QI Initiative Increases Goals of Care Conversations

By Stacey Kusterbeck

Many hospitalized patients lack goals of care conversations, causing ethical conflicts at the end of life. “As palliative care physicians, we have seen firsthand how impactful goals of care conversations can be for seriously ill patients,” says Gordon J. Wood, MD, a palliative care physician and associate professor of medicine and medical education at Northwestern University’s Feinberg School of Medicine.

Preference-Aligned Communication and Treatment (PACT) is a multisite quality improvement project to increase goals of care conversations in patients who are hospitalized with serious illness.¹ Trained facilitators screen all patients admitted to a hospital unit to identify those who may benefit from discussing goals of care. The facilitators then have those conversations, and communicate the results to the patient’s care team, both inside and outside of the hospital.

Wood and colleagues conducted a study to evaluate the effect of PACT on the percentage of patients who received care discordant with their stated preferences.² The study included 1,347 intervention group patients and 4,019 patients in the control group, all of whom were seriously ill hospitalized patients.

For the intervention group, rates of discordance between stated wishes and the care received generally were low. The researchers were not able to assess discordant care rates for the control group, since those patients did not receive the intervention and, therefore, did not complete the same documentation of goals of care.

The researchers also examined end-of-life resource use. “Many patients at the end of life value comfort-focused care. We found that the process was associated with less aggressive interventions and lower costs in the last week of life, as well as more use of hospice,” says Wood. Patients in the intervention group had lower costs, were less likely to be on a ventilator, and were less likely to undergo cardioversion or cardiopulmonary resuscitation during their hospital stay than the control group. The intervention group also was more likely to enroll in hospice and had longer hospice stays.

One surprising outcome was the high degree of engagement from the medical team. “There will never be enough palliative care physicians to have these conversations with all of the patients in need,” explains Wood. The researchers trained everyone who might have contact with seriously ill patients — physicians, nurses, social workers, chaplains, physical and occupational therapists, and patient care technicians. Some sites went even further and trained administrative and custodial staff to encourage serious illness conversations when they sensed a patient or family in need.

“Providing staff members with training and giving them explicit permission to begin exploring goals and values in the context of serious illness was empowering and meaningful,” reports Wood.

For example, a social worker who underwent communication skills training as part of the project said, “It has allowed me to connect to people in a way that maybe I wouldn’t have without PACT.” Nurses observed that some patients avoided interventions they would not have wanted, specifically because conversations took place earlier in the course of illness before a prolonged crisis.

Before the project, many members of the team felt moral distress in caring for seriously ill patients without a way to understand their goals and values. Clinicians had no way to know if the care being provided was in line with the patients’ priorities. “PACT’s approach is to engage the whole team in goals of care conversations. That helped the team to understand why care was being provided the way it was for the sickest patients in the hospital,” says Wood.

The main ethical implication for clinicians is that, to effectively honor the autonomy of seriously ill patients, “you need systems to engage patients and families in these conversations,” says Eytan Szmuilowicz, MD, another of the study’s authors. Szmuilowicz is a palliative care physician at Northwestern Medical Group and an associate professor of medicine at Northwestern University’s Feinberg School of Medicine.

The two ethicists involved in PACT helped with communication skills training. “Ethicists were critical in the success of this project. Ethicists could play similar roles at their institutions in garnering leadership support for this work and helping lead its implementation,” says Szmuilowicz.

PACT champions engage patients in a general goals of care conversation that documents the patient’s or their family’s understanding of the illness, the questions they have, their hopes and worries, how they balance length and quality of life, and medical interventions they know they want to avoid. “I suspect many ethicists would find this conversation mirrors many consultations they do in their normal practice,” says Szmuilowicz.

In addition to having goals of care conversations, PACT champions also had an educational role. Champions trained colleagues to implement the process, using web modules, conversation guide handouts, and skills practice sessions that included role-playing exercises with simulated patients. “This educator role is another way ethicists could make important contributions to an initiative like PACT,” offers Szmuilowicz.

REFERENCES

1. Szmuilowicz E, Clepp RK, Neagle J, et al. The PACT project: Feasibility of a multidisciplinary, multi-faceted intervention to promote goals of care conversations. Am J Hosp Palliat Care 2024;41:355-362.
2. Wood GJ, Clepp RK, Lee J, et al. Outcomes of a multisite mentored implementation approach to promoting goals of care conversations. J Pain Symptom Manage 2024;68:163-170.e2.