As deaths in hospitals increase, clear discussions regarding resuscitation status and treatment limitations, referred to as goals of care (GOC), are vital. GOC may need revision as disease and patient priorities change over time. There is limited data about who is involved in GOC discussions, and how this changes as patients deteriorate in hospital.
Aims:
To review the timing and clinicians involved in GOC discussions for a cohort of patients who died in hospital.
Methods:
Retrospective observational audit of 80 consecutive end of life admissions between March 11th and April 9th, 2019.
Results:
Of 80 patients, 75 (93.6%) had GOC recorded during their admission, about half for ward-based non-burdensome symptom management or end-of-life care. GOC were revised in 68.0% of cases. Medical staff involved in initial versus final GOC discussions included home team junior doctor (54.7% versus 72.5%), home team consultant (37.3% versus 56.9%) and ICU doctor (16.0% versus 21.6%). For initial versus final GOC decisions, patients were involved in 34.7% versus 31.4%, and family in 53.3% versus 86.3%. Dying was documented for 92.0% of patients and this was documented to have been communicated to the family and patient in 98.6% and 19.5% of cases respectively.
Conclusions:
As patients deteriorated, family and senior clinician involvement in GOC discussions increased, but patient involvement did not. Junior doctors were most heavily involved in discussions. We advocate for further GOC training and modeling to enhance junior doctors’ confidence and competence in conducting and involving patients and families in GOC conversations.
Australian Institute of Health and Welfare. Australia’s Health 2016. AIHW; 2016.
2.
GehlbachTGShinkunasLAForman-HoffmanVLThomasKWSchmidtGAKaldjianLC. Code status orders and goals of care in the medical ICU. Chest. 2011;139(4):802–809.
3.
ThomasRLZubairMYHayesBAshbyMA. Goals of care: a clinical framework for limitation of medical treatment. Med J Aust. 2014;201(8):452–455.
4.
BrightonLJBristoweK. Communication in palliative care: talking about the end of life, before the end of life. Postgrad Med J. 2016;92(1090):466–470.
5.
KottewarSABearellyDBearellySJohnsonEDFlemingDA. Residents’ end-of-life training experience: a literature review of interventions. J Palliat Med. 2014;17(6):725–732.
6.
MeoNHwangUMorrisonRS. Resident perceptions of palliative care training in the emergency department. J Palliat Med. 2011;14(5):548–555.
7.
MulderSFBleijenbergGVerhagenSCStuytPMSchijvenMPTackCJ. Improved competence after a palliative care course for internal medicine residents. Palliat Med. 2009;23(4):360–368.
8.
WeilJGoldMMcIverSRotsteinLPhilipJ. Australian resident doctors want more palliative medicine education: a survey of attitudes and perceived needs. Intern Med J. 2012;42(7):828–830.
9.
SchwartzCEGouletJLGorskiVSelwynPA. Medical residents’ perceptions of end-of-life care training in a large urban teaching hospital. J Palliat Med. 2003;6(1):37–44.
10.
GormanTEAhernSPWisemanJSkrobikY. Residents’ end-of-life decision making with adult hospitalized patients: a review of the literature. Acad Med. 2005;80(7):622–633.
HanningJWalkerKJHorriganDLevinsonMMillsA. Review article: goals-of-care discussions for adult patients nearing end of life in emergency departments: a systematic review. Emerg Med Australas. 2019;31(4):525–532.
14.
BernackiREBlockSD; American College of Physicians High Value Care Task Force. Communication about serious illness care goals: a review and synthesis of best practices. JAMA Intern Med. 2014;174(12):1994–2003.
15.
WeinerJSRothJ. Avoiding iatrogenic harm to patient and family while discussing goals of care near the end of life. J Palliat Med. 2006;9(2):451–463.
16.
NevilleTHTarnDMYamamotoMGarberBJWengerNS. Understanding factors contributing to inappropriate critical care: a mixed-methods analysis of medical record documentation. J Palliat Med. 2017;20(11):1260–1266.
17.
Australian Commission on Safety and Quality in Health Care. National Consensus Statement: Essential Elements for Safe and High-Quality End-of-Life Care. ACSQHC; 2015.
18.
Australian Commission on Safety and Quality in Health Care. Safety and Quality of End-of-life Care in Acute Hospitals: A Background Paper. ACSQHC; 2013.
HarrisPATaylorRMinorBL, et al.The REDCap consortium: building an international community of software platform partners. J Biomed Inform. 2019;95. doi: 10.1016/j.jbi.2019.103208.
21.
HarrisPATaylorRThielkeRPayneJGonzalezNCondeJG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–381.
YouJJDownarJFowlerRA; et al.Canadian Researchers at the End of Life Network. Barriers to goals of care discussions with seriously ill hospitalized patients and their families: a multicenter survey of clinicians. JAMA Intern Med. 2015;175(4):549–556.
25.
PiggottKLPatelAWongA, et al.Breaking silence: a survey of barriers to goals of care discussions from the perspective of oncology practitioners. BMC Cancer. 2019;19(1):130.
26.
DevRCoulsonLDel FabbroE, et al.A prospective study of family conferences: effects of patient presence on emotional expression and end-of-life discussions. J Pain Symptom Manage. 2013;46(4):536–545.
27.
El-JawahriALau-MinKNippRD, et al.Processes of code status transitions in hospitalized patients with advanced cancer. Cancer. 2017;123(24):4895–4902.
28.
HeylandDKBarwichDPichoraD; et al.ACCEPT (Advance Care Planning Evaluation in Elderly Patients) Study Team; Canadian Researchers at the End of Life Network (CARENET). Failure to engage hospitalized elderly patients and their families in advance care planning. JAMA Intern Med. 2013;173(9):778–787.
29.
GibbinsJMcCoubrieRAlexanderNKinzelCForbesK. Diagnosing dying in the acute hospital setting—are we too late?Clin Med (Lond). 2009;9(2):116–119.
30.
WentlandtKToupinPNovosedlikNLeLWZimmermannCKayaE. Language used by health care professionals to describe dying at an acute care hospital. J Pain Symptom Manage. 2018;56(3):337–343.
31.
ScheunemannLPErnecoffNCBuddadhumarukP, et al.Clinician-family communication about patients’ values and preferences in intensive care units. JAMA Intern Med. 2019;179(5):676–684.
32.
BillingsMECurtisJREngelbergRA. Medicine residents’ self-perceived competence in end-of-life care. Acad Med. 2009;84(11):1533–1539.
33.
SchroderCHeylandDJiangXRockerGDodekP; Canadian Researchers at the End of Life Network. Educating medical residents in end-of-life care: insights from a multicenter survey. J Palliat Med. 2009;12(5):459–470.
34.
BinderAFHuangGCBussMK. Uninformed consent: do medicine residents lack the proper framework for code status discussions?J Hosp Med. 2016;11(2):111–116.
35.
SharmaRKJainNPeswaniNSzmuilowiczEWayneDBCameronKA. Unpacking resident-led code status discussions: results from a mixed methods study. J Gen Intern Med. 2014;29(5):750–757.
36.
EinsteinDJEinsteinKLMathewP. Dying for advice: code status discussions between resident physicians and patients with advanced cancer—a national survey. J Palliat Med. 2015;18(6):535–541.
37.
TulskyJAChesneyMALoB. How do medical residents discuss resuscitation with patients?J Gen Intern Med. 1995;10(8):436–442.
38.
CurtisJRBackALFordDW, et al.Effect of communication skills training for residents and nurse practitioners on quality of communication with patients with serious illness: a randomized trial. JAMA. 2013;310(21):2271–2281.
