Impact of an interdisciplinary goals of care program on hospital outcomes at a comprehensive cancer center during the COVID-19 pandemic: A propensity score analysis

Background: Many hospitals have established goals-of-care (GOC) programs in response to the COVID- 19 pandemic;however, few have reported their outcomes. MD Anderson Cancer Center launched a multicomponent interdisciplinary GOC (myGOC) program in March 2020 that involved risk stratification, team huddles to discuss care planning, oncologist-initiated GOC discussions, communication training, palliative care involvement, rapid-response GOC team deployment, and daily monitoring with immediate feedback. We examined the impact of this myGOC program among medical inpatients. Methods: This single-center study with a quasi-experimental design included consecutive adult patients with cancer admitted to medical units at MD Anderson Cancer Center, Texas during an 8-month pre-implementation (May 1, 2019 to December 31, 2019) and post-implementation period (May 1, 2020 to December 31, 2020). The primary outcome was intensive care unit (ICU) mortality. Secondary outcomes included ICU length of stay, hospital mortality, and proportion/timing of patients with inhospital do-not-resuscitate (DNR) orders, medical power of attorney (MPOA), living will (LW) and outof- hospital DNR (OOHDNR). Propensity score weighting was used to adjust for differences in potential covariates, including age, sex, cancer diagnosis, race/ethnicity, and Sequential Organ Failure Assessment (SOFA) Score. With a sample size of 600 ICU patients over each time period and a baseline ICU mortality of 28%, we had 80% power to detect a 5% reduction in mortality using a two-tailed test at 5% significance level. Results: This study involved 12,941 hospitalized patients with cancer (Pre n = 6,977;Post n = 5,964) including 1365 ICU admissions (Pre n = 727;Post n = 638). After myGOC initiation, we observed a significant reduction in ICU mortality (28.2% vs. 21.9%;change -6.3%, 95% CI -9.6, -3.1;P = 0.0001). We also observed significant decreases in length of ICU stay (mean change -1.4 days, 95% CI -2.0, -0.7 days;P < 0.0001) and in-hospital mortality (7% vs. 6.1%, mean change -0.9%, 95% CI -1.5%, -0.3%;P = 0.004). The proportion of hospitalized patients with an inhospital DNR order increased significantly from 14.7% to 19.6% after implementation (odds ratio [OR] 1.4, 95% CI 1.3, 1.5;P < 0.0001) and DNR was established earlier (mean difference -3.0 d, 95% CI -3.9 d, -2.1 d;P < 0.0001). OOHDNR (OR 1.3, 95% CI 1.1, 1.6, P < 0.0007) also increased post-implementation but not MPOA and LW. MPOA, LW and OOHDNR were documented significantly earlier relative to the index hospitalization in the post-implementation period (P < 0.005 for all). Conclusions: This study showed improvement in hospital outcomes and care plan documentation after implementation of a system-wide, multicomponent GOC intervention. Our findings may have implications for GOC programs during the pandemic and beyond.

Addressing end-of-life care in the chronically ill: Conversations in the emergency department.

Patients present to the emergency department in various stages of chronic illness. Advance directives (ADs) aid emergency physicians in making treatment decisions, but only a minority of Americans have completed an AD, and the percentage of those who have discussed their end-of-life wishes may be even lower. This article addresses the use of common ADs and roadblocks to their use from the perspectives of families, patients, and physicians. Cases to examine new approaches to optimizing end-of-life conversations in patients who are chronically ill, such as the Improving Palliative Care in Emergency Medicine Project, a decision-making framework that opens discussion for patients to gain understanding and determine preferences, and the Brief Negotiated Interview, a 7-minute, scripted, motivational interview that determines willingness for behavior change and initiates care planning, are used.

Advance Care Plans and the Potentially Conflicting Interests of Bedside Patient Agents: A Thematic Analysis.

AIM: People diagnosed with a neurodegenerative disorder often contend with a threat to independence and control, leading some to complete an advance care plan. Advance care plans are commonly associated with treatment limitations; however, key patient agents (such as doctors, allied health, nurses and family) may instead make temporal, best interests or good medical practice decisions on behalf of the patient. Accordingly, there is a need to better understand ancillary decision-maker's perspectives, particularly of doctors. PURPOSE: To explain how the potentially conflicting interests of bedside patient agents operates as a factor which influences doctors' application of advance care plans of people with a neurodegenerative disorder. PARTICIPANTS AND METHODS: Using a constructivist grounded theory informed thematic analysis, 38 semi-structured interviews were conducted with hospital-based doctors, allied health, nurses and family of people with a neurodegenerative disorder who had an advance care plan. Data were inductively analysed using open and focused coding. RESULTS: Analysis revealed two main themes: dynamics of discerning best interests; and avoiding conflict. Rather than applying advance care plans, doctors largely involved families to attempt best interests decision-making partnerships on patients' behalf. Bedside agents demonstrated significant intra and interpersonal challenges associated with their roles as patient agents. Doctors appeared protective of families and patients with neurodegenerative disorder. CONCLUSION: Although bedside agents value advance care plans, doctors often favour temporal healthcare decisions in consultation with family. We suggest there are limitations to the effectiveness of advance care plans in practice, with application typically only occurring close to death. Despite the intentions of advance care planning, bedside agents may still experience considerable dissonance.

Perceptions of the Importance of Advance Care Planning During the COVID-19 Pandemic Among Older Adults Living With HIV.

Background: The importance of advance care planning (ACP) discussions have been heightened during the COVID-19 pandemic. We assessed advance directive completion, healthcare proxy (HCP), and attitudes toward ACP among older adults ages 50+ living with HIV during the COVID-19 pandemic. Methods: Internet-based surveys were administered to 100 participants residing in the Coachella Valley, California from April to June 2020. We examined self-reported completion of an advance directive, HCP, and attitudes toward ACP before and after COVID-19. Adjusted regressions were performed on attitudes toward ACP. Results: Participants' mean age was 64.2 years, most were non-Hispanic white (88.0%), men (96.0%), and identified as sexual minorities (96.0%). Many reported having an advance directive (59.6%) or HCP (67.3%). Most (57.6%) believed ACP to be more important now compared to the pre-pandemic era. Having an advance directive was associated with increase in age, higher education, living with other people, never having an AIDS diagnosis, and current undetectable viral load (p < 0.05). Having a HCP was associated with higher education, being married/partnered, and living with other people (p < 0.05). In a logistic regression model adjusted for education and living situation, the belief that ACP was more important during COVID was associated with not having an advance directive (OR: 5.07, 95% CI: 1.78-14.40) and fear of COVID-19 infection (OR: 4.17, 95% CI: 1.61-10.76.) Conclusions: The COVID-19 pandemic presents a window of opportunity to engage people aging with HIV in ACP discussions, particularly those who do not already have an advance directive.

Rethinking the Role of Advance Care Planning in the Context of Infectious Disease.

Advance care planning (ACP) for medical decision-making at the end of life has developed around the expectation of death from long-term, progressive chronic illnesses. We reexamine advance care planning in light of the increased probability of death from COVID-19, an exemplar of death that occurs relatively quickly after disease onset. We draw several conclusions about ACP in the context of infectious diseases: interpersonal and sociostructural barriers to ACP are high; ACP is not well-oriented toward decision-making for treatment of an acute illness; and the U.S. health care system is not well positioned to fulfill patients' end of life preferences in a pandemic. Passing the peak of the crisis will reduce, but not eliminate, these problems.