Illness Conversations Research Articles

Using Quality Improvement Methods to Pilot Test and Scale a Program of Serious Illness Conversations in an Oncology Learning Health System

Using Quality Improvement Methods to Pilot Test and Scale a Program of Serious Illness Conversations in an Oncology Learning Health System

Serious Illness Conversations (SIC) in the Community: A Quality Improvement Project to Increase SIC Documentation in the Community Oncology Setting (QI420)

Serious Illness Conversations (SIC) in the Community: A Quality Improvement Project to Increase SIC Documentation in the Community Oncology Setting (QI420)

The Impact of a Curriculum to Teach Advance Care Planning Communication to Pediatric Interprofessional Clinicians Using a Serious Illness Conversation Guide

The Impact of a Curriculum to Teach Advance Care Planning Communication to Pediatric Interprofessional Clinicians Using a Serious Illness Conversation Guide

Patient Identification for Serious Illness Conversations: A Scoping Review.

Serious illness conversations aim to align medical care and treatment with patients’ values, goals, priorities, and preferences. Timely and accurate identification of patients for serious illness conversations is essential; however, existent methods for patient identification in different settings and population groups have not been compared and contrasted. This study aimed to examine the current literature regarding patient identification for serious illness conversations within the context of the Serious Illness Care Program and/or the Serious Illness Conversation Guide. A scoping review was conducted using the Joanna Briggs Institute guidelines. A comprehensive search was undertaken in four databases for literature published between January 2014 and September 2021. In total, 39 articles met the criteria for inclusion. This review found that patients were primarily identified for serious illness conversations using clinical/diagnostic triggers, the ’surprise question’, or a combination of methods. A diverse assortment of clinicians and non-clinical resources were described in the identification process, including physicians, nurses, allied health staff, administrative staff, and automated algorithms. Facilitators and barriers to patient identification are elucidated. Future research should test the efficacy of adapted identification methods and explore how clinicians inform judgements surrounding patient identification.

Identifying high-risk hospitalised chronic kidney disease patient using electronic health records for serious illness conversation

This study aimed to identify risk factors that are associated with increased mortality that could prompt a serious illness conversation (SIC) among patients with chronic kidney disease (CKD). The electronic health records of adult CKD patients admitted between August 2018 and February 2020 were retrospectively reviewed to identify CKD patients with >1 hospitalisation and length of hospital stay ≥4 days. Outcome measures were mortality and the duration of hospitalisation. We also assessed the utility of the Cohen's model to predict 6-month mortality among CKD patients. A total of 442 patients (mean age 68.6 years) with median follow-up of 15.3 months were identified. The mean (standard deviation) Charlson Comorbidity Index [CCI] was 6.8±2.0 with 48.4% on chronic dialysis. The overall mortality rate until August 2020 was 36.7%. Mortality was associated with age (hazard ratio [HR] 1.51, 95% confidence interval [CI] 1.29-1.77), CCI≥7 (1.58, 1.08-2.30), lower serum albumin (1.09, 1.06-1.11), readmission within 30-day (1.96, 1.43-2.68) and CKD non-dialysis (1.52, 1.04-2.17). Subgroup analysis of the patients within first 6-month from index admission revealed longer hospitalisation stay for those who died (CKD-non dialysis: 5.5; CKD-dialysis: 8.0 versus 4 days for those survived, P<0.001). The Cohen's model demonstrated reasonable predictive ability to discriminate 6-month mortality (area under the curve 0.81, 95% CI 0.75-0.87). Only 24 (5.4%) CKD patients completed advanced care planning. CCI, serum albumin and recent hospital readmission could identify CKD patients at higher risk of mortality who could benefit from a serious illness conversation.

How Well are Serious Illness Conversations Documented and What are Patient and Physician Perceptions of These Conversations?

Background: The Serious Illness Care Program (SICP), developed in 2011 by Ariadne Labs, restructures care so that knowing and then honoring patients' wishes becomes part of routine care. Objectives: 1) summarize patient perceptions of use of the Serious Illness Conversation Guide (SICG) components, 2) assess whether a serious illness conversation was documented in the electronic health record (EHR) and identify the SICG components that were included, 3) summarize clinician perceptions of use of the SICG components, and 4) assess the association of documented SICG components with the patient's perception of the SICG discussion. Methods: Clinicians at three family medicine offices were trained in serious illness conversations using the SICG. They documented their serious illness conversations in the medical record. Retrospective chart review for SICG components was conducted for patients. Patients and clinicians completed questionnaires about their experience with the SICG. Statistical analysis included the Pearson chi-square test for categorical variables and Cohen's kappa to determine agreement between clinician documentation and patient perception. Results: Eighty-nine patients consented and completed their baseline questionnaire. Mean age of the 89 patients was 72 years and 65 (73%) were female. Thirty (34%) medical records had one or more SICG components documented. Seventy-nine (89%) patients reported at least one individual component of the SICG being discussed. Clinicians reported they engaged in asking patients what is important to them at a mean of 5.9, with 7 being "all the time". There was slight agreement (kappa = .19) for patient perception and clinician documentation of discussing patient goals, but no agreement for any of the other SICG components. Conclusion: Even among trained clinicians, only one-third of patients had documentation of at least one SICG component. Only slight agreement was found between clinician documentation of SICG in the medical record and patient perception of SICG discussion.

Aotearoa New Zealand emergency medicine specialists on the provision of care at or near the end of life: A survey.

The ED is an increasingly important venue for the initiation of palliative care. We sought to characterise the opinions, experience, training and education of ED staff in Aotearoa/New Zealand (NZ) with regard to specific aspects of palliative care in the NZ ED setting. All NZ FACEMs were personally emailed a simple unstructured 16-part survey asking questions about initiating palliative care, goals of care, initiation and availability of advance care plans, frailty screening, availability of palliative expertise, training and education, cultural safety and pastoral care of staff. All EDs were contacted and a link provided for non-FACEM ED staff who wished to participate. Free-text comments were analysed for dominant themes. All NZ EDs had at least one participant. There was a high level of senior medical staff engagement with 60% of NZ FACEMs participating. More than 300 free-text comments from this group were available for theme analysis. A total of 93% of NZ FACEM respondents agree that palliative care should be able to be initiated in the ED. Only 25% of this group knew of training in serious illness conversations in the ED while only 34% felt culturally competent when providing end-of-life care for Māori and their whanau (family). Pastoral care for ED staff appears to be ad hoc. Time and privacy limitations were common themes. There is significant opportunity for quality improvement in the initiation and provision of palliative care from the ED. Attention to how departments provide pastoral care to their staff is needed.

Content of Tele-Palliative Care Consultations with Patients Receiving Dialysis.

Background: Little is known about the content of communication in palliative care telehealth conversations in the dialysis population. Understanding the content and process of these conversations may lead to insights about how palliative care improves quality of life. Methods: We conducted a qualitative analysis of video recordings obtained during a pilot palliative teleconsultation program. We recruited patients receiving dialysis from five facilities affiliated with an academic medical center. Palliative care clinicians conducted teleconsultation using a wall-mounted screen with a camera mounted on a pole and positioned mid-screen in the line of sight to facilitate direct eye contact. Patients used an iPad that was attached to an IV pole positioned next to the dialysis chair. Conversations were coded using a preexisting framework of themes and content from the Serious Illness Conversation Guide (SICG) and revised Edmonton Symptom Assessment System-Renal. Results: We recruited 39 patients to undergo a telepalliative care consultation while receiving dialysis, 34 of whom completed the teleconsultation. Specialty palliative care clinicians (3 physicians and 1 nurse practitioner) conducted 35 visits with 34 patients. Median (interquartile range) duration of conversation was 42 (28-57) minutes. Most frequently discussed content included sources of strength (91%), critical abilities (88%), illness understanding (85%), fears and worries (85%), what family knows (85%), fatigue (77%), and pain (65%). Process features such as summarizing statements (85%) and making a recommendation (82%) were common, whereas connectional silence (56%), and emotion expression (21%) occurred less often. Conclusions: Unscripted palliative care conversations in outpatient dialysis units through telemedicine exhibited many domains recommended by the SICG, with less frequent discussion of symptoms. Emotion expression was uncommon for these conversations that occurred in an open setting.

Patient Perspectives on Serious Illness Conversations in Primary Care.

Background: The Serious Illness Care Program has been shown to improve quality and feasibility of value-based end-of-life conversations in primary care. Objectives: To elicit patients' perspectives on serious illness conversations conducted by primary care clinicians. Subjects and Methods: Telephone interviews were conducted with patients at an academic center in the United States, who had a recent serious illness conversation with their primary care clinician. Interviews were audio-recorded and qualitatively analyzed using thematic analysis. Results: A total of eleven patients were enrolled. We identified three major themes: (1) positive emotional experiences are facilitated by established patient-clinician relationships and/or clinicians' skills in navigating emotional challenges, (2) patients appreciate a personalized conversation, and (3) clinicians should orchestrate the experience of the conversation, from preparation through follow-up. Conclusion: Patients appreciate having serious illness conversations in the primary care setting. Future efforts can be focused on improving clinicians' skills in navigating emotional challenges during conversations and implementing system changes to optimize orchestration.

Serious Illness Care Programme—contextual factors and implementation strategies: a qualitative study

ObjectivesThe Serious Illness Care Programme (SICP) is a multicomponent evidence-based intervention that improves communication about patients’ values and goals in serious illness. We aim to characterise implementation strategies for programme...

Concerning Confidence: Serious Illness Conversations During the Medicine Acting Internship.

Background: Despite increased recognition that physician–patient communication represents a key competency for medical trainees, relatively little is known about student exposures to conversations about serious illness.Objective: To characterize student experiences with multiple types of serious illness conversations during their medicine acting internship (AI).Design: This is a cross-sectional survey.Setting/Subjects: Final-year medical students who had completed a medicine AI within one year at one U.S. medical school.Measurements: Exposures to and perceptions of multiple conversation domains (discussions with upset patients/families, breaking bad news, assessing code status, and conversations about limiting or withdrawing life-sustaining treatments).Results: We collected 82 survey responses (78% response rate). Students reported multiple exposures across most domains, some of which included leading conversations without supervision or formal instruction. In most domains, at least 50% of students reported confidence in their ability to lead unsupervised conversations moving forward.Conclusions: After a four-week AI, students reported multiple exposures to a variety of serious illness conversations. Some reported having these conversations without supervision. Student confidence in their ability to lead these conversations independently was higher than has been previously reported in other small studies. Further exploration is required to better understand these trends, and targeted curricular development may be indicated.

Refinement of an Emergency Department-Based, Advance Care Planning Intervention for Nurses.

Background: Most older adults visit the emergency department (ED) near the end of life without advance care planning (ACP) and thus are at risk of receiving care that does not align with their wishes and values. ED GOAL is a behavioral intervention administered by ED clinicians, which is designed to engage seriously ill older adults in serious illness conversations in the ED. Seriously ill older adults found it acceptable in the ED. However, its potential to be used by nurses remains unclear. Objective: The aim of this study is to identify refinements to adapt an ED-based ACP intervention by eliciting the perspectives of nurses. Design: This is a qualitative study using semistructured interviews. Data were analyzed using axial coding methods. Setting/Subjects: We recruited a purposeful sample of ED nurses in one urban academic ED and one urban community ED in the northeastern region of the United States. Results: Twenty-five nurses were interviewed (mean age 46 years, 84% female, and mean clinical experience of 16 years). Emerging themes were identified within six domains: (1) nurses' prior experience with serious illness conversations, (2) overall impression of ED GOAL, (3) refinements to ED GOAL, (4) implementation of ED GOAL by ED nurses, (5) specially trained nursing model, and (6) use of telehealth with ED GOAL. Conclusions: ED nurses were generally supportive of using ED GOAL and provided insight into how to best adapt and implement it in their clinical practice. Empirical evidence for adapting ED GOAL to the nursing practice remains to be seen.

Trained Clinician's Documentation of Serious Illness Conversations and Use of Billing CPT 99497.

Background: Advance care planning (ACP) involves patients and family members in discussions with clinicians about their values, goals, and preferences regarding future medical care. Objectives: To (1) assess whether an ACP conversation using the Serious Illness Conversation (SIC) was initiated and documented; (2) assess which components of SIC were documented; (3) determine how frequently clinicians trained to use the SIC guide used ACP billing codes during the study time period, (4) determine whether there was a significant difference in mortality risk score according to documentation of each component of the SIC. Methods; Thirteen clinicians at three family medicine offices were trained in the Serious Illness Care Program and asked to document SICs in the electronic medical record (EMR). A retrospective chart review of SIC components was conducted in the EMRs of patients who presumably had ACP conversations initiated by the trained clinicians. Patients were identified using the billing codes for ACP conversations and through referrals from another study that requires clinicians to have ACP conversations with their patients. Pearson chi-square test for categorical variables and t-tests for continuous variables were conducted. Results: A total of 157 patients were included in this study; 131 patients referred from another ACP study and an additional 26 patients using the billing codes of ACP conversations. Through retrospective chart review, the mean age of patients was 72 years and 54 were male. Sixty-two (40%) charts had one or more SIC components documented. "Explore key topics" was documented most frequently for 58 (38%) patients by the 13 participating clinicians. Mean mortality risk score was 10.7 and higher scores were significantly correlated with more SIC components documented (rp = 0.217, P = 0.007). Conclusion: Little use of the SIC guide among trained physicians was found in the EMR. It was expected that provision of an EMR template for documenting the SIC would have facilitated documentation of SICs.

Virtual Geriatric Education Preferences of Rural Social Workers

Older adults in rural communities need access to comprehensive healthcare services provided by practitioners equipped with geriatric knowledge and skills. The Geriatric Rural Extension of Expertise through Telegeriatric Service (GREETS) project goal is to use telemedicine and telehealth to expand geriatric service options to underserved Michigan regions. GREETS educational programs train health practitioners to provide geriatric care for vulnerable older adults. To determine gaps in geriatric competencies, the team conducted an online survey of health professionals including behavioral health practitioners. Respondents identified educational topics and preferred virtual delivery methods. Demographic information included respondent’s professional position, practice setting, and county. The respondents were asked to indicate level of educational need using a scale ranging from a low, medium, or high need. Fifty (47%) of 106 total responses were from social workers. We compared the percent of social workers to other practitioners’ responses in our analysis. Four topics emerged for both groups as medium or high educational needs: 1) transitional care when changing residential settings or post-hospitalization; 2) assisting family caregivers cope with caregiving responsibilities; 3) incorporating community-based services into care plans; and 4) and managing frail older adults. Social workers noted higher need than the other respondents for: 1) managing chronic pain; 2) managing care of patients with multiple chronic conditions; 3) having serious illness conversations; 4) diagnosing dementia; and 5) discussing advance care planning. Both social worker and other respondents indicated interactive case-based webinars; published tools, toolkits, tip sheets; and didactic webinars as their top three learning formats.

Impact of Behavioral Nudges on the Quality of Serious Illness Conversations Among Patients With Cancer: Secondary Analysis of a Randomized Controlled Trial.

Serious Illness Conversations (SICs) are structured conversations between clinicians and patients about prognosis, treatment goals, and end-of-life preferences. Although behavioral interventions may prompt earlier or more frequent SICs, their impact on the quality of SICs is unclear. This was a secondary analysis of a randomized clinical trial (NCT03984773) among 78 clinicians and 14,607 patients with cancer testing the impact of an automated mortality prediction with behavioral nudges to clinicians to prompt more SICs. We analyzed 318 randomly selected SICs matched 1:1 by clinicians (159 control and 159 intervention) to compare the quality of intervention vs. control conversations using a validated codebook. Comprehensiveness of SIC documentation was used as a measure of quality, with higher integer numbers of documented conversation domains corresponding to higher quality conversations. A conversation was classified as high-quality if its score was ≥ 8 of a maximum of 10. Using a noninferiority design, mixed effects regression models with clinician-level random effects were used to assess SIC quality in intervention vs. control groups, concluding noninferiority if the adjusted odds ratio (aOR) was not significantly < 0.9. Baseline characteristics of the control and intervention groups were similar. Intervention SICs were noninferior to control conversations (aOR 0.99; 95% CI, 0.91 to 1.09). The intervention increased the likelihood of addressing patient-clinician relationship (aOR = 1.99; 95% CI, 1.23 to 3.27; P < .01) and decreased the likelihood of addressing family involvement (aOR = 0.56; 95% CI, 0.34 to 0.90; P < .05). A behavioral intervention that increased SIC frequency did not decrease their quality. Behavioral prompts may increase SIC frequency without sacrificing quality.

Epidemiology of Connectional Silence in specialist serious illness conversations

ContextHuman connection can reduce suffering and facilitate meaningful decision-making amid the often terrifying experience of hospitalization for advanced cancer. Some conversational pauses indicate human connection, but we know little about their prevalence, distribution or association with outcomes. PurposeTo describe the epidemiology of Connectional Silence during serious illness conversations in advanced cancer. MethodsWe audio-recorded 226 inpatient palliative care consultations at two academic centers. We identified pauses lasting 2+ seconds and distinguished Connectional Silences from other pauses, sub-categorized as either Invitational (ICS) or Emotional (ECS). We identified treatment decisional status pre-consultation from medical records and post-consultation via clinicians. Patients self-reported quality-of-life before and one day after consultation. ResultsAmong all 6769 two-second silences, we observed 328 (4.8%) ECS and 240 (3.5%) ICS. ECS prevalence was associated with decisions favoring fewer disease-focused treatments (ORadj: 2.12; 95% CI: 1.12, 4.06). Earlier conversational ECS was associated with improved quality-of-life (p = 0.01). ICS prevalence was associated with clinicians' prognosis expectations. ConclusionsConnectional Silences during specialist serious illness conversations are associated with decision-making and improved patient quality-of-life. Further work is necessary to evaluate potential causal relationships. Practice implicationsPauses offer important opportunities to advance the science of human connection in serious illness decision-making.

Improving Serious Illness Communication: Testing the Serious Illness Care Program with Trainees

BackgroundEarly conversations about patients’ goals and values improve care, but clinicians struggle to conduct them. The systems-based Serious Illness Care Program (SICP) helps clinicians have more, better, and earlier conversations. Central to this approach is a clinician conversation guide for patient encounters. While the SICP works for practicing clinicians, it has not been tested with medical trainees. InterventionWe adapted the SICP training to emphasize assessing prognostic awareness and responding to emotion. We developed a 2.5-hour SICP workshop for medical students and medical interns that included large- and small-group work, practice with an actor, and interdisciplinary clinician facilitators. We trained 81 students and 156 interns and obtained anonymous quantitative and qualitative feedback. OutcomesEighty-six percent of students and 91% of residents rated the session as “very good” or “excellent” and >90% of all learners would either recommend this training or intended to apply this to their practice. Post-session learner confidence increased in all communication skills. Learners said the training provided a helpful framework and useful language for these conversations. Resident documentation of serious illness conversations in the medical record increased dramatically during the year following training commencement. ConclusionsGrounded in principles of adult learning theory, this training was rated highly by trainees and resulted in demonstrable practice change. These early learners were more flexible and willing to try this approach than practicing clinicians who tend to resist or revert to old habits. A Guide represents a new paradigm for teaching communication skills and is valued by early learners.

Serious illness conversations in patients with multiple myeloma and their family caregivers-A qualitative interview study.

Patients treated for multiple myeloma often suffer from anxiety and depression related to concerns about the future. This indicates a need for improvement of communication between patients and healthcare professionals within haematology. The aim of this study was to explore how patients with multiple myeloma and their caregivers experience serious illness conversation focusing on illness understanding, concerns, values, and wishes for the future. Phenomenological, semi-structured dyad interviews were carried out in patients with multiple myeloma (n= 12) and their caregivers (n= 11) 2-20 days after participation in one serious illness conversation. interpretive phenomenological analysis was used for analysing data. Three themes emerged (1) transforming patient-caregiver communication, (2) redeeming communication, and (3) equality in communication in an unequal relation. Furthermore, time allocated for the conversation and preparatory materials for the conversations highly influenced outcome. The findings suggest that serious illness conversation can help patients and family caregivers managing living life with multiple myeloma by increasing dyadic communication and strengthen their use of existential language together with healthcare professionals. This study highlights the benefits of preparing patients and caregivers prior to the conversation and cancer care systems should strive to allocate ample time for serious illness conversations.

One Hospital's Response to the Institute of Medicine Report, “Dying in America”

BackgroundIn response to the Institute of Medicine (IOM) report, Dying in America, we undertook an institution wide effort to improve the experience of patients and families facing serious illness by engaging leadership and developing a program to promote the practice of generalist palliative care. MeasuresThe impact of the program was measured with process measures related to its’ three parts. InterventionWe developed a three-part generalist palliative care program that focuses on 1) instructional design, 2) advance care planning, and 3) engagement. OutcomesOver four years, the program trained 51 interprofessional clinicians in a two-week intensive palliative care course and 1,541 interprofessional clinicians in a 90–150 min skills-based training. Clinicians documented 15,791 serious illness conversations. Zoom community engagement sessions were attended by 411 live viewers, and subsequently, 1918 YouTube views. Additionally, we report on the impact of the COIVD-19 crisis on our efforts. Early in the pandemic, over two months, 464 interprofessional clinicians documented 5,168 conversations with patients. Conclusion/Lessons LearnedA broad based strategy resulted wide institutional engagement with serious illness care.

Geriatric Surgical Service Complements Care of Older Adult Emergency General Surgery Patients

Introduction: Older adults comprise an increasing proportion of emergency general surgery (EGS) admissions and face high morbidity and mortality. We created a geriatric surgical service with geriatric and palliative expertise to mitigate risks of hospitalization most hazardous to older patients. In this study, we identified geriatric surgical service interventions most relevant to EGS patients. Methods: We conducted a retrospective chart review of patients >75 years admitted to the EGS service at our urban tertiary care hospital with a score >3 by the FRAIL scale, a five-point frailty screening instrument, or history of dementia. The geriatric surgical service, led by a dually-board certified geriatric and palliative care specialist, consulted on these patients from January 2020-January 2021;a hiatus was taken for the COVID-19 pandemic. Consults included a comprehensive geriatric assessment and calculated a modified Rockwood Frailty Index. Hospital admission characteristics and consultation components were collected via chart review. Results: Forty patients were evaluated (median age 82 years (IQR 78-89), 55.0% female). The most common admission diagnosis was small bowel obstruction (32.5%). 62.5% of patients underwent >1 surgical procedure. Median time to geriatric consult from admission was 3 days (IQR 1.0-4.3). By Frailty Index, 58% were moderately or severely frail. Interventions included medication changes (97.5%), symptom management (82.5%), delirium prevention and management (65.0%), mobility and function recommendations (65.0%), serious illness conversations (55.0%), and code status change (17.5%). Conclusion: Geriatric service involvement identifies and addresses a high burden of both geriatric and palliative care needs in older adult EGS patients.