Documenting Goals of Care Among Patients With Advanced Cancer: Results of a Quality Improvement Initiative

Karim, Safiya; Harle, Ingrid; O’Donnell, Jennifer; Li, Shirley Xin; Booth, Christopher M.

doi:10.1200/jop.18.00031

Cited by 10 publications

(12 citation statements)

References 23 publications

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“…In this cohort of patients, pre‐study GOC completion rate was high compared to other studies, 18,24 albeit in keeping with previous inpatient studies from our centre 20 . The combination of a communication skills refresher course and verbal prompting of the patients' current GOC improved documentation of GOC during routine clinic reviews of patients with advanced lung cancer.…”

Section: Discussionsupporting

confidence: 82%

Implementing ‘Goals of Care’ discussion and palliative care referral for patients with advanced lung cancer: an outpatient‐based pilot project

Conduit

Thompson

Thomas

et al. 2021

Internal Medicine Journal

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Background Early involvement of palliative care and advance care planning improves quality‐of‐life outcomes and survival for patients with advanced lung cancer; however, there are barriers to implementation. Aims A single‐centre prospective audit reviewing ‘Goals of Care’ (GOC) form completion and palliative care referrals in an oncology clinic was undertaken with the aim of increasing GOC completion and palliative care referrals for patients with advanced lung cancer. Methods Involved physicians attended a communication skills course and then received a communication‐priming intervention. Clinicopathological factors associated with GOC completion and palliative care referral were explored. Results A total of 84 patients receiving palliative treatment for advanced lung cancer was enrolled. Clinicopathological factors, such as poorer performance status, were associated with higher likelihood of GOC completion (P = 0.018) prior to the intervention. Male sex (P = 0.023), absence of sensitising epidermal growth factor receptor mutation or anaplastic lymphoma kinase rearrangement (P = 0.017), type of systemic therapy (P = 0.031) and poorer performance status (P < 0.001) were associated with higher likelihood of palliative care referral. The intervention improved GOC completion (relative risk (RR) 1.29, P = 0.004); however, this was not sustained in a follow‐up audit (RR 0.98, P = 0.92) and there was no change in palliative care referral rate (RR 2.5, P = 0.16). Predictors of palliative referral following clinical review included age (RR 1.16, P = 0.001), male sex (RR 14.2, P = 0.02) and poorer performance status (RR 1.76, P < 0.001). Conclusions Communication‐priming interventions can improve GOC completion for patients with advanced lung cancer. Further investigation is needed to pursue sustainable options for managing this complex patient group and improve guideline‐adherence and patient care.

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Section: Discussionsupporting

confidence: 82%

Implementing ‘Goals of Care’ discussion and palliative care referral for patients with advanced lung cancer: an outpatient‐based pilot project

Conduit

Thompson

Thomas

et al. 2021

Internal Medicine Journal

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“…Our initiative adds to other communication interventions (prompts, different templates, and order sets) recently described in modern EHRs. 34,35 In a prior study, 36 GOC documentation was found to increase during a quality improvement initiative that included email reminders to physicians as well as a scorecard to display overall and individual physician rates of GOC documentation. We did not use these strategies, although encouragement by departmental leadership, as well as anticipated and real worsening of patients' health status with COVID-19 infection, may have contributed to increases we saw in GOC documentation on our new GOC template during the study period.…”

Section: Discussionmentioning

confidence: 99%

Goals of care documentation by medical oncologists and oncology patient end‐of‐life care outcomes

Epstein

Riley

Nelson

et al. 2022

Cancer

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Background Goals of care (GOC) documentation is important but underused. We aimed to improve oncologist GOC documentation and end‐of‐life (EOL) care. Methods In April 2020, our cancer center launched a GOC note template, including optional fields for documenting discussion with the patient about: cancer natural history, goals, and/or EOL (resuscitation preferences, hospice receptivity). Associations between GOC notes and EOL care were evaluated. Results Among 1721 patients dying between June 1, 2020 and June 30, 2021, median days from first GOC note (± with documentation of EOL discussion) to death was 92, whereas a GOC note including EOL discussion (“GOC EOL note”), specifically, was 31. Patients with a first GOC note >60 days before death spent fewer days inpatient (6.7 vs 10.6 days, p < .001). Among patients with GOC EOL notes, those with such documentation >30 days before death had fewer inpatient (5 vs 11, p < .001) and intensive care unit days (0.5 vs 1.5, p < .001), more hospice referrals (57% vs 44%, p = .003), and less chemotherapy ≤14 days before death (6% vs 11%, p = .010). Of 925 admissions of patients dying within ≤30 days, those with GOC EOL notes were shorter (7 vs 9 days, p = .013) but not associated with more hospice discharge (30% vs 25%, p = .163). Oncologist (vs nononcologist) GOC documentation and earlier documentation of EOL discussion were associated in subset analyses with less inpatient care and more hospice referrals. Conclusions Documentation of GOC, including EOL discussions, is associated with favorable performance on accepted indicators of quality EOL care.

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“…Following the intervention, there was an increase in documented GoCCs from 20.5% for the control group versus 44.6% in the intervention group. More recently, use of email reminders to 9 medical oncologists, to identify 184 high-risk patients, also resulted in an increase in documentation of GoCCs from 0% to 29% (Karim et al, 2018).…”

Section: Discussionmentioning

confidence: 99%

Triggering goals of care conversations in heart failure patients

Fang

Peralta

2022

J Am Assoc Nurse Pract

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Background: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.Local Problem:Implementation of E-Gagne tool to identify HF patients with high 1-year mortality risk and trigger GoCCs.Methods: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.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.Results: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).Conclusion:Implementation of the E-Gagne tool, an electronic prognostication tool, identified high-risk PH HF patients and was effective in increasing documentation of GoCCs.

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Documenting Goals of Care Among Patients With Advanced Cancer: Results of a Quality Improvement Initiative

Abstract: Our QI initiative was successful in improving rates of GOC documentation in patients with advanced cancer.

Cited by 10 publications

References 23 publications

Implementing ‘Goals of Care’ discussion and palliative care referral for patients with advanced lung cancer: an outpatient‐based pilot project

Implementing ‘Goals of Care’ discussion and palliative care referral for patients with advanced lung cancer: an outpatient‐based pilot project

Goals of care documentation by medical oncologists and oncology patient end‐of‐life care outcomes

Triggering goals of care conversations in heart failure patients

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