The Problem
Many patients who are near the end of life and facing difficult choices have not had a conversation with a health care provider to define their goals of care. Aggressive care might not match the patient’s goals and values and can also have unnecessary costs for families and the health system. Even when goal of care are elicited, varied documentation practices may make it difficult for other providers to locate in the EHR, resulting in this valuable information not being known to future providers and not guiding the patient care.
Our Solution
We developed and implemented a project to identify patients who may benefit from a goals of care discussion, and to help hospitalists better facilitate that conversation. To inform when to have the conversation, we designed an EHR alert based on triggering criteria determined with help from the hospital medicine program. To improve how hospitalists facilitate the conversation, the coach (Dr. Pollak) met with each hospitalist to educate on use of the “SUPER” script for goals of care conversations. The hospitalists then audio recorded goals of care conversations for identified patients on an encrypted iPod, which uploaded to HIPAA compliant cloud storage. After reviewing and coding on the audio transcriptions, the coach held feedback sessions with each hospitalist. Additionally, the hospitalists received education on documenting goals of care conversations in The Advance Care Planning Module in Maestro Care.
Impact
Hospitalists involved rated the intervention highly. 80% rated the intervention as “very helpful,” that they had “made changes in their clinical practice,” that the coaching would “have an impact on how effectively they communicate with patients,” and that they would “definitely recommend to a colleague.” Early analysis of the patients for whom an EHR alert was triggered provides some information about our study: approximately 12% of patients with an EHR alert died over the course of the study, suggesting the triggering conditions did correctly identify an ill cohort of patients at risk of near term mortality. 12% of those patients received palliative care consultation, with 9% being discharged to hospice care. Nearly half of the discharge summaries for these patients note that goals of care were addressed by the treatment team, but ultimately that conversation was documented in the Advance Care Planning note only a minority (n=15) of times. This suggests that the workflow of documenting these conversations in a distinct area of the chart rather than in conventional areas (progress notes, discharge summaries) was uncommon and that the training/ education and rationale provided for doing so was insufficient to change provider behavior.
HOSPITALIST FEEDBACK
“The personalized assessment and review of my encounters with patients was most helpful. I learned what I was doing well and was given insight as to why the various techniques were effective.”
“I found the goals of care discussion template as well as the personal feedback on my discussions very helpful.”
