cohort revealed no structured or accessible GOC documentation by oncologists. During the intervention period, 300 Stage IV and recurrent cancer patients were eligible for GOC documentation. The median age of the intervention group was 70 years, with the most common types of cancers represented: Prostate (21%), Breast (19%), and Lung (17%). Our study cohort included a diverse population: White (45%), Asian (36%), Black/African American (11%), and Hispanic (7%). Between 1/1/2022 to 5/14/22, 142 (47%) patients had at least one documented GOC conversation, exceeding the target of 25%. 100% of these structured conversations were viewable in the designated area in the EMR. Conclusions: Our ASCO Quality Training Program initiative successfully increased oncologists' overall number of GOC conversations and made those conversations more easily accessible to the entire care team. Our process for standardizing the documentation of GOC conversations was based on the use of a Smartphrase that helped organize the collected information within the EMR. During the study period, we increased the documented GOC rate from 0% to 47%. This can improve patient and physician satisfaction, as well as improve goal concordant care for patients with advanced cancer. Further efforts will be focused on sustaining these initial gains in GOC documentation and on promoting their broader use across our organization.

Creating a proactive interdisciplinary approach to care: Embedding oncology care coordination within an oncology patient and family support program.

51 Background: The benefits of providing psycho-oncology services have been well documented in producing better effective team collaboration, patient outcomes, and reduced healthcare utilization. Cedars-Sinai Cancer spans five locations and serves over 11,000 patients a year. Their robust Patient and Family Support program (PFSP) includes psychiatry, palliative medicine, social work, nutrition, cancer rehabilitation, survivorship, and chaplaincy to envelop patients in multiple dimensions of support. A new oncology care coordination (CC) model embedded a social work (SW) and nurse (RN) CC within PFSP to identify and meet diverse unmet needs of patients through close interdisciplinary collaboration. Methods: Oncology CC was established within PFSP, containing an oncology SW CC and an oncology RN CC. Patients with higher acuity needs were identified through multiple avenues such as: health plan reporting and dashboards in the electronic medical record (EMR) providing alerts for patients with unmet needs. Preliminary data was captured on interdisciplinary collaboration and care coordination from a daily log kept by coordinators, as well as from the EMR. Results: Over 6 months (9/2021 to 2/2022), the PFSP CC team served 688 patients providing 1280 interventions. Of the 1280 interventions, 22% were coordination with other PFSP services; of which 54% was with SCM, 36% with Clinical SW, and 18% represented new referrals. 13% focused on outside services including medical devices, home health, and community resources. 6% comprised of post-discharge calls by the RN CC and 16% represented direct SW CC outreach. Care coordination such as appointment scheduling, assistance with prescriptions and communication with medical teams represented 9%, 1% and 11% of the interventions respectively. Conclusions: Results demonstrated for this subset of patients that the highest needs of oncology PFSP CC were SW and SCM, to address needs such as pain and symptom management, goals of care conversations and community resource linkage. Anecdotally, communication with primary oncology and other medical teams proved to be an essential role of the CC team, particularly to address inpatient to outpatient transitions of care. Discussion: CC team involvement is time-limited and appears to rely on the long-term relationship patients have with PFSP interdisciplinary team members for interventions to be long-lasting and effective. The CC team leveraged existing relationships that PFSP providers had established with primary oncology teams, allowing for timely care coordination. Future goals include: 1) developing an algorithm to better identify patients with higher acuity and unmet needs; 2) measuring impacts of CC services on care outcomes, health care utilization and reduced symptom burden; 3) expanding the CC team to serve more of the patient population.

Integrating Narrative Goals of Care in the Medical Intensive Care Unit: Impact on Educational and Clinical Outcomes.

BackgroundHigh-quality goals of care (GOC) communication is fundamental to providing excellent critical care.ObjectiveEducate medical intensive care unit (MICU) clinicians, design and implement workflows relating to GOC communication, and measure the impact on communication proficiency and rate of GOC documentation.MethodsGuided by Lean Six Sigma principles, an interprofessional team from palliative and critical care tailored a multicomponent intervention—the 3-Act Model communication training and workflow modification—to equip and empower the pulmonary and critical care medicine (PCCM) fellow as the clinical lead for GOC discussions. Fellows’ education included in-person narrative reflection, asynchronous online didactic and demonstration videos of the 3-Act Model, online roleplays, and direct observation leading GOC discussions in the ICU. PCCM fellows were objectively evaluated for proficiency using the Goals of Care Assessment Tool. To evaluate the impact of our intervention on documented GOC conversations, we performed a retrospective chart review over two 3-month periods (before and after intervention) when the MICU cared exclusively for critically ill patients with coronavirus disease (COVID-19).ResultsAll PCCM fellows demonstrated proficiency in GOC communication via online simulated roleplays, as well as in observed bedside GOC communication. Per chart review of patients with a minimum of 7 consecutive days in the MICU, documented GOC conversations were found for 5.55% (2/36) of patients during the preintervention period and for 28.89% (13/45) of patients in the postintervention period. Palliative care consults increased in the pre- versus postintervention period: for all patients, 4.85% versus 14.52% (P < 0.05); for patients age ⩾80 years, 3.54% versus 29.41% (P < 0.05); and for patients with MICU length of stay ⩾7 days, 2.78% versus 24.44% (P < 0.05).ConclusionCombining 3-Act Model education for PCCM fellows with Lean Six Sigma quality improvement resulted in effective GOC communication training and improved palliative care integration in the ICU.

Implementing Advance Care Planning for dialysis patients: HIGHway project

BackgroundPatients undergoing hemodialysis have a high mortality rate and yet underutilize palliative care and hospice resources. The Shared Decision Making-Renal Supportive Care (SDM-RSC) intervention focused on goals of care conversations between patients and family members with the nephrologist and social worker. The intervention targeted deficiencies in communication, estimating prognosis, and transition planning for seriously ill dialysis patients. The intervention showed capacity to increase substantially completion of advance care directives. The HIGHway Project, adapted from the previous SDM-RSC, scale up training social workers or nurses in dialysis center in advance care planning (ACP), and then support them for a subsequent 9-month action period, to engage in ACP conversations with patients at their dialysis center regarding their preferences for end-of-life care.MethodsWe will train between 50–60 dialysis teams, led by social workers or nurses, to engage in ACP conversations with patients at their dialysis center regarding their preferences for end-of-life care. This implementation project uses the Knowledge to Action (KTA) Framework within the Consolidated Framework for Implementation Research (CFIR) to increase adoption and sustainability in the participating dialysis centers. This includes a curriculum about how to hold ACP conversation and coaching with monthly teleconferences through case discussion and mentoring. An application software will guide on the process and provide resources for holding ACP conversations. Our project will focus on implementation outcomes. Success will be determined by adoption and effective use of the ACP approach. Patient and provider outcomes will be measured by the number of ACP conversations held and documented; the quality and fidelity of ACP conversations to the HIGHway process as taught during education sessions; impact on knowledge and skills; content, relevance, and significance of ACP intervention for patients, and Supportive Kidney Care (SKC) App usage. Currently HIGHway is in the recruitment stage.DiscussionEffective changes to advance care planning processes in dialysis centers can lead to institutional policy and protocol changes, providing a model for patients receiving dialysis treatment in the US. The result will be a widespread improvement in advance care planning, thereby remedying one of the current barriers to patient-centered, goal-concordant care for dialysis patients.Trial registrationThe George Washington University Protocol Record NCR213481, Honoring Individual Goals and Hopes: Implementing Advance Care Planning for Persons with Kidney Disease on Dialysis, is registered in ClinicalTrials.gov Identifier: NCT05324878 on April 11th, 2022.

Gift of time: learning together to embed a palliative approach to care in long-term care

BackgroundEmbedding a Palliative Approach to Care (EPAC) is a model that helps shift the culture in long-term care (LTC) so that residents who could benefit from palliative care are identified...

Associations Between Family Member Involvement and Outcomes of Patients Admitted to the Intensive Care Unit: Retrospective Cohort Study

BackgroundLittle is known about family member involvement, by relationship status, for patients treated in the intensive care unit (ICU).ObjectiveUsing documentation of family interactions in clinical notes, we examined associations between child and spousal involvement and ICU patient outcomes, including goals of care conversations (GOCCs), limitations in life-sustaining therapy (LLST), and 3-month mortality.MethodsUsing a retrospective cohort design, the study included a total of 858 adult patients treated between 2008 and 2012 in the medical ICU at a tertiary care center in northeastern United States. Clinical notes generated within the first 48 hours of admission to the ICU were used with standard machine learning methods to predict patient outcomes. We used natural language processing methods to identify family-related documentation and abstracted sociodemographic and clinical characteristics of the patients from the medical record.ResultsMost of the 858 patients were White (n=650, 75.8%); 437 (50.9%) were male, 479 (55.8%) were married, and the median age was 68.4 (IQR 56.5-79.4) years. Most patients had documented GOCC (n=651, 75.9%). In adjusted regression analyses, child involvement (odds ratio [OR] 0.81; 95% CI 0.49-1.34; P=.41) and child plus spouse involvement (OR 1.28; 95% CI 0.8-2.03; P=.3) were not associated with GOCCs compared to spouse involvement. Child involvement was not associated with LLST when compared to spouse involvement (OR 1.49; 95% CI 0.89-2.52; P=.13). However, child plus spouse involvement was associated with LLST (OR 1.6; 95% CI 1.02-2.52; P=.04). Compared to spouse involvement, there were no significant differences in the 3-month mortality by family member type, including child plus spouse involvement (OR 1.38; 95% CI 0.91-2.09; P=.13) and child involvement (OR 1.47; 95% CI 0.9-2.41; P=.12).ConclusionsOur findings demonstrate that statistical models derived from text analysis in the first 48 hours of ICU admission can predict patient outcomes. Early child plus spouse involvement was associated with LLST, suggesting that decisions about LLST were more likely to occur when the child and spouse were both involved compared to the involvement of only the spouse. More research is needed to further understand the involvement of different family members in ICU care and its association with patient outcomes.

Heart to Heart Discussions: Characterizing Goals of Care Conversations for Advanced Heart Failure Patients Initiating Palliative Inotropes

BackgroundGuidelines recommend goals of care conversations (GOCC) and specialty palliative care at the time of initiation of palliative inotropes for patients with advanced heart failure. The extent to which GOCC are occurring, the content of the GOCC, and the frequency of palliative care involvement is unknown. Methods and ResultsWe conducted a retrospective chart review of all patients discharged from a tertiary medical center between October 2015 and April 2020 initiated on continuous palliative inotropes. We identified 53 patients who were discharged on continuous palliative inotropes. Most patients (46/53 [87%]) had a documented GOCC, including discussions around preferences for life-sustaining treatments, hospice, and/or prognosis. However, just more than one-half of the patients (55% [15/27]) with an ICD had a documented discussion regarding preferences for ICD deactivation. Patients seen by palliative care were more likely to have a documented discussion about ICD deactivation (68% vs 0%, P = .0098). The frequency of palliative care consultation and documented GOCC conversations increased over time. ConclusionsAlthough we observed overall high rates of documented GOCC, there is room for improving the rate of discussions with patients about whether they wish to have their ICD deactivated. Future research should test interventions to improve the frequency of ICD discussions.

Relationship of travel distance with patient demographics, advance care planning, and survival in early-phase clinical trials (EP-CTs).

6558 Background: EP-CTs are often conducted at large academic centers, which may require some patients to travel further for their care. Little is known about either the distance EP-CT participants travel for their care or the association of distance traveled with patient characteristics and outcomes. Methods: We retrospectively reviewed the electronic health records of consecutive patients enrolled in EP-CTs at Massachusetts General Hospital from 2017-2019 to obtain patient characteristics (demographics and clinical factors) and outcomes (including time spent on trial, survival, and presence or absence of an advance care planning [ACP] discussion, defined as documentation of a code status or goals of care conversation in the medical record). We also used patients’ home zip codes to derive the social deprivation index (SDI; a composite demographic measurement from 0-100 quantifying social determinants of health, with higher numbers indicating more disadvantage). To estimate distance traveled, we calculated the miles traveled in one direction driving from home zip code to trial site. We used descriptive statistics to compare patient characteristics and outcomes for those traveling &lt; 50 miles (short distance) versus those traveling 50+ miles (long distance). Results: Among 421 patients (median age = 63.0 years, 56.9% female, 97.6% metastatic disease), median distance traveled was 36.4 miles. Half of patients (n = 217; 51.5%) traveled 50+ miles to receive care on trial. There were no significant differences between those traveling short and long distances in most patient characteristics evaluated, including age (60.9 vs 60.6 years; p = 0.635), sex (53.9% female vs 57.6%; p = 0.447), race (85.3% white vs 84.8%; p = 0.346), marital status (71.8% married vs 69.3%; p = 0.586), insurance (51% private vs 54.4%; p = 0.266), cancer type (22.5% GI vs 21.2%; p = 0.666), prior lines of therapy (52.5% one-two lines vs 51.2%; p = 0.981), and performance status (62.3% ECOG 1 vs 66.8%; p = 0.270. However, those with a higher SDI score were less likely to travel a long distance for trial participation (mean SDI 36.7 for short distance vs 30.5 for long distance; p = 0.026). Patients traveling a long distance were less likely to have a documented ACP discussion (48.8% vs 66.7%; p &lt; 0.001). We found no significant difference in time spent on trial between those traveling short and long distances (mean days: 98 vs 93.5; p = 0.175) or in time from coming off trial to death (mean days: 147.7 vs 153.7; p = 0.099). Conclusions: We found that half of EP-CT participants travel 50+ miles in one direction to their trial site, with disparities in travel distance based on the social deprivation index. Notably, those traveling long distances were less likely to have a documented ACP discussion. Our findings suggest several unmet needs in the EP-CT population and highlight opportunities for future intervention development.

Novel use of clinical pathways to identify poor prognosis lung cancer patients: Implementation and outcomes.

1589 Background: Cancer patients in the last year of life have different clinical needs and evolving goals of care. Using our oncology decision-support pathways to help clinicians consistently identify such patients in a systematic and prospective fashion, at a discrete moment in the care trajectory, may be an important step towards matching the care of these patients with their stated goals. Methods: Medical oncologists from each disease group at the Dana-Farber Cancer Institute (DFCI) were tasked with identifying clinical settings in each oncology care pathway associated with an expected median survival of &lt; 12 months. This information was embedded into the underlying data model of the pathways platform, allowing us to determine how often clinicians navigated through each poor prognosis node. Results: From 3/1/20 – 6/30/21, there were 264 navigations in 205 unique lung cancer patients receiving standard of care (i.e., not on clinical trial) for a clinical condition associated with poor prognosis. Overall, the median overall survival from the time of a patient’s first navigation through a poor prognosis node during the defined study period was 6.4 months. Table lists outcomes for each specific setting. Patients with squamous or small cell lung cancer being treated in or beyond the third-line setting had notably poor outcomes, with less than a third of these patients surviving 6 months from the time of navigation. Conclusions: A clinical pathways platform can be a key tool in designating clinical scenarios associated with poor prognosis and identifying patients who may be particularly at risk. Pathways analytics provide real-world evidence corroborating the expected poor prognosis based on published studies and can identify specific clinical subsets for whom specific resources are warranted. By embedding this into the pathways data model, we aim to alert physicians to conduct goals of care conversations, offer supportive care resources, and match patients to appropriate treatment options and clinical trials. [Table: see text]

Documented Goals of Care Conversations with Hospitalized Patients After Severe Stroke (GP715)

Documented Goals of Care Conversations with Hospitalized Patients After Severe Stroke (GP715)

The VA Life-Sustaining Treatment Decisions Initiative: A qualitative analysis of veterans with advanced kidney disease.

Documentation of patients' goals of care is integral to promoting goal-concordant care. In 2017, the Department of Veterans Affairs (VA) launched a system-wide initiative to standardize documentation of patients' preferences for life-sustaining treatments (LST) and related goals-of-care conversations (GoCC) that included using a note template in its national electronic medical record system. We describe implementation of the LST note based on documentation in the medical records of patients with advanced kidney disease, a group that has traditionally experienced highly intensive patterns of care. We performed a qualitative analysis of documentation in the VA electronic medical record for a national random sample of 500 adults with advanced kidney disease for whom at least one LST note was completed between July 2018 and March 2019 to identify prominent themes pertaining to the content and context of LST notes. During the observation period, a total of 723 (mean 1.5, range 1-6) LST notes were completed for this cohort. Two themes emerged from the analysis: (1) Reactive approach: LST notes were largely completed in response to medical crises, in which they focused on short-term goals and preferences rather than patients' broader health and goals, or certain clinical encounters designated by the initiative as "triggering events" for LST note completion; (2) Practitioner-driven: Documentation suggested that practitioners would attempt to engage patients/surrogates in GoCC to lay out treatment options in order to move care forward, but patients/surrogates sometimes appeared reluctant to engage in GoCC and had difficulty communicating in ways that practitioners could understand. Standardized documentation of patients' treatment preferences and related GoCC was used to inform in-the-moment decision-making during acute illness and certain junctures in care. There is opportunity to expand standardized documentation practices and related GoCC to address patients'/surrogates' broader health concerns and goals and to enhance their engagement in these processes.