Time is of the Essence: Why Goals-of-Care Conversations and Prognosis Documentation Matters in Advanced Cancer Patients in an Integrated Health System.

Background: Advanced cancer patients benefit less from aggressive therapies and more from goal-directed palliative management. Early and clearly documented goals-of-care discussions, including end-of-life decision making, are essential in this patient population. Integrated healthcare systems are comprehensive care models associated with improved quality of care and lower mortality compared to other healthcare models. The role of advance care planning within our system is understudied. Methods: Patients 18 years and older with a diagnosis of advanced-stage cancer were identified over a 6-month period. Expert panel review was performed to evaluate medical appropriateness of the selected diagnostic workup and management. The role and extent of care planning was reviewed in association with the clinical context. Results: In a cohort of 82 patients, evidence-based and individualized appropriateness of medical management was found to be consistent for all patients. Eighty-two percent of patients elected for oncologic-based treatment, 5% pursued active surveillance, and 11% did not receive treatment. Seventy-three percent of patients were referred to palliative care. Fifty-six percent of patients had a full goals-of-care conversation documented; yet only 9% of goals-of-care conversations were documented by an oncologist. Prognosis was documented fully for only 22% of patients. At the end of the study period, 43 patients were deceased (52%), further indicating the critical importance of documentation. Conclusions: Within our integrated health system, we found consistent guideline- and patient-directed diagnosis and management, along with frequent integration of palliative care services. Goals-of-care conversation and prognosis documentation, especially by the oncologist, remains an area of needed improvement.

What Matters Most: The Documented Goals, Values and Motivators of Advanced Cancer Patients.

BACKGROUND: Goals of care conversations are essential to delivery of goal concordant care. Infrequent and inconsistent goals of care documentation potentially limit delivery of goal concordant care. METHODS: At Kaiser Permanente San Francisco Cancer Center, a standardized documentation template was designed and implemented to increase goals of care documentation by oncologists. The centralized, prompt-based template included value clarification of the goals and values of advanced cancer patients beyond treatment preferences. Documented conversations using the template during the initial pilot period were reviewed to characterization the clinical context in which conversations were recorded. Common goals and motivators were also identified. RESULTS: A total of 178 advanced cancer patients had at least 1 documented conversation by a medical oncologist using the goals of care template. Oncologists consistently documented within the template goals of therapy and motivating factors in decision making. The most frequently documented goals of care were "Avoiding Pain and Suffering," "Physical Independence," and "Living as Long as Possible." The least recorded goal was "Comfort Focused Treatment Only." CONCLUSIONS: Review of oncologist documented goals of care conversations using a prompt-based template allowed for characterization of the clinical context, therapy goals and motivators of advanced cancer patients. Communication of goals of care conversations by oncologists using a standardized prompt-based template within a centralized location has the potential to improve delivery of goal concordant care.

Vaccine Hesitancy Counseling-an Educational Intervention to Teach a Critical Skill to Preclinical Medical Students.

INTRODUCTION: There has been a recent rise in public perception that vaccines are unsafe, fostering vaccine hesitancy (VH). Few interventions have focused on teaching medical students' communication skills for counseling vaccine-hesitant patients. METHODS: Our educational intervention, designed for medical students, involved a self-study module followed by an interactive session on VH. Students practiced counseling vaccine-hesitant standardized patients (SPs). Faculty and SPs assessed student counseling skills. Students completed pre- and post-intervention surveys to assess attitudes and preparedness to counsel VH patients. RESULTS: Students showed a better ability to talk to parents about Human Papillomavirus (HPV) vaccine concerns and Measles Mumps Rubella (MMR)/autism-related issues than to address patients' concerns related to the Varicella Zoster Virus (VZV) vaccine.Students' surveys pre- and post-intervention revealed significant improvement in their vaccination knowledge and comfort with counseling vaccine-hesitant patients. Student counseling skills as part of an Objective Structured Clinical Exam (OSCE) showed 73% of students asked about immunization and elicited SP concerns, but only 36% counseled appropriately. CONCLUSIONS: In the face of emerging VH, physicians play a critical role in advising and influencing vaccination decisions. Therefore, it is a core responsibility of medical educators to train medical students on recommending vaccinations and responding effectively to vaccine-hesitant parents and patients. Our multifaceted interactive session provided preclinical students with knowledge and skills to improve communication skills with VH patients and parents and the need for ongoing practice of these VH counseling skills.