Goals of Care Ambulatory Resident Education: Training Residents in Advance Care Planning Conversations in the Outpatient Setting

2017 ◽  
Vol 20 (12) ◽  
pp. 1345-1351 ◽  
Author(s):  
Stephen H. Berns ◽  
Marianne Camargo ◽  
Diane E. Meier ◽  
Jacqueline K. Yuen
Keyword(s):  
Advance Care Planning ◽  
Resident Education ◽  
Outpatient Setting ◽  
Care Planning ◽  
Goals Of Care ◽  
Advance Care ◽  
Education Training

Advance care planning for patients with COVID-19: a communication guide

2021 ◽  
pp. 1-6
Author(s):  
Natasha Palipane ◽  
Abi Ponnampalampillai ◽  
Srirupa Gupta
Keyword(s):  
Advance Care Planning ◽  
Symptom Control ◽  
Patient Choice ◽  
High Morbidity ◽  
Care Planning ◽  
Goals Of Care ◽  
Disease Trajectory ◽  
Improve Symptom ◽  
Inappropriate Admissions ◽  
Advance Care

In view of the high morbidity and mortality associated with COVID-19, early and honest conversations with patients about goals of care are vital. Advance care planning in its traditional manner may be difficult to achieve given the unpredictability of the disease trajectory. Despite this, it is crucial that patients' care wishes are explored as this will help prevent inappropriate admissions to hospital and to critical care, improve symptom control and advocate for patient choice. This article provides practical tips on how to translate decisions around treatment escalation plans into conversations, both face-to-face and over the phone, in a sensitive and compassionate manner. Care planning conversations for patients with COVID-19 should be individualised and actively involve the patient. Focusing on goals of care rather than ceilings of treatment can help to alleviate anxiety around these conversations and will remind patients that their care will never cease. Using a framework such as the ‘SPIKES’ mnemonic can help to structure this conversation. Verbally conveying empathy will be key, particularly when wearing personal protective equipment or speaking to relatives over the phone. It is also important to make time to recognise your own emotions during and/or after these conversations.

Quality Improvement Initiatives to Reduce Mortality: An Opportunity to Engage Palliative Care and Improve Advance Care Planning

2018 ◽  
Vol 36 (2) ◽  
pp. 97-104 ◽  
Author(s):  
Signe Peterson Flieger ◽  
Erica Spatz ◽  
Emily J. Cherlin ◽  
Leslie A. Curry
Keyword(s):  
Palliative Care ◽  
Quality Improvement ◽  
End Of Life ◽  
Advance Care Planning ◽  
Secondary Analysis ◽  
Care Quality ◽  
Care Planning ◽  
Goals Of Care ◽  
Patient Goals ◽  
Advance Care

Background: Despite substantial efforts to integrate palliative care and improve advance care planning, both are underutilized. Quality improvement initiatives focused on reducing mortality may offer an opportunity for facilitating engagement with palliative care and advance care planning. Objective: In the context of an initiative to reduce acute myocardial infarction (AMI) mortality, we examined challenges and opportunities for engaging palliative care and improving advance care planning. Methods: We performed a secondary analysis of qualitative data collected through the Leadership Saves Lives initiative between 2014 and 2016. Data included in-depth interviews with hospital executives, clinicians, administrators, and quality improvement staff (n = 28) from 5 hospitals participating in the Mayo Clinic Care Network. Focused analysis examined emergent themes related to end-of-life experiences, including palliative care and advance care planning. Results: Participants described challenges related to palliative care and advance care planning in the AMI context, including intervention decisions during an acute event, delivering care aligned with patient and family preferences, and the culture around palliative care and hospice. Participants proposed strategies for addressing such challenges in the context of improving AMI quality outcomes. Conclusions: Clinicians who participated in an initiative to reduce AMI mortality highlighted the challenges associated with decision-making regarding interventions, systems for documenting patient goals of care, and broader engagement with palliative care. Quality improvement initiatives focused on mortality may offer a meaningful and feasible opportunity for engaging palliative care. Primary palliative care training is needed to improve discussions about patient and family goals of care near the end of life.

95 Goals-Of-Care and Advance Care Planning Discussions with Hospitalised Frail Older People: What is the Evidence?

2020 ◽  
Vol 49 (Supplement_1) ◽  
pp. i30-i32
Author(s):  
S A Hopkins ◽  
A Bentley ◽  
V Phillips ◽  
S Barclay
Keyword(s):  
Literature Review ◽  
Older People ◽  
Advance Care Planning ◽  
Controlled Trial ◽  
Care Planning ◽  
Frail Older People ◽  
National Guidelines ◽  
Goals Of Care ◽  
Hospitalised Patients ◽  
Advance Care

Abstract Introduction National guidelines suggest that patients in the last year of life should be identified, their prognosis and future care options discussed, with advance care planning (ACP) recorded. Goals-of-care should be discussed with hospitalised patients at risk of deteriorating or with life-limiting conditions. The stated purpose of ACP and goals-of-care discussions is to increase goal-concordant care (i.e. patients receiving treatments they would wish to receive, and not receiving those they would not want). This literature review investigates the evidence-base for these policies and outcomes. Review question What is the evidence for goals-of-care and ACP discussions with hospitalised frail older people? Methods Systematic literature review and narrative synthesis. Electronic search of MEDLINE, CINAHL, ASSIA, PsycINFO, and Embase databases from January 1990 to September 2017. An updated search until May 2019 is currently underway. Results Of 8077 unique articles identified, 17 met inclusion criteria. There is no evidence that goals-of-care discussions lead to increased goal-concordant care; there is observational evidence that they increase the accuracy of documented preferences. Currently, rates of goals-of-care discussions are variable (38-72%), and there is poor concordance between patients’ actual and documented preferences, with agreement in only 31-33% of cases. Present rates of ACP are very low (0-3%), with mixed evidence for benefits of ACP. One single-centre randomised controlled trial suggests ACP improves outcomes for patients who die within 6 months of discharge, including increased goal-concordant care and reduced family distress. There is very limited evidence concerning patients’ and family members’ experiences of these discussions, their reasons for wishing (or not) to participate in discussions, or their perceptions of the important outcomes. Most (80%) patients would like to be involved in decisions about their care; 48% consider these conversations very important. The views and experiences of healthcare professionals have been little studied. Conclusions The asserted aim of goals-of-care and ACP discussions is to increase goal-concordant care; the extent to which this reflects patients’ priorities is unknown. In younger patient populations, while 40% of patients consider goal-concordant care the most important outcome, one third of patients consider family-related outcomes to be more important. Further research is needed to understand the perspectives of frail older patients, their families and clinicians, in order to make these discussions and subsequent care truly patient-centred.

Impact of mindfulness training on avoidant coping and advance care planning.

2014 ◽  
Vol 32 (31_suppl) ◽  
pp. 86-86
Author(s):  
Shelley A. Johns ◽  
Kathleen Beck-Coon ◽  
Karen Schmidt ◽  
Timothy E. Stump ◽  
Jennifer Kim Bernat ◽  
...  
Keyword(s):  
End Of Life ◽  
Advance Care Planning ◽  
Avoidant Coping ◽  
Present Moment ◽  
Care Planning ◽  
Cognitive Avoidance ◽  
Post Intervention ◽  
Psychiatric Disturbance ◽  
Goals Of Care ◽  
Advance Care

86 Background: Timely end-of-life (EOL) discussions and advance care planning (ACP) are crucial to quality cancer care; however, patients, family caregivers (CGs), and oncologists often avoid these tender conversations. When EOL discussions are avoided, patients are more likely to receive non-beneficial treatment near death and CGs are more likely to experience psychiatric disturbance. Mindfulness meditation facilitates emotional regulation and may enhance adaptive coping necessary for EOL discussions and ACP. Methods: Mindfully Optimizing Delivery of End-of-Life (MODEL) Care is a within-group pilot study developed to train patients with advanced-stage solid malignancies and their CGs (n=13 dyads) in present-moment awareness and non-reactive coping through a variety of mindfulness practices. Eligible patients met a threshold for avoidant coping and had not completed a Physician Orders for Scope of Treatment (POST) form documenting care preferences. Cognitive avoidance and quality of life (QoL) for patients and CGs were assessed from baseline (T1) to post-intervention (T2) and 1-month follow-up (T3) with standardized response mean (SRM) effect sizes. ACP from T1 to T3 was assessed descriptively. Results: Moderate decreases in cancer-related avoidance were found for patients (SRM=-0.47) and CGs (SRM=-0.59) T1 to T2, while T1 to T3 effects were small for patients (SRM=-0.31) and large for CGs (SRM=-1.12). At T1, no patient had completed a POST form; by T3, 50% reported completing one and 40% were preparing to do so soon. At T1, 23% of patients reported having had a ‘goals of care’ discussion with their oncologist, with 82% doing so by T3. At T1, 46% of patients reported having discussed ‘goals of care’ with their CGs, with 100% doing so by T3. Large improvements in QoL were found at both time points for patients and CGs (SRMs ranging from 0.85 to 1.21). Conclusions: Mindfulness was associated with mostly moderate reductions in avoidant coping and large improvements in QoL for patients and caregivers, with notable ACP progress for patients.

Utilizing advance care planning videos to empower perioperative cancer patients and families: Results from a randomized controlled trial.

2017 ◽  
Vol 35 (31_suppl) ◽  
pp. 5-5
Author(s):  
Rebecca Aslakson ◽  
Sarina Isenberg ◽  
Norah L. Crossnohere ◽  
Alison M. Conca-Cheng ◽  
Madeleine Moore ◽  
...  
Keyword(s):  
Advance Care Planning ◽  
Interaction Analysis ◽  
Controlled Trial ◽  
Tertiary Care ◽  
Care Planning ◽  
Care Hospital ◽  
Patient Centeredness ◽  
Goals Of Care ◽  
Randomized Controlled ◽  
Advance Care

5 Background: The feasibility and impact of integrating advance care planning (ACP) in surgical oncologic populations is unknown. We hypothesized that an ACP video could be integrated into surgical oncologic care and that patients who preoperatively viewed the video would engage in more ACP and patient-centered communication with their surgeon. Methods: Randomized controlled, phase II trial with two study arms: intervention ACP video and control (no ACP) video; and four data collection periods: enrollment, presurgical consent, postoperative one week, and postoperative one month. Participants included patients undergoing major cancer surgery recruited from nine surgical oncology clinics at a single, academic, inner city, tertiary care hospital. Main Outcomes and Measures: Primary Outcome - Content of ACP and patient-centeredness during the presurgical consent visit as measured through the Roter Interaction Analysis System (RIAS). Secondary patient outcomes – mood; goals of care; and video helpfulness. Results: Ninety-two patients (target enrollment of ninety) were enrolled over 15 months. The ACP video was successfully integrated into the intervention arm and no study-related harms were noted. Patient-centeredness was unchanged between the study arms (IRR=1.06, CI [0.87,1.3], p=0.545) and there was a trend of increased ACP content in the intervention arm (23% intervention vs. 10% control, p=0.182). There were no differences in secondary outcomes other than patients found the intervention video more “helpful” (p=0.007). There was a statistically significant increase in mood symptoms in both groups one week post-operative as compared to enrollment (p=0.01). Patients in both groups most frequently noted cure-related goals of care. Conclusions: The ACP video was integrated successfully into surgical care, well-tolerated, and thought helpful by patients, but did not significantly change the nature or ACP content in patient-surgeon pre-operative conversation. Future studies could increase the “dose” of ACP through modifying video content and/or how or who presents that content prior to surgery. Clinical trial information: NCT02489799.

Effect of a communication skills intervention on resident comfort and knowledge of discussing goals of care and advance care planning.

2016 ◽  
Vol 34 (26_suppl) ◽  
pp. 50-50 ◽  
Author(s):  
Rushil Virendra Patel ◽  
Elizabeth Golding ◽  
Aaron Lampkin ◽  
Mary Walker Larach ◽  
Lawrence Klima
Keyword(s):  
Communication Skills ◽  
Advance Care Planning ◽  
Comfort Level ◽  
Clinical Psychologist ◽  
Care Planning ◽  
Post Intervention ◽  
Goals Of Care ◽  
Online Curriculum ◽  
Planning Methods ◽  
Advance Care

50 Background: Inpatient providers are sometimes challenged with advanced care planning for their patients. At a teaching hospital, resident physicians find themselves tasked with this responsibility for inpatients they may have only just met, as well as in their assigned outpatient panel. Education on communication skills though has been shown to improve resident comfort level and knowledge of discussing goals of care and advance care planning. Methods: Internal medicine categorical residents (n = 15) and preliminary (n = 3) residents at a university-affiliated, community hospital learned the fundamentals of discussing goals of care and advance care planning using selected modules from the Center for Advancing Palliative Care’s (CAPC) online curriculum in communication skills during their outpatient clinic rotation from February through June 2016. Residents then discussed a patient encounter from their experience with their colleagues along with a member from the inpatient palliative care team and a clinical psychologist in weekly 1-hour afternoon sessions. A pre- and post-intervention survey was administered and recoded by a numerical identifier to assess the change in each resident's comfort level and knowledge level with conducting these discussions with their patients. Sessions were also audiorecorded to identify recurrent themes and insights for future follow-up projects. Results: Preliminary analysis (n = 11) demonstrates a statistically significant improvement in the median difference between overall resident comfort level (p = 0.007) and knowledge (p = 0.027) of discussing goals of care and advance care planning. Several participants also expressed desires for additional opportunities to practice these skills under supervision by experienced providers. Conclusions: Residents value developing skills requisite to facilitate goals of care discussions and advance care planning. Further opportunities for practice and feedback should be identified.

scholarly journals Exploring the Expanded Role of Pharmacists in Advance Care Planning

2021 ◽  
pp. OP.20.00684
Author(s):  
Joseph D. Ma ◽  
Alexandra Dullea ◽  
Chelsea Hagmann ◽  
Sarah Friedman ◽  
Michelle Russell ◽  
...  
Keyword(s):  
Advance Care Planning ◽  
Clinical Skill ◽  
Outpatient Setting ◽  
Treatment Preferences ◽  
Care Planning ◽  
Incurable Cancer ◽  
Care Clinic ◽  
Location Of Death ◽  
Advance Care ◽  
Resuscitation Status

PURPOSE: Advance care planning (ACP) is a clinical skill that can be taught. An opportunity exists to teach how to conduct ACP to clinicians not typically engaged in these conversations to increase the likelihood that patients and caregivers engage in ACP. We conducted a prospective study exploring the feasibility of a pharmacist-led ACP intervention. METHODS: We completed a prospective, single-center study from July 2015 to July 2017. We included patients of age ≥ 18 years with incurable cancer referred to the palliative care clinic. A trained pharmacist led an ACP discussion with the patient and selected proxy. We defined feasibility as completion of ≥ 30 pharmacist-led ACP discussions over the study period. Additionally, we defined an informed healthcare proxy as someone who understood three key end-of-life (EOL) treatment preferences: the patient's personal definition of quality of life, desired resuscitation status, and preferred location of death (in or out of the hospital). Patients were followed until the end of the study or death. For those patients who died, the pharmacist contacted the proxy for follow-up and explored satisfaction with the ACP intervention. RESULTS: Thirty-four patients completed the study. All selected proxies completed the intervention and were able to understand the three EOL preferences. At the time of the patient’s death (n = 20), proxies reported that 66.6% received their preferred resuscitation status and 72.2% died in their preferred location. Proxy satisfaction with the ACP process was 7.6 ± 2.5 (mean ± SD) on a 11-point Likert scale. CONCLUSION: These findings indicate the potential for pharmacists to lead and engage in ACP in the outpatient setting.

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