Advance Care Planning at London Health Sciences Centre

Study Overview
=================
Brief Summary
-----------------
All patients admitted to London Health Sciences Centre (LHSC) are asked to indicate their preferences for CPR (cardiopulmonary resuscitation) and other life-sustaining treatments that necessitate an Intensive Care Unit (ICU) admission. Complex, high-risk patients at LHSC require multiple admissions to the hospital towards their end-of-life (EOL). Documentation of their resuscitation status should be a part of a broader dialogue with patients around their goals of care (GOC) and advance care planning (ACP), but rarely is this the case. The innovation will involve the use of trained nurse facilitators to have meaningful conversations with patients and their families in an effective way that bridges the gap between resuscitation status, GOC discussions and ACP across the continuum of care.

Detailed Description
-----------------
On admission, the usual LHSC process will be followed whereby the patient's wishes for resuscitation are documented on the resuscitation record in the patient's chart. This constitutes the original resuscitation status. After referral or screening and written consent, the RA will conduct semi-structured, face-to-face interviews with the patient and or SDM as appropriate. If the RA has concern about a discordance, he/she will then provide verbal feedback to the health-care team (Attending Physician or the Senior Medical Resident (SMR)) immediately and request them to communicate with the patient/SDM again. A case of discordance shall be recorded ONLY if the health-care team (Attending Physician or Senior Medical Resident) confirms that a change in resuscitation status is needed. The output of this intervention will be the revised resuscitation status. This standardized process for determining this outcome has worked well in our pilot study. Any disagreements between RA and SMR on patient/SDM preferences will be reported to Team#1 Attending and recorded. It will be up to the team to reconcile the revised resuscitation preferences on official records (Resuscitation status can only be filled in only by an MD as per hospital policy). 4. Advanced Clinical Notes: These will be typed by the RA and a note be made of the revised resuscitation preferences along with GOC and ACP discussions. 5. A pilot study related to this work started in August 2016 and has allowed the research team to evaluate barriers and facilitators of conducting this intervention on Internal Medicine patients.

Official Title
-----------------
Advance Care Planning at London Health Sciences Centre

Conditions
-----------------
Advance Care Planning

Intervention / Treatment
-----------------
* Other: In-depth conversation about Goals of Care and ACP


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Patients admitted to internal medicine teams at or after hospitalization day 2 with: Age ≥55 years with ≥1 diagnoses: Chronic lung disease, Coronary artery disease, Congestive heart failure, Cirrhosis, Renal failure, Diabetes, Peripheral vascular disease, Cancer, Dementia (inability with ADLs) or If none of these criteria were met, any patient whose death within the next 1 year would not surprise health-care team members. Exclusion Criteria: Lack of written consent Patients who do not speak English; hard of hearing Expected to die or be discharged ≤ 24 hours Referral to or having an established palliative care plan

Ages Eligible for Study
-----------------
Minimum Age: 18 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Healthcare teams in Internal Medicine at London Health Sciences Centre will be asked if they have any patients that need further goals of care discussions or ACP. A random selection of Internal Medicine patients will also be selected for further indepth conversations related to goals of care discussions or ACP
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Team Referrals<br>In-depth conversations about Goals of Care and ACP (the intervention) will be held for the patients referred to the research team by the three healthcare teams in Internal Medicine at London Health Sciences Centre (University Campus) | Other: In-depth conversation about Goals of Care and ACP<br>* In-depth conversation regarding Goals of Care and ACP by an experienced practitioner<br>|
| Active Comparator: Random selection<br>A random selection of patients (not referred to the research team by the healthcare team) in Internal Medicine at London Health Sciences Centre (University Campus) will be selected to have in-depth conversations about Goals of Care and ACP (the intervention) | Other: In-depth conversation about Goals of Care and ACP<br>* In-depth conversation regarding Goals of Care and ACP by an experienced practitioner<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Incidence of Discordance | Discordance between patients' prior expressed preferences and those documented in their healthcare record | 2 years | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Risk factors associated with discordance | Evaluate predisposing factors for the discordance | 2 years | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
Advance Care Planning, End of life, CPR