Impact of an Interdisciplinary Goals-of-Care Program Among Medical Inpatients at a Comprehensive Cancer Center During the COVID-19 Pandemic: A Propensity Score Analysis

Abstract

PURPOSE Many hospitals have established goals-of-care programs in response to the coronavirus disease 2019 pandemic; however, few have reported their outcomes. We examined the impact of a multicomponent interdisciplinary goals-of-care program on intensive care unit (ICU) mortality and hospital outcomes for medical inpatients with cancer. METHODS This single-center study with a quasi-experimental design included consecutive adult patients with cancer admitted to medical units at the MD Anderson Cancer Center, TX, during the 8-month preimplementation (May 1, 2019-December 31, 2019) and postimplementation period (May 1, 2020-December 31, 2020). The primary outcome was ICU mortality. Secondary outcomes included ICU length of stay, hospital mortality, and proportion/timing of care plan documentation. Propensity score weighting was used to adjust for differences in potential covariates, including age, sex, cancer diagnosis, race/ethnicity, and Sequential Organ Failure Assessment score. RESULTS This study involved 12,941 hospitalized patients with cancer (pre n = 6,977; post n = 5,964) including 1,365 ICU admissions (pre n = 727; post n = 638). After multicomponent goals-of-care program initiation, we observed a significant reduction in ICU mortality (28.2% v 21.9%; change −6.3%, 95% CI, −9.6 to −3.1; P = .0001). We also observed significant decreases in length of ICU stay (mean change −1.4 days, 95% CI, −2.0 to −0.7; P < .0001) and in-hospital mortality (7% v 6.1%, mean change −0.9%, 95% CI, −1.5 to −0.3; P = .004). The proportion of hospitalized patients with an in-hospital do-not-resuscitate order increased significantly from 14.7% to 19.6% after implementation (odds ratio, 1.4; 95% CI, 1.3 to 1.5; P < .0001), and do-not-resuscitate order was established earlier (mean difference −3.0 days, 95% CI, −3.9 to −2.1; P < .0001). CONCLUSION This study showed improvement in hospital outcomes and care plan documentation after implementation of a system-wide, multicomponent goals-of-care intervention.

Leveraging Goals of Care Interventions to Deliver Personalized Care Near the End of Life

“…A randomized clinical trial that nudged physicians and advanced practitioners to have GOCCs with patients with high predicted mortality resulted in patients receiving 75% less systemic therapy near the end of life . Other interventions using documentation templates and inpatient multidisciplinary goals of care teams have been associated with 37% to 55% fewer hospitalizations and 22% lower mortality in the intensive care unit . However, additional interventions have lacked impact, with 2 trials providing GOCC training having no impact on care delivery .…”

“…Second, GOCC interventions often facilitate meaningful conversations. Successful interventions engaged patients starting at diagnosis, reduced efforts to document and find patient preferences in charts, and reduced efforts to identify patients appropriate for GOCCs . Third, successful interventions often minimized clinician burden by flagging appropriate patients for clinicians and leveraging team members (eg, lay workers) to facilitate more meaningful patient-clinician communication.…”

“…Drawing from successful examples, institutions can equip clinicians by providing training, financial support, and interventions to facilitate incorporation of GOCCs into routine practice . There is no one-size-fits-all solution; for instance, large institutions may build technical tools while small practices may rely on staff review of schedules.…”

Personalizing the Setting of Palliative Care Delivery for Patients with Advanced Cancer: “Care Anywhere, Anytime”

“…For example, proper symptom management provided by the inpatient consultation team, thoughtful discharge planning, and telemedicine visits and/or community-based care after discharge may work together to prevent readmissions. Prognostic discussions in the outpatient setting to enhance patients' understanding of their illnesses, coupled with goals-of-care discussions in inpatient visits, may reduce the use of chemotherapy and intensive care unit admissions in the last days of life [17,38]. The dose of supportive care offered to patients matters.…”

Changes in dietary habits and weight status during the COVID-19 pandemic and its association with socioeconomic status among Iranians adults

“…Poor dietary habits along with an unhealthy lifestyle, can cause serious health problems. Therefore, in this critical period optimizing nutrition is essential ( 23 , 24 ). Having knowledge about individuals' dietary habits may help prevent chronic conditions and their associated risks ( 24 ).…”