Early serious illness communication in hospitalized patients: A study of the implementation of the Speaking About Goals and Expectations (SAGE) program

Lakin, Joshua R.; Arnold, Catherine; Catzen, Hannah Z.; Rangarajan, Arjun; Berger, Rebecca; Brannen, Elise N; Cunningham, Robert J.; Schaffer, Adam C.; Lamey, Jan; Baker, Olesya; Bernacki, Rachelle

doi:10.1016/j.hjdsi.2020.100510

Cited by 24 publications

(15 citation statements)

References 25 publications

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“…Randomized controlled trials of the SICP in oncology [ 7 ] and primary care [ 8 ] also described positive impacts on the quality and frequency of conversation documentation. Similar results were found after the SICP implementation in acute care and internal medicine [ 9 , 10 ].…”

Section: Introductionsupporting

confidence: 82%

Content of Serious Illness Care conversation documentation is associated with goals of care orders—a quantitative evaluation in hospital

et al. 2022

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Background The Serious Illness Care Program (SICP) increases quality of documentation about patients’ values and priorities, but it is not known whether patient characteristics and goals of care are associated with the elements documented. The purpose of this study was to explore for associations between the quantity and type of elements documented after SICP conversations with patient characteristics and goals of care order. Methods Documentation of SICP conversations by internal medicine physicians with hospitalized patients was evaluated in a retrospective chart review between March 2018 to December 2019. The conversations occurred after SICP implementation in a Tertiary Hospital, Medical teaching unit which uses “Goals of Care Designation” (GCD) medical orders to communicate a patient’s general intent, specific interventions, and preferred locations of care. A validated SICP codebook was used to determine the frequency of conversation elements documented for (1) Goals and Values; (2) Prognosis/illness understanding; (3) End-of-life care planning and (4) GCD/Life-sustaining treatment preferences. Univariate and multivariate generalized linear models were used to analyze associations between quantity of elements documented and patient characteristics (age, gender, frailty, language spoken and GCD). Results Of 175 SICP conversations documented, in the univariate analysis more goals and values were documented for patients who understand/speak English (0.89; 95% CI: 0.14 - 1.63) and more content was recorded for patients with a non-resuscitative GCD focus (“Medical”: 2.42; 95% CI: 1.51 – 3.33; “Comfort”: 1.06; 95% CI: 0.24 – 1.88) although not in all domains. In the multivariate analysis, controlling for age, gender, language and frailty, the association between content scores and GCD remained highly significant. Patients with a non-resuscitative GCD had higher total domain scores than those with a resuscitative GCD (“Medical”: 1.27 95% CI: 0.42–2.13; “Comfort”: 2.67, 95% CI:1.71–3.62). Conclusion The type of content documented by physicians after a SICP conversation is associated with the patient’s goals of care.

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Section: Introductionsupporting

confidence: 82%

Content of Serious Illness Care conversation documentation is associated with goals of care orders—a quantitative evaluation in hospital

et al. 2022

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“…But even in programs fortunate to have such interventions in place, performing SICs during the hospital encounter will continue to be challenging without meaningful changes to how healthcare is reimbursed (ie, away from fee-for-service and towards population and value-based care). 8 Nonetheless, identifying and initiating these conversations during acute illness is beneficial, 9 particularly for high-risk, elderly patients with multiple chronic conditions who have elevated 1 year mortality following hospitalization. 10 Furthermore, patients (and/or their surrogates) value end-of-life care and are increasingly expecting these conversations.…”

Section: Discussionmentioning

confidence: 99%

“…11 While current approaches to identifying appropriate patients for SICs using the "surprise" question, 7 patient surveys, 12 risk indices, 13,14 and other methods 15 to assess mortality risk and trigger advance care planning (ACP) or other end-of-life interventions have been described, these methods are not well integrated into clinician workflows or the EHR. Furthermore, prior successful efforts to increase SICs have required robust and multi-pronged interventions 8,9 ; importantly, patient identification is a key step in each. 3,15 Since RRS is readily available at institutions using Epic's EHR, it could be leveraged for systematic screening efforts to identify a smaller subset of hospitalized patients who may benefit from SICs, which can then be confirmed by the clinician's qualitative assessment of the case.…”

Section: Discussionmentioning

confidence: 99%

Who Gets (and Who Should Get) a Serious Illness Conversation in the Hospital? An Analysis of Readmission Risk Score in an Electronic Health Record

Serna

Fiskio

Yoon

et al. 2022

Am J Hosp Palliat Care

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Serious Illness Conversations (SICs) explore patients’ prognostic awareness, hopes, and worries, and can help establish priorities for their care during and after hospitalization. While identifying patients who benefit from an SIC remains a challenge, this task may be facilitated by use of validated prediction scores available in most commercial electronic health records (EHRs), such as Epic’s Readmission Risk Score (RRS). We identified the RRS on admission for all hospital encounters from October 2018 to August 2019 and measured the area under the receiver operating characteristic (AUROC) curve to determine whether RRS could accurately discriminate post discharge 6-month mortality. For encounters with standardized SIC documentation matched in a 1:3 ratio to controls by sex and age (±5 years), we constructed a multivariable, paired logistic regression model and measured the odds of SIC documentation per every 10% absolute increase in RRS. RRS was predictive of 6-month mortality with acceptable discrimination (AUROC .71) and was significantly associated with SIC documentation (adjusted OR 1.42, 95% CI 1.24-1.63). An RRS >28% used to identify patients with post discharge 6-month mortality had a high specificity (89.0%) and negative predictive value (NPV) (97.0%), but low sensitivity (25.2%) and positive predictive value (PPV) (7.9%). RRS may serve as a practical EHR-based screen to exclude patients not requiring an SIC, thereby leaving a smaller cohort to be further evaluated for SIC needs using other validated tools and clinical assessment.

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“…Participants: We recruited a purposive sample of 19 bereaved caregivers from two large academic medical centers in Boston, MA (Brigham and Women's Hospital, through the Integrated Care Management 20 and Speaking About Goals and Expectations 21 programs, and Dana-Farber Cancer Institute) between June 2018 and January 2019. Caregivers were identified based on their relationship to a deceased patient who died within the last six months who was 21 years or older and identified as Black/African American or White/ Caucasian in their medical chart.…”

Section: Methodsmentioning

confidence: 99%

“I think that she would have wanted. . .”: Qualitative interviews with bereaved caregivers reveal complexity in measuring goal-concordant care at the end of life

et al. 2022

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Background: Experts consider goal-concordant care an important healthcare outcome for individuals with serious illness. Despite their relationship to the patient and knowledge about the patient’s wishes and values, little is known about bereaved family caregivers’ perceptions of how end-of-life care aligns with patient goals and preferences. Aim: To understand caregivers’ perceptions about patients’ care experiences, the extent to which care was perceived as goal-concordant, and the factors that contextualized the end-of-life care experience. Design: Qualitative interview study employing a semi-structured interview guide based on the National Health and Aging Trends Survey end-of-life planning module. Template analysis was used to identify themes. Setting/participants: Nineteen recently bereaved family caregivers of people with serious illness in two academic medical centers in the Northeastern United States. Results: Most caregivers reported goal-concordant care, though many also recalled experiences of goal discordance. Three themes characterized care perceptions and related to perceived quality: communication, relationships and humanistic care, and care transitions. Within communication, caregivers described the importance of clear communication, inadequate prognostic communication, and information gaps that undermined caregiver confidence in decision making. Patient-clinician relationships enriched care and were considered higher-quality when felt to be humanistic. Finally, care transitions impacted goal discordance when marked by logistical barriers, a need to establish relationships with new providers, inadequate information transfer, and poor care coordination. Conclusions: Bereaved caregivers commonly rated care as goal-concordant while also identifying areas of disappointing and low-quality care. Communication, relationships and humanistic care, and care transitions are modifiable quality improvement targets for patients with advanced cancer.

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Early serious illness communication in hospitalized patients: A study of the implementation of the Speaking About Goals and Expectations (SAGE) program

Cited by 24 publications

References 25 publications

Content of Serious Illness Care conversation documentation is associated with goals of care orders—a quantitative evaluation in hospital

Content of Serious Illness Care conversation documentation is associated with goals of care orders—a quantitative evaluation in hospital

Who Gets (and Who Should Get) a Serious Illness Conversation in the Hospital? An Analysis of Readmission Risk Score in an Electronic Health Record

“I think that she would have wanted. . .”: Qualitative interviews with bereaved caregivers reveal complexity in measuring goal-concordant care at the end of life

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