User login
Study Overview
Objective. To evaluate the efficacy of an intervention targeting both patients and clinicians intended to increase goals-of-care conversations.
Design. Multicenter cluster-randomized controlled trial.
Setting and participants. Clinicians (physicians or nurse practitioners) were recruited between February 2014 and November 2015 from 2 large health centers in the Pacific Northwest and were eligible if they provided primary or specialty care and had at least 5 eligible patients in their panels. Using the electronic health record (EHR) and clinic schedules, study staff identified and contacted (via mail or telephone) consecutive patients cared for by participating clinicians between March 2014 and May 2016 with the following eligibility criteria: age 18 years or older, 2 or more visits with the clinician in the last 18 months, and 1 or more qualifying conditions. Qualifying conditions included (1) metastatic cancer or inoperable lung cancer; (2) COPD with FEV1 values below 35% of that predicted or oxygen dependence, restrictive lung disease with a total lung capacity below 50% of that predicted, or cystic fibrosis with FEV1 below 30% of that predicted; (3) New York Heart Association class III or IV heart failure, pulmonary arterial hypertension, or left ventricular assist device or implantable cardioverter defibrillator implant; 4) cirrhosis or end-stage liver disease; (5) dialysis-dependent renal failure and diabetes; (6) age 75 or older with one or more life-limiting chronic illness; (7) age 90 or older; (8) hospitalization in the last 18 months with a life-limiting illness; (9) Charlson comorbidity index of 6 or higher. The qualifying criteria were selected to identify a median survival of approximately 2 years, suggesting relevance of goals-of-care discussions.
Intervention. The intervention was the patient-specific Jumpstart-Tips intervention, intended to prime clinicians and patients for a brief discussion of goals of care during a routine clinic visit. Patients in the intervention group received a survey to assess their preferences, barriers and facilitators for communication about end-of-life care. Survey responses were used to (1) generate an abstracted version of the patient’s preferences, (2) identify the most important communication barrier or facilitator, and (3) provide communication tips based on curricular materials from VitalTalk (http://vitaltalk.org) tailored to patient responses. The 1-page communication guide, called Jumpstart-Tips, was sent to clinicians 1 or 2 days prior to the target clinic visit date. Patients also received 1-page patient-specific Jumpstart-Tips forms, which summarized their survey responses and provided suggestions for having a goals-of-care conversation with the clinician. Patients in the control group completed the same surveys, but no information was provided to the patients or clinicians. Clinicians were randomly assigned in a 1:1 ratio to intervention or enhanced usual care.
Main outcome measures. The primary outcome was patient-reported occurrence of goals-of-care communication, which was evaluated using a validated dichotomous survey item. Other outcomes included clinician documentation of a goals-of-care conversation in the medical record, patient-reported quality of communication (measured using Quality of Communication questionnaire) at 2 weeks, patient reports of goal-concordant care at 3 months, and patient-reported symptoms of depression and anxiety at 3 and 6 months. All analyses included covariate adjustment for the baseline measure of the outcome and adjustment for other variables found to confound the association between randomization group and outcome.
Main results. Of 485 potentially eligible clinicians, 65 clinicians were randomized to the intervention group and 69 were randomized to the control group. Of these 132 clinicians, 124 had patients participating in the study: 537 out of 917 eligible patients enrolled, with 249 allocated to intervention and 288 to usual care.
Patients in the intervention group were more likely to report a goals-of-care conversation with their provider among all patients (74%, n = 137 vs 31%, n = 66; P n = 112 vs 28%, n = 44; P n = 140 vs 17%, n = 45; P n = 114 vs 17%, n = 34; P
Patients in the intervention group also reported higher quality ratings of goals-of-care conversations at the target visit (mean values, 4.6 v 2.1, P = 0.01, on the 4-indicator construct). Additionally, intervention members reported statistically significant higher ratings on 3 of the 7 individual quality-of-communication survey items.
Patient-assessed goal concordant care did not increase significantly overall (70% vs 57%; P = 0.08) but did increase for patients with stable goals between 3-month follow-up and last prior assessment (73% vs 57%; P = 0.03). Symptoms of depression or anxiety were not different between groups at 3 or 6 months.
Conclusion. The Jumpstart-Tips intervention was associated with an increase in patient reports and clinician documentation of goals-of-care communication. Increased patient-reported goal-concordant care among patients with stable goals was also associated with the intervention. Statistical significance was not detected for changes in depression or anxiety as a result of the intervention. The impact on goals-of-care discussion between patients and caregivers is suggestive of enhanced patient-centered care; however, further studies are needed to evaluate whether this communication is associated with changes in health care delivery.
Commentary
Previous research has shown that patients with serious illness who discuss their goals-of-care fare better in terms of quality of life and reducing intensity of care at the end-of-life [1]. However, providers often fail to or inadequately discuss goals of care with seriously ill patients [2,3]. This contributes to the lack of concordance between patient wishes, particularly related to end-of-life care, and clinical plans of care [4,5]. Addressing this gap between care provided and care desired, as well as providing high-quality, patient-centered care is needed.
Access to palliative care providers (who are trained to address these priorities) in the outpatient setting lags, despite an increase in specialists [6,7]. Thus, primary and specialty care providers in the outpatient setting are best positioned to align their care strategy with the goals of their patients. However, there have been limited results in showing that goals-of-care communication can be improved within the practice setting [8,9]. A randomized clinical trial among hospitalized seniors at the end-of-life showed an association where those who received advanced care planning with had improved quality of life, reduced care at dying, and reduced psychological distress among family [10]. However, in another randomized trial, simulation-based communication training compared with usual education among internal medicine and nurse practitioner trainees did not improve quality of communication about end-of-life care or quality of end-of-life care but was associated with a small increase in patients’ depressive symptoms [11]. A recent 2018 literature review of strategies used to facilitate the discussion of advance care planning with older adults in primary care settings identified effective interventions, including delivering education using various delivery methods, computer-generated triggers for primary care physicians (PCPs), inclusion of multidisciplinary professionals for content delivery, and patient preparation for PCP visit [12].
This article adds to the literature by demonstrating the feasibility and impact of implementing an intervention to increase communication about goals of care and end-of-life care. Further, this study highlights how communication that is bilateral, predetermined, and structured can be integrated into primary care. Strengths of the study include the use of randomization; deployment of validated survey tools; and confirmatory factor analysis to assess whether the survey variables are consistent with the hypothesized constructs. In addition, study staff were blinded when extracting data from the EHR record around discussions and documentation of goals-of-care conversations during patient visits. However, several limitations are present. There may be limited generalizability as the study was performed at low-scale, across one region as well as selection bias among clinicians participating in the study. Clinicians were not blinded of their assignment, which may have influenced their behaviors to discuss and document goals-of-care conversations.
Applications for Clinical Practice
Increasing quality communication around the end of life and understanding of a patient’s goals is important. Good communication can facilitate the development of a comprehensive treatment plan that is medically sound and concordant with the patient’s wishes and values. Clinicians and practices should consider adopting approaches to communication priming and accurate documentation, including: (1) incorporating/automating Jumpstart-Tips forms into practice (and tailoring as needed); (2) identifying similar education material that can serve as a primer for patients; (3) creating a pre-visit form for patients/caregivers to document and inform the clinician of their goals prior to the visit; (4) incorporating a standard EHR note to document and update goals-of-care discussion at each visit; and (5) more broadly encouraging (or providing training for) clinicians to practice bilateral communications with patients during visits.
—Ronald Sanchez, MPH, and Katrina F. Mateo, MPH
1. Wright AA, Zhang B, Ray A, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA 2008;300:1665–73.
2. Anderson WG, Chase R, Pantilat SZ, et al. Code status discussions between attending hospitalist physicians and medical patients at hospital admission. J Gen Intern Med 2011;26:359–66.
3. Osborn TR, Curtis JR, Nielsen EL, et al. Identifying elements of ICU care that families report as important but unsatisfactory: decision-making, control, and ICU atmosphere. Chest 2012;142:1185–92.
4. Covinsky KE, Fuller JD, Yaffe K, et al. Communication and decision-making in seriously ill patients: findings of the SUPPORT project. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. J Am Geriatr Soc 2000;48:S187–93.
5. Heyland DK, Dodek P, Rocker G, et al. What matters most in end-of-life care: perceptions of seriously ill patients and their family members. CMAJ 2006;174:627–33
6. Dumanovsky T, Augustin R, Rogers M, Lettang K, Meier DE, Morrison RS. The growth of palliative care in U.S. hospitals: a status report. J Palliat Med 2016;19:8–15.
7. Dumanovsky T, Rogers M, Spragens LH, Morrison RS, Meier DE. Impact of staffing on access to palliative care in U.S. hospitals. J Palliat Med 2015;18:998–9.
8. Roze des Ordons, AL, Sharma N, Heyland DK, et al. Strategies for effective goals of care discussions and decision-making: perspectives from a multi-centre survey of Canadian hospital-based healthcare providers. BMC Palliative Care, 2015;14:38.
9. You JJ, Dodek P, Lamontagne F, et al. What really matters in end-of-life discussions? Perspectives of patients in hospital with serious illness and their families. CMAJ 2014;18:E679–E687.
10. Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ. 2010;340:c1345.
11. Curtis JR, Back AL, Ford DW, et al. Effect of communication skills training for residents and nurse practitioners on quality of communication with patients with serious illness: a randomized trial. JAMA 2013;310:2271–81.
12. Solis GR, Mancera BM, Shen MJ. Strategies used to facilitate the discussion of advance care planning with older adults in primary care settings: A literature review. J Am Assoc Nurse Pract 2018;30:270–9.
Study Overview
Objective. To evaluate the efficacy of an intervention targeting both patients and clinicians intended to increase goals-of-care conversations.
Design. Multicenter cluster-randomized controlled trial.
Setting and participants. Clinicians (physicians or nurse practitioners) were recruited between February 2014 and November 2015 from 2 large health centers in the Pacific Northwest and were eligible if they provided primary or specialty care and had at least 5 eligible patients in their panels. Using the electronic health record (EHR) and clinic schedules, study staff identified and contacted (via mail or telephone) consecutive patients cared for by participating clinicians between March 2014 and May 2016 with the following eligibility criteria: age 18 years or older, 2 or more visits with the clinician in the last 18 months, and 1 or more qualifying conditions. Qualifying conditions included (1) metastatic cancer or inoperable lung cancer; (2) COPD with FEV1 values below 35% of that predicted or oxygen dependence, restrictive lung disease with a total lung capacity below 50% of that predicted, or cystic fibrosis with FEV1 below 30% of that predicted; (3) New York Heart Association class III or IV heart failure, pulmonary arterial hypertension, or left ventricular assist device or implantable cardioverter defibrillator implant; 4) cirrhosis or end-stage liver disease; (5) dialysis-dependent renal failure and diabetes; (6) age 75 or older with one or more life-limiting chronic illness; (7) age 90 or older; (8) hospitalization in the last 18 months with a life-limiting illness; (9) Charlson comorbidity index of 6 or higher. The qualifying criteria were selected to identify a median survival of approximately 2 years, suggesting relevance of goals-of-care discussions.
Intervention. The intervention was the patient-specific Jumpstart-Tips intervention, intended to prime clinicians and patients for a brief discussion of goals of care during a routine clinic visit. Patients in the intervention group received a survey to assess their preferences, barriers and facilitators for communication about end-of-life care. Survey responses were used to (1) generate an abstracted version of the patient’s preferences, (2) identify the most important communication barrier or facilitator, and (3) provide communication tips based on curricular materials from VitalTalk (http://vitaltalk.org) tailored to patient responses. The 1-page communication guide, called Jumpstart-Tips, was sent to clinicians 1 or 2 days prior to the target clinic visit date. Patients also received 1-page patient-specific Jumpstart-Tips forms, which summarized their survey responses and provided suggestions for having a goals-of-care conversation with the clinician. Patients in the control group completed the same surveys, but no information was provided to the patients or clinicians. Clinicians were randomly assigned in a 1:1 ratio to intervention or enhanced usual care.
Main outcome measures. The primary outcome was patient-reported occurrence of goals-of-care communication, which was evaluated using a validated dichotomous survey item. Other outcomes included clinician documentation of a goals-of-care conversation in the medical record, patient-reported quality of communication (measured using Quality of Communication questionnaire) at 2 weeks, patient reports of goal-concordant care at 3 months, and patient-reported symptoms of depression and anxiety at 3 and 6 months. All analyses included covariate adjustment for the baseline measure of the outcome and adjustment for other variables found to confound the association between randomization group and outcome.
Main results. Of 485 potentially eligible clinicians, 65 clinicians were randomized to the intervention group and 69 were randomized to the control group. Of these 132 clinicians, 124 had patients participating in the study: 537 out of 917 eligible patients enrolled, with 249 allocated to intervention and 288 to usual care.
Patients in the intervention group were more likely to report a goals-of-care conversation with their provider among all patients (74%, n = 137 vs 31%, n = 66; P n = 112 vs 28%, n = 44; P n = 140 vs 17%, n = 45; P n = 114 vs 17%, n = 34; P
Patients in the intervention group also reported higher quality ratings of goals-of-care conversations at the target visit (mean values, 4.6 v 2.1, P = 0.01, on the 4-indicator construct). Additionally, intervention members reported statistically significant higher ratings on 3 of the 7 individual quality-of-communication survey items.
Patient-assessed goal concordant care did not increase significantly overall (70% vs 57%; P = 0.08) but did increase for patients with stable goals between 3-month follow-up and last prior assessment (73% vs 57%; P = 0.03). Symptoms of depression or anxiety were not different between groups at 3 or 6 months.
Conclusion. The Jumpstart-Tips intervention was associated with an increase in patient reports and clinician documentation of goals-of-care communication. Increased patient-reported goal-concordant care among patients with stable goals was also associated with the intervention. Statistical significance was not detected for changes in depression or anxiety as a result of the intervention. The impact on goals-of-care discussion between patients and caregivers is suggestive of enhanced patient-centered care; however, further studies are needed to evaluate whether this communication is associated with changes in health care delivery.
Commentary
Previous research has shown that patients with serious illness who discuss their goals-of-care fare better in terms of quality of life and reducing intensity of care at the end-of-life [1]. However, providers often fail to or inadequately discuss goals of care with seriously ill patients [2,3]. This contributes to the lack of concordance between patient wishes, particularly related to end-of-life care, and clinical plans of care [4,5]. Addressing this gap between care provided and care desired, as well as providing high-quality, patient-centered care is needed.
Access to palliative care providers (who are trained to address these priorities) in the outpatient setting lags, despite an increase in specialists [6,7]. Thus, primary and specialty care providers in the outpatient setting are best positioned to align their care strategy with the goals of their patients. However, there have been limited results in showing that goals-of-care communication can be improved within the practice setting [8,9]. A randomized clinical trial among hospitalized seniors at the end-of-life showed an association where those who received advanced care planning with had improved quality of life, reduced care at dying, and reduced psychological distress among family [10]. However, in another randomized trial, simulation-based communication training compared with usual education among internal medicine and nurse practitioner trainees did not improve quality of communication about end-of-life care or quality of end-of-life care but was associated with a small increase in patients’ depressive symptoms [11]. A recent 2018 literature review of strategies used to facilitate the discussion of advance care planning with older adults in primary care settings identified effective interventions, including delivering education using various delivery methods, computer-generated triggers for primary care physicians (PCPs), inclusion of multidisciplinary professionals for content delivery, and patient preparation for PCP visit [12].
This article adds to the literature by demonstrating the feasibility and impact of implementing an intervention to increase communication about goals of care and end-of-life care. Further, this study highlights how communication that is bilateral, predetermined, and structured can be integrated into primary care. Strengths of the study include the use of randomization; deployment of validated survey tools; and confirmatory factor analysis to assess whether the survey variables are consistent with the hypothesized constructs. In addition, study staff were blinded when extracting data from the EHR record around discussions and documentation of goals-of-care conversations during patient visits. However, several limitations are present. There may be limited generalizability as the study was performed at low-scale, across one region as well as selection bias among clinicians participating in the study. Clinicians were not blinded of their assignment, which may have influenced their behaviors to discuss and document goals-of-care conversations.
Applications for Clinical Practice
Increasing quality communication around the end of life and understanding of a patient’s goals is important. Good communication can facilitate the development of a comprehensive treatment plan that is medically sound and concordant with the patient’s wishes and values. Clinicians and practices should consider adopting approaches to communication priming and accurate documentation, including: (1) incorporating/automating Jumpstart-Tips forms into practice (and tailoring as needed); (2) identifying similar education material that can serve as a primer for patients; (3) creating a pre-visit form for patients/caregivers to document and inform the clinician of their goals prior to the visit; (4) incorporating a standard EHR note to document and update goals-of-care discussion at each visit; and (5) more broadly encouraging (or providing training for) clinicians to practice bilateral communications with patients during visits.
—Ronald Sanchez, MPH, and Katrina F. Mateo, MPH
Study Overview
Objective. To evaluate the efficacy of an intervention targeting both patients and clinicians intended to increase goals-of-care conversations.
Design. Multicenter cluster-randomized controlled trial.
Setting and participants. Clinicians (physicians or nurse practitioners) were recruited between February 2014 and November 2015 from 2 large health centers in the Pacific Northwest and were eligible if they provided primary or specialty care and had at least 5 eligible patients in their panels. Using the electronic health record (EHR) and clinic schedules, study staff identified and contacted (via mail or telephone) consecutive patients cared for by participating clinicians between March 2014 and May 2016 with the following eligibility criteria: age 18 years or older, 2 or more visits with the clinician in the last 18 months, and 1 or more qualifying conditions. Qualifying conditions included (1) metastatic cancer or inoperable lung cancer; (2) COPD with FEV1 values below 35% of that predicted or oxygen dependence, restrictive lung disease with a total lung capacity below 50% of that predicted, or cystic fibrosis with FEV1 below 30% of that predicted; (3) New York Heart Association class III or IV heart failure, pulmonary arterial hypertension, or left ventricular assist device or implantable cardioverter defibrillator implant; 4) cirrhosis or end-stage liver disease; (5) dialysis-dependent renal failure and diabetes; (6) age 75 or older with one or more life-limiting chronic illness; (7) age 90 or older; (8) hospitalization in the last 18 months with a life-limiting illness; (9) Charlson comorbidity index of 6 or higher. The qualifying criteria were selected to identify a median survival of approximately 2 years, suggesting relevance of goals-of-care discussions.
Intervention. The intervention was the patient-specific Jumpstart-Tips intervention, intended to prime clinicians and patients for a brief discussion of goals of care during a routine clinic visit. Patients in the intervention group received a survey to assess their preferences, barriers and facilitators for communication about end-of-life care. Survey responses were used to (1) generate an abstracted version of the patient’s preferences, (2) identify the most important communication barrier or facilitator, and (3) provide communication tips based on curricular materials from VitalTalk (http://vitaltalk.org) tailored to patient responses. The 1-page communication guide, called Jumpstart-Tips, was sent to clinicians 1 or 2 days prior to the target clinic visit date. Patients also received 1-page patient-specific Jumpstart-Tips forms, which summarized their survey responses and provided suggestions for having a goals-of-care conversation with the clinician. Patients in the control group completed the same surveys, but no information was provided to the patients or clinicians. Clinicians were randomly assigned in a 1:1 ratio to intervention or enhanced usual care.
Main outcome measures. The primary outcome was patient-reported occurrence of goals-of-care communication, which was evaluated using a validated dichotomous survey item. Other outcomes included clinician documentation of a goals-of-care conversation in the medical record, patient-reported quality of communication (measured using Quality of Communication questionnaire) at 2 weeks, patient reports of goal-concordant care at 3 months, and patient-reported symptoms of depression and anxiety at 3 and 6 months. All analyses included covariate adjustment for the baseline measure of the outcome and adjustment for other variables found to confound the association between randomization group and outcome.
Main results. Of 485 potentially eligible clinicians, 65 clinicians were randomized to the intervention group and 69 were randomized to the control group. Of these 132 clinicians, 124 had patients participating in the study: 537 out of 917 eligible patients enrolled, with 249 allocated to intervention and 288 to usual care.
Patients in the intervention group were more likely to report a goals-of-care conversation with their provider among all patients (74%, n = 137 vs 31%, n = 66; P n = 112 vs 28%, n = 44; P n = 140 vs 17%, n = 45; P n = 114 vs 17%, n = 34; P
Patients in the intervention group also reported higher quality ratings of goals-of-care conversations at the target visit (mean values, 4.6 v 2.1, P = 0.01, on the 4-indicator construct). Additionally, intervention members reported statistically significant higher ratings on 3 of the 7 individual quality-of-communication survey items.
Patient-assessed goal concordant care did not increase significantly overall (70% vs 57%; P = 0.08) but did increase for patients with stable goals between 3-month follow-up and last prior assessment (73% vs 57%; P = 0.03). Symptoms of depression or anxiety were not different between groups at 3 or 6 months.
Conclusion. The Jumpstart-Tips intervention was associated with an increase in patient reports and clinician documentation of goals-of-care communication. Increased patient-reported goal-concordant care among patients with stable goals was also associated with the intervention. Statistical significance was not detected for changes in depression or anxiety as a result of the intervention. The impact on goals-of-care discussion between patients and caregivers is suggestive of enhanced patient-centered care; however, further studies are needed to evaluate whether this communication is associated with changes in health care delivery.
Commentary
Previous research has shown that patients with serious illness who discuss their goals-of-care fare better in terms of quality of life and reducing intensity of care at the end-of-life [1]. However, providers often fail to or inadequately discuss goals of care with seriously ill patients [2,3]. This contributes to the lack of concordance between patient wishes, particularly related to end-of-life care, and clinical plans of care [4,5]. Addressing this gap between care provided and care desired, as well as providing high-quality, patient-centered care is needed.
Access to palliative care providers (who are trained to address these priorities) in the outpatient setting lags, despite an increase in specialists [6,7]. Thus, primary and specialty care providers in the outpatient setting are best positioned to align their care strategy with the goals of their patients. However, there have been limited results in showing that goals-of-care communication can be improved within the practice setting [8,9]. A randomized clinical trial among hospitalized seniors at the end-of-life showed an association where those who received advanced care planning with had improved quality of life, reduced care at dying, and reduced psychological distress among family [10]. However, in another randomized trial, simulation-based communication training compared with usual education among internal medicine and nurse practitioner trainees did not improve quality of communication about end-of-life care or quality of end-of-life care but was associated with a small increase in patients’ depressive symptoms [11]. A recent 2018 literature review of strategies used to facilitate the discussion of advance care planning with older adults in primary care settings identified effective interventions, including delivering education using various delivery methods, computer-generated triggers for primary care physicians (PCPs), inclusion of multidisciplinary professionals for content delivery, and patient preparation for PCP visit [12].
This article adds to the literature by demonstrating the feasibility and impact of implementing an intervention to increase communication about goals of care and end-of-life care. Further, this study highlights how communication that is bilateral, predetermined, and structured can be integrated into primary care. Strengths of the study include the use of randomization; deployment of validated survey tools; and confirmatory factor analysis to assess whether the survey variables are consistent with the hypothesized constructs. In addition, study staff were blinded when extracting data from the EHR record around discussions and documentation of goals-of-care conversations during patient visits. However, several limitations are present. There may be limited generalizability as the study was performed at low-scale, across one region as well as selection bias among clinicians participating in the study. Clinicians were not blinded of their assignment, which may have influenced their behaviors to discuss and document goals-of-care conversations.
Applications for Clinical Practice
Increasing quality communication around the end of life and understanding of a patient’s goals is important. Good communication can facilitate the development of a comprehensive treatment plan that is medically sound and concordant with the patient’s wishes and values. Clinicians and practices should consider adopting approaches to communication priming and accurate documentation, including: (1) incorporating/automating Jumpstart-Tips forms into practice (and tailoring as needed); (2) identifying similar education material that can serve as a primer for patients; (3) creating a pre-visit form for patients/caregivers to document and inform the clinician of their goals prior to the visit; (4) incorporating a standard EHR note to document and update goals-of-care discussion at each visit; and (5) more broadly encouraging (or providing training for) clinicians to practice bilateral communications with patients during visits.
—Ronald Sanchez, MPH, and Katrina F. Mateo, MPH
1. Wright AA, Zhang B, Ray A, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA 2008;300:1665–73.
2. Anderson WG, Chase R, Pantilat SZ, et al. Code status discussions between attending hospitalist physicians and medical patients at hospital admission. J Gen Intern Med 2011;26:359–66.
3. Osborn TR, Curtis JR, Nielsen EL, et al. Identifying elements of ICU care that families report as important but unsatisfactory: decision-making, control, and ICU atmosphere. Chest 2012;142:1185–92.
4. Covinsky KE, Fuller JD, Yaffe K, et al. Communication and decision-making in seriously ill patients: findings of the SUPPORT project. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. J Am Geriatr Soc 2000;48:S187–93.
5. Heyland DK, Dodek P, Rocker G, et al. What matters most in end-of-life care: perceptions of seriously ill patients and their family members. CMAJ 2006;174:627–33
6. Dumanovsky T, Augustin R, Rogers M, Lettang K, Meier DE, Morrison RS. The growth of palliative care in U.S. hospitals: a status report. J Palliat Med 2016;19:8–15.
7. Dumanovsky T, Rogers M, Spragens LH, Morrison RS, Meier DE. Impact of staffing on access to palliative care in U.S. hospitals. J Palliat Med 2015;18:998–9.
8. Roze des Ordons, AL, Sharma N, Heyland DK, et al. Strategies for effective goals of care discussions and decision-making: perspectives from a multi-centre survey of Canadian hospital-based healthcare providers. BMC Palliative Care, 2015;14:38.
9. You JJ, Dodek P, Lamontagne F, et al. What really matters in end-of-life discussions? Perspectives of patients in hospital with serious illness and their families. CMAJ 2014;18:E679–E687.
10. Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ. 2010;340:c1345.
11. Curtis JR, Back AL, Ford DW, et al. Effect of communication skills training for residents and nurse practitioners on quality of communication with patients with serious illness: a randomized trial. JAMA 2013;310:2271–81.
12. Solis GR, Mancera BM, Shen MJ. Strategies used to facilitate the discussion of advance care planning with older adults in primary care settings: A literature review. J Am Assoc Nurse Pract 2018;30:270–9.
1. Wright AA, Zhang B, Ray A, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA 2008;300:1665–73.
2. Anderson WG, Chase R, Pantilat SZ, et al. Code status discussions between attending hospitalist physicians and medical patients at hospital admission. J Gen Intern Med 2011;26:359–66.
3. Osborn TR, Curtis JR, Nielsen EL, et al. Identifying elements of ICU care that families report as important but unsatisfactory: decision-making, control, and ICU atmosphere. Chest 2012;142:1185–92.
4. Covinsky KE, Fuller JD, Yaffe K, et al. Communication and decision-making in seriously ill patients: findings of the SUPPORT project. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. J Am Geriatr Soc 2000;48:S187–93.
5. Heyland DK, Dodek P, Rocker G, et al. What matters most in end-of-life care: perceptions of seriously ill patients and their family members. CMAJ 2006;174:627–33
6. Dumanovsky T, Augustin R, Rogers M, Lettang K, Meier DE, Morrison RS. The growth of palliative care in U.S. hospitals: a status report. J Palliat Med 2016;19:8–15.
7. Dumanovsky T, Rogers M, Spragens LH, Morrison RS, Meier DE. Impact of staffing on access to palliative care in U.S. hospitals. J Palliat Med 2015;18:998–9.
8. Roze des Ordons, AL, Sharma N, Heyland DK, et al. Strategies for effective goals of care discussions and decision-making: perspectives from a multi-centre survey of Canadian hospital-based healthcare providers. BMC Palliative Care, 2015;14:38.
9. You JJ, Dodek P, Lamontagne F, et al. What really matters in end-of-life discussions? Perspectives of patients in hospital with serious illness and their families. CMAJ 2014;18:E679–E687.
10. Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ. 2010;340:c1345.
11. Curtis JR, Back AL, Ford DW, et al. Effect of communication skills training for residents and nurse practitioners on quality of communication with patients with serious illness: a randomized trial. JAMA 2013;310:2271–81.
12. Solis GR, Mancera BM, Shen MJ. Strategies used to facilitate the discussion of advance care planning with older adults in primary care settings: A literature review. J Am Assoc Nurse Pract 2018;30:270–9.