Jamie Wang, BHS

Hospitalizations of long‐term care (LTC) residents are known to be frequent, costly, often preventable,[1, 2, 3] and potentially associated with negative health outcomes.[4] Often, an advance directive (AD) is made at LTC admission and updated annually when residents are in relatively stable health. An AD is a document that helps to inform a substitute decision maker (SDM) about the consent process for life‐sustaining treatments and is a resource that supports advance care planning (ACP). ACP is a process that allows individuals to consider, express, and plan for future healthcare in the event that they lack capacity to make their own decisions. When an LTC resident's health deteriorates and hospitalization is required, there is an opportunity to update prognosis, discuss risks and benefits of previously held treatment preferences, as well as reassess goals of care (GOC).

Engaging in ACP discussions during relatively stable health can help ensure patient preferences are followed.[5, 6] These discussions, however, are often insufficient, as they involve decision making for hypothetical situations that may not cover all potential scenarios, and may not reflect a patient's reality at the time of health status decline. Discussions held in the moment more authentically reflect the decisions of patients and/or SDM based on the specific needs and clinical realities particular to the patient at that time.[7] GOC discussions, defined in this context as ACP discussions occurring during hospitalization, have the potential to better align patient wishes with care received,[6] improve quality of life and satisfaction,[8, 9, 10] and reduce unwanted extra care.[11, 12] Although in‐the‐moment GOC discussions are recommended for all hospitalized patients who are seriously ill with a high risk of dying,[13] research suggests that this occurs infrequently for elderly patients. A recent multicenter survey of seriously ill hospitalized elderly patients found that only 25% of patients and 32% of family members reported that they had been asked about prior ACP or AD.[14] Another study of hospitalized LTC residents found that resuscitation status and family discussion was documented in only 55% and 42% of admissions, respectively.[15]

Further investigation is required to determine how often LTC patients have GOC discussions, what prompts these discussions, and what are the outcomes. Previous studies have focused on barriers to performing GOC discussions, rather than the factors that are associated with them.[16] By understanding why these discussions currently happen, we can potentially improve how often they occur and the quality of their outcomes.

The objectives of this study were to determine the rate of documented GOC discussions among hospitalized LTC residents, identify factors that were associated with documentation, and examine the association between documentation and outcomes of care.

METHODS

RESULTS

We identified a total of 7084 hospitalizations to GIM between January 1, 2012 and December 31, 2012, of which 665 (9.4%) met inclusion criteria of residence in LTC and age 65 years. Of these 665 hospitalizations, 512 were unique patients. We randomly selected a convenience sample of 200 index hospitalizations of the 512 eligible hospitalizations (39%) to perform the chart review.

DISCUSSION

Our retrospective study of LTC residents admitted to the GIM service showed that these admissions comprised 9.4% of all admissions and that GOC discussions occurred infrequently (37.5%). Our study revealed no differences in baseline patient characteristics associated with discussions, whereas patient acuity at hospital presentation independently contributed to the likelihood of discussions. We found strong associations between documentation and certain outcomes of care, including orders for AD, LOS, in‐hospital death, and 1‐year mortality. No significant associations were found between documentation and subsequent hospital use. Lastly, we found that consistent communication back to the LTC home when there was a change in AD was very poor; only 26% of discharge summaries included this documentation.

Our finding of infrequent GOC discussions during hospitalization aligns with prior studies. A study that identified code status discussions in transcripts of audio‐recorded admission encounters found that code status was discussed in only 24% of seriously ill patient admissions.[17] Furthermore, in a study specific to LTC residents, only 42% of admissions longer than 48 hours had a documented GOC discussion.[15]

We found visit‐level, but not baseline, characteristics were associated with discussions. These findings are supported by a recent study that found that whether GOC discussions took place largely depended on the acute condition presented on admission.[15] Although these results suggest that clinicians are appropriately prioritizing sicker patients who might have the most pressing need for GOC discussions, they also highlight the gap in care for less‐sick patients and the need to broaden clinical practice and consider underlying conditions and functional status. Of note, although the GCS score was found to be significantly associated with discussions, patients in the lowest GCS range did not have significantly different odds of discussions compared to the reference level (highest GCS range). A recent study by You et al. may offer some insight into this finding. They found that patients lacking capacity to make GOC decisions was ranked fifth, whereas lack of SDM availability was eighth among 21 barriers to GOC discussions, as perceived by hospital‐based clinicians.[16]

A major finding of this study was that both in‐hospital and 1‐year mortality were strongly associated with having a GOC discussion, suggesting that patients at higher risk of dying are more likely to have discussions. This is reflected by illness severity measured at initial assessment and by persistence of the association between discussions and mortality after discharge back to LTC. To the best of our knowledge, no previous studies have reported these findings. There are likely some unmeasured clinical factors such as clinical deterioration during hospitalization that contributed to this strong association. Interestingly, in our logistic regression analysis for independent predictors of in‐hospital death, we found that having dementia was associated with lower odds of in‐hospital death. One interpretation of this finding is that perhaps only patients with mild dementia were hospitalized, and those with more advanced dementia had an AD established in LTC that allowed them to remain in their LTC home. This possibility is supported by a systematic review of factors associated with LTC home hospitalization, which found that dementia was shown to be associated with less hospitalization.[18]

For patients who survived hospitalization, we did not find an association between GOC discussions and hospital use in the year following index hospitalization. In both groups, nearly 30% of patients had 1 or more subsequent hospitalizations. This is relevant especially in light of the finding that among patients where GOC discussions resulted in an AD change, only 26% of discharge summaries back to LTC included this documentation. We can only speculate that had these discussions been properly documented, subsequent hospitalizations would have decreased in the GOC group. Previous research has found that omissions of critical information in discharge summaries were common. In a study of hip fracture and stroke patients discharged from a large Midwestern academic medical center in the United States, code status was included in the discharge summary only 7% of the time.[19] The discharge summary is the primary means of sharing patient information between the hospital and LTC home. If GOC discussions are not included in the discharge summary, it is very unlikely that this information will be subsequently updated in the LTC medical record and impact the care the patient receives. A key recommendation for hospital‐based providers is ensuring that GOC discussions are clearly, consistently, and completely documented in the discharge summary so that the care provided is based on the patients' wishes.

Our study has several limitations. Our analysis was based on chart review, and although our analyses take into account a number of patient characteristics, we did not capture other characteristics that might influence GOC discussions such as culture/religion, language barriers, SDM availability, or whether patients clinically deteriorated during the index admission. Additionally, provider‐level predictors, including seniority, previous GOC training, and time available to conduct these discussions, were not captured. We also did not capture the timing or number of occasions that GOC discussions took place during hospitalization. Due to the retrospective nature of our study, we were able to only look at documented GOC discussions. GOC discussions may have happened but were never documented. However, the standard of care is to document these discussions as part of the medical record, and if they are not documented, it can be considered not to have happened and indicates a lower quality of practice. A recent survey of Canadian hospital‐based healthcare providers identified standardized GOC documentation as an effective practice to improve GOC communication.[20] Finally, because our study was conducted in 2 academic hospitals, our results may be less generalizable to other community hospitals. However, our hospitals' catchment areas capture a diverse population, both culturally and in terms of their socioeconomic status.

CONCLUSION

GOC discussions occurred infrequently, appeared to be triggered by illness severity, and were poorly communicated back to LTC. Important outcomes of care, including in‐hospital death and 1‐year mortality, were associated with discussions. This study serves to identify gaps in who might benefit from GOC discussions and illustrates opportunities for improvement including implementing standardized documentation practices.

Hospitalizations of long‐term care (LTC) residents are known to be frequent, costly, often preventable,[1, 2, 3] and potentially associated with negative health outcomes.[4] Often, an advance directive (AD) is made at LTC admission and updated annually when residents are in relatively stable health. An AD is a document that helps to inform a substitute decision maker (SDM) about the consent process for life‐sustaining treatments and is a resource that supports advance care planning (ACP). ACP is a process that allows individuals to consider, express, and plan for future healthcare in the event that they lack capacity to make their own decisions. When an LTC resident's health deteriorates and hospitalization is required, there is an opportunity to update prognosis, discuss risks and benefits of previously held treatment preferences, as well as reassess goals of care (GOC).

Engaging in ACP discussions during relatively stable health can help ensure patient preferences are followed.[5, 6] These discussions, however, are often insufficient, as they involve decision making for hypothetical situations that may not cover all potential scenarios, and may not reflect a patient's reality at the time of health status decline. Discussions held in the moment more authentically reflect the decisions of patients and/or SDM based on the specific needs and clinical realities particular to the patient at that time.[7] GOC discussions, defined in this context as ACP discussions occurring during hospitalization, have the potential to better align patient wishes with care received,[6] improve quality of life and satisfaction,[8, 9, 10] and reduce unwanted extra care.[11, 12] Although in‐the‐moment GOC discussions are recommended for all hospitalized patients who are seriously ill with a high risk of dying,[13] research suggests that this occurs infrequently for elderly patients. A recent multicenter survey of seriously ill hospitalized elderly patients found that only 25% of patients and 32% of family members reported that they had been asked about prior ACP or AD.[14] Another study of hospitalized LTC residents found that resuscitation status and family discussion was documented in only 55% and 42% of admissions, respectively.[15]

Further investigation is required to determine how often LTC patients have GOC discussions, what prompts these discussions, and what are the outcomes. Previous studies have focused on barriers to performing GOC discussions, rather than the factors that are associated with them.[16] By understanding why these discussions currently happen, we can potentially improve how often they occur and the quality of their outcomes.

The objectives of this study were to determine the rate of documented GOC discussions among hospitalized LTC residents, identify factors that were associated with documentation, and examine the association between documentation and outcomes of care.

METHODS

RESULTS

We identified a total of 7084 hospitalizations to GIM between January 1, 2012 and December 31, 2012, of which 665 (9.4%) met inclusion criteria of residence in LTC and age 65 years. Of these 665 hospitalizations, 512 were unique patients. We randomly selected a convenience sample of 200 index hospitalizations of the 512 eligible hospitalizations (39%) to perform the chart review.

DISCUSSION

Our retrospective study of LTC residents admitted to the GIM service showed that these admissions comprised 9.4% of all admissions and that GOC discussions occurred infrequently (37.5%). Our study revealed no differences in baseline patient characteristics associated with discussions, whereas patient acuity at hospital presentation independently contributed to the likelihood of discussions. We found strong associations between documentation and certain outcomes of care, including orders for AD, LOS, in‐hospital death, and 1‐year mortality. No significant associations were found between documentation and subsequent hospital use. Lastly, we found that consistent communication back to the LTC home when there was a change in AD was very poor; only 26% of discharge summaries included this documentation.

Our finding of infrequent GOC discussions during hospitalization aligns with prior studies. A study that identified code status discussions in transcripts of audio‐recorded admission encounters found that code status was discussed in only 24% of seriously ill patient admissions.[17] Furthermore, in a study specific to LTC residents, only 42% of admissions longer than 48 hours had a documented GOC discussion.[15]

We found visit‐level, but not baseline, characteristics were associated with discussions. These findings are supported by a recent study that found that whether GOC discussions took place largely depended on the acute condition presented on admission.[15] Although these results suggest that clinicians are appropriately prioritizing sicker patients who might have the most pressing need for GOC discussions, they also highlight the gap in care for less‐sick patients and the need to broaden clinical practice and consider underlying conditions and functional status. Of note, although the GCS score was found to be significantly associated with discussions, patients in the lowest GCS range did not have significantly different odds of discussions compared to the reference level (highest GCS range). A recent study by You et al. may offer some insight into this finding. They found that patients lacking capacity to make GOC decisions was ranked fifth, whereas lack of SDM availability was eighth among 21 barriers to GOC discussions, as perceived by hospital‐based clinicians.[16]

A major finding of this study was that both in‐hospital and 1‐year mortality were strongly associated with having a GOC discussion, suggesting that patients at higher risk of dying are more likely to have discussions. This is reflected by illness severity measured at initial assessment and by persistence of the association between discussions and mortality after discharge back to LTC. To the best of our knowledge, no previous studies have reported these findings. There are likely some unmeasured clinical factors such as clinical deterioration during hospitalization that contributed to this strong association. Interestingly, in our logistic regression analysis for independent predictors of in‐hospital death, we found that having dementia was associated with lower odds of in‐hospital death. One interpretation of this finding is that perhaps only patients with mild dementia were hospitalized, and those with more advanced dementia had an AD established in LTC that allowed them to remain in their LTC home. This possibility is supported by a systematic review of factors associated with LTC home hospitalization, which found that dementia was shown to be associated with less hospitalization.[18]

For patients who survived hospitalization, we did not find an association between GOC discussions and hospital use in the year following index hospitalization. In both groups, nearly 30% of patients had 1 or more subsequent hospitalizations. This is relevant especially in light of the finding that among patients where GOC discussions resulted in an AD change, only 26% of discharge summaries back to LTC included this documentation. We can only speculate that had these discussions been properly documented, subsequent hospitalizations would have decreased in the GOC group. Previous research has found that omissions of critical information in discharge summaries were common. In a study of hip fracture and stroke patients discharged from a large Midwestern academic medical center in the United States, code status was included in the discharge summary only 7% of the time.[19] The discharge summary is the primary means of sharing patient information between the hospital and LTC home. If GOC discussions are not included in the discharge summary, it is very unlikely that this information will be subsequently updated in the LTC medical record and impact the care the patient receives. A key recommendation for hospital‐based providers is ensuring that GOC discussions are clearly, consistently, and completely documented in the discharge summary so that the care provided is based on the patients' wishes.

Our study has several limitations. Our analysis was based on chart review, and although our analyses take into account a number of patient characteristics, we did not capture other characteristics that might influence GOC discussions such as culture/religion, language barriers, SDM availability, or whether patients clinically deteriorated during the index admission. Additionally, provider‐level predictors, including seniority, previous GOC training, and time available to conduct these discussions, were not captured. We also did not capture the timing or number of occasions that GOC discussions took place during hospitalization. Due to the retrospective nature of our study, we were able to only look at documented GOC discussions. GOC discussions may have happened but were never documented. However, the standard of care is to document these discussions as part of the medical record, and if they are not documented, it can be considered not to have happened and indicates a lower quality of practice. A recent survey of Canadian hospital‐based healthcare providers identified standardized GOC documentation as an effective practice to improve GOC communication.[20] Finally, because our study was conducted in 2 academic hospitals, our results may be less generalizable to other community hospitals. However, our hospitals' catchment areas capture a diverse population, both culturally and in terms of their socioeconomic status.

CONCLUSION

GOC discussions occurred infrequently, appeared to be triggered by illness severity, and were poorly communicated back to LTC. Important outcomes of care, including in‐hospital death and 1‐year mortality, were associated with discussions. This study serves to identify gaps in who might benefit from GOC discussions and illustrates opportunities for improvement including implementing standardized documentation practices.

Hospitalizations of long‐term care (LTC) residents are known to be frequent, costly, often preventable,[1, 2, 3] and potentially associated with negative health outcomes.[4] Often, an advance directive (AD) is made at LTC admission and updated annually when residents are in relatively stable health. An AD is a document that helps to inform a substitute decision maker (SDM) about the consent process for life‐sustaining treatments and is a resource that supports advance care planning (ACP). ACP is a process that allows individuals to consider, express, and plan for future healthcare in the event that they lack capacity to make their own decisions. When an LTC resident's health deteriorates and hospitalization is required, there is an opportunity to update prognosis, discuss risks and benefits of previously held treatment preferences, as well as reassess goals of care (GOC).

Engaging in ACP discussions during relatively stable health can help ensure patient preferences are followed.[5, 6] These discussions, however, are often insufficient, as they involve decision making for hypothetical situations that may not cover all potential scenarios, and may not reflect a patient's reality at the time of health status decline. Discussions held in the moment more authentically reflect the decisions of patients and/or SDM based on the specific needs and clinical realities particular to the patient at that time.[7] GOC discussions, defined in this context as ACP discussions occurring during hospitalization, have the potential to better align patient wishes with care received,[6] improve quality of life and satisfaction,[8, 9, 10] and reduce unwanted extra care.[11, 12] Although in‐the‐moment GOC discussions are recommended for all hospitalized patients who are seriously ill with a high risk of dying,[13] research suggests that this occurs infrequently for elderly patients. A recent multicenter survey of seriously ill hospitalized elderly patients found that only 25% of patients and 32% of family members reported that they had been asked about prior ACP or AD.[14] Another study of hospitalized LTC residents found that resuscitation status and family discussion was documented in only 55% and 42% of admissions, respectively.[15]

Further investigation is required to determine how often LTC patients have GOC discussions, what prompts these discussions, and what are the outcomes. Previous studies have focused on barriers to performing GOC discussions, rather than the factors that are associated with them.[16] By understanding why these discussions currently happen, we can potentially improve how often they occur and the quality of their outcomes.

The objectives of this study were to determine the rate of documented GOC discussions among hospitalized LTC residents, identify factors that were associated with documentation, and examine the association between documentation and outcomes of care.

METHODS

RESULTS

We identified a total of 7084 hospitalizations to GIM between January 1, 2012 and December 31, 2012, of which 665 (9.4%) met inclusion criteria of residence in LTC and age 65 years. Of these 665 hospitalizations, 512 were unique patients. We randomly selected a convenience sample of 200 index hospitalizations of the 512 eligible hospitalizations (39%) to perform the chart review.

DISCUSSION

Our retrospective study of LTC residents admitted to the GIM service showed that these admissions comprised 9.4% of all admissions and that GOC discussions occurred infrequently (37.5%). Our study revealed no differences in baseline patient characteristics associated with discussions, whereas patient acuity at hospital presentation independently contributed to the likelihood of discussions. We found strong associations between documentation and certain outcomes of care, including orders for AD, LOS, in‐hospital death, and 1‐year mortality. No significant associations were found between documentation and subsequent hospital use. Lastly, we found that consistent communication back to the LTC home when there was a change in AD was very poor; only 26% of discharge summaries included this documentation.

Our finding of infrequent GOC discussions during hospitalization aligns with prior studies. A study that identified code status discussions in transcripts of audio‐recorded admission encounters found that code status was discussed in only 24% of seriously ill patient admissions.[17] Furthermore, in a study specific to LTC residents, only 42% of admissions longer than 48 hours had a documented GOC discussion.[15]

We found visit‐level, but not baseline, characteristics were associated with discussions. These findings are supported by a recent study that found that whether GOC discussions took place largely depended on the acute condition presented on admission.[15] Although these results suggest that clinicians are appropriately prioritizing sicker patients who might have the most pressing need for GOC discussions, they also highlight the gap in care for less‐sick patients and the need to broaden clinical practice and consider underlying conditions and functional status. Of note, although the GCS score was found to be significantly associated with discussions, patients in the lowest GCS range did not have significantly different odds of discussions compared to the reference level (highest GCS range). A recent study by You et al. may offer some insight into this finding. They found that patients lacking capacity to make GOC decisions was ranked fifth, whereas lack of SDM availability was eighth among 21 barriers to GOC discussions, as perceived by hospital‐based clinicians.[16]

A major finding of this study was that both in‐hospital and 1‐year mortality were strongly associated with having a GOC discussion, suggesting that patients at higher risk of dying are more likely to have discussions. This is reflected by illness severity measured at initial assessment and by persistence of the association between discussions and mortality after discharge back to LTC. To the best of our knowledge, no previous studies have reported these findings. There are likely some unmeasured clinical factors such as clinical deterioration during hospitalization that contributed to this strong association. Interestingly, in our logistic regression analysis for independent predictors of in‐hospital death, we found that having dementia was associated with lower odds of in‐hospital death. One interpretation of this finding is that perhaps only patients with mild dementia were hospitalized, and those with more advanced dementia had an AD established in LTC that allowed them to remain in their LTC home. This possibility is supported by a systematic review of factors associated with LTC home hospitalization, which found that dementia was shown to be associated with less hospitalization.[18]

For patients who survived hospitalization, we did not find an association between GOC discussions and hospital use in the year following index hospitalization. In both groups, nearly 30% of patients had 1 or more subsequent hospitalizations. This is relevant especially in light of the finding that among patients where GOC discussions resulted in an AD change, only 26% of discharge summaries back to LTC included this documentation. We can only speculate that had these discussions been properly documented, subsequent hospitalizations would have decreased in the GOC group. Previous research has found that omissions of critical information in discharge summaries were common. In a study of hip fracture and stroke patients discharged from a large Midwestern academic medical center in the United States, code status was included in the discharge summary only 7% of the time.[19] The discharge summary is the primary means of sharing patient information between the hospital and LTC home. If GOC discussions are not included in the discharge summary, it is very unlikely that this information will be subsequently updated in the LTC medical record and impact the care the patient receives. A key recommendation for hospital‐based providers is ensuring that GOC discussions are clearly, consistently, and completely documented in the discharge summary so that the care provided is based on the patients' wishes.

Our study has several limitations. Our analysis was based on chart review, and although our analyses take into account a number of patient characteristics, we did not capture other characteristics that might influence GOC discussions such as culture/religion, language barriers, SDM availability, or whether patients clinically deteriorated during the index admission. Additionally, provider‐level predictors, including seniority, previous GOC training, and time available to conduct these discussions, were not captured. We also did not capture the timing or number of occasions that GOC discussions took place during hospitalization. Due to the retrospective nature of our study, we were able to only look at documented GOC discussions. GOC discussions may have happened but were never documented. However, the standard of care is to document these discussions as part of the medical record, and if they are not documented, it can be considered not to have happened and indicates a lower quality of practice. A recent survey of Canadian hospital‐based healthcare providers identified standardized GOC documentation as an effective practice to improve GOC communication.[20] Finally, because our study was conducted in 2 academic hospitals, our results may be less generalizable to other community hospitals. However, our hospitals' catchment areas capture a diverse population, both culturally and in terms of their socioeconomic status.

CONCLUSION

GOC discussions occurred infrequently, appeared to be triggered by illness severity, and were poorly communicated back to LTC. Important outcomes of care, including in‐hospital death and 1‐year mortality, were associated with discussions. This study serves to identify gaps in who might benefit from GOC discussions and illustrates opportunities for improvement including implementing standardized documentation practices.