Earlier Goals of Care Discussions in Hospitalized Terminally Ill Patients and the Quality of End-of-Life Care: A Retrospective Study

Gieniusz, Marzena; Nunes, Rosane; Saha, Valerie; Renson, Audrey; Schubert, Finn D.; Carey, Jeanne

doi:10.1177/1049909116682470

Cited by 28 publications

(32 citation statements)

References 28 publications

(42 reference statements)

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“…31 In addition, the risk of inpatient death, aggressive medical interventions and ICU transfers increase each day of admission when there has been no goals-of-care discussion with the inpatient team. 32 Regarding the consultation itself, there is potential for other team members such as nursing staff to identify patients in need of discussions or to facilitate the discussions. 33 The discussions should not need to be significantly modified for cultural contexts as they should already be patient-centred.…”

Section: Discussionmentioning

confidence: 99%

Review article: Goals‐of‐care discussions for adult patients nearing end of life in emergency departments: A systematic review

Hanning

Walker

Horrigan

et al. 2019

Emerg Medicine Australasia

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Goals-of-care discussions at end-oflife are associated with increased patient satisfaction and reduced treatment burdens, reduced family and healthcare worker distress and healthcare costs, while achieving equal life-expectancy. It is unclear how goals-of-care discussions should occur. The objective of the study was to determine which patients could benefit, requirements, content, documentation, and harms and benefits of emergency medicine goals-of-care discussions. We sought primary evidence on goals-of-care discussions in EDs with adult patients nearing end-oflife, published in English after 1989. Data sources included Medline, Embase, PsycINFO, CINAHL, Web of Science and reference lists of included articles. One thousand nine hundred and twenty abstracts were screened, five articles selected. There was no consensus on the meaning of goals-of-care, which is often confused with advanced care planning and treatment limitation. Emergency clinicians can identify most patients needing discussions following training. There was no evidence for how to involve stakeholders, nor how to adapt conversations to meet cultural and linguistically diverse needs. Expert panels have suggested requirements and content for conversations with little supporting evidence. There was no evidence for how emergency conversations differ to those in other settings, nor for harms or benefits for holding goals-of-care conversations in EDs. Increased ED goals-of-care conversations increased hospice referral and reduced in-patient admissions. Most studies were of moderate quality only, outcomes were not standardised and sample sizes were small. 'Goals-of-care' is used inconsistently across the literature. This is the first systematic review regarding goals-of-care discussions in EDs. Further research is needed on all aspects of these conversations.

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Section: Discussionmentioning

confidence: 99%

Review article: Goals‐of‐care discussions for adult patients nearing end of life in emergency departments: A systematic review

Hanning

Walker

Horrigan

et al. 2019

Emerg Medicine Australasia

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“…Medical Education 2019: 53: 1230-1242 doi: 10.1111/medu.14006 INTRODUCTION Goals of care (GoC) discussions, ideally, are personcentred conversations amongst patients, family members and clinicians about individual values and plans of care, including the use of life-sustaining treatments. [1][2][3] Associated with better patient and caregiver quality of life, as well as less aggressive, costly medical care, [4][5][6][7] they are low-cost, high-value aspects of end-of-life care. 2 As the provision of intensive technology-laden care, including cardiopulmonary resuscitation (CPR), is the default for hospitalised patients, the assessment and documentation of GoC are crucial and are considered as indicators of quality of care, especially for older patients.…”

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confidence: 99%

Medical students’ experiences with goals of care discussions and their impact on professional identity formation

2019

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Context Goals of care (GoC) discussions occur amongst patients, family members and clinicians in order to establish plans of care and are invaluable aspects of end‐of‐life care. In previous research, medical learners have reported insufficient training and emotional distress about end‐of‐life decision making, but most studies have focused on postgraduate trainees and have been quantitative or have evaluated specific educational interventions. None have qualitatively explored medical students’ experiences with GoC discussions, their perceptions of associated hidden curricula, and the impacts of these on professional identity formation (PIF), the individualised developmental processes by which laypersons evolve to think, act and feel like, and ultimately become, medical professionals. Methods Using purposive sampling at one Canadian medical school, individual semi‐structured interviews were conducted with 18 medical students to explore their experiences with GoC discussions during their core internal medicine clerkship. Interviews were audiorecorded, transcribed and anonymised. Concurrently with data collection, transcripts were analysed iteratively and inductively using interpretative phenomenological analysis, a qualitative research approach that allows the rich exploration of subjective experiences. Results Participants reported minimal support and supervision in conducting GoC discussions, which were experienced as ethically challenging, emotionally powerful encounters exemplifying tensions between formal and hidden curricula. Role modelling and institutional culture were key mechanisms through which hidden curricula were transmitted, subverting formal curricula in doing so and contributing to participants’ emotional distress. Participants’ coping responses were generally negative and included symptoms of burnout, the pursuit of standardisation, rationalisation, compartmentalisation and the adaptation of previously held, more idealised professional identities. Conclusions GoC discussions in this study were often led by inexperienced medical students and impacted negatively on their PIF. Through complex emotional processes, they struggled to reconcile earlier concepts of physician identities with newly developing ones and often reluctantly adopted suboptimal professional behaviours and attitudes. Improved education about GoC discussions is necessary for patient care and may represent concrete and specific opportunities to influence students’ PIF positively.

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“…46 Clear guidelines about when and for whom the GOC process should be initiated need to be embedded within hospital policies and into communication skills training (CST) around GOC. Education around GOC for clinicians will need to cover more than just effective communication, but also when to initiate the conversation 39 and how to create an appropriate setting. 47,48 Most patients viewed the conversation as necessary despite the challenges.…”

Section: Discussionmentioning

confidence: 99%

A Qualitative Exploration of Seriously Ill Patients’ Experiences of Goals of Care Discussions in Australian Hospital Settings

et al. 2020

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BACKGROUND: Goals of care (GOC) is a communication and decision-making process that occurs between a clinician and a patient (or surrogate decision-maker) during an episode of care to facilitate a plan of care that is consistent with the patient's preferences and values. Little is known about patients' experiences of these discussions. OBJECTIVE: This study explored patients' perspectives of the GOC discussion in the hospital setting. DESIGN: An explorative qualitative design was used within a social constructionist framework. PARTICIPANTS: Adult patients were recruited from six Australian hospitals across two states. Eligible patients had had a GOC discussion and they were identified by the senior nurse or their doctor for informed consent and interview. APPROACH: Semi-structured individual or dyadic interviews (with the carer/family member present) were conducted at the bedside or at the patient's home (for recently discharged patients). Interviews were audio-recorded and transcribed verbatim. Data were analysed for themes. KEY RESULTS: Thirty-eight patient interviews were completed. The key themes identified were (1) values and expectations, and (2) communication (sub-themes: (i) facilitators of the conversation, (ii) barriers to the conversation, and (iii) influence of the environment). Most

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Earlier Goals of Care Discussions in Hospitalized Terminally Ill Patients and the Quality of End-of-Life Care: A Retrospective Study

Abstract: Later GOCDs were associated with greater risk of aggressive interventions and death as an inpatient and greater odds of ICU admission. Goals of care discussion should be done routinely and early during the hospitalization of terminally ill patients.

Cited by 28 publications

References 28 publications

Review article: Goals‐of‐care discussions for adult patients nearing end of life in emergency departments: A systematic review

Review article: Goals‐of‐care discussions for adult patients nearing end of life in emergency departments: A systematic review

Medical students’ experiences with goals of care discussions and their impact on professional identity formation

A Qualitative Exploration of Seriously Ill Patients’ Experiences of Goals of Care Discussions in Australian Hospital Settings

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