A Descriptive Analysis of End-of-Life Conversations With Long-Term Glioblastoma Survivors.

BACKGROUND: Early, high-quality serious illness (SI) conversations are critical for patients with glioblastoma (GBM) but are often mistimed or mishandled. OBJECTIVE: To describe the prevalence, timing, and quality of documented SI conversations and evaluate their focus on patient goals/priorities. DESIGN/PARTICIPANTS: Thirty-three patients with GBM enrolled in the control group of a randomized controlled trial of a communication intervention and were followed for 2 years or until death. At baseline, all patients answered a validated question about preferences for life-extending versus comfort-focused care and completed a Life Priorities Survey about their goals/priorities. In this secondary analysis, retrospective chart review was performed for 18 patients with GBM who died. Documented SI conversations were systematically identified and evaluated using a codebook reflecting 4 domains: prognosis, goals/priorities, end-of-life planning, and life-sustaining treatments. Patient goals/priorities were compared to documentation. MEASUREMENTS/RESULTS: At baseline, 16 of 24 patients preferred life-extending care. In the Life Priorities Survey, goals/priorities most frequently ranked among the top 3 were "Live as long as possible," "Be mentally aware," "Provide support for family," "Be independent," and "Be at peace." Fifteen of 18 patients had at least 1 documented SI conversation (range: 1-4). Median timing of the first documented SI conversation was 84 days before death (range: 29-231; interquartile range: 46-119). Fifteen patients had documentation about end-of-life planning, with "hospice" and "palliative care" most frequently documented. Five of 18 patients had documentation about their goals. CONCLUSION: Patients with GBM had multiple goals/priorities with potential treatment implications, but documentation showed SI conversations occurred relatively late and infrequently reflected patient goals/priorities.

Reading level of Medicaid renewal applications.

OBJECTIVE: To examine compliance of Medicaid-renewal applications to established state guidelines for reading level of Medicaid-related materials. METHODS: We assessed the reading level of the 2008 Medicaid renewal applications by using 3 readability tests: Flesch-Kincaid Grade Level Index, New Fog Count, and FORCAST. RESULTS: In 2008, 45 states and the District of Columbia had reading level guidelines for Medicaid-related materials. Of these, 24 (52.2%) states' Medicaid renewal applications failed to meet their guidelines on all 3 readability tests; in particular, 41 states (89.1%) failed the Flesch-Kincaid Grade Level Index. Only one state's application had a Flesch-Kincaid score below a 5th-grade reading level. CONCLUSIONS: As health care reform unfolds, complying with established reading level guidelines for Medicaid-related materials is one simplification strategy that should be implemented to improve access for Medicaid-eligible families and prevent eligible children from losing coverage unnecessarily.