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Timing is Everything: Improving the quality and timeliness of critical end-of-life conversations

End-of-Life Talks DOA? New System Seeks Remedy

Bridget M. Kuehn

March 15, 2016, Medscape

http://www.medscape.com/viewarticle/860405

CHICAGO — An intervention that included physician training, a system for identifying patients nearing the end of life, and electronic medical record prompts led to more and earlier end-of-life discussions, according to new research.

In a cluster-randomized trial, a systematic intervention involving the discussion of end-of-life care was compared with usual care in adult oncology outpatients. Results of the trial were presented at the Annual Assembly of the American Academy of Hospice and Palliative Medicine (AAHPM) and the Hospice and Palliative Nurses Association (HPNA) in March.

“End-of-life discussions are associated with better outcomes,” said study presenter Joanna Paladino, MD, of the Dana Farber Cancer Institute, in Boston, Massachusetts. “But multiple studies show planning about end-of-life care happens too late, in the last days or weeks of life, or not at all.”

To improve the quality and timing of these critical conversations, Dr Paladino and her colleagues set out to create a systematic intervention in 2012.

They reviewed literature for information about system failures that hamper care discussions and best practices that help ensure that the conversations happen at critical moments.

The team developed the Serious Illness Care Program (Bernacki R et al. BMJ Open. 2015;5:e009032), which includes a 2.5-hour physician training session taught by palliative care specialists on how to use the program’s Serious Illness Conversation Guide, an electronic medical record-prompt device to spur discussions, and a system for identifying patients.

The trial enrolled 90 clinicians; 47 were randomly assigned to the intervention, and 43 were assigned to the control arm. End-of-life patients were identified on the basis of whether their physician responded “no” to a question about whether he or she would be surprised if the patient died by the end of the year.

Nearly all (97%) of the intervention physicians used the conversation guide and found it acceptable; 70% of the physicians reported that they would want their own provider to use the guide. System reminders to discuss end-of-life care led to discussions with 90% of the target patients within two visits.

End-of-life conversations occurred for 92.5% of the patients in the intervention group vs 76% in the control group.

“The intervention leads to more and earlier discussions,” Dr Paladino said.

On average, the conversations occurred about 3 months earlier, about 5 months prior to death, in the intervention group. A review of discussion documentation in the patients’ records also suggested that the quality of the discussions was better in the intervention group.

 

The group assessed how the conversations affected patients. They found that 1 week after the conversations, patients’ anxiety was cut in half. Similar results were seen for patient-reported depression.

A majority of the patients (86%) said they found the conversations worthwhile, and two thirds reported that they took action, such as changing a will or planning their funeral, as a result. Patients also reported better discussions with family and physicians going forward, Dr Paladino said.

“The preliminary results are definitely promising, with the intervention triggering earlier goals of care discussions among a seriously ill patient population,” said Rashmi K. Sharma, MD, of the Cambia Palliative Care Center of Excellence at the University of Washington, in Seattle.

 

Dr Sharma said she would like to learn more about the quality of the discussions and whether the brief training is sufficient to prepare physicians to handle these very complex discussions.

Dr Paladino said that recordings of the discussions will be analyzed to more thoroughly assess the quality of the conversations.

“Just because they are happening doesn’t mean they are happening well,” Dr Sharma said. “I’m looking forward to seeing how additional results from the study address these questions.”

 

Dr Sharma noted that the patient population in the study was overwhelmingly white and that there is a need for additional research into end-of-life discussions in more diverse populations.

“We do need this type of research to identify tools to help both clinicians and patients and their families with these discussions, but I hope that future studies can also look at how such interventions work in more diverse patient populations,” Dr Sharma said.

The trial was funded by the Charina Endowment Fund, Partners Healthcare, and the Margaret T. Morris Foundation. The authors haved disclosed no relevant financial relationships.

Annual Assembly of the American Academy of Hospice and Palliative Medicine (AAHPM) and the Hospice and Palliative Nurses Association (HPNA): FR481C, presented March 11, 2016.

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