Documented goals-of-care discussions on patients’ values and preferences often are lacking for hospitalized older adults with serious illness. “These discussions have improved patient and family outcomes, and also have reduced intensity of care at the end of life,” says Ruth Engelberg, PhD, a research professor in the division of pulmonary, critical care, and sleep medicine at the University of Washington School of Medicine.
Engelberg and colleagues tested a timely, brief intervention to promote goals-of-care discussions in a randomized, controlled trial.1 Physicians randomized to the intervention used a one-page “jumpstart guide” with scripting to prompt discussions. For instance, physicians might say to patients: “I want to know what’s important to you so that we provide the best care to fit your goals. Is that OK?”
Researchers enrolled 2,512 patients at three U.S. hospitals, and randomized participants to an intervention group or usual care group. In the intervention group, 34.5% of patients had documented goals-of-care discussions within 30 days. In the usual care group, 30.4% had documented goals-of-care discussions. The intervention was especially effective among ethnic and racial minority patients. “The jumpstart guide seemed to ‘correct’ for disparities in documented goals-of-care discussions,” Engelberg observes.
Among ethnic and racial minority patients, the percentage with goals-of-care discussions was 10.2% higher in the intervention group than the usual care group. In contrast, for non-Hispanic white patients, goals-of-care discussions were 1.6% higher in the intervention group vs. usual care group. “Clinician-facing prompting interventions might be one way to address health equity,” Engelberg suggests.
Goals-of-care discussions still do not occur frequently enough in the hospital, even among older patients with serious illness.
“Benign nudges may advance those discussions. These discussions do not need to be lengthy,” Engelberg says.
A few short inquiries asked by a respectful, attentive provider is all that is needed to help many patients share concerns and preferences for care. “Once documented, this information can then be used to guide patient-centered care decisions,” Engelberg says.
Of 186 emergency department (ED) patients with advanced illness, none had coding of advance care planning discussion in the medical record, according to another group of researchers.2 Investigators also surveyed 50 patients, and only 18 recalled engaging in an advance care planning discussion.
“For anyone with a serious illness, we would hope that their clinician has at least broached the conversation with them before they end up in the ED,” says Paul J. Hutchison, MD, MA, HEC-C, associate professor of medicine and bioethics at Loyola University Chicago’s Stritch School of Medicine.
If those conversations happen, it helps ED clinicians and/or admitting physicians to provide goal-concordant care. “That work should be done upstream, in the outpatient setting,” Hutchison argues.
Unfortunately, many seriously ill patients arrive at EDs without ever engaging in advance care planning conversation with any healthcare provider. If the patient loses capacity and is admitted, providers are left to figure out what the patient’s wishes are for end-of-life care.
“Clinicians are navigating tricky situations, and encountering conflict between the family and the team. Everyone is trying to do the right thing for the patient, but may have a different perspective on what that actually means,” Hutchison says.
Early advance care planning conversations can prevent these problems by establishing what the patient wants ahead of time. Good documentation of those discussions clarifies the patient’s values and priorities. “This can prevent conflict once the patient loses capacity,” Hutchison says.
Ethicists can provide clinicians with encouragement, resources, and tactics to include advance care planning in their normal, routine workflows. However, the reality is outpatient providers probably lack the time for advance care planning discussions. Lack of appropriate reimbursement is one obstacle. To obtain reimbursement for advance care planning, as rules stand currently, providers must spend a minimum of 16 minutes on the task.3 This is not realistic, considering many providers are allotted a 15-minute period for the entire visit.
“Unless you have a dedicated visit just for advance care planning, you’re not going to be able to use the billing code,” Hutchison explains.
Hutchison schedules specific appointments just for advance care planning, blocking out 40 minutes for each visit. Another approach is for clinicians to connect patients with the palliative care team in the inpatient setting before discharge. That way, advance care planning conversations might happen during the hospitalization. “Ideally, advance care planning is woven into the fabric of a hospital’s culture,” Hutchison says.
REFERENCES
1. Curtis JR, Lee RY, Brumback LC, et al. Intervention to promote communication about goals of care for hospitalized patients with serious illness: A randomized clinical trial. JAMA 2023; May 21:e238812. doi: 10.1001/jama.2023.8812. [Online ahead of print].
2. Asiaban JN, Patel S, Ormseth CH, et al. Advance care planning among patients with advanced illness presenting to the emergency department. J Emerg Med 2023;64:476-480.
3. CMS.gov. Billing and coding: Advance care planning. Updated March 2, 2023.
Benign nudges may advance those discussions. These conversations do not need to be lengthy. A few short inquiries asked by a respectful, attentive provider is all that is needed to help many patients share concerns and preferences for care.
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