Clinical question: Can primed communication increase the frequency of goals-of-care conversations in the outpatient setting?
Background: Effective outpatient communication helps patients and families with serious illnesses with increased quality of life, improved quality of the dying process, and decreased resource utilization at the end of life.
Study design: Cluster-randomized trial.
Setting: Multicenter, primary care, and subspecialty clinics for adults in the Pacific Northwest.
Synopsis: Patients with advanced age and/or severe chronic medical conditions were selected to participate. The median survival for these patients was 2 years. Clinicians were eligible to participate if they had five or more of the selected patients in their panel.
In the intervention group (57 clinicians and 184 patients), all patients were surveyed to identify preferences, barriers, and facilitators for goals-of-care discussions. These data were compiled into “Jumpstart Tips” and distributed to providers before a visit with a study patient. The control group (57 clinicians and 211 patients) had patients complete these surveys but no information was provided to clinicians.
The “Jumpstart Tips” led to an increase in patient-reported (74% vs. 31%; P less than .001) and EHR-documented (62% vs. 17%; P less than .001) occurrences of goals-of-care discussions. Patients also reported increased quality of these conversations (4.6 vs. 2.1; P = .01).
However, no significant improvements were noted in goal-concordant care, depression, or anxiety scores, which may have been because of selection bias and overall difficulty in defining goal-concordant care.
Bottom line: Patient-centered primed communication can increase the frequency and quality of goals-of-care discussions in the outpatient setting.
Citation: Curtis JR et al. Effect of a patient and clinician communication-priming intervention on patient-reported goals-of-care discussions between patients with serious illness and clinicians: A randomized clinical trial. JAMA Intern Med. 2018 Jul 1;178(7):930-40.
Dr. Chowdury is an assistant professor in the division of hospital medicine, University of Colorado, Denver.
