Context. Many hospitalized patients receive care that is not concordant with their goals. Teaching communication skills that better align goals and treatment can improve the care that patients receive.Objective. To develop and test an innovative approach that encourages hospitalists to engage in goals of care (GOC) conversations with their patients.Methods. We recruited 14 hospitalists and randomized half to receive electronic health record alerts for patients who might benefit most from a goals-of-care conversation, as well as communication coaching. The coaching required an initial meeting, then audio recording of two GOC conversations and feedback from the coach. Outcomes were the presence of GOC conversations (primary), the quality of the GOC conversations, physician perceptions of the intervention, and hospital metrics (e.g., 30-day readmissions, referrals to palliative care).Results. We did not increase the frequency of GOC conversations but did improve the quality of the conversations. Patients of physicians who received the intervention had fewer 30-day readmission rates and were less likely to die 90 days after admission than patients of physicians in the control arm. Patients of intervention physicians also had fewer palliative care consults than patients of control physicians.Conclusions. Teaching hospitalists to have GOC conversations translated into better skills and outcomes for patients. This pilot study shows promise and should be tested in a larger trial.

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Objectives: To determine the relative contributions of tetrahydrocannabinol (THC) and cannabidiol (CBD) to patients' self-ratings of efficacy for common palliative care symptoms.Design: This is an electronic record-based retrospective cohort study. Model development used logistic regression with bootstrapped confidence intervals (CIs), with standard errors clustered to account for multiple observations by each patient.Setting: This is a national Canadian patient portal.Participants: A total of 2,431 patients participated.Main Outcome Measures: Self-ratings of efficacy of cannabis, defined as a three-point reduction in neuropathic pain, anorexia, anxiety symptoms, depressive symptoms, insomnia, and post-traumatic flashbacks.Results: We included 26,150 observations between October 1, 2017 and November 28, 2018. Of the six symptoms, response was associated with increased THC:CBD ratio for neuropathic pain (odds ratio [OR]: 3.58; 95% CI: 1.32–9.68; p = 0.012), insomnia (OR: 2.93; 95% CI: 1.75–4.91; p < 0.001), and depressive symptoms (OR: 1.63; 95% CI: 1.07–2.49; p = 0.022). Increased THC:CBD ratio was not associated with a greater response of post-traumatic stress disorder (PTSD)-related flashbacks (OR: 1.43; 95% CI: 0.60–3.41; p = 0.415) or anorexia (OR: 1.61; 95% CI: 0.70–3.73; p = 0.265). The response for anxiety symptoms was not significant (OR: 1.13; 95% CI: 0.77–1.64; p = 0.53), but showed an inverted U-shaped curve, with maximal benefit at a 1:1 ratio (50% THC).Conclusions: These preliminary results offer a unique view of real-world medical cannabis use and identify several areas for future research.

Objectives Discuss challenges in perimortem genetic testing and funding. Describe process of genetic testing approval and how to align this with family goals of care.