Query: Goals of care discussions

title: Perceived barriers and facilitators to goals of care discussions in the emergency department: A descriptive analysis of the views of emergency medicine physicians and residents.
abstract: Few studies have examined the challenges faced by emergency medicine (EM) physicians in conducting goals of care discussions. This study is the first to describe the perceived barriers and facilitators to these discussions as reported by Canadian EM physicians and residents.  A team of EM, palliative care, and internal medicine physicians developed a survey comprising multiple choice, Likert scale and open ended questions to explore four domains of goals of care discussions: training; communication; environment; and patient beliefs.  Surveys were sent to 273 EM staff and residents in six sites, and 130 (48% responded. Staff physicians conducted goals of care discussions several times per month or more, 74.1% (80/108) of the time versus 35% (8/23) of residents. Most agreed that goals of care discussions are within their scope of practice (92% they felt comfortable having these discussions (96% and they are adequately trained (73% However, 66% reported difficulty initiating goals of care discussions, and 54% believed that admitting services should conduct them. Main barriers were time (46% lack of a relationship with the patient (25% patient expectations (23% no prior discussions (21% and the inability to reach substitute decision makers (17% Fifty four percent of respondents indicated that the availability of 24 hour palliative care consults would facilitate discussions in the emergency department (ED) CONCLUSIONS Important barriers to discussing goals of care in the ED were identified by respondents, including acuity and lack of prior relationship, highlighting the need for system and environmental interventions, including improved availability of palliative care services in the ED.

title: Did a Goals of Care Discussion Happen? Differences in the Occurrence of Goals of Care Discussions as Reported by Patients, Clinicians, and in the Electronic Health Record.
abstract: Goals of care discussions are associated with improved end of life care for patients and therefore may be used as a process measure in quality improvement, research, and reimbursement programs.  To examine three methods to assess occurrence of a goals of care discussion patient report, clinician report, and documentation in the electronic health record (EHR) at a clinic visit for seriously ill patients and determine whether each method is associated with patient reported receipt of goal concordant care.  We conducted a secondary analysis of a multicenter cluster randomized trial, with 494 patients and 124 clinicians caring for them. Self reported surveys collected from patients and clinicians two weeks after a clinic visit assessed occurrence of a goals of care discussion. Documentation of a goals of care discussion was abstracted from the EHR. Patient reported receipt of goal concordant care was assessed by survey two weeks after the visit.  Fifty two percent of patients reported occurrence of a goals of care discussion at the clinic visit; clinicians reported occurrence of a discussion at 66% of visits. EHR documentation occurred in 42% of visits (P 0.001 for each compared with other two) Patients who reported occurrence of a goals of care discussion at the visit were more likely to report receipt of goal concordant care than patients who reported no discussion (b 0.441, 95% CI 0.190 0.692; P 0.001) Neither occurrence of a discussion by clinician report nor by EHR documentation was associated with goal concordant care.  Different approaches to assess goals of care discussions give differing results, yet each may have advantages. Patient report is most likely to correlate with patient reported receipt of goal concordant care.

title: Review article: Goals of care discussions for adult patients nearing end of life in emergency departments: A systematic review
abstract: Goals of care discussions at end of life are associated with increased patient satisfaction and reduced treatment burdens, reduced family and healthcare worker distress and healthcare costs, while achieving equal life expectancy. It is unclear how goals of care discussions should occur. The objective of the study was to determine which patients could benefit, requirements, content, documentation, and harms and benefits of emergency medicine goals of care discussions. We sought primary evidence on goals of care discussions in EDs with adult patients nearing end of life, published in English after 1989. Data sources included Medline, Embase, PsycINFO, CINAHL, Web of Science and reference lists of included articles. One thousand nine hundred and twenty abstracts were screened, five articles selected. There was no consensus on the meaning of goals of care, which is often confused with advanced care planning and treatment limitation. Emergency clinicians can identify most patients needing discussions following training. There was no evidence for how to involve stakeholders, nor how to adapt conversations to meet cultural and linguistically diverse needs. Expert panels have suggested requirements and content for conversations with little supporting evidence. There was no evidence for how emergency conversations differ to those in other settings, nor for harms or benefits for holding goals of care conversations in EDs. Increased ED goals of care conversations increased hospice referral and reduced in patient admissions. Most studies were of moderate quality only, outcomes were not standardised and sample sizes were small. 'Goals of care' is used inconsistently across the literature. This is the first systematic review regarding goals of care discussions in EDs. Further research is needed on all aspects of these conversations.

title: Medical students' experiences with goals of care discussions and their impact on professional identity formation
abstract: Goals of care (GoC) discussions occur amongst patients, family members and clinicians in order to establish plans of care and are invaluable aspects of end of life care. In previous research, medical learners have reported insufficient training and emotional distress about end of life decision making, but most studies have focused on postgraduate trainees and have been quantitative or have evaluated specific educational interventions. None have qualitatively explored medical students' experiences with GoC discussions, their perceptions of associated hidden curricula, and the impacts of these on professional identity formation (PIF) the individualised developmental processes by which laypersons evolve to think, act and feel like, and ultimately become, medical professionals.

title: Breaking silence: a survey of barriers to goals of care discussions from the perspective of oncology practitioners
abstract: BackgroundCancer is the leading cause of death in the developed world, and yet healthcare practitioners infrequently discuss goals of care (GoC) with hospitalized cancer patients. We sought to identify barriers to GoC discussions from the perspectives of staff oncologists, oncology residents, and oncology nurses.MethodsThis was a single center survey of staff oncologists, oncology residents, and inpatient oncology nurses. Barriers to GoC discussions were assessed on a 7 point Likert scale (1 extremely unimportant; 7 extremely important).ResultsBetween July 2013 and May 2014, of 185 eligible oncology clinicians, 30 staff oncologists, 10 oncology residents, and 28 oncology nurses returned surveys (response rate of 37% The most important barriers to GoC discussions were patient and family factors. They included family members' difficulty accepting poor prognoses (mean score 5.9, 95% CI [5.7, 6.2] lack of family agreement in the goals of care (mean score 5.8, 95% CI [5.5, 6.1] difficulty understanding the limitations of life sustaining treatments (mean score 5.8, 95% CI [5.6, 6.1] lack of patients' capacity to make goals of care decisions (mean score 5.7, 95% CI [5.5, 6.0] and language barriers (mean score 5.7, 95% CI [5.4, 5.9] Participants viewed system factors and healthcare provider factors as less important barriers.ConclusionsOncology practitioners perceive patient and family factors as the most limiting barriers to GoC discussions. Our findings underscore the need for oncology clinicians to be equipped with strong communication skills to help patients and families navigate GoC discussions.

title: Application of Kern's 6 Step Approach in the Development of a Novel Anesthesiology Curriculum for Perioperative Code Status and Goals of Care Discussions.
abstract: Code status discussions, goals of care discussions, and shared decision making in the perioperative setting are of great importance. As perioperative physicians, anesthesiologists are uniquely poised to handle these discussions. Yet formal training for anesthesiology residents in how to approach these scenarios is currently lacking.  Using Kern's 6 step approach to curriculum development, we describe an innovative curriculum for anesthesiology residents designed to teach the necessary skills to successfully conduct code status and goals of care discussions and to assess its efficacy.  Our curriculum is composed of the following educational components: (1) formal, online learning modules, (2) selected journal articles describing code status and goals of care discussions skills and communication strategies, and (3) 2 objective structured clinical examination experiences, with 1 occurring prior to and the other occurring after completion of the educational content. The educational content focuses on evidence based best practices content covering professional guidelines, current literature, shared decision making, and effective communication strategies. We also describe the potential methodology to evaluate the effectiveness of our proposed educational interventions.  Using Kern's framework, we developed a curriculum focusing on code status discussions, goals of care discussions, and shared decision making in the perioperative setting which provides trainees with the opportunity to practice communication skills and receive feedback from a standardized patient through participation in an objective structured clinical examination.

title: Clarifying Core Content of Goals of Care Discussions
abstract: A recent review 1 reveals what many of us observe in practice: clinicians use the phrase "goals of care" in a variety of ways, often with a definition more assumed than revealed. The phrase is of particular importance when it is used to refer to a certain kind of conversation between a clinician and patient (or family) often called a "goals of care discussion." Sometimes the need for such a discussion is a clinician's shorthand way of indicating it is time to clarify a patient's code status or shift the focus of care to palliation. At other times, goals of care discussions refer to the need for a specific approach to conversation about a more general plan of care. For instance, one task force recommends that goals of care discussions in serious illness should address not only prognosis and goals, but also decision making preferences, family involvement, fears, function, and tradeoffs. Others suggest that goals of care discussions should help patients' establish "agreed on, desired health expectations that are appropriate, documented and communicated," that these conversations should clarify patients' values, goals, and priorities in light of information about their diagnosis, prognosis, and treatment options, or that these conversations should include a leading emphasis on the decision that needs to be made and the likelihoods of different possible outcomes regarding survival, symptoms, and functional ability. Such differences in approach are reflected in another recent review that assessed elements of goals of care discussions and their operationalization and concluded that consensus is lacking on the question of content. Moreover, some authors suggest these discussions may be less about goals directed at treatment decisions, and more about emotional issues, management of symptoms, and rapport building. In defense of such diversity, we can accept the need for flexibility in the content of goals of care discussions given the many differences among patients, their conditions, and their circumstances. But we also do well to consider the content that should form the consistent core of these conversations when significant clinical decisions need to be made especially when we are trying to explain and model for trainees practices that are clinically meaningful and feasible within the demands of clinical practice. To this end, based on literature and experience, I suggest the core content of goals of care discussions should include diagnosis, prognosis, goals of care, treatment or test, burdens of treatment or test, and probabilities of outcomeswith or without treatment or test  These are key dimensions of decision making we need to comprehend and remember to communicate so that shared decision making with patients is facilitated by shared understanding. Not surprisingly, these dimensions have much in common with elements of informed consent. By making the patient's most important goals of care the conversational focal point, decision making is patient centered, purpose oriented, and premised on the patient's beliefs, values, priorities, preferences, and circumstances. Specific goals of care can be elicited by open ended and closedended questions regarding goals, expectations, or hopes. For many patients, preferred goals of care will fall within one of the following categories: cure, live longer, improve or maintain function, comfort, achieve life goals, or provide support for family. The core content I suggest endeavors to capture what is most essential and feasible in other approaches, and to keep goals at the center of goals of care discussions. This content is fundamental enough to be consistent with the risks, benefits, and likelihoods of informed consent discussions. As a clinician and teacher, I believe this approach satisfies the need for a clinically practical way to articulate (and sometimes even diagram in front of patients) the dimensions that guide reasoning about decisions, and to communicate that these different dimensions are inter related and therefore need to be taken together. One of the hallmarks of a successful goals of care discussion is that it allows everyone to take a step back from the intense focus on a specific intervention (such as cardiopulmonary resuscitation) by considering the broader purpose and context of that intervention. While interventionoriented decision making tends to focus on the most readily available means of addressing the most immediate medical problem, goal oriented discussions take a larger, longer view. Framed by goals of care, conversation about decision making moves the question from "Would you like us to do this, or not?" to "Will this help us achieve your goals of care, or not?" In this way, goal oriented decision making draws our attention Received September 20, 2019 Accepted October 25, 2019 35(3):913 5

title: Effect of a Patient and Clinician Communication Priming Intervention on Patient Reported Goals of Care Discussions Between Patients With Serious Illness and Clinicians: A Randomized Clinical Trial
abstract: Importance Clinician communication about goals of care is associated with improved patient outcomes and reduced intensity of end of life care, but it is unclear whether interventions can improve this communication.  To evaluate the efficacy of a patient specific preconversation communication priming intervention (Jumpstart Tips) targeting both patients and clinicians and designed to increase goals of care conversations compared with usual care.  Multicenter cluster randomized trial in outpatient clinics with physicians or nurse practitioners and patients with serious illness. The study was conducted between 2012 and 2016.  Clinicians were randomized to the bilateral, preconversation, communication priming intervention (n 65) or usual care (n 67) with 249 patients assigned to the intervention and 288 to usual care.  The primary outcome was patient reported occurrence of a goals of care conversation during a target outpatient visit. Secondary outcomes included clinician documentation of a goals of care conversation in the medical record and patient reported quality of communication (Quality of Communication questionnaire [QOC] 4 indicator latent construct) at 2 weeks, as well as patient assessments of goal concordant care at 3 months and patient reported symptoms of depression (8 item Patient Health Questionnaire; PHQ 8) and anxiety (7 item Generalized Anxiety Disorder survey; GAD 7) at 3 and 6 months. Analyses were clustered by clinician and adjusted for confounders.  We enrolled 132 of 485 potentially eligible clinicians (27% participation; 71 women [53.8% mean [SD] age, 47.1 [9.6] years) and 537 of 917 eligible patients (59% participation; 256 women [47.7% mean [SD] age, 73.4 [12.7] years) The intervention was associated with a significant increase in a goals of care discussion at the target visit (74% vs 31% P .001) and increased medical record documentation (62% vs 17% P .001) as well as increased patient rated quality of communication (4.6 vs 2.1; P .01) Patient assessed goal concordant care did not increase significantly overall (70% vs 57% P .08) but did increase for patients with stable goals between 3 month follow up and last prior assessment (73% vs 57% P .03) Symptoms of depression or anxiety were not different between groups at 3 or 6 months.  This intervention increased the occurrence, documentation, and quality of goals of care communication during routine outpatient visits and increased goal concordant care at 3 months among patients with stable goals, with no change in symptoms of anxiety or depression. Understanding the effect on subsequent health care delivery will require additional study.

title: Narrative Approach to Goals of Care Discussions: A Novel Curriculum.
abstract: Innovative patient centered approaches to goals of care (GOC) communication training are needed. Teaching a narrative approach, centered on the patient's unique story, is conceptually sound but has not been evaluated with respect to objective skills attainment. We developed a curriculum based on a novel, easily remembered narrative approach to GOC, the 3 Act Model, and piloted it with a cohort of Internal Medicine (IM) interns.  To describe the development of the 3 Act Model curriculum and to assess its impact on the GOC communication skills of IM interns.  The curriculum was developed with input from multidisciplinary experts, IM residents, and patient/family representative. Notable elements included instrument development with validity evidence established, determination of proficiency standards, and creation of role play scenarios. In two 3 hour workshops, interns participated in role plays as both providers and patients, before and after teaching (which included narrative reflection, didactics, and video demonstration) RESULTS 22 interns played the role of provider in 5 unique scenarios; 106 proficiency ratings were analyzable. Interns objectively rated as proficient increased from 30% (pre test) to 100% (final role play) By the end of the training, 96% of interns strongly agreed or agreed that they felt ready to independently lead basic GOC discussions, and the percentage who strongly agreed increased with successive role plays. All interns indicated they would recommend the training.  This pilot demonstrates that the 3 Act Model is teachable and appreciated by learners. This GOC curriculum is the first based on a narrative approach to demonstrate objective skills improvement.

title: Goals of Care Discussions for the Imminently Dying Trauma Patient.
abstract: A structured family meeting (FM) is recommended within 72 h of admission for trauma patients with high risk of mortality or disability. Multidisciplinary FMs (MDFMs) may further facilitate decision making. We hypothesized that FM within three hospital days (HDs) or MDFM would be associated with increased use of comfort measures.  We reviewed all adult trauma deaths at an academic level 1 trauma center from December 2014 to December 2017. Death in the first 24 h or on nonsurgical services were excluded. Demographics, injury characteristics, FM characteristics, and outcomes such as length of stay (LOS) were recorded. Early FM was defined as occurring within three HDs; MDFM required attendance by two or more specialty teams.  A total of 177 patients were included. Median LOS was 6 d (interquartile range 4 12) FMs were documented in 166 patients (94% with 57% occurring early. MDFM occurred in 49 (28% but usually occurred later (median HD 5 and interquartile range 2 8) Early FM was associated with reduced LOS (5 versus 11 d, P 0.001) ventilator days (4 versus 9 d, P 0.001) and deaths during a code (1.2% versus 13.2% P 0.001) MDFM was associated with higher use of comfort measures (88% versus 68% P 0.05) Of patients who transitioned to comfort care status (n 130, 73.4% code status change occurred earlier if an early FM occurred (5 versus 13 d, P 0.001) CONCLUSIONS MDFM is associated with increased comfort care measures, whereas early FM is associated with reduced LOS, ventilator days, death during a code, and earlier comfort care transition.