Care Planning for Inpatients Referred for Palliative Care Consultation

Abstract

IMPORTANCE Care planning is a critical function of palliative care teams, but the impact of advance care planning and goals of care discussions by palliative care teams has not been well characterized.OBJECTIVE To describe the population of patients referred to inpatient palliative care consultation teams for care planning, the needs identified by palliative care clinicians, the care planning activities that occur, and the results of these activities. DESIGN, SETTING, AND PARTICIPANTSThis was a prospective cohort study conducted between January 1, 2013, and December 31, 2016. Seventy-eight inpatient palliative care teams from diverse US hospitals in the Palliative Care Quality Network, a national quality improvement collaborative. Standardized data were submitted for 73 145 patients. EXPOSURES Inpatient palliative care consultation.RESULTS Overall, 52 571 of 73 145 patients (71.9%) referred to inpatient palliative care were referred for care planning (range among teams, 27.5%-99.4% of patients). Patients referred for care planning were older (73.3 vs 67.9 years; F statistic, 1546.0; P<.001), less likely to have cancer (30.0% vs 41.1%; P < .001), and slightly more often had a clinical order of full code at the time of referral (54.6% vs 52.1%; P < .001). Palliative care teams identified care planning needs in 52 825 of 73 145 patients (72.2%) overall, including 42 467 of 49 713 patients (85.4%) referred for care planning and in 10 054 of 17 475 patients (57.5%) referred for other reasons. Through care planning conversations, surrogates were identified for 10 571 of 11 149 patients (94.8%) and 9026 patients (37.4%) elected to change their code status. Substantially more patients indicated that a status of do not resuscitate/do not intubate was consistent with their goals (7006 [32.1%] preconsultation to 13 773 [63.1%] postconsultation). However, an advance directive was completed for just 2160 of 67 955 patients (3.2%) and a Physicians Orders for Life-Sustaining Treatment form was completed for 8359 of 67 955 patients (12.3%) seen by palliative care teams.CONCLUSIONS AND RELEVANCE Care planning was the most common reason for inpatient palliative care consultation, and care planning needs were often found even when the consultation was for other reasons. Surrogates were consistently identified, and patients' preferences regarding life-sustaining treatments were frequently updated. However, a minority of patients completed legal forms to document their care preferences, highlighting an area in need of improvement.

Trends in Hospital-Based Specialty Palliative Care in the United States From 2013 to 2017

“…Advance care planning was the most common reason for PC consultation (73.5%; range, 39.9%-97.4%) (Table 1), a finding discussed in more detail in previous work. 20…”

TRIAD XII: Are Patients Aware of and Agree With DNR or POLST Orders in Their Medical Records

“…For patients with POLST documents, this rate was higher. Medical record inaccuracy related to code status is not new and was effectively reported by Bischoff et al 19 Furthermore, previous research supports discordant rates (30%–50%) of what was documented on a POLST versus patient informed consent. 18…”

“…The result was creation of DNR orders or having changed full-code orders to DNR orders after interventions. 19 Additional research has been directed to study code status transition from full code to DNR. 20 These studies did not included patients with existing DNR orders or the reversal of DNR to Full Code Orders.…”

Stability of end-of-life preferences in relation to health status and life-events: A cohort study with a 6-year follow-up among holders of an advance directive

“…Third, although we were able to follow our respondents over time in order to assess stability of preferences and the experiences of life-events, this study doesn’t provide data about the end of life of the participants. We know from a study by Bischoff et al that 37% of patients change their code status near the end of life [29]. On the other hand Bolt et al found that a change or deterioration in health near the end of life generally did not seem to influence preferences concerning euthanasia of people with an advance euthanasia directive [30].…”