Goals Of Care Discussions Research Articles

Aligning to a New Normal During COVID-19

The Acute Life interventions Goals and Needs Program (ALIGN) is an inter-professional team of medical and social work providers dedicated to offering time-limited intensive ambulatory care to the most complex, high cost, high needs older patient population at Mount Sinai Hospital in NYC. During the 2020 COVID19 pandemic, ALIGN pivoted to focus on emergency planning actions. Such actions included language and culturally concordant goals of care discussions with patients and family, completion of electronic Medical Orders for Life Sustaining Treatment, reassessment of patient’s social determinants of health, determination of adequate access to food, medication, and emotional support to those alone and isolated, and assistance with video telemedicine. ALIGN’s model of care has shown how adaptable this program and others were during the height of the pandemic.

Promoting timely goals of care conversations between gynecologic cancer patients at high-risk of death and their providers

ObjectiveWe designed a multi-faceted intervention to increase the rate of outpatient goals of care (GOC) conversations in women with gynecologic cancers who are at high-risk of death. Methods and materialsA multidisciplinary team developed an educational program around GOC conversations at end-of-life and chose criteria to prospectively identify patients at high-risk of death who might benefit from timely GOC conversations: recurrent or metastatic endometrial, cervical or vulvar cancer or platinum-resistant ovarian cancer. Gynecologic oncology provider consensus was built regarding the need to improve the quality and timing of GOC conversations. Eligible outpatients were prospectively identified and providers alerted pre-encounter; timely GOC documentation within 3 visits of high-risk identification was tracked. Our institution concurrently and subsequently tracked GOC documentation during the last 6 months of life among all established oncology patients. ResultsOf 220 pilot period high-risk patients (96 pre- and 124 during pilot period 2017–2018), timely GOC discussion documentation increased from 30.2% to 88.7% (p < 0.001) and this increase was sustained over time. In the post-pilot period (2019–2020), among patients seen by oncologists during last 6 months of life, compared to other cancer types, gynecologic cancer patients had a higher rate of GOC documentation (81% versus 9%; p < 0.001), a lower rate of receiving chemotherapy during the last 14 days of life (2% vs 5%; p = 0.051), and no difference in end-of-life admissions (29% vs 31%; p = NS). ConclusionsImplementation of systematic outpatient identification of high-risk gynecologic oncology patients is feasible, sustainable, and increases the timely conduct of GOC conversations.

Outcomes of second-tier rapid response activations in a tertiary referral hospital: A prospective observational study

A second-tier rapid response team (RRT) is activated for patients who do not respond to first-tier measures. The premise of a tiered response is that first-tier responses by a ward team may identify and correct early states of deterioration or establish goals of care, thereby reducing unnecessary escalation of care to the RRT. Currently, utilisation and outcomes of tiered RRTs remain poorly described. A prospective observational study of adult patients (age ≥18 years) who required RRT activations was conducted from February 2018 to December 2019. There were 951 consecutive RRT activations from 869 patients and 76.0% patients had a National Early Warning Score (NEWS) ≥5 at the time of RRT activation. The majority (79.8%) of patients required RRT interventions that included endotracheal intubation (12.7%), point-of-care ultrasound (17.0%), discussing goals of care (14.7%) and intensive care unit (ICU) admission (24.2%). Approximately 1 in 3 (36.6%) patients died during hospitalisation or within 30 days of RRT activation. In multivariate analysis, age ≥65 years, NEWS ≥7, ICU admission, longer hospitalisation days at RRT activation, Eastern Cooperative Oncology Group performance scores ≥3 (OR [odds ratio] 2.24, 95% CI [confidence interval] 1.45-3.46), metastatic cancer (OR 2.64, 95% CI 1.71-4.08) and haematological cancer (OR 2.78, 95% CI 1.84-4.19) were independently associated with mortality. Critical care interventions and escalation of care are common with second-tier RRTs. This supports the need for dedicated teams with specialised critical care services. Poor functional status, metastatic and haematological cancer are significantly associated with mortality, independent of age, NEWS and ICU admission. These factors should be considered during triage and goals of care discussion.

131 Characterizing atlanto-occipital dissociation and its association with pediatric traumatic cardiac arrest: A descriptive case series

Abstract Primary Subject area Emergency Medicine - Paediatric Background Atlanto-occipital dislocation (AOD) is a type of cervical spine injury (CSI) that is commonly fatal or associated with severe neurologic consequences. Although rare, AOD is now more commonly recognized in children as improved prehospital care allows for more patients to reach trauma centres and undergo definitive imaging. Patients with AOD often present with cardiorespiratory instability and prompt diagnosis is crucial. However, diagnosis may be delayed due to variation in imaging practices and lack of literature on this topic. Objectives Primary objective: Describe the demographic characteristics, clinical presentation, and long-term outcomes of children with AOD, compared to other upper CSI. Secondary objective: Describe the frequency of AOD and other upper CSI in pediatric traumatic cardiac arrest (PTCA) and the utility of a lateral c-spine radiograph in this setting. Design/Methods This was a retrospective, single-centre case series of all pediatric trauma patients age &amp;lt; 16 years diagnosed with upper CSI seen at a tertiary pediatric trauma centre from 2000-2020. Patients were included if they had evidence of bony or ligamentous injury from C0-2. The diagnosis of upper CSI was ascertained on autopsy, when available, then cross-sectional imaging, then plain radiographs, when the other modalities were unavailable. Data was obtained from manual chart review and analyzed using descriptive statistics. Results Thirty-six patients were excluded for not meeting upper CSI criteria. Of 93 patients with upper CSI, 24 had AOD: 14 (15%) complete and 10 (11%) incomplete (Table 1). The mechanism of injury was motor-vehicle-collision in 23 (96%) of these patients, and a fall in one (4%). All patients with complete AOD presented in PTCA and only one (7%) survived. Of seven patients with AOD who received a lateral c-spine x-ray during resuscitation, 5 (71%) had identifiable injuries. In contrast, of the 10 patients with incomplete AOD, only 1 (10%) presented in arrest and none died. Only one patient received an x-ray during resuscitation, which showed the injury but went undetected, and 100% of final diagnoses were made through CT. The majority of incomplete AOD patients were managed non-operatively and had minimal to mild disability. Conclusion In our study population, complete AOD was highly fatal with all patients presenting in PTCA. In contrast, incomplete AOD carried a more favorable prognosis with 100% survival and minimal-mild disability. If there is suspicion for AOD, a lateral c-spine XR in the trauma bay can aid in early diagnosis, guiding neurosurgical management and/or goals of care discussions.

Supportive care services and goals of care in early phase clinical trials (EP-CTs).

26 Background: EP-CTs investigate novel therapeutic approaches for patients with cancer, but little is known about the use of supportive care services and timing of goals of care (GOC) discussions in EP-CTs. Methods: We conducted a retrospective review of consecutive patients with cancer enrolled on EP-CTs at Massachusetts General Hospital from 2017-2019. We collected information about patients’ demographic/clinical characteristics, use of supportive care services (palliative care [PC], social work [SW], physical therapy [PT], and nutrition), as well as documentation of GOC discussions and code status (before/during EP-CT vs after/never) via chart review. We examined patient characteristics associated with earlier receipt of supportive care services (before/during EP-CT vs after/never) and compared differences in the timing of GOC discussions and code status documented based on the receipt of supportive care services. Results: Among 425 patients enrolled on EP-CTs (median age 63.0; 56.0% female; 97.4% metastatic cancer; 22.1% gastrointestinal cancer), under half received supportive care services before/during trial (PC: 33.2% before/during, 66.8% post/never; SW: 41.9% before/during, 58.1% post/never; PT: 38.4% before/during, 61.6% post/never; and Nutrition: 33.2% before/during, 62.1% post/never). We identified the most common reasons for consulting each of the supportive care services (PC: 82.4% symptom management and 12.4% GOC; SW: 65.3% adjustment to illness and 23.8% referral for resources; PT: 44.8% safety/discharge planning and 24.6% mobility concerns; Nutrition: 73.2% for symptoms of anorexia/poor appetite and 21.5% nutrition assessment). Patients with GI cancer were more likely than those with other cancers to receive PC and SW before/during EP-CT (PC: 29.8% v 18.3%, p =.009; SW: 27.5% v 18.2%, p =.025). Earlier PC was associated with earlier hospice referral (HR = 1.95, p =.014) and shorter survival (HR = 1.54, p &lt;.001). Patients receiving earlier supportive care services were more likely to have GOC discussions documented earlier (PC: 65.2% v 13.0%, p &lt;.001; SW: 41.0% v 22.7%, p &lt;.001; PT: 38.7% v 25.2%, p =.005; Nutrition: 39.1% v 25.0%, p =.002). Patients with earlier PC were more likely to have earlier documented code status (46.8% v 24.3%, p &lt;.001), but not for any other service. Conclusions: In this cohort of patients with advanced cancer, under half received supportive care services before/during their participation in EP-CTs. We found that symptom management represented a common reason for referral to supportive care, highlighting the needs of this population. Patients who received earlier supportive care services were more likely to have earlier documentation of GOC discussions, with those receiving earlier PC having code status documented earlier and also experiencing earlier hospice use and shorter survival. These findings underscore the utility of supportive care services in EP-CTs.

375 Telemedicine and Goals of Care Discussions: A Successful Combination in the Emergency Department

There has been a long-standing need for emergency department (ED) clinicians to conduct goals of care (GOC) discussions in the ED despite the perceived barriers of constrained time and discomfort with these conversations. The COVID-19 pandemic led to rapid adoption and wider acceptance of telehealth. We developed a quality improvement project that evaluated having a dedicated clinician lead GOC discussions in the ED with support staffing by a virtual expert.

SEVERE CORONARY ARTERY SPASM WITH CARDIAC ARREST IN A PATIENT WITH COVID-19

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: SARS-CoV-2 has been associated with cardiac complications, especially in patients with pre-existing cardiovascular disease. We present a case of a patient without any history of coronary artery disease (CAD), who contracted COVID-19 and developed severe coronary artery spasms resulting in cardiac arrest. CASE PRESENTATION: A 55-year-old man with past medical history of tobacco use of 30 years was admitted with severe COVID-19 pneumonitis with acute hypercapnic and hypoxemic respiratory failure, requiring invasive mechanical ventilation. On hospital day 9, he had intermittent episodes of polymorphic ventricular tachycardia. An EKG showed acute ST elevations in leads II, III, aVF and V1-V3 with troponin T rise to 0.83 ng/mL. He developed cardiac arrest due to polymorphic ventricular tachycardia. Successful resuscitation was achieved after 5 minutes including defibrillation and 2 cycles of CPR. An emergent left heart catheterization revealed insignificant CAD, normal left ventricular systolic function and no wall motion abnormalities with a presumptive diagnosis of coronary artery spasm (CAS) as the most likely cause for his cardiac arrest. He was started on a nitroglycerin patch, and his vasopressor support was switched from norepinephrine to epinephrine. The previously observed EKG changes resolved within five hours and troponin levels started to decline. A head CT showed diffuse cerebral edema with early uncal herniation and following goals of care discussion, the patient was transitioned to comfort with terminal extubation. DISCUSSION: Rarely does CAS result in polymorphic ventricular tachycardia with cardiac arrest, in patients without CAD. Initial reports showed that patients with COVID-19 and ST segment elevations are found to have myocardial injury with non-obstructive coronary arteries (MINOCA), however there are no reports of COVID-19 patients with CAS resulting in cardiac arrest. The pathophysiology of CAS is not completely understood however, the current literature has described multiple mechanisms including endothelial dysfunction, systemic inflammation, oxidative stress and smooth muscle hyperreactivity, amongst others. CONCLUSIONS: More studies are required to elucidate the mechanism of myocardial injury associated with COVID-19 infection in order to risk stratify those patients at increased risk of CAS and arrthymias and possibly tailor their management;including choice of vasopressor support and use of nitrates to lower the risk of life-threatening complications. REFERENCE #1: Bangalore S, Sharma A, Slotwiner A, et al. ST-Segment Elevation in Patients with Covid-19 — A Case Series. N Engl J Med. 2020;382(25):2478-2480. doi:10.1056/NEJMc2009020 REFERENCE #2: Matta A, Bouisset F, Lhermusier T, et al. Coronary Artery Spasm: New Insights. J Intervent Cardiol. 2020;2020:1-10. doi:10.1155/2020/5894586 REFERENCE #3: Rivero F, Antuna P, Cuesta J, Alfonso F. Severe coronary spasm in a COVID -19 patient. Catheter Cardiovasc Interv. Published online August 2020:ccd.29056. doi:10.1002/ccd.29056 DISCLOSURES: No relevant relationships by Andres Cordova Sanchez, source=Web Response No relevant relationships by Markus Gutsche, source=Web Response No relevant relationships by Matthew Kovach, source=Web Response No relevant relationships by Jasmine Sandhu, source=Web Response

COLORECTAL CARCINOMA: A CASE OF MALIGNANT FISTULA FORMATION PRESENTING AS SEPTIC SHOCK

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Colorectal carcinoma (CRC) is the third most common cause of malignancy in the United States. Common signs and symptoms include hematochezia, melena, abdominal pain, anemia, and change in bowel habits. Rarely, CRC can present with fistula formation and subsequent infection. Here we highlight a patient with known CRC who presented with intrapulmonary abscesses due to colopleural fistula formation. CASE PRESENTATION: A 57-year-old male with recently diagnosed stage IV colon adenocarcinoma presents with a productive cough of brown, foul-smelling sputum and left-sided chest and abdominal pain for three weeks. Vitals showed tachycardia and hypotension. Exam revealed diminished breath sounds of the left hemithorax and tenderness to palpation of the left chest wall and left upper quadrant. Labs were significant for anemia 6.2 g/dL, leukocytosis 21.3 thou/cmm with bandemia 17%, and peak lactate 20.1 mmol/L. Computed tomography (CT) of the chest, abdomen, and pelvis showed a large gas containing mass within the left lower lobe contiguous with the splenic flexure and chest wall as well as left-side intrapulmonary abscesses and extensive soft tissue gas within the left hemithorax concerning for pleurocutaneous fistula. These findings were consistent with colopleural fistula formation due to extension of his known splenic flexure mass. Patient was fluid resuscitated, transfused one unit of packed red blood cells, and started on vasopressors and broad-spectrum antibiotics. Multidisciplinary discussions determined that patient would require extensive surgical debridement for source control; however, his overall prognosis remained poor given the advanced state of his cancer and poor performance status. A goals of care discussion was held with the patient who declined surgery and opted to pursue hospice care. DISCUSSION: Colopleural fistula formation is an extremely rare complication of CRC with the potential to manifest as serious pulmonary infections arising due to perforation or invasion of nearby tissue. Our patient developed intrapulmonary abscesses and pleurocutaneous fistula with soft tissue gas concerning for necrotizing fasciitis due to colopleural fistula formation. Management involves a multidisciplinary approach and ultimately, requires emergent surgical intervention. Unfortunately, this is not always possible as in our patient who was too far advanced in his disease course making him a poor surgical candidate. CONCLUSIONS: Malignant fistulas associated with CRC can present as life-threatening infections, which require emergent surgical and medical management. It is important for all patients to undergo age-appropriate CRC screening with close follow-up to prevent such dire complications. REFERENCE #1: Lian R, Zhang G, Zhang G. Empyema caused by a colopleural fistula: A case report. Medicine (Baltimore). 2017 Sep;96(39):e8165. doi: 10.1097/MD.0000000000008165. PMID: 28953667; PMCID: PMC5626310. REFERENCE #2: Papagiannopoulos K, Gialvalis D, Dodo I, Darby MJ. Empyema resulting from a true colopleural fistula complicating a perforated sigmoid diverticulum. Ann Thorac Surg. 2004 Jan;77(1):324-6. doi: 10.1016/s0003-4975(03)01378-x. PMID: 14726092. REFERENCE #3: Siegel RL, Miller KD, Fuchs HE, Jemal A. Cancer Statistics, 2021. CA Cancer J Clin. 2021 Jan;71(1):7-33. doi: 10.3322/caac.21654. Epub 2021 Jan 12. PMID: 33433946. DISCLOSURES: No relevant relationships by Arjan Ahluwalia, source=Web Response No relevant relationships by Henry Lam, source=Web Response No relevant relationships by Kaitlyn Musco, source=Web Response No relevant relationships by Andres Zirlinger, source=Web Response

EARLY IDENTIFICATION FOR PREVENTING SEVERE BABESIA PARASITEMIA AND ARDS IN A POST-SPLENECTOMY PATIENT

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Babesiosis is an emerging health risk and a nationally notifiable disease in the United States.1 It can present as shock and multi-organ dysfunction in immunocompromised host. As babesiosis prophylaxis in patients with splenectomy is not common, it should be considered in post-splenectomy sepsis syndrome.1 This case describes a post-splenectomy patient with severe babesiosis presenting with refractory Acute Respiratory Distress Syndrome (ARDS). CASE PRESENTATION: 59-year-old man presented to emergency department with 2 weeks of worsening generalized weakness, fever, and headaches, not getting better on oral antibiotics prescribed outpatient. His Computed Tomography (CT) head, lumbar puncture was normal. He developed severe respiratory distress and was emergently intubated. Chest imaging revealed bilateral pulmonary infiltrates. Arterial blood gas analysis confirmed severe ARDS with a PaO2/FiO2 (P/F) ratio <100. The patient was managed with lung protective ventilation and prone positioning. Peripheral smear revealed intraerythrocytic ring inclusions consistent with Babesia microti trophozoites (Figure1). Testing for other bacterial infections, viral pathogens, and tick-borne illnesses were negative. Labs were significant for hemoglobin (Hb) 10.8 g/dl, platelet count 170 K/uL, haptoglobin <10 mg/dl, lactate dehydrogenase 373 U/L, aspartate aminotransferase 68 U/L and alanine aminotransferase 71 U/L. He was treated with atovaquone and azithromycin. Doxycycline was initiated for possible co-infection with other tick-borne illnesses. The patient also had red cell exchange transfusion given his critical condition and history of splenectomy. He was evaluated for Veno-venous extracorporeal membrane oxygenation (ECMO), but cannulation was deferred due to initial improvement with prone positioning. Though there was initial improvement, his hemodynamic status continued to decline requiring initiation of vasopressor support and was transitioned to comfort care after prolonged intubation with goals of care discussions with family. DISCUSSION: Early recognition and diagnosis of babesia, especially in patients with asplenia, is imperative as babesiosis can progress to refractory ARDS, shock and multi-organ dysfunction. Clinicians should have a high index of suspicion for a patient living in an endemic area who presents with unexplained nonspecific symptoms and laboratory findings including thrombocytopenia, hemolytic anemia, and/or elevation of liver enzymes. If clinical suspicion is high, sever real-time PCR assays are useful to detect low-grade parasitemia and are more sensitive than blood smears.2 Prone positioning has been shown to improve outcomes with ARDS if used early and for longer sessions and may help patients avoid need for ECMO.3 CONCLUSIONS: Our case reveals the importance of early recognition of babesiosis in immunocompromised patients living in endemic areas for preventing refractory ARDS. REFERENCE #1: Rosner F, Zarrabi MH, Benach JL, Habicht GS. Babesiosis in splenectomized adults: review of 22 reported cases. The American journal of medicine. 1984 Apr 1;76(4):696-701. REFERENCE #2: Sanchez E, Vannier E, Wormser GP, Hu LT. Diagnosis, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: a review. Jama. 2016 Apr 26;315(16):1767-77. REFERENCE #3: Guérin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, Mercier E, Badet M, Mercat A, Baudin O, Clavel M. Prone positioning in severe acute respiratory distress syndrome. New England Journal of Medicine. 2013 Jun 6;368(23):2159-68. DISCLOSURES: No relevant relationships by Kinjal Banerjee, source=Web Response No relevant relationships by Taesung Kwon, source=Web Response No relevant relationships by Thomas Lettich, source=Web Response No relevant relationships by Sanjeev Shrestha, source=Web Response No relevant relationships by Cynthia Tsai, source=Web Response

PALLIATIVE CARE PRACTICE FOR THE END-STAGE CARDIAC DISEASE POPULATION

<h3>BACKGROUND/PURPOSE</h3> End-stage cardiac disease processes lead to progressive, symptomatic and complex end-of-life care. Associated with physical and emotional distress, advanced cardiac disease remains undertreated in the outpatient population that presents a unique symptom burden, increased caregiver demands, and variable disease trajectory, all leading to challenging prognostication. The palliative approach to care of cardiac life-limiting disease helps improve the quality of life for patients and their caregivers. Historically, the focus of palliative care has been malignant disease processes with clear transition points, rather than diseases with non-linear trajectories. Due to its varying clinical course and life-limiting progression, cardiac disease prognostication is difficult, thus challenging the norms of approaches to palliative care. Cardiologists, cardiac patients and their caregivers are confronted with the management of end-stage cardiac disease while respecting the wishes of patient and caregiver for quality palliative and end-of-life care. <h3>METHODS/RESULTS</h3> The University of Ottawa Heart Institute's (UOHI) innovative Cardiac Supportive and Palliative Care Program (CSPCP) provides specialized outpatient service for patients diagnosed with advanced cardiac disease. The program's goal is to initiate and bridge access to cardiac palliative care across Eastern Ontario. End-stage cardiac disease patients are referred for symptom management, goals of care discussion, advance care planning, community care coordination, caregiver support and end-of-life planning. In collaboration with UOHI allied health services and community resources, and under the direction of a Cardiologist with expertise in palliative care, the Advanced Practice Nurse (APN) is able to fulfill a supportive and consultative role. Advanced medical assessments, in-depth cardiac symptom management, and community care coordination support, respect, and honour the patient's goals of care. Using direct clinical and comprehensive care, the APN optimizes and synthesizes health information, provides patient and caregiver education, and ensures optimal end-stage cardiac palliative patient care. With this innovative model of care, the UOHI CSPCP has successfully met the needs of end-stage cardiac patients and their caregivers throughout Eastern Ontario. <h3>CONCLUSION/IMPLICATIONS FOR PRACTICE</h3> Through a complex case study, one is best able to understand the APN's role in facilitating excellent cardiac palliative care. Implementing CSPCP has allowed patients to explore their goals of care and advance care plans with the UOHI CSPCP team, optimize end-stage cardiac symptom burden, initiate home care services and provide quality end-of-life care.

Documentation of goals of care discussions: Lessons from the Improving Goal Concordant Care Collaborative.

166 Background: Patients with advanced cancer do not reliably receive care consistent with their goals and values. Goal-concordant care requires effective, efficient and timely communications between patients and their providers, as well as systems to capture patient goals and ensure future accessibility. Currently, electronic health records (EHR) in most oncology settings do not adequately support structured documentation that is most relevant to goals of cancer care. Methods: The Alliance of Dedicated Cancer Centers (ADCC) initiated the Improving Goal Concordant Care (IGCC) Initiative in 2019. ADCC members are 10 U.S. freestanding, academic cancer hospitals, which are also the IGCC participants. In 2019 and 2020, we convened palliative care and oncology experts in the IGCC’s planning phase, via a series of structured consensus building sessions. We employed modified Delphi processes - including literature review, brainstorming, voting, and refinement - in conceptualization four core components considered essential to improving goal concordant care for cancer patients. One of these core components is EHR documentation of GOC discussions; an additional EHR workgroup created detailed recommendations. The three-year IGCC implementation phase launched in September 2020. Results: We achieved consensus on minimum desired fields for GOC documentation: intent of the current treatment, physician's estimated prognosis, prognosis disclosed/discussed with patient, patient prognostic awareness, patient goals, recommendations. Further, GOC documentation must be discrete and structured whenever possible to ease entry and facilitate retrieval/reporting. As GOC discussions evolve over time, documentation may be iterated over multiple encounters. GOC documentation is distinct from, but may rely on, advance directives or other ACP documentation, such as code status, POLST/MOLST, and healthcare agents. At IGCC collaborative launch, none of the 10 cancer hospitals had EHRs that were fully compliant. Progress toward development, training, and use of structured GOC documentation is ongoing. Conclusions: Establishing feasible and useful expectations for electronic documentation of GOC discussions by oncologists presented unique challenges for the IGCC. Ongoing and planned work in this area includes: Facilitating collaborative learning and promoting sharing of best practices; Measuring the presence of GOC documentation among priority patients, as well as other measures including patient and family reported outcomes; Assessing quality of the GOC documentation; Ongoing engagement of patient and family advisors, including regarding patient access to records containing GOC documentation; Potential application of natural language processing/artificial intelligence in prompting GOC documentation and facilitating retrieval.

SCSS-02. INVOLVEMENT OF SUPPORTIVE CARE TEAM AND SOCIAL WORK IN NEUROONCOLOGY IN A TERTIARY CARE HOSPITAL

Abstract BACKGROUND/OBJECTIVES Supportive Care and Social Work services are underutilized in Neurooncology. ASCO Quality Oncology Program Initiative (QOPI) includes emotional assessment by second and advance care planning (ACP) by third oncologic visit in solid malignancies. We looked (1) reason, location, and the duration from diagnosis for the involvement of supportive care teams and (2) what are the determining factors for advanced care planning in glioblastoma. METHODS After obtaining an IRB approval for the study, we performed a retrospective chart review of glioblastoma patients seen at University of Illinois Chicago 2015-2020 using the ICD Code C71.9 for malignant gliomas. Patients who had a pathologic diagnosis of glioblastoma, age &amp;gt; 18 years, and had their entire neurooncologic care at UIC were included in the study. Demographic features, socioeconomic determinants, tumor characteristics, and treatment history were noted. Supportive Care Teams and Social Work notes were reviewed. RESULTS Out of the total 403 patients, there were 78 glioblastoma patients. A total 33 met the inclusion criteria. 10 out of 33 had been seen by the supportive care team. Patients in both groups were equally matched for demographics, socioeconomic determinants, and tumor characteristics. ACP were significantly better documented in the supportive care group (p = 0.035). Supportive Care teams were consulted much later after the disease diagnosis, usually in the inpatient setting mostly consulted for goals of care discussion and hospice enrollment. There was a significant positive correlation between the involvement of Supportive Care team and Social Work. DISCUSSION A multidisciplinary clinic including an inbuilt palliative and social work teams can improve the Quality of Life (QoL) in glioblastoma patients and their caregivers. ICD code 99497 for a dedicated ACP discussion by the neurooncologist can be used. An ongoing phase III RCT EPCOG aims to assess (QoL) in patients with glioblastoma receiving early palliative intervention.

Portable medical orders and end-of-life measures in acute myeloid leukemia and myelodysplastic syndromes

AbstractPatients with acute myeloid leukemia (AML) or a myelodysplastic syndrome (MDS) experience high rates of hospitalization, intensive care unit (ICU) admission, and in-hospital death at the end of life. Early goals-of-care (GOC) discussions may reduce the intensity of end-of-life (EOL) care. Portable Medical Order forms, known as Medical Orders for Life-Sustaining Treatment (MOLST) forms in New York state, assist patients in translating GOC discussions into specific medical orders that communicate their wishes during a medical emergency. To determine whether the timing of completion of a MOLST form is associated with EOL care in patients with AML or MDS, we conducted a retrospective study of 358 adult patients with AML or MDS treated at a single academic center and its affiliated sites, who died during a 5-year period. One-third of patients completed at least 1 MOLST form >30 days before death. Compared with patients who completed a MOLST form within 30 days of death or never, those who completed a MOLST form >30 days before death were less likely to receive transfusion (adjusted odds ratio [AOR], 0.39; P < .01), chemotherapy (AOR, 0.24; P < .01), or life-sustaining treatments (AOR, 0.21; P < .01) or to be admitted to the ICU (AOR, 0.21; P < .01) at EOL. They were also more likely to use hospice services (AOR, 2.72; P < .01). Earlier MOLST form completion was associated with lower intensity of care near EOL in patients with MDS or AML.

POSTER ABSTRACTS 1- 48: 2021 ASCIP Hybrid Educational Conference & Expo

Context: This is a case of a 71-year-old male who presented with sudden onset tetraplegia after a mechanical ground level fall. He was diagnosed with a traumatic C3 AIS B spinal cord injury (SCI) and neurogenic shock requiring vasopressors and intubation. He underwent C3-C5 surgical decompression and stabilization. His course was complicated by cardiac arrest, aspiration pneumonia, alcoholic pancreatitis, and failure to wean off vasopressors. Findings: The patient was alert and intermittently cognitively intact, but his communication was limited by intubation. The healthcare team discussed his likely prognosis including long-term artificial ventilation, tube feeding, and severe tetraplegia. Under COVID-19 restrictions, the patient's wife, his durable power of attorney, and son had limited encounters with the patient. Initially, she wanted to pursue tracheostomy so the patient may participate in goals of care discussions. However, the family recalled his preference to not be on life support. The decision was made to withdraw care and he passed away on hospital day 11. Conclusion/Clinical Relevance: This case highlights the ethical dilemma of withdrawing care in the acute phase of a severe traumatic SCI. While undergoing intensive care, many factors interfere with decision making including the patient's acute medical status, altered cognition, communication limitation, and the family's physical distance and emotional state. Lastly, the patient and his family may not have had sufficient time to process the given information and understand that a meaningful life is possible with a severe disability. Informed decision making includes not only clear and thorough information but also time to adjust.

Patients’ Awareness of Advanced Disease Status, Psychological Distress and Quality of Life Among Patients With Advanced Cancer: Results From the APPROACH Study, India

Prognostic disclosure to patients with advanced cancer facilitates treatment decisions and goals of care discussions. However, the perspectives of patients, families and physicians differ in this regard across different cultures. Non-disclosure of cancer diagnosis or prognosis is commonly observed in family-centric cultures such as India. To assess the prevalence of and factors associated with cancer patients' awareness of advanced disease status; and its with quality of life and psychological distress. Patients for this cross-sectional questionnaire-based survey were recruited from oncology and palliative medicine clinics at a tertiary cancer hospital in India from January 2017 to June 2018. Patients aged ≥ 21 years, aware of cancer diagnosis and receiving oncology treatment for Stage IV solid cancer were included in the study after obtaining written informed consent. Two hundred patients were enrolled, of which 146 (73%) were not aware of the stage of their malignancy and 9 (4.5%) believed that their disease was at stage I, II or III. Those who were aware of their advanced cancer stage had more years of education (9.9 years vs 8.1 years, p = .05) and had poorer spiritual wellbeing in the faith domain (adjusted difference -1.6, 95% confidence interval -3.1 to -0.1, p = .03) compared to those who were unaware. It is recommended that future studies may explore prognostic understanding in Indian patients according to their socio-cultural, spiritual and educational background.

Expected clinical utility of automatable prediction models for improving palliative and end-of-life care outcomes: Toward routine decision analysis before implementation.

ObjectiveThe study sought to evaluate the expected clinical utility of automatable prediction models for increasing goals-of-care discussions (GOCDs) among hospitalized patients at the end of life (EOL).Materials and MethodsWe built a decision model from the perspective of clinicians who aim to increase GOCDs at the EOL using an automated alert system. The alternative strategies were 4 prediction models—3 random forest models and the Modified Hospital One-year Mortality Risk model—to generate alerts for patients at a high risk of 1-year mortality. They were trained on admissions from 2011 to 2016 (70 788 patients) and tested with admissions from 2017-2018 (16 490 patients). GOCDs occurring in usual care were measured with code status orders. We calculated the expected risk difference (beneficial outcomes with alerts minus beneficial outcomes without alerts among those at the EOL), the number needed to benefit (number of alerts needed to increase benefit over usual care by 1 outcome), and the net benefit (benefit minus cost) of each strategy.ResultsModels had a C-statistic between 0.79 and 0.86. A code status order occurred during 2599 of 3773 (69%) hospitalizations at the EOL. At a risk threshold corresponding to an alert prevalence of 10%, the expected risk difference ranged from 5.4% to 10.7% and the number needed to benefit ranged from 5.4 to 10.9 alerts. Using revealed preferences, only 2 models improved net benefit over usual care. A random forest model with diagnostic predictors had the highest expected value, including in sensitivity analyses.DiscussionPrediction models with acceptable predictive validity differed meaningfully in their ability to improve over usual decision making.ConclusionsAn evaluation of clinical utility, such as by using decision curve analysis, is recommended after validating a prediction model because metrics of model predictiveness, such as the C-statistic, are not informative of clinical value.

Features and perceptions of a critical care outreach physician role

Objective: To describe the tasks completed by the critical care outreach physician (CCOP) and staff perceptions of the CCOP role.Design: Prospective observational study and survey of intensive care unit (ICU) staff.Setting: University-affiliated teaching hospital in Australia.Participants: ICU consultants, registrars and nurses.Interventions: Implementing a dedicated ICU consultant to review deteriorating patients outside the ICU.Main outcome measures: Prospective collection of CCOP tasks and survey of ICU staff.Results: During 101 clinical shifts, the CCOP had 1524 encounters (mean, 15.1 [standard deviation, 6.1]; median, 14 [interquartile range, 10–19] per day). The three commonest interventions were emergency department visits, direct consultant communication, and coordinating ICU admissions. Involvement in Medical Emergency Team (MET) calls, expediting patient care, and goals of care discussions were also relatively common. Survey responses were obtained from 55/84 (66%) eligible participants. Most respondents thought the CCOP would improve the predefined processes of care and patient-centred outcomes. The areas of greatest perceived benefit included supporting the MET registrar and coordinating simultaneous emergencies outside the ICU. Areas where the role was perceived to be less beneficial included improving handover, identifying patients at clinical risk outside the ICU, and reducing repeat MET calls.Conclusions: The tasks of a CCOP involved high level communication, coordination of care, and supervision of ICU staff. The effect of this role on patient-centred outcomes requires further research.

Patient and Caregiver Prioritization of Palliative and End-of-Life Cancer Care Quality Measures.

Development and prioritization of quality measures typically relies on experts in clinical medicine, but patients and their caregivers may have different perspectives on quality measurement priorities. To inform priorities for health system implementation of palliative cancer and end-of-life care quality measures by eliciting perspectives of patients and caregivers. Using modified RAND-UCLA Appropriateness Panel methods and materials tailored for knowledgeable lay participants, we convened a panel to rate cancer palliative care process quality measure concepts before and after a 1-day, in-person meeting. Nine patients and caregivers with experience living with or caring for patients with cancer. Panelists rated each concept on importance for providing patient- and family-centered care on a nine-point scale and each panelist nominated five highest priority measure concepts ("top 5"). Cancer patient and caregiver panelists rated all measure concepts presented as highly important to patient- and family- centered care (median rating ≥ 7) in pre-panel (mean rating range, 6.9-8.8) and post-panel ratings (mean rating range, 7.2-8.9). Forced choice nominations of the "top 5" helped distinguish similarly rated measure concepts. Measure concepts nominated into the "top 5" by three or more panelists included two measure concepts of communication (goals of care discussions and discussion of prognosis), one measure concept on providing comprehensive assessments of patients, and three on symptoms including pain management plans, improvement in pain, and depression management plans. Patients and caregivers nominated one additional measure concept (pain screening) back into consideration, bringing the total number of measure concepts under consideration to 21. Input from cancer patients and caregivers helped identify quality measurement priorities for health system implementation. Forced choice nominations were useful to discriminate concepts with the highest perceived importance. Our approach serves as a model for incorporating patient and caregiver priorities in quality measure development and implementation.

Assessing Goals-of-Care Documentation during the COVID-19 Patient Surge in an Academic Safety-Net Medical Center.

Context/Objectives: It is paramount that clinicians assess and document patients' priorities to guide goal-concordant interventions, especially during a public health crisis. Design: Retrospective chart review. Setting: Academic safety-net medical center in central Massachusetts, United States. Methods: We examined electronic medical records (EMRs) to discern goals-of-care (GOC) conversations with COVID-19 patients seen at some point by palliative care during their hospitalization, and all clinicians' use of a structured note template during the peak incidence of COVID-19 from March to May 2020. Patients were grouped based on comorbidities and preadmission living situation. GOC discussions were categorized into three types: code status decisions, other treatment decisions, and no treatment decisions. Results: Nearly all (97%) patients had GOC documentation within 48 hours of admission. Forty-four percent of first GOC conversations incorporated the template. Patients with dementia living in nursing facilities had GOC documentation within hours of hospital admission, whereas healthier patients had their first GOC conversation at one week of hospitalization. Decisions about code status predominated in the first (83%) and second (49%) discussions, followed by a focus on other treatment decisions in subsequent discussions (44%-57%). Many did not require a treatment decision (19%-27%) but focused on quality-of-life definitions. Nearly all survivors were discharged to a facility and only four patients returned home. Many survivors died within three months (case fatality rate: 77%). Conclusions: GOC documentation using a structured template combined with easy EMR retrievability and clinician training holds promise for aligning patients' values with real-time medical decisions, during and after the pandemic.

A Case-Control Study Evaluating the Impact of Dedicated Palliative Care Training on Critical Care Interventions at the end of Life.

Many patients admitted to intensive care units (ICUs) are at high risk of dying. We hypothesize that focused training sessions for ICU providers by palliative care (PC) certified experts will decrease aggressive medical interventions at the end of life. We designed and implemented a 6-session PC training program in communication skills and goals of care (GOC) meetings for ICU teams, including house staff, critical care fellows, and attendings. We then reviewed charts of ICU patients treated before and after the intervention. Forty-nine of 177 (28%) and 63 of 173 (38%) patients were identified to be at high risk of death in the pre- and postintervention periods, respectively, and were included based on the study criteria. Inpatient mortality (45% vs 33%; P = .24) and need for mechanical ventilation (59% vs 44%, P = .13) were slightly higher in the preintervention population, but the difference was not statistically significant. The proportion of patients in whom the decision not to initiate renal replacement therapy was made because of poor prognosis was significantly higher in the postintervention population (14% vs 67%, P = .05). There was a nonstatistically significant trend toward earlier GOC discussions (median time from ICU admission to GOC 4 vs 3 days) and fewer critical care interventions such as tracheostomies (17% vs 4%, P = .19). Our study demonstrates that directed PC training of ICU teams has a potential to reduce end of life critical care interventions in patients with a poor prognosis.