Documented Goals of Care Conversations with Hospitalized Patients after Severe Stroke

Abstract

Background: Identifying goals of care is important for patients suffering severe ischemic stroke (SIS) and their caregivers to ensure patient- and family-centered treatment decisions. This study sought to determine the prevalence and patient predictors associated with having a documented goals-of-care conversation (dGOCC) after SIS. Methods: We reviewed the medical charts of all patients with National Institutes of Health Stroke Scale (NIHSS) ≥10 admitted to four hospitals in the Midwestern US. In addition to sociodemographic and clinical characteristics, we searched for dGOCC during the acute stroke hospitalization, defined as any documented conversation or meeting that addressed one or more of the following domains: prognostic information, treatment plan, patient preferences and values, quality of life, or establishing goals. We determined prevalence, frequency, timing, and content of dGOCCs. Additionally, we obtained information on treatment utilization and outcomes. Results: Among 1297 patients, 26.5% (n=344) had at least one dGOCC. Treatment plan was the most discussed domain (n=264, 20% of all patients) and was the most common first dGOCC (n=207, 60% of first conversations). Median day for first dGOCC was on hospital day zero. Patient preferences, values, and goals were documented in 112 (8.6%) of all patients' charts and quality of life conversations were documented in only 61 (4.7%) charts. In multivariate analysis, having a NIHSS ≥21 (OR 1.46, p-value .01) was associated with having a dGOCC. Conclusion: After severe stroke, most patients do not have a dGOCC, despite the important decisions that often arise about treatment and rehabilitation. Documentation of patient preferences, values and goals are even rarer. This suggests missed opportunities for high quality decision making informed by patient goals to improve person centered care.