When clinicians discuss patient goals and preferences, the discussion needs to be added to the medical record for other healthcare providers to access the information when necessary. Yet the documentation often is missing or incomplete.
“As clinicians, we might see multiple patients at a time, and may need to document these conversations later in the day. Clinicians document as best as they can, but may inadvertently miss documenting items discussed during the visit,” says Jessica Ma, MD, an assistant professor at Duke University School of Medicine and a physician in the Geriatric Research Education and Clinical Center at the Durham VA Health System. Ma and colleagues analyzed the content and documentation of 40 goals of care conversations led by nurses and social workers. The researchers reviewed transcripts of the conversations to see if these five key components were covered:
• goals and values;
• illness understanding;
• end-of-life planning;
• surrogates;
• advance directives.
Then, the researchers looked to see if these same components were documented in the medical record. Some key findings include:
• For most (67%) of the conversations, all the key components were discussed with patients.
• Surrogates and advance directives often were documented completely.
• Overall, most components were discussed and documented.
After patients articulate their goals and values, healthcare providers are ethically obligated to respect autonomy. “This study shows that nurses and social workers can play a key role in this ethical obligation,” says Ma.
• Goals and values and end-of-life planning were less likely to be documented in comparison to more tangible, concrete components (such as the name of a surrogate decision-maker or whether an advance directive was completed).
This could be because patients are more likely to be able to name surrogates than to articulate their core values and goals, suggests David Bekelman, MD, MPH, another of the study authors and professor of medicine and psychiatry at the University of Colorado School of Medicine, a core investigator at the Seattle-Denver Center of Innovation, and a physician in the VA Eastern Colorado Health Care System.
Bekelman says ethicists can help to address this issue in these ways:
• Remind clinicians of the importance of eliciting and honoring patient values and goals, and of the importance of identifying a surrogate decision maker.
• Find ways for clinicians to document goals of care conversations succinctly, such as by using templates.
• Identify how inaccuracies in documentation can occur. For instance, there may be an issue with clinician, nurse, or social worker workflows that needs to be addressed.
The ethical concern is that incomplete documentation could cause patients to receive care discordant to their preferences. Additionally, it always is possible that patient preferences have changed since the initial conversation took place. “Clinicians should verify if patient goals are consistent with what is reported in the documentation,” advises Bekelman.
REFERENCE
- Ma JE, Schlichte L, Haverfield M, et al. Do goals of care documentation reflect the conversation?: Evaluating conversation-documentation accuracy. J Am Geriatr Soc 2024; Apr 9. doi: 10.1111/jgs.18913. [Online ahead of print].
When clinicians discuss patient goals and preferences, the discussion needs to be added to the medical record for other healthcare providers to access the information when necessary. Yet the documentation often is missing or incomplete.
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