More, Earlier, and Better Goals-of-Care Conversations at the End of Life Are Feasible
There is a rapidly growing evidence base to show that high-quality communication is associated with better serious illness care. Despite this evidence, we don’t have conversations with our seriously ill patients often enough.
—Rachelle E. Bernacki, MD, MS
The highlight of this work is that it’s a multicomponent intervention that influences outcomes in systems of high complexity.
—Anthony L. Back, MD
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– John Smith, MD
–>An intervention called the Serious Illness Care Program helps clinicians to conduct more, earlier, and better conversations about goals of care with their seriously ill patients, according to Rachelle E. Bernacki, MD, MS, who presented the preliminary results of a study using this approach at the 2015 Palliative Care in Oncology Symposium in Boston.1
“There is a rapidly growing evidence base to show that high-quality communication is associated with better serious illness care,” said Dr. Bernacki, Director of Quality Initiatives and Psychosocial Oncology and Palliative Care Senior Physician at the Dana-Farber Cancer Institute in Boston. “But despite this evidence base, we don’t have conversations with our seriously ill patients often enough.”
According to Dr. Bernacki, earlier conversations about patient goals and priorities are associated with more goal-concordant care and improved quality of life, but these conversations often occur too late or not at all.
“These conversations are difficult for clinicians, and they often fail to address key elements of quality discussions,” she said. As a result, patients with serious illness routinely receive treatments that are not aligned with their goals.
High-Value but Limited Resource
“Palliative care, with a strong emphasis on quality communication, is a high-value intervention. However, we do not and will not have enough palliative care clinicians to reach all patients who would benefit,” said Dr. Bernacki. “Therefore, we need scalable interventions targeted at non–palliative care generalist and specialist clinicians in order to assure universal access to serious illness conversations.”
Clinician factors such as lack of training and time are barriers to these conversations, but the Serious Illness Care Program aims to develop, implement, and evaluate a standardized approach to training and supporting physicians and other health-care professionals in conducting more, earlier, and better conversations about goals of care with seriously ill patients and their families. The Serious Illness Conversation Guide, a seven-question, open-ended guide within the intervention, guides clinicians through these conversations.
A cluster-randomized trial is underway to test the feasibility and acceptability of the Serious Illness Care intervention for both patients and clinicians and to determine the intervention’s impact on the frequency, timing, and quality of goals-of-care conversations before death.
Physicians, physician assistants, and nurse practitioners from 10 disease centers and 2 satellite locations within the Dana-Farber Cancer Institute were invited to participate in the study and enrolled on a volunteer basis. Patients at high risk of death were identified by use of the so-called Surprise Question—“Would you be surprised if this patient died within the next year?”—which is posed to clinicians involved in the care of cancer patients and has been studied in related research presented at the Palliative Care in Oncology Symposium.2
Subsequent to clinician identification of high-risk patients, the intervention group received a structured, patient-centered discussion about values and priorities conducted by trained oncology clinicians utilizing the Serious Illness Conversation Guide. The control group received usual oncology care.
Clinicians attended a 2½-hour training session on the Serious Illness Conversation Guide. “We chose this very deliberately,” said Dr. Bernacki. “This is a feasible time frame in which busy oncologists can come for training.” Trained clinicians then received an e-mail reminder to have these conversations with their patients. “We found that they really liked being prompted to have these discussions,” she added.
Patients are also prepared prior to discussion, via a letter outlining the topics that their clinician will discuss. All information is documented with electronic medical records.
“I would call this ‘sequencing building blocks to improve early discussion,’ and it really is a terrific achievement,” said Anthony L. Back, MD, a medical oncologist at the University of Washington, Seattle.
“The highlight of this work is that it’s a multicomponent intervention that influences outcomes in systems of high complexity. By that I mean there are so many things going on with the patients that I don’t control—by the time I see them and after I see them—that I don’t think I can expect my conversation, even if it’s terrific, to be the only factor,” he said.
Of all eligible oncology clinicians, 72% volunteered. Ninety oncology clinicians were randomly assigned in clusters to the intervention group (n = 47) or the control group (n = 43).
Of 47 intervention clinicians, 46 were trained and rated the training as effective (4.3/5). Of the trained clinicians who have received e-mail prompts, 97% have completed at least one conversation, and the Conversation Guide has been established as acceptable (4.2/5). Further, the trigger system stimulates discussions in 90% of patients within two visits.
A total of 331 patients were enrolled in the study (163 intervention, 168 control). A preliminary chart review revealed that more goals-of-care conversations occurred before death in the intervention group compared to controls (92% vs 70%, P = .0037); intervention conversations also took place 4 months earlier than in the control group (median, 143 vs 63 days, P = .0008).
Dr. Bernacki pointed out that conversations in the intervention group were more patient-centered (95% vs 45%, P < .0001). Conversations in the intervention group were also more readily retrievable in the electronic medical record (68% vs 28%, P < .0001), and far fewer of them used code status only (5% vs 55%, P < .0001).
Preliminary data about the Serious Illness Care systematic approach have demonstrated strong feasibility and acceptability among both clinicians and patients. The investigators concluded that this intervention results in more, earlier, and better conversations about serious illness care values and goals, also resulting in more robust, patient-centered, and comprehensive electronic medical record documentation. ■
Disclosure: Dr. Back reported no potential conflicts of interest. Dr. Bernacki is Associate Director of the Serious Illness Care Program at Ariadne Labs.
1. Bernacki R, et al: Delivering more, earlier and better goals-of-care conversations to seriously ill oncology patients. 2015 Palliative Care in Oncology Symposium. Abstract 39. Presented October 9, 2015.
2. Vick JB, et al: The utility of the surprise question in identifying patients most at risk of death. 2015 Palliative Care in Oncology Symposium. Abstract 108. Presented October 9, 2015