Communication Training and Code Status Conversation Patterns Reported by Emergency Clinicians

Prachanukool, Thidathit; Aaronson, Emily; Lakin, Joshua R.; Higuchi, Masakazu; Lee, Rachel S.; Santangelo, Ilianna; Hasdianda, Mohammad Adrian; Wang, Wei; George, Naomi; Liu, Shan W.; Kennedy, Maura; Schonberg, Mara A.; Block, Susan D.; Tulsky, James A.; Ouchi, Kei

doi:10.1016/j.jpainsymman.2022.10.006

Cited by 7 publications

(4 citation statements)

References 22 publications

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“…For example, conversation with emergency clinicians is often superficially treatment-focused rather than value-focused and may fail to reliably capture patients’ actual wishes. 54 …”

Section: Discussionmentioning

confidence: 99%

Mid-Atlantic primary care providers’ perception of barriers and facilitators to end-of-life conversation

Horning,

Habermann

2024

Palliat�Care

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Background: Among the chronically ill, end-of-life conversations are often delayed until emergently necessary and the quality of those conversations and subsequent decision-making become compromised by critical illness, uncertainty, and anxiety. Many patients receive treatment that they would have declined if they had a better understanding of benefits and risks. Primary care providers are ideal people to facilitate end-of-life conversations, but these conversations rarely occur in the out-patient setting. Objective: To investigate the self-reported experiences of physicians and advanced practice nurses with conversational barriers and facilitators while leading end-of-life discussions in the primary care setting. Design: A qualitative descriptive study. Methods: Six physicians and eight advanced practice nurses participated in singular semi-structured interviews. Results were analyzed using a qualitative descriptive design and content analysis approach to coding. Results: Reported barriers in descending order included resistance from patients and families, insufficient time, and insufficient understanding of prognosis and associated expectations. Reported facilitators in descending order included established trusting relationship with provider, physical and/or cognitive decline and poor prognosis; and discussion standardization per Medicare guidelines. Conclusion: Recommendations for improving the end-of-life conversational process in the primary care setting include further research regarding end-of-life conversational facilitators within families, the improvement of patient/family education about hospice/palliative care resources and examining the feasibility of longer appointment allotment.1

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“…For example, conversation with emergency clinicians is often superficially treatment-focused rather than value-focused and may fail to reliably capture patients’ actual wishes. 54 …”

Section: Discussionmentioning

confidence: 99%

Mid-Atlantic primary care providers’ perception of barriers and facilitators to end-of-life conversation

Horning,

Habermann

2024

Palliat�Care

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“…Despite this, few ED physicians report incorporating patient values and goals into treatment decisions, instead focusing primarily on procedures (eg, intubation) and processes (eg, admission). 7 Closing this care gap requires the development of scalable and useful interventions designed to support ED clinicians first eliciting patient goals for care and then integrating these goals into the medical decision-making process. While proactive patient identification is a key facilitator to the success of these interventions, 8 there is a lack of pragmatic tools to identify the patients most likely to benefit.…”

Section: Introductionmentioning

confidence: 99%

“…For these reasons, incorporating patient preferences is critical for patient-centered ED care. Despite this, few ED physicians report incorporating patient values and goals into treatment decisions, instead focusing primarily on procedures (eg, intubation) and processes (eg, admission) …”

Section: Introductionmentioning

confidence: 99%

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Geriatric End-of-Life Screening Tool Prediction of 6-Month Mortality in Older Patients

Haimovich,

Burke,

Nathanson

et al. 2024

JAMA Netw Open

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ImportanceEmergency department (ED) visits by older adults with life-limiting illnesses are a critical opportunity to establish patient care end-of-life preferences, but little is known about the optimal screening criteria for resource-constrained EDs.ObjectivesTo externally validate the Geriatric End-of-Life Screening Tool (GEST) in an independent population and compare it with commonly used serious illness diagnostic criteria.Design, Setting, and ParticipantsThis prognostic study assessed a cohort of patients aged 65 years and older who were treated in a tertiary care ED in Boston, Massachusetts, from 2017 to 2021. Patients arriving in cardiac arrest or who died within 1 day of ED arrival were excluded. Data analysis was performed from August 1, 2023, to March 27, 2024.ExposureGEST, a logistic regression algorithm that uses commonly available electronic health record (EHR) datapoints and was developed and validated across 9 EDs, was compared with serious illness diagnoses as documented in the EHR. Serious illnesses included stroke/transient ischemic attack, liver disease, cancer, lung disease, and age greater than 80 years, among others.Main Outcomes and MeasuresThe primary outcome was 6-month mortality following an ED encounter. Statistical analyses included area under the receiver operating characteristic curve, calibration analyses, Kaplan-Meier survival curves, and decision curves.ResultsThis external validation included 82 371 ED encounters by 40 505 unique individuals (mean [SD] age, 76.8 [8.4] years; 54.3% women, 13.8% 6-month mortality rate). GEST had an external validation area under the receiver operating characteristic curve of 0.79 (95% CI, 0.78-0.79) that was stable across years and demographic subgroups. Of included encounters, 53.4% had a serious illness, with a sensitivity of 77.4% (95% CI, 76.6%-78.2%) and specificity of 50.5% (95% CI, 50.1%-50.8%). Varying GEST cutoffs from 5% to 30% increased specificity (5%: 49.1% [95% CI, 48.7%-49.5%]; 30%: 92.2% [95% CI, 92.0%-92.4%]) at the cost of sensitivity (5%: 89.3% [95% CI, 88.8-89.9]; 30%: 36.2% [95% CI, 35.3-37.1]). In a decision curve analysis, GEST outperformed serious illness criteria across all tested thresholds. When comparing patients referred to intervention by GEST with serious illness criteria, GEST reclassified 45.1% of patients with serious illness as having low risk of mortality with an observed mortality rate 8.1% and 2.6% of patients without serious illness as having high mortality risk with an observed mortality rate of 34.3% for a total reclassification rate of 25.3%.Conclusions and RelevanceThe findings of this study suggest that both serious illness criteria and GEST identified older ED patients at risk for 6-month mortality, but GEST offered more useful screening characteristics. Future trials of serious illness interventions for high mortality risk in older adults may consider transitioning from diagnosis code criteria to GEST, an automatable EHR-based algorithm.

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Patient Preferences for Code Status Discussions: A Randomized Trial of Information- vs. Patient Values-Centered Frameworks

Joshi,

Malik,

Wang

et al. 2024

J GEN INTERN MED

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Communication Training and Code Status Conversation Patterns Reported by Emergency Clinicians

Cited by 7 publications

References 22 publications

Mid-Atlantic primary care providers’ perception of barriers and facilitators to end-of-life conversation

Mid-Atlantic primary care providers’ perception of barriers and facilitators to end-of-life conversation

Geriatric End-of-Life Screening Tool Prediction of 6-Month Mortality in Older Patients

Patient Preferences for Code Status Discussions: A Randomized Trial of Information- vs. Patient Values-Centered Frameworks

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