Improving Communication by Preparing Patients and Doctors for a Conversation about Care Goals for Serious Illness [Internet]

Excerpt

Background: For patients with serious illness, communication about goals of care is associated with improved patient outcomes and reduced intensity of end-of-life care, but it is unclear whether interventions can improve this communication.

Objective: To evaluate the efficacy of a patient-specific communication-priming intervention designed to increase goals-of-care conversations and targeting both patients with serious illness and their clinicians.

Methods: Multicenter cluster-randomized trial of a patient-centered intervention implemented in outpatient clinics with physicians or nurse practitioners and their patients with serious illness. The intervention consisted of the Jumpstart-Tips form, a patient-specific communication feedback form that was generated from each patient's self-reported preferences for communication about his or her goals of care. The Jumpstart-Tips form was delivered to patients, family members, and clinicians before a routine visit between the patient and the clinician. The comparison group received usual care. The study team assessed the effectiveness of the intervention by following patients until death or up to 6 months. The primary outcome was patient-reported occurrence of a goals-of-care conversation during a target outpatient visit. Secondary outcomes included clinician documentation of a goals-of-care conversation in the medical record and patient-reported quality of communication (mean rating of 4 items) at 2 weeks, as well as patient assessments of goal-concordant care at 3 months and patient-reported symptoms of depression (Patient Health Questionnaire-8) and anxiety (General Anxiety Disorder-7) at 3 and 6 months. Analyses were clustered by clinician and adjusted for baseline patient characteristics.

Results: We enrolled 132 of 485 potentially eligible clinicians (27% participation) and 537 of 917 eligible patients (59% participation). Clinicians were randomized to the preconversation communication-priming intervention (n = 65) or usual care (n = 67). Of the patients, 249 received the intervention and 288 received usual care. The intervention was associated with a significant increase in a goals-of-care discussion at the target visit (74% vs 31%; p < .001) and increased medical record documentation of a goals-of-care discussion (62% vs 17%; P < .001), as well as increased patient-rated quality of communication (4.6 vs 2.1; P = .010). Patient-assessed goal-concordant care did not increase significantly overall (70% vs 57%; P = .077) but did increase for the prespecified subgroup of patients with stable goals between the 3-month follow-up and the last prior assessment (74% vs 57%; P = .029). Patients' symptoms of depression or anxiety did not differ between groups at 3 or 6 months (P > .1 for all).

Conclusions: This intervention increased the occurrence, documentation, and quality of goals-of-care communication during routine outpatient clinic visits and was associated with increased patient-assessed goal-concordant care at 3 months for patients with stable goals between the 3-month follow-up and the last prior assessment. The intervention was not associated with any change in symptoms of anxiety or depression. Limitations include a relatively low participation rate among clinicians and the fact that the study took place in only 1 region of the United States with a high proportion of white, non-Hispanic patients. Although additional studies are needed to evaluate whether this communication is associated with changes in health care delivery, the use of a simple communication tool prepared from patient responses to a discrete set of questions and provided to clinicians and patients before a routine clinic visit holds promise for health care systems seeking to increase goals-of-care communication for patients with serious illness.