ffective communication plays a major role in facilitating adaptation to illness realities, appropriate decision making, and quality of life 1,2 throughout the trajectory of a serious illness. As patients approach the end of life, communication about goals of care and planning is a key element in helping assure that patients receive the care they want, in alleviating anxiety, and in supporting families. [3][4][5] Effective communication supports, not only endof-life care, but quality of life throughout the illness trajectory, even if death is not an imminent outcome.In this review, we evaluate current practices in communication about serious illness, their effects on patients, and factors that may influence these practices; we conclude by identifying best practices in communication about goals of care in serious illness, primarily in the ambulatory setting. On the basis of this assessment, we propose a systematic approach, informed by evidence, to help assure that each seriously ill patient has a personalized serious illness treatment plan. The most common clinical conditions relevant to this discussion include cancer, congestive heart failure, chronic obstructive pulmonary disease, and chronic kidney disease and/or end-stage renal disease. This work was undertaken as part of the American College of Physicians (ACP) High Value Care Initiative and subsequently endorsed by the High Value Task Force of the ACP. MethodsWe conducted a narrative review of evidence about advance care planning and end-of-life communication practices to provide clinicians with practical, evidence-based advice. Both observational and intervention studies were included, as well as indirect evidence from high-quality studies of palliative care specialist interventions that address the impact of communication about serious illness care planning on outcomes. We use the term serious illness care goals to include discussions about goals of care, advance care planning, and end-of-life discussions for patients with serious illness to emphasize the targeted population and the potential impact on these discussions, not just for the very end of life but for care throughout the course of serious illness. In citing specific studies, we use the terms (eg, end-of-life care) used by the authors (see eMethods in the Supplement for a detailed description of methodology). For a summary of the ACP High Value Care Advice, see Box 1.An understanding of patients' care goals in the context of a serious illness is an essential element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early discussions about goals of care are associated with better quality of life, reduced use of nonbeneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs. Existing evidence does not support the commonly held belief that communication about end-of-life issues increases patient distress. However, conversations about care goals are often conducted by physicians who do no...
IntroductionEnsuring that patients receive care that is consistent with their goals and values is a critical component of high-quality care. This article describes the protocol for a cluster randomised controlled trial of a multicomponent, structured communication intervention.Methods and analysisPatients with advanced, incurable cancer and life expectancy of <12 months will participate together with their surrogate. Clinicians are enrolled and randomised either to usual care or the intervention. The Serious Illness Care Program is a multicomponent, structured communication intervention designed to identify patients, train clinicians to use a structured guide for advanced care planning discussion with patients, ‘trigger’ clinicians to have conversations, prepare patients and families for the conversation, and document outcomes of the discussion in a structured format in the electronic medical record. Clinician satisfaction with the intervention, confidence and attitudes will be assessed before and after the intervention. Self-report data will be collected from patients and surrogates approximately every 2 months up to 2 years or until the patient's death; patient medical records will be examined at the close of the study. Analyses will examine the impact of the intervention on the patient receipt of goal-concordant care, and peacefulness at the end of life. Secondary outcomes include patient anxiety, depression, quality of life, therapeutic alliance, quality of communication, and quality of dying and death. Key process measures include frequency, timing and quality of documented conversations.Ethics and disseminationThis study was approved by the Dana-Farber Cancer Institute Institutional Review Board. Results will be reported in peer-reviewed publications and conference presentations.Trial registration numberProtocol identifier NCT01786811; Pre-results.
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