Hispanic/Latinx and Spanish Language Concordance Among Palliative Care Clinicians and Patients in Hospital Settings in California.

Background: Members of racial or ethnic minority groups utilize palliative care (PC) services less than non-Hispanic White patients and multiple factors contribute to this disparity. The impact of racial, ethnic, and language (REL) concordance between patients and clinicians has been demonstrated in general medical populations, but not in PC populations. We characterized the racial and ethnic composition and languages spoken of California PC clinicians and patients to examine clinical impacts of REL concordance. Methods: Using Palliative Care Quality Network data, 15 inpatient teams were identified in California that had collected data on patient race/ethnicity and language. Patient and clinician data were analyzed using means and medians for continuous variables, and chi-squared tests to explore similarities and differences between clinician and patient data. Results: 51 clinicians from nine teams completed the survey. The largest non-White and non-English speaking groups among patients and clinicians identified as Hispanic/Latinx (31.5% of patients, 16.3% of clinicians) and as Spanish speakers (22.6% of patients, 7.5% of clinicians). There was a significantly higher proportion of Hispanic/Latinx patients compared to clinicians (p-value 0.01), with Southern California demonstrating the largest difference (30.4% of patients vs. 10.7 % of clinicians, p-value 0.01). Similar proportions of patients and clinicians reported Spanish fluency (22.6% vs 27.5%, p-value 0.31). Discussion: We found significant differences in the racial/ethnic distributions of Hispanic/Latinx patients and clinicians in California, prompting consideration of whether a lack of representation of Hispanic/Latinx clinicians relative to the patient population may contribute to lower palliative care utilization among Hispanic/Latinx patients.

"At the End I Have a Say": Engaging the Chinese Community in Advance Care Planning.

CONTEXT: Despite the association of advance care planning (ACP) with improved patient and caregiver outcomes, Chinese American elders have low rates of ACP. OBJECTIVES: Assess ACP facilitators/barriers in the San Francisco (SF) Chinese community and codesign, implement, and test community-based ACP-promoting pilot events. METHODS: A Chinese Community Committee (N = 19 community-based organization leaders, health system representatives, community members) conducted focus groups in Cantonese and English with Chinese older adults (age ≥55), caregivers, and community leaders. The Committee designed and implemented pilot events in-person and online. We analyzed focus group data using thematic analysis; assessed pre-to-post-event readiness to engage in ACP (validated survey; 14 scale, 4 = most ready); and assessed event acceptability. RESULTS: A total of 34 people participated in six focus groups. Themes described Chinese community-specific importance of ACP (e.g., reduces family burden), barriers (e.g., younger generations lack tools to discuss ACP with elders and vice versa), and facilitators (e.g., intergenerational events, culturally/linguistically appropriate materials). Based on focus groups findings, the Committee developed a novel ACP tool and designed intergenerational events. A total of 195 participants attended 10 events; 95% were Chinese, 90% spoke Chinese languages, 80% were women. ACP readiness increased significantly (1.66 [SD 0.84] vs. 2.03 [SD 0.85]; P < 0.001); 94% of participants were comfortable attending and 96% would recommend events. CONCLUSION: Community-developed intergenerational events that highlight the value of ACP and address barriers are acceptable and increase ACP engagement in the Chinese community.

A Systematic Approach to Assessing and Addressing Palliative Care Needs in an Outpatient Population.

CONTEXT/OBJECTIVES: A critical frontier for palliative medicine is to develop systems to routinely and equitably address the palliative care (PC) needs of seriously ill populations. METHODS: An automated screen identified Medicare primary care patients who had serious illness based on diagnosis codes and utilization patterns. A stepped-wedge design was used to evaluate a six-month intervention through which a healthcare navigator assessed these seriously ill patients and their care partners for PC needs in the domains of 1) physical symptoms, 2) emotional distress, 3) practical concerns, and 4) advance care planning (ACP) via telephone surveys. Identified needs were addressed with tailored PC interventions. RESULTS: A total of 292/2175 (13.4%) patients screened positive for serious illness. A total of 145 completed an intervention phase; 83 completed a control phase. Severe physical symptoms were identified in 27.6%, emotional distress in 57.2%, practical concerns in 37.2%, and ACP needs in 56.6%. Twenty-five intervention patients (17.2%) were referred to specialty PC compared to six control patients (7.2%). Prevalence of ACP notes increased 45.5%-71.7% (p = 0.001) during the intervention and remained stable during the control phase. Quality of life remained stable during the intervention and declined 7.4/10-6.5/10 (P =0.04) during the control phase. CONCLUSION: Through an innovative program, patients with serious illness were identified from a primary care population, assessed for PC needs, and offered specific services to meet those needs. While some patients were appropriate for specialty PC, even more needs were addressed without specialty PC. The program resulted in increased ACP and preserved quality of life.

"We've Got to Bring Information to Where People Are Comfortable": Community-Based Advance Care Planning with the Black Community.

BACKGROUND: People identifying as Black/African American are less likely to engage in advance care planning (ACP) compared to their White peers, despite the association of ACP with improved patient and caregiver outcomes. OBJECTIVES: Assess facilitators/barriers to ACP in the San Francisco (SF) Black community and co-design/implement/test community-based ACP pilot events. DESIGN: Community-based participatory research, including qualitative research, intervention development, and implementation. PARTICIPANTS: In partnership with the SF Palliative Care Workgroup (which includes health system, city, and community-based organizations), we formed an African American Advisory Committee (n = 13). We conducted 6 focus groups with Black older adults (age ≥ 55), caregivers, and community leaders (n = 29). The Advisory Committee then selected 5 community-based organizations through a widespread request for proposal. These community-based organizations designed and implemented community-based pilot events to support ACP engagement. MAIN MEASURES: Two authors analyzed recorded focus group transcripts using thematic analysis. We assessed pre- vs post-event readiness to engage in ACP (validated ACP Engagement Survey; 1-4 scale, 4 = most ready) using Wilcoxon signed rank tests and assessed event acceptability with open-ended questions. KEY RESULTS: Themes included the importance of ACP to the Black community (sub-themes: strengthens families; preserves dignity, particularly for sexual/gender minorities; is tied to financial planning) and facilitators for increasing ACP engagement (sub-themes: culturally relevant materials; events in trusted community spaces including Black-owned businesses). A total of 114 participants attended 5 events; 74% identified as Black, and 16% as sexual/gender minorities. Readiness to engage in ACP was similar pre- vs post-events; 98% would recommend the events to others. CONCLUSIONS: Community-based ACP events designed and led by and for the Black community are highly acceptable. Novel insights underscored the importance of financial planning as part of ACP and the role of Black-owned businesses as trusted spaces for ACP-related discussions.

Honoring What We Say We Do: Developing Real-World Tools for Routine Family Caregiver Assessment and Support in Outpatient Palliative Care.

Background: Family caregivers are essential to the care of patients with serious illness and supporting caregivers alongside patients is a core tenet of palliative care. While there is increasing recognition of the need to support family caregivers, there are limited resources to assess and support their needs in a systematic way in outpatient palliative care practice. Objectives: The aim of this study is to develop an approach to conducting assessments of routine needs and support of family caregivers in outpatient palliative care practice using a quality improvement framework. Setting: Seven, interdisciplinary, outpatient palliative care teams in California collaborated in this study. Measurements: Family caregivers were surveyed about levels of distress and support using a 10-point scale and asked about specific areas of need for support. Usefulness of a supportive caregiver resource was also measured on a 10-point scale, in addition to qualitative assessment of clinician satisfaction and feasibility of routine caregiver assessment and support. Results: Seven hundred thirty-six caregiver needs assessments were conducted and 44 supportive tool kits were distributed. A majority of family caregivers reported moderate or severe distress related to caregiving (score ≥4 on a 10-point scale). The most common sources of distress included emotional distress, worry caregiving was negatively impacting their own health, and planning for the future. Most caregivers reported feeling moderately or very well supported, most commonly by family, friends, and faith/spirituality. Caregivers rated the supportive tool kit an 8.4 on a 10-point usefulness scale and 92% would recommend it to others. Conclusions: We successfully developed and piloted practical clinical tools for routine family caregiver screening and support.

"Advocating for what we need": A CBPR approach to advance care planning in the Latinx older adult community.

BACKGROUND: Advance care planning (ACP) is low among Latinx older adults. We used community-based participatory research (CBPR) to identify ACP barriers/facilitators and design community-based ACP events. METHODS: In partnership with community-based organizations, clinicians, and local government, we formed a Latinx Community Committee (n = 13 community members). We then conducted 6 focus groups with Latinx-identifying, English or Spanish-speaking older adults (age ≥ 55), caregivers, and community leaders to assess ACP barriers/facilitators. We analyzed transcripts using thematic analysis and, based on these learnings, designed and implemented community-based ACP events. Using a validated survey, we assessed acceptability and pre-to-post-event ACP readiness (4-point scale; 4 = most ready; 0.2 change considered meaningful) with Wilcoxon signed-rank tests. RESULTS: Focus groups included 10 Spanish-speaking older adults, 8 caregivers, and 10 community leaders. Themes highlighted the importance of ACP (e.g., means of advocacy), barriers (e.g., how to start conversations), and facilitators (e.g., trusted community spaces) in the Latinx community. Ninety-seven people attended 5 events targeting 3 Latinx populations (LGBTQI+, intergenerational, and older adults broadly). Overall pre-to-post-event ACP readiness increased (2.62 (SD 0.97) to 2.95 (SD 0.93); p = 0.05). Readiness to document wishes increased significantly (2.44 (SD 1.0) to 2.98 (SD 0.95); p = 0.003). Most reported being comfortable attending events (85%) and would recommend them to others (90%). CONCLUSIONS: This study describes a feasible, acceptable, and effective CBPR ACP intervention. Co-developed community events represent a promising approach to reducing disparities in ACP among the Latinx population.

Recommendations for Integrating Antiracist Practice at the JPSM.

Journals like the JPSM are part of the system of gatekeepers to the academic literature that defines and represents our field. This paper explores how the JPSM leadership, staff and editorial board can design, implement, and foster active antiracist ideas and practice at the individual and system level, focused on an examination of who is represented across the organization, reflective practice on individual attitudes and beliefs, and policy analysis and changes. We explore the current and historical context in the United States that makes this approach foundational to the work of addressing and dismantling systemic racism. We define key terms and a theoretical framework while proposing concrete steps the journal can take in this effort. Together, these actions can actively challenge the ways in which white supremacy shapes the status quo, marginalizing Black Indigenous People of Color, and dehumanizing all. While this paper focuses on discrete actions the JPSM can undertake, it also serves as an invitation to the field at large to commit to the daily practice of antiracism. We do not promote ourselves as experts, only as individuals interested in and committed to antiracism and invite our colleagues to correct, edit, and build upon our suggestions. We hope our proposed approach helps our field to address all forms of oppression, including those due to gender, sexual orientation, socioeconomic status, and profession.

Proactive Identification of Palliative Care Needs Among Patients With COVID-19 in the ICU.

In the setting of the coronavirus disease 2019 (COVID-19) pandemic, new strategies are needed to address the unique and significant palliative care (PC) needs of patients with COVID-19 and their families, particularly when health systems are stressed by patient surges. Many PC teams rely on referral-based consultation methods that can result in needs going unidentified and/or unmet. Here, we describe a novel system to proactively identify and meet the PC needs of all patients with COVID-19 being cared for in our hospital's intensive care units. Patients were screened through a combination of chart review and brief provider interview, and PC consultations were provided via telemedicine for those with unmet needs identified. In the first six weeks of operation, our pilot program of proactive screening and outreach resulted in PC consultation for 12 of the 29 (41%) adult patients admitted to the intensive care unit with COVID-19 at our institution. Consultations were most commonly for patient and family support as well as for goals of care and advance care planning, consistent with identified PC needs within this unique patient population.

Drivers of care costs and quality in the last 3 months of life among older people receiving palliative care: A multinational mortality follow-back survey across England, Ireland and the United States.

BACKGROUND: Care costs rise towards the end of life. International comparison of service use, costs and care experiences can inform quality and improve access. AIM: The aim of this study was to compare health and social care costs, quality and their drivers in the last 3 months of life for older adults across countries. Null hypothesis: no difference between countries. DESIGN: Mortality follow-back survey. Costs were calculated from carers' reported service use and unit costs. SETTING: Palliative care services in England (London), Ireland (Dublin) and the United States (New York, San Francisco). PARTICIPANTS: Informal carers of decedents who had received palliative care participated in the study. RESULTS: A total of 767 questionnaires were returned: 245 in England, 282 in Ireland and 240 in the United States. Mean care costs per person with cancer/non-cancer were US$37,250/US$37,376 (the United States), US$29,065/US$29,411 (Ireland), US$15,347/US$16,631 (England) and differed significantly (F = 25.79/14.27, p < 0.000). Cost distributions differed and were most homogeneous in England. In all countries, hospital care accounted for > 80% of total care costs; community care 6%-16%, palliative care 1%-15%; 10% of decedents used ~30% of total care costs. Being a high-cost user was associated with older age (>80 years), facing financial difficulties and poor experiences of home care, but not with having cancer or multimorbidity. Palliative care services consistently had the highest satisfaction. CONCLUSION: Poverty and poor home care drove high costs, suggesting that improving community palliative care may improve care value, especially as palliative care expenditure was low. Major diagnostic variables were not cost drivers. Care costs in the United States were high and highly variable, suggesting that high-cost low-value care may be prevalent.

A Person-Centered, Registry-Based Learning Health System for Palliative Care: A Path to Coproducing Better Outcomes, Experience, Value, and Science.

BACKGROUND: Palliative care offers an approach to the care of people with serious illness that focuses on quality of life and aligning care with individual and family goals, and values in the context of what is medically achievable. OBJECTIVE: Measurement of the impact of palliative care is critical for determining what works for which patients in what settings, to learn, improve care, and ensure access to high value care for people with serious illness. METHODS: A learning health system that includes patients and families partnering with clinicians and care teams, is directly linked to a registry to support networks for improvement and research, and offers an ideal framework for measuring what matters to a range of stakeholders interested in improving care for this population. MEASUREMENTS: Measurement focuses on the individual patient and family experience as the fundamental outcome of interest around which all care delivery is organized. RESULTS: We describe an approach to codesigning and implementing a palliative care registry that functions as a learning health system, by combining patient and family inputs and clinical data to support person-centered care, quality improvement, accountability, transparency, and scientific research. DISCUSSION: The potential for a palliative care learning health system that, by design, brings together enriched information environments to support coproduction of healthcare and facilitated peer networks to support patients and families, collaborative clinician networks to support palliative care program improvement, and collaboratories to support research and the application of research to benefit individual patients is immense.

Self-Reported California Hospital Palliative Care Program Composition, Certification, and Staffing Level Are Associated with Lower End-of-Life Medicare Utilization.

BACKGROUND: California hospitals report palliative care (PC) program characteristics to the California Office of Statewide Health Planning and Development (OSHPD), but the significance of this information is unknown. OBJECTIVE: Our objective was to determine whether self-reported California hospital PC program characteristics are associated with lower end-of-life (EoL) Medicare utilization. DESIGN: We performed a cross-sectional study of hospitals submitting 2012 data to OSHPD and included in the 2012 Dartmouth Atlas of Healthcare (DAHC) dataset, using statistical hypothesis testing, multivariate regression, and fuzzy set qualitative comparative analysis. SETTING/SUBJECTS: Our analysis included 203 hospitals primarily providing general medical-surgical (GMS) care. MEASUREMENTS: The following measures were available for each hospital: licensed GMS beds; type of control; presence of an inpatient or outpatient PC program; number of physicians, nurses, social workers, and chaplains on the PC team; number of PC-certified staff; percentage of Medicare decedents dying as inpatients; and average total hospital days, ICU days, and physician visits per Medicare decedent in the last six months of life. RESULTS: Investor-owned hospitals have fewer PC programs and higher EoL utilization than do nonprofit hospitals. Among nonprofit hospitals, small size (substantially fewer than 150 medical-surgical beds), or large size and having an inpatient PC program with more than three PC staff per 100 GMS beds, or an interdisciplinary PC-certified team, is associated with significantly lower EoL hospital utilization and percentage of deaths occurring in the inpatient setting. DISCUSSION: Improved program performance associated with higher staffing levels may be mediated by increased access to and earlier PC interventions. CONCLUSION: California hospital-reported PC program characteristics are associated with significantly lower inpatient utilization by Medicare decedents.

Starting and Sustaining Palliative Care in Public Hospitals: Lessons Learned from a Statewide Initiative.

BACKGROUND: Compared with private, not-for-profit hospitals, significantly fewer public hospitals report that they provide palliative care services for their patients. Because uninsured and underinsured patients largely depend on public hospitals for acute medical care, they therefore experience disparities in access to inpatient palliative care services. To address this disparity, the statewide Spreading Palliative Care in Public Hospitals Initiative (SPCPHI) was established to help implement or expand inpatient palliative care services in all 17 of California's public acute care hospitals. AIM: The aim of this article is to use the experiences from the SPCPHI to describe the unique challenges to providing palliative care in public hospitals; the major barriers to initiating, growing, and sustaining palliative care programs in public hospitals; and the common solutions to overcoming those barriers. CONCLUSIONS: Palliative care programs in public hospitals must develop the necessary skills and staffing to meet the complex needs of vulnerable patients and their families. These programs face a variety of unique organizational and operational challenges such as limited and uncertain funding, limited access to hospital data and analytic support, and complex regulatory structures, which may hinder growth of palliative care in these systems. Experiences from the SPCPHI suggest that networking, technical assistance, and startup funding are helpful to overcome these barriers and to develop high-quality, sustainable palliative care programs in public hospitals.

The quality imperative for palliative care.

Palliative medicine must prioritize the routine assessment of the quality of clinical care we provide. This includes regular assessment, analysis, and reporting of data on quality. Assessment of quality informs opportunities for improvement and demonstrates to our peers and ourselves the value of our efforts. In fact, continuous messaging of the value of palliative care services is needed to sustain our discipline; this requires regularly evaluating the quality of our care. As the reimbursement mechanisms for health care in the U.S. shift from fee-for-service to fee-for-value models, palliative care will be expected to report robust data on quality of care. We must move beyond demonstrating to our constituents (including patients and referrers), "here is what we do," and increase the focus on "this is how well we do it" and "let us see how we can do it better." It is incumbent on palliative care professionals to lead these efforts. This involves developing standardized methods to collect data without adding additional burden, comparing and sharing our experiences to promote discipline-wide quality assessment and improvement initiatives, and demonstrating our intentions for quality improvement on the clinical frontline.

An assessment of the screening performance of a single-item measure of depression from the Edmonton Symptom Assessment Scale among chronically ill hospitalized patients.

CONTEXT: Few studies have examined the validity of using a single item from the Edmonton Symptom Assessment Scale (ESAS) for screening for depression. OBJECTIVES: To examine the screening performance of the single-item depression question from the ESAS in chronically ill hospitalized patients. METHODS: A total of 162 chronically ill inpatients aged 65 and older completed a survey after admission that included the well-validated, 15-item Geriatric Depression Scale (GDS-15) and four single-item screening questions for depression based on the ESAS question, using two different time frames ("now" and "in the past 24 hours") and two response categories (a 0-10 numeric rating scale [NRS] and a categorical scale: none, mild, moderate, and severe). RESULTS: The GDS-15 categorized 20% (n = 33) of participants as possibly being depressed with a score ≥ 6. The NRS for depression "now" achieved the highest level of sensitivity at a cutoff ≥ 1 (68.8%), and an acceptable level of specificity was obtained at a cutoff of ≥ 5 (82.2%). For depression "in the past 24 hours," a cutoff of ≥ 1 achieved a sensitivity of 68.8% and a cutoff of ≥ 7 a specificity of 80.3%. For the categorical scale, a cutoff of "none" provided the best level of sensitivity for depression "now" (65.6%) and "in the past 24 hours" (81.3%), with an acceptable level of specificity being obtained at ≥"mild" (68.8%) and ≥"moderate" (68.8%), respectively. CONCLUSION: These single-item measures were not effective in screening for probable depression in chronically ill patients regardless of the time frame or the response format used, but a cutoff of ≥ 5 or "mild" or greater did achieve sufficient specificity to raise clinical suspicion.

Longitudinal assessment of symptom severity among hospitalized elders diagnosed with cancer, heart failure, and chronic obstructive pulmonary disease.

BACKGROUND: Pain, dyspnea, and anxiety are common among patients with cancer, heart failure (HF), and chronic obstructive pulmonary disease (COPD), yet little is known about the severity of symptoms over time. OBJECTIVE: To determine the prevalence, severity, burden, and predictors of symptoms during the course of hospitalization and at 2 weeks after discharge. DESIGN: A prospective cohort study. SETTING: A large academic university. PATIENTS: Patients were 65 years or older with a primary diagnosis of cancer, COPD, or HF. MEASUREMENTS: Daily living skills and depression were recorded at enrollment. Symptoms were assessed daily and 2 weeks postdischarge. RESULTS: At baseline, most participants reported moderate/severe pain (54%), dyspnea (53%), and anxiety (62%). Almost two-thirds (64%) had 2 or more symptoms at a moderate/severe level. The prevalence of moderate/severe symptoms decreased at the 24-hour assessment (pain = 42%, dyspnea = 45%, anxiety = 55%, burden = 55%) and again at follow-up (pain = 28%, dyspnea = 27%, anxiety = 25%, burden = 30%). While there was no association between primary diagnosis and symptom severity at baseline or 24-hour assessment, at 2-week follow-up, a higher percentage of patients with COPD had moderate/severe pain (54%, χ(2) = 22.0, P = 0.001), dyspnea (45%, χ(2) = 9.3, P = 0.05), and overall symptom burden (55%, χ(2) = 25.9, P = 0.001) than those with cancer (pain = 22%, dyspnea = 16%, symptom burden = 16%) or HF (pain = 25%, dyspnea = 24%, symptom burden = 28%). Predictors of symptom burden at follow-up were COPD (odds ratio [OR] = 7.5; 95% confidence interval [CI] = 2.0, 27.7) and probable depression (OR = 6.1; 95% CI = 2.1, 17.8). CONCLUSION: The majority of inpatients with chronic illness reported high severity of symptoms. Symptoms improved over time but many patients, particularly those with COPD, had high symptom severity at follow-up.

Code status discussions at hospital admission are not associated with patient and surrogate satisfaction with hospital care: results from the multicenter hospitalist study.

BACKGROUND: Physicians may avoid code status discussions for fear of decreasing patient or surrogate satisfaction. METHODS: Charts of patients admitted to medical services at 6 university hospitals were reviewed for documentation of a code status discussion in the first 24 hours of admission. Satisfaction with care provided during the hospitalization was assessed by telephone 1 month after discharge. RESULTS: Of the 11 717 patients with 1-month follow-up, 1090 (9.3%) had a code status discussion documented. Patient or surrogate satisfaction did not differ by whether a discussion was documented. The lack of association persisted after adjusting for patient's severity of illness and using propensity adjustment for likelihood of having a discussion. CONCLUSIONS: Discussing code status on admission to the inpatient setting did not affect patient or surrogate satisfaction.

The intersection of need and opportunity: assessing and capitalizing on opportunities to expand hospital-based palliative care services.

BACKGROUND: To develop and grow most effectively, palliative care programs must consider how best to align their mission with that of their institution. To do so, programs must identify their institutional mission and needs, what palliative care can do to address those needs given available resources, and how the palliative care team can measure and document its value. Such an approach encourages the palliative care team to think strategically and to see themselves and their service as a solution to issues and concerns within the institution. It also helps a palliative care team decide which, among many potential opportunities and possible initiatives, is the one most likely to be supported by the institution and have a recognized and significant impact. SUBJECTS AND METHODS: We present five case studies to demonstrate how successful programs identify and address institutional needs to create opportunities for palliative care program growth. These case studies can serve as models for other programs seeking to develop or expand their palliative care services.

Factors associated with discussion of care plans and code status at the time of hospital admission: results from the Multicenter Hospitalist Study.

BACKGROUND: Hospital admission is a time when patients are sickest and also often encountering an entirely new set of caregivers. As a result, understanding and documenting a patient's care preferences at hospital admission is critically important. OBJECTIVE: To understand factors associated with documentation of care planning discussions in patients admitted to general medical services at 6 academic medical centers. DESIGN: Observational cohort study using data collected during the Multicenter Hospitalist Study, conducted between July 1, 2002 and June 30, 2004. SETTING: Prospective trial enrolling patients admitted to general medicine services at 6 university-based teaching hospitals. PATIENTS: Patients were eligible for this study if they were 18 years of age or older, admitted to a hospitalist or nonhospitalist physician, and able to give informed consent. MEASUREMENTS: Presence of chart documentation that the admitting team had discussed care plans with the patient within the first 24 hours of hospitalization. Notations such as "full code" were not counted as a discussion, whereas notations such as "discussed care wishes and plan with patient" were counted. RESULTS: A total of 17,097 patients over the age of 18 gave informed consent and completed an interview and chart abstraction; of these, 1776 (10.3%) had a code status discussion (CD) documented in the first 24 hours of their admission. Patients with a CD were older (69 years vs. 56 years, P < 0.0001), more often white (52.8% vs. 43.3%, P < 0.0001), and more likely to have cancer (19.8% vs. 11.4%, P < 0.0001), or depression (35.1% vs. 30.9%, P < 0.0001). There was marked variability in CD documentation across sites of enrollment (2.8%-24.9%, P < 0.0001). Despite strong associations seen in unadjusted comparisons, in multivariable models many socioeconomic factors, functional status, comorbid illness, and documentation of a surrogate decision maker were only moderately associated with a CD (adjusted odds ratios all less than 2.0). However, patients' site of enrollment (odds ratios 1.74-5.14) and informal notations describing prehospital care wishes (eg, orders for "do not resuscitate"/"do not intubate;" odds ratios 3.22-11.32 compared with no preexisting documentation) were powerfully associated with CD documentation. Site remained a powerful influence even in patients with no documented prehospital wishes. LIMITATIONS: Our results are derived from a relatively small number of academic sites, and we cannot connect documentation differences to differences in patient outcomes. CONCLUSIONS: Documentation of a CD at admission was more strongly associated with informal documentation of prehospital care wishes and where the patient was hospitalized than legal care planning documents (such as durable power of attorney), or comorbid illnesses. Efforts to improve communication between hospitalists and their patients might target local documentation practices and culture.

Reach and impact of a mass media event among vulnerable patients: the Terri Schiavo story.

BACKGROUND: It is unknown whether health-related media stories reach diverse older adults and influence advance care planning (ACP). OBJECTIVE: To determine exposure to media coverage of Terri Schiavo (TS) and its impact on ACP. DESIGN AND PARTICIPANTS: Descriptive study of 117 English/Spanish-speakers, aged >or=50 years (mean 61 years) from a county hospital, interviewed six months after enrollment into an advance directive study. MEASUREMENTS: We assessed whether participants had heard of TS and subject characteristics associated with exposure. We also asked whether, because of TS, subjects engaged in ACP. MAIN RESULTS: Ninety-two percent reported hearing of TS. Participants with adequate literacy were more likely than those with limited literacy to report hearing of TS (100% vs. 79%, P < .001), as were participants with >or= a high school vs. < high school education (97% vs. 82%, P = .004), and English vs. Spanish-speakers (96% vs. 85%, P = .04). Because of TS, many reported clarifying their own goals of care (61%), talking to their family/friends about ACP (66%), and wanting to complete an advance directive (37%). CONCLUSIONS: Most diverse older adults had heard of TS and reported that her story activated them to engage in ACP. Media stories may provide a powerful opportunity to engage patients in ACP and develop public health campaigns.