Managing Code Status Conversations for Seriously Ill Older Adults in Respiratory Failure

Ouchi, Kei; Lawton, Andrew; Bowman, Jason; Bernacki, Rachelle; George, Naomi

doi:10.1016/j.annemergmed.2020.05.039

Cited by 31 publications

(16 citation statements)

References 34 publications

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“…These observations highlight the opportunity and importance of ED‐based end‐of‐life screening. Significant efforts are being made to advance the science of ED based end‐of‐life care through the development of conversation and decision aids as well as trials of ED‐based palliative care 2,42–44 . If validated, the work described here presents a pragmatic approach to initiate interventions with at‐risk patient populations in a resource‐sensitive manner.…”

Section: Discussionmentioning

confidence: 99%

Automatable end‐of‐life screening for older adults in the emergency department using electronic health records

Haimovich

Wang

Wei

et al. 2023

J American Geriatrics Society

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Background Emergency department (ED) visits are common at the end‐of‐life, but the identification of patients with life‐limiting illness remains a key challenge in providing timely and resource‐sensitive advance care planning (ACP) and palliative care services. To date, there are no validated, automatable instruments for ED end‐of‐life screening. Here, we developed a novel electronic health record (EHR) prognostic model to screen older ED patients at high risk for 6‐month mortality and compare its performance to validated comorbidity indices. Methods This was a retrospective, observational cohort study of ED visits from adults aged ≥65 years who visited any of 9 EDs across a large regional health system between 2014 and 2019. Multivariable logistic regression that included clinical and demographic variables, vital signs, and laboratory data was used to develop a 6‐month mortality predictive model—the Geriatric End‐of‐life Screening Tool (GEST) using five‐fold cross‐validation on data from 8 EDs. Performance was compared to the Charlson and Elixhauser comorbidity indices using area under the receiver‐operating characteristic curve (AUROC), calibration, and decision curve analyses. Reproducibility was tested against data from the remaining independent ED within the health system. We then used GEST to investigate rates of ACP documentation availability and code status orders in the EHR across risk strata. Results A total of 431,179 encounters by 123,128 adults were included in this study with a 6‐month mortality rate of 12.2%. Charlson (AUROC (95% CI): 0.65 (0.64–0.69)) and Elixhauser indices (0.69 (0.68–0.70)) were outperformed by GEST (0.82 (0.82–0.83)). GEST displayed robust performance across demographic subgroups and in our independent validation site. Among patients with a greater than 30% mortality risk using GEST, only 5.0% had ACP documentation; 79.0% had a code status previously ordered, of which 70.7% were full code. In decision curve analysis, GEST provided greater net benefit than the Charlson and Elixhauser scores. Conclusions Prognostic models using EHR data robustly identify high mortality risk older adults in the ED for whom code status, ACP, or palliative care interventions may be of benefit. Although all tested methods identified patients approaching the end‐of‐life, GEST was most performant. These tools may enable resource‐sensitive end‐of‐life screening in the ED.

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Section: Discussionmentioning

confidence: 99%

Automatable end‐of‐life screening for older adults in the emergency department using electronic health records

Haimovich

Wang

Wei

et al. 2023

J American Geriatrics Society

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“…A majority of physicians who referred to comfort care expounded the benefits, such as symptom control and peace during the dying process. Some physicians, however, emphasized that comfort care could accelerate the dying process, especially when explaining the effects of morphine on breathing: ''With the medications that would make him more comfortable, it could potentially, actually, slow down his breathing, and he could be in a position where he would pass away a little faster'' (Participant [2][3][4][5][6][7][8][9][10][11][12][13][14]. No physician explicitly invoked the doctrine of double effect, which in some instances justifies the foreseen but unintended adverse effects of a treatment if the treatment's intended effect is morally acceptable, but the physicians who highlighted the potentially life-shortening Comparison of specialties.…”

Section: Qualitative Analysismentioning

confidence: 99%

“…6 Physicians must ascertain the values of the patient, and may choose to summarize these goals to confirm alignment with the patient's needs. 7 Expert physicians are noted to devote proportionally more time to build partnership with the patients and allow for patient expression of opinion, understanding, and beliefs. 8 In executing these best practice guidelines, clinicians encounter challenges specific to their practice environments.…”

Section: Introductionmentioning

confidence: 99%

Cultures of Practice: Specialty-Specific Differences in End-of-Life Conversations

Morales

Schultz

Gao

et al. 2021

Palliative Medicine Reports

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Importance: Goals of care discussions at the end of life give opportunity to affirm the autonomy and humanity of dying patients. Best practices exist for communication around goals of care, but there is no research on differences in approach taken by different specialties engaging these conversations. Objective: To describe the communication practices of internal medicine (IM), emergency medicine (EM), and critical care (CC) physicians in a high-fidelity simulation of a terminally ill patient with stable and defined end-of-life preferences. Design, Setting, and Participants: Mixed-methods secondary analysis of transcripts obtained from a multicenter study simulating high stakes, time-limited end-of-life decision making in a cohort of 88 volunteer physicians (27 IM, 22 EM, and 39 CC) who were called to evaluate a standardized patient in extremis. The patient had clear comfort-oriented goals of care that the physician needed to elicit and use to inform treatment decisions. Discussions were coded at the level of the sentence for semantic content. Exposures: Data were analyzed by physician specialty. Main Outcome Measure: Occurrence of content codes indicative of prudent (right outcome by the right means) goals of care conversations. Data were analyzed both for number of occurrences of the code in a simulated conversation and for presence or absence of the code within a conversation. Results: There was no difference between physician types in intubation rates or intensive care unit admissions. Codes for ''comfort as a goal of care,'' ''noncurative goals of care,'' and ''oblique references to death'' emerged as significantly different between physician types. Conclusions and Relevance: This experiment shows demonstrable differences in practice patterns between physician specialties when addressing end-of-life decision making. Some of the variation likely arose from differences in setting, but these data suggest that training in goals of care conversations may benefit if it is adapted to the distinct needs and culture of each specialty.

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“…For patients at the end of life, a structured approach to transition to hospice care in the ED is possible but remains difficult given the complexity of steps required. 28 Although emergency physicians are becoming more experienced with goals‐of‐care conversations, 29 , 30 most patients requiring hospice initiation are admitted to the hospital to facilitate this process. With our home hospital service, we can serve as a bridge to home hospice if it cannot be deployed quickly enough or after a trial of acute care can transition to a home hospice agency.…”

Section: What Is Home Hospital?mentioning

confidence: 99%

Home hospital as a disposition for older adults from the emergency department: Benefits and opportunities

et al. 2021

Self Cite

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The $1 trillion industry of acute hospital care in the United States is shifting from inside the walls of the hospital to patient homes. To tackle the limitations of current hospital care in the United States, on November 25, 2020, the Center for Medicare & Medicaid Services announced that the acute hospital care at home waiver would reimburse for “home hospital” services. A “home hospital” is the home‐based provision of acute services usually associated with the traditional inpatient hospital setting. Prior work suggests that home hospital care can reduce costs, maintain quality and safety, and improve patient experiences for select acutely ill adults who require hospital‐level care. However, most emergency physicians are unfamiliar with the evidence of benefits demonstrated by home hospital services, especially for older adults. Therefore, the lead author solicited narrative inputs on this topic from selected experts in emergency medicine and home hospital services with clinical experience, publications, and funding on home hospital care. Then we sought to identify information most relevant to the practice of emergency medicine. We outline the proven and potential benefits of home hospital services specific to older adults compared to traditional acute care hospitalization with a focus on the emergency department.

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Managing Code Status Conversations for Seriously Ill Older Adults in Respiratory Failure

Abstract: Figure 3. Recommendation based on quality of life acceptable to patients.

Cited by 31 publications

References 34 publications

Automatable end‐of‐life screening for older adults in the emergency department using electronic health records

Automatable end‐of‐life screening for older adults in the emergency department using electronic health records

Cultures of Practice: Specialty-Specific Differences in End-of-Life Conversations

Home hospital as a disposition for older adults from the emergency department: Benefits and opportunities

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