The Problem
Many patients admitted to the hospital are seriously ill and at risk of dying. Improving goals of care discussions in the hospital requires providers to be able to accurately identify patients who are at risk of mortality. In addition, the inpatient providers must be able to communicate to their patients the severity of their illness so that they may have realistic expectations and be able to make informed medical decisions.(1) However, evidence suggests that physicians perform poorly in predicting prognosis and life expectancy for patients.(1,2) Hence, goals of care discussions between physicians and patients do not occur consistently and the content, detail, documentation, and timing of these discussions are also variable. Seriously ill patients are, thus, at an increasing risk of being exposed to potentially unwanted interventions at their end of life (EOL).(3,4)
These observations from the literature are also true at Duke University Health System. Multiple physician reviewers on the mortality OnBase tool have identified having earlier goals of care discussion as an opportunity to improve care for patients who die in the hospital. Improving end of life care delivery and advance planning, including improving hospice referral for seriously ill patients, has also been identified as a strategic goal for Duke University Health System.
Our Solution
In 2018-2019 the Duke Institute for Health Innovation developed a model by using EMR data to estimate the probability that a patient will die during a hospital stay as well as 30 days after discharge. We want to use this mortality risk predictor model to identify patients who are admitted to the hospitalist service at Duke Regional Hospital with a high 30-day risk of mortality. Once identified, we will inform physicians who are taking care of those patients about the high risk of mortality and offer them a Transition of Care Toolkit (TOCTK) for their patients. The TOCTK comprised of a multidisciplinary team, will include tools and resources for the physician to improve goals of care and end of life discussions with their patient. It will also include personalized tools for the patient geared towards improving their quality of life and to support them as needed after discharge.
