Current status of advance care planning, palliative care consultation, and end-of-life care in patients with glioblastoma in South Korea.

BACKGROUND: Given the typical trajectory of glioblastoma, many patients lose decision-making capacity over time, which can lead to inadequate advance care planning (ACP) and end-of-life (EOL) care. We aimed to evaluate patients' current ACP and EOL care status. PATIENTS AND METHODS: We conducted a cohort study on 205 patients referred to oncologists at a Korean tertiary hospital between 2017 and 2022. We collected information on sociodemographic factors, cancer treatment, palliative care consultation, ACP, legal documents on life-sustaining treatment (LST) decisions, and aggressiveness of EOL care. RESULTS: With a median follow-up time of 18.3 months: 159 patients died; median overall survival: 20.3 months. Of the 159 patients, 11 (6.9%) and 63 (39.6%) had advance directive (AD) and LST plans, respectively, whereas 85 (53.5%) had neither. Among the 63 with LST plans, 10 (15.9%) and 53 (84.1%) completed their forms through self-determination and family determination, respectively. Of the 159 patients who died, 102 (64.2%) received palliative care consultation (median time: 44 days from the first consultation to death) and 78 (49.1%) received aggressive EOL care. Those receiving palliative care consultations were less likely to receive aggressive EOL care (83.3% vs 32.4%, P < .001), and more likely to use more than 3 days of hospice care at EOL (19.6% vs 68.0%, P < .001). CONCLUSIONS: The right to self-determination remains poorly protected among patients with glioblastoma, with nearly 90% not self-completing AD or LST plan. As palliative care consultation is associated with less aggressive EOL care and longer use of hospice care, physicians should promptly introduce patients to ACP conversations and palliative care consultations.

Barriers and Strategies to Effective Serious Illness Communication for Patients with End-Stage Liver Disease in the Intensive Care Setting.

Background: Patients with end-stage liver disease (ESLD) often require Intensive Care Unit (ICU) admission during the disease trajectory, but aggressive medical treatment has not resulted in increased quality of life for patients or caregivers. Methods: This narrative review synthesizes relevant data thematically exploring the current state of serious illness communication in the ICU with identification of barriers and potential strategies to improve performance. We provide a conceptual model underscoring the importance of providing comprehensible disease and prognosis knowledge, eliciting patient values and aligning these values with available goals of care options through a series of discussions. Achieving effective serious illness communication supports the delivery of goal concordant care (care aligned with the patient's stated values) and improved quality of life. Results: General barriers to effective serious illness communication include lack of outpatient serious illness communication discussions; formalized provider training, literacy and culturally appropriate patient-directed serious illness communication tools; and unoptimized electronic health records. ESLD-specific barriers to effective serious illness communication include stigma, discussing the uncertainty of prognosis and provider discomfort with serious illness communication. Evidence-based strategies to address general barriers include using the Ask-Tell-Ask communication framework; clinician training to discuss patients' goals and expectations; PREPARE for Your Care literacy and culturally appropriate written and online tools for patients, caregivers, and clinicians; and standardization of documentation in the electronic health record. Evidence-based strategies to address ESLD-specific barriers include practicing with empathy; using the "Best-Case, Worst Case" prognostic framework; and developing interdisciplinary solutions in the ICU. Conclusion: Improving clinician training, providing patients and caregivers easy-to-understand communication tools, standardizing EHR documentation, and improving interdisciplinary communication, including palliative care, may increase goal concordant care and quality of life for critically ill patients with ESLD.

Reimagining and rebranding advance care planning.

Advance care planning (ACP) has traditionally aimed at ensuring that patients' end-of-life (EOL) wishes are understood and respected. However, recent literature raises concerns about its effectiveness, with many trials indicating that ACP does not significantly improve goal-concordant care, enhance quality of life or reduce healthcare costs. This is because patients' future decisions are influenced by their transient preferences due to projection bias. To remain relevant, ACP requires a radical shift in perspective, implementation and branding. First, ACP's mission must be redefined with a focus on: Educate, Share and Prepare. This perspective emphasises ongoing conversations about patient health and illness, sharing of patients' current values and goals of care and preparation for the future, rather than making definitive future decisions. Second, ACP should be integrated into routine care, normalising these discussions. Simplifying ACP processes and shifting incentives to support shared responsibility among stakeholders can enhance integration. Last, rebranding ACP as 'Advance Care Preparation' can clarify its purpose, distinguishing it from EOL planning and increasing its uptake. This rebranding ensures that ACP meets the evolving needs of patients and their families, ultimately enhancing the quality of care and patient satisfaction. These changes in perspective, implementation and branding can transform ACP into a valuable tool for delivering compassionate, patient-centred healthcare, making it relevant to all individuals.

Emergency department discharges directly to hospice: Longitudinal assessment of a streamlined referral program.

INTRODUCTION: 80 % of Americans wish to die somewhere other than a hospital, and hospice is an essential resource for providing such care. The emergency department (ED) is an important location for identifying patients with end-of-life care needs and providing access to hospice. The objective of this study was to analyze a quality improvement (QI) program designed to increase the number of patients referred directly to hospice from the ED, without the need for an observation stay and without access to in-hospital hospice. METHODS: We implemented a QI program in September 2021 consisting of three components: (1) clarification and streamlining of referral workflows, (2) staff/provider education on hospice and workflows, and (3) electronic medical record (EMR) tools to facilitate hospice transitions. The primary outcome was the change in monthly ED-to-hospice cases pre- and post-implementation. We also calculated the monthly incidence rate of ED-to-hospice transfers. The secondary outcome was ED length of stay (LOS). RESULTS: 202 patients completed ED-to-hospice transfers from January 1, 2019 to February 29, 2024. 98 patients transitioned from the ED to hospice before QI implementation, and 104 patients transitioned after implementation. We observed a slight but insignificant increase in the mean monthly ED-to-hospice cases from 3.16 patients per month pre-implementation to 3.47 patients per month post-implementation (P = 0.46). We found no significant difference in the monthly incidence rate of ED-to-hospice cases before and after implementation (P = 0.78). ED LOS was unaffected (P = 0.21). CONCLUSION: In this largest study to date on direct ED-to-hospice discharges, a QI program focused on workflow optimization, education, and EMR modification was insufficient to significantly impact ED-to-hospice discharges. Future efforts to increase hospice transitions from the ED should investigate methods to improve patient identification, the impact of in-hospital hospice programs, and coordination with hospital and community teams to support home-based care for those desiring to remain there.

Patient Engagement With Early Stage Advance Care Planning at a Comprehensive Cancer Center.

BACKGROUND: Establishing care preferences and selecting a prepared medical decision-maker (MDM) are basic components of advance care planning (ACP) and integral to treatment planning. Systematic ACP in the cancer setting is uncommon. We evaluated a systematic social work (SW)-driven process for patient selection of a prepared MDM. METHODS: We used a pre/post design, centered on SW counseling incorporated into standard-of-care practice. New patients with gynecologic malignancies were eligible if they had an available family caregiver or an established Medical Power of Attorney (MPOA). Questionnaires were completed at baseline and 3 months to ascertain MPOA document (MPOAD) completion status (primary objective) and evaluate factors associated with MPOAD completion (secondary objectives). RESULTS: Three hundred and sixty patient/caregiver dyads consented to participate. One hundred and sixteen (32%) had MPOADs at baseline. Twenty (8%) of the remaining 244 dyads completed MPOADs by 3 months. Two hundred and thirty-six patients completed the values and goals survey at both baseline and follow-up: at follow-up, care preferences were stable in 127 patients (54%), changed toward more aggressive care in 60 (25%), and toward the focus on the quality of life in 49 (21%). Correlation between the patient's values and goals and their caregiver's/MPOA's perception was very weak at baseline, improving to moderate at follow-up. Patients with MPOADs by study completion had statistically significant higher ACP Engagement scores than those without. CONCLUSION: A systematic SW-driven intervention did not engage new patients with gynecologic cancers to select and prepare MDMs. Change in care preferences was common, with caregivers' knowledge of patients' treatment preferences moderate at best.

Advance Care Planning Conversations: Laying the Foundation for Goal-Concordant Care at End of Life.

The delivery of culturally congruent, person-centered, family-focused quality care requires an exploration of the values, beliefs, and preferences of those we serve [13]. Nuanced advance care planning conversations lay the foundation for shared decision making and promotes the delivery of goal-concordant care. This chapter will provide clinicians with guidance and resources to aid this process with a focus on contextualized communication with those with serious illness.

Easing Suffering for ICU Patients and Their Families: Evidence and Opportunities for Primary and Specialty Palliative Care in the ICU.

Intensive care unit (ICU) admissions are often accompanied by many physical and existential pressure points that can be extraordinarily wearing on patients and their families and surrogate decision makers (SDMs). Multidisciplinary palliative support, including physicians, advanced practice nurses, nutritionists, chaplains and other team members, may alleviate many of these sources of potential suffering. However, the palliative needs of ICU patients undoubtedly exceed the bandwidth of current consultative specialty palliative medicine teams. Informed by standard-of-care palliative medicine domains, we review common ICU symptoms (pain, dyspnea and thirst) and their prevalence, sources and their treatment. We then identify palliative needs and impacts in the domains of communication, SDM support and transitions of care for patients and their families through their journey in the ICU, from discharge and recovery at home to chronic critical illness, post-ICU disability or death. Finally, we examine the evidence for strategies to incorporate specialty palliative medicine and palliative principles into ICU care for the improvement of patient- and family-centered care. While randomized controlled studies have failed to demonstrate measurable improvement in pre-determined outcomes for patient- and family-relevant outcomes, embracing the principles of palliative medicine and assuring their delivery in the ICU is likely to translate to overall improvement in humanistic, person-centered care that supports patients and their SDMs during and following critical illness.

The importance of facilitating goal-concordant care (GCC) in a pandemic: the MD Anderson Experience with hospitalized COVID-19-positive patients.

PURPOSE: Provider-patient communication (PPC) about goals of care (GOC) facilitates goal-concordant care (GCC) delivery. Hospital resource limitations imposed during the pandemic made it vital to deliver GCC to a patient cohort with COVID-19 and cancer. We aimed to evaluate the implementation of a real-time goals of care intervention and to make recommendations for future pandemics with similar clinical scenarios. METHODS: This is a retrospective cohort study, of all COVID-19 positive patients admitted to The University of Texas MD Anderson Cancer Center between March of 2020 and January of 2021. The cohort included the following: (1) patients 18 years of age or older; (2) positive COVID-19 infection; (3) requiring hospitalization. Medical records were reviewed and all patient data including demographics, comorbidities, and outcomes were collected and analyzed in the Syntropy platform, Palantir Foundry, as part of the institutional Data-Driven Determinants of COVID-19 Oncology Discovery Effort (D3CODE) protocol. A multidisciplinary GOC task force developed processes for ease of conducting GOC-PPC and implemented structured documentation. We looked at ACP documentation pre- and post-implementation alongside demographics, length of stay (LOS), 30-day readmission rate and mortality. RESULTS: There were 494 unique patients identified, 53% male, 61.5% Caucasian, 16.8% African American, and 3.2% Asian. Active cancer was identified in 84.6% patients, of which 65.6% were solid tumors and 34.4% hematologic malignancies. LOS was 9 days with a 30-day readmission rate of 15% and inpatient mortality of 14%. Inpatient ACP note documentation was significantly higher post-implementation as compared to pre-implementation (90% vs 8%, P<0.05). We saw sustained ACP documentation throughout the pandemic suggesting effective processes. CONCLUSIONS: The implementation of institutional structured processes for GOC-PPC resulted in rapid sustainable adoption of ACP documentation for COVID-19-positive cancer patients. This was highly beneficial for this population during the pandemic, as it demonstrated the role of agile processes in care delivery models, which will be beneficial in the future when rapid implementation is needed.

Barriers to advance care planning among patients with advanced serious illnesses: A national survey of health-care professionals in Singapore.

OBJECTIVES: To assess the barriers that health-care professionals (HCPs) face in having advance care planning (ACP) conversations with patients suffering from advanced serious illnesses and to provide care consistent with patients' documented preferences. METHODS: We conducted a national survey of HCPs trained in facilitating ACP conversations in Singapore between June and July 2021. HCPs responded to hypothetical vignettes about a patient with an advanced serious illness and rated the importance of barriers (HCP-, patient-, and caregiver-related) in (i) conducting and documenting ACP conversations and (ii) providing care consistent with documented preferences. RESULTS: Nine hundred eleven HCPs trained in facilitating ACP conversations responded to the survey; 57% of them had not facilitated any in the last 1 year. HCP factors were reported as the topmost barriers to facilitating ACP. These included lack of allocated time to have ACP conversations and ACP facilitation being time-consuming. Patient's refusal to engage in ACP conversations and family experiencing difficulty in accepting patient's poor prognosis were the topmost patient- and caregiver-related factors. Non-physician HCPs were more likely than physicians to report being fearful of upsetting the patient/family and lack of confidence in facilitating ACP conversations. About 70% of the physicians perceived caregiver factors (surrogate wanting a different course of treatment and family caregivers being conflicted about patients' care) as barriers to providing care consistent with preferences. SIGNIFICANCE OF RESULTS: Study findings suggest that ACP conversations be simplified, ACP training framework be improved, awareness regarding ACP among patients, caregivers, and general public be increased, and ACP be made widely accessible.

Developing a Value Framework: Utilizing Administrative Data to Assess an Enhanced Care Initiative.

BACKGROUND: There remains no tool to quantify the total value of comparative processes in health care. Hospital administrative data sets are emerging as valuable sources to evaluate performance. Thus, we use a framework to simultaneously assess multiple domains of value associated with an enhanced recovery initiative using national administrative data. MATERIALS AND METHODS: Risk-stratified clinical pathways for patients undergoing pancreatic surgery were implemented in 2016 at our institution. We used a national administrative database to characterize changes in value associated with this initiative. Value metrics assessed included in-hospital mortality, complication rates, length of stay (LOS), 30-day readmission rates, and institutional costs. We compared our performance with other hospitals both before and after implementation of the pathways. Metrics were graphed on radar charts to assess overall value. RESULTS: 22,660 cases were assessed. Comparing 75 cases at our institution and 5520 cases at all other hospitals before pathway implementation, mean in-hospital LOS was 9.6 versus 10.8 d, in-hospital mortality was 0.0% versus 1.9%, mean costs were $23,585 versus $21,387, 30-day readmission rates were 1.3% versus 7.4%, and complication rates were 8.0% versus 11.2%, respectively. Comparing 334 cases at our institution and 16,731 cases at all other hospitals after pathway implementation, mean in-hospital LOS was 7.7 versus 10.3 d, in-hospital mortality was 0.3% versus 1.6%, mean costs were $19,428 versus $22,032, 30-day readmission rates were 6.6% versus 7.5%, and complication rates were 6.3% versus 10.3%, respectively. Notably, LOS and institutional costs were reduced at our institution after implementation of the enhanced clinical care pathways. Our costs were higher than comparators before implementation, but lower than comparators after implementation. CONCLUSIONS: Herein, we used an analytic framework and used national administrative data to assess the value of an enhanced care initiative as benchmarked with data from other hospitals. We thus illustrate how to identify and measure opportunities for targeted improvements in health care delivery. We also recognize the limitations of the use of administrative data in a comprehensive assessment of value in health care.

"I want to go home": How location at death influences caregiver well-being in bereavement.

OBJECTIVES: Goal concordant or congruent care involves having expressed wishes upheld. Yet, the preferred location for end-of-life care may be unaddressed. Caregiver-patient congruence between preferred and actual locations of care may influence the quality of life in bereavement. The study aimed to explore how the congruence between caregiver-patient preferred and actual locations of death influenced well-being in bereavement. METHODS: Mixed methods were employed. In-depth in-person interviews were conducted with 108 bereaved caregivers of a hospice patient about 4 months after the death. An interview guide was used to collect quantitative and qualitative data: demographics, decision-making, Core Bereavement Items (CBI), Health Related Quality of Life, and perspectives on the end-of-life experiences. Data were analyzed with a convergent mixed methods one-phase process. RESULTS: Patient preference-actual location congruence occurred for 53%; caregiver preference-actual location congruence occurred for 74%; caregiver-patient preference and location of death occurred for 48%. Participants who reported some type of incongruence demonstrated higher levels of distress, including more days of being physically and emotionally unwell and more intense bereavement symptoms. The Acute Separation subscale and CBI total scores demonstrated significant differences for participants who experienced incongruence compared with those who did not. Preference location congruence themes emerged: (1) caregiver-patient location congruence, (2) caregiver-patient location incongruence, and (3) location informed bereavement. CONCLUSIONS: Congruence between a dying person's preferred and actual locations at death has been considered good care. There has been little focus on the reciprocity between caregiver-patient wishes. Discussing preferences about the place of end-stage care may not make location congruence possible, but it can foster shared understanding and support for caregivers' sense of coherence and well-being in bereavement.

Time-Limited Trials in the Intensive Care Unit to Promote Goal-Concordant Patient Care.

Consider the hypothetical case of a 75-year-old patient admitted to the intensive care unit (ICU) for acute hypoxic respiratory failure due to pneumonia and systolic heart failure. Although she suffers from a potentially treatable infection, her advanced age and chronic illness increase her risk of experiencing a poor outcome. Her family feels conflicted about whether the use of mechanical ventilation would be acceptable given what they understand about her values and preferences. In the ICU setting, clinicians, patients, and surrogate decision-makers frequently face challenges of prognostic uncertainty as well as uncertainty regarding patients' goals and values. Time-limited trials (TLTs) of life-sustaining treatments in the ICU have been proposed as one strategy to help facilitate goal-concordant care in the midst of a complex and high-stakes decision-making environment. TLTs represent an agreement between clinicians and patients or surrogate decision-makers to employ a therapy for an agreed-upon time period, with a plan for subsequent reassessment of the patient's progress according to previously-established criteria for improvement or decline. Herein, we review the concept of TLTs in intensive care, and explore their potential benefits, barriers, and challenges. Research demonstrates that, in practice, TLTs are conducted infrequently and often incompletely, and are challenged by system-level factors that diminish their effectiveness. The promise of TLTs in intensive care warrants continued research efforts, including implementation studies to improve adoption and fidelity, observational research to determine optimal timeframes for TLTs, and interventional trials to determine if TLTs ultimately improve the delivery of goal-concordant care in the ICU.

Achieving goal-concordant care: Formal and informal advance care planning for White, Black, and Hispanic older adults.

INTRODUCTION: Advance care planning (ACP) aims to ensure that patients receive goal-concordant care (GCC), which is especially important for racially or ethnically minoritized populations at greater risk of poor end-of-life outcomes. However, few studies have evaluated the impact of advance directives (i.e., formal ACP) or goals-of-care conversations (i.e., informal ACP) on such care. This study aimed to examine the relationship between each of formal and informal ACP and goal-concordant end-of-life care among older Americans and to determine whether their impact differed between individuals identified as White, Black, or Hispanic. METHODS: We conducted a retrospective cohort study using 2012-2018 data from the biennial Health and Retirement Study. We examined the relationships of interest using two, separate multivariable logistic regression models. Model 1 regressed a proxy report of GCC on formal and informal ACP and sociodemographic and health-related covariates. Model 2 added interaction terms between race/ethnicity and the two types of ACP. RESULTS: Our sample included 2048 older adults. There were differences in the proportions of White, Black, and Hispanic decedents who received GCC (83.1%, 75.3%, and 71.3%, respectively, p < 0.001) and in the use of each type of ACP by racial/ethnic group. In model 1, informal compared with no informal ACP was associated with higher odds of GCC (adjusted odds ratio = 1.38 [95% confidence interval, 1.05-1.82]). In model 2, Black decedents who had formal ACP were more likely to receive GCC than those who did not, but there were no statistically significant differences between decedents of different racial/ethnic groups who had no ACP, informal ACP only, or both types of ACP. CONCLUSIONS: Our results build on previous work by indicating the importance of incorporating goals-of-care conversations into routine healthcare for older adults and encouraging ACP usage among racially and ethnically minoritized populations who use ACP tools at lower rates.

Goals, Values, and Priorities of Hospitalized Patients: Using a Structured Communication Tool to Engage Medical Students in Serious Illness Communication.

Background: To build third-year medical students' serious illness communication skills, we implemented a structured communication tool-the VALUES tool-focused on patients' goals, values, and priorities and described students' experiences using this tool. Methods: Medical students participated in a social worker-led VALUES didactic and discussion with a patient on the palliative care consult service and, subsequently, completed an anonymous survey about their comfort with the VALUES tool and its usefulness for learning (5-point Likert scales). Results: Of the 142 medical students who participated in the VALUES didactic, 37 completed the survey (26%). The VALUES tool was rated highly in terms of usefulness (mean 4.5; standard deviation [SD] 0.7) and rated lower in terms of overall comfort (mean 3.7; SD 0.7). Conclusion: Our project explored the integration of a VALUES tool into medical student education, and we show that the tool is well rated by learners in terms of comfort and usefulness.

Black Americans, hospitalization, and advance care planning: Structural vulnerability in Home Health Value-Based Purchasing.

Skilled home health (HH) is the largest long-term care setting and the fastest-growing site of healthcare in the United States (U.S.). Home Health Value-Based Purchasing (HHVBP) is a structure of Medicare that penalizes U.S. HH agencies for high hospitalization rates. Prior studies have shown inconsistent evidence about associations of race with hospitalization rates in HH. Evidence supports that Black or African Americans are less likely to participate in advance care planning (ACP), or to complete written advance directives, which could affect their potential for hospitalization when nearing end of life. In this quasi-experimental study, we used Medicare administrative datasets, the Weighted Acute Care Services Use Rates (WACSUR) score, and the Advance Care Planning Protocol (ACPP) score to determine whether the proportion of Black HH patients in the U.S. was correlated with acute care use rates and the robustness of agency protocols on ACP. We used primary and secondary data from the U.S. from 2016-2020. We included Medicare-certified HH agencies. Spearman's correlation coefficient was used. We found a statistical trend showing that the greater proportion of Black patients enrolled in a HH agency, the greater tendency to have a high hospitalization rate. Our findings suggest that HHVBP may encourage patient selection and exacerbate health disparities. Our findings support recommendations for alternative measures of quality in HH to include measures of goal-concordant care coordination when patients are denied admission to HH.

Improving Goal-Concordant Care in Intensive Care Unit Admissions from the Emergency Department in a Comprehensive Cancer Center.

CONTEXT: As patients approach the end of life, discussion of their treatment goals is essential to avoid unnecessary suffering and deliver care in a manner consistent with their overall values. OBJECTIVES: Implement a multipronged approach to improve the rates of advance care planning (ACP) documentation among providers admitting patients with cancer to the intensive care unit (ICU) from the emergency department (ED). METHODS: We developed multiple interventions including the development of a best-practice advisory to alert providers when patients had previous do-not-resuscitate orders; standardization of ACP documentation; early oncologist involvement in goals-of-care conversations with patients; a survey of ED providers to identify barriers to success; and positive reinforcement strategies aimed at improving the rates of ACP documentation in patients admitted from the ED to the ICU. RESULTS: Prior to our interventions, only 13% of patients admitted to the ICU from the ED had ACP notes. This percentage increased to 90% by the last month of our project. CONCLUSION: Through our multipronged approach, we significantly improved the rates of ACP documentation among providers admitting patients from the ED to the ICU.

Advance Care Planning in Nursing Homes: Comparing Characteristics and Outcomes of Participants and Non-Participants.

BACKGROUND: There is an increasing need to integrate Advance Care Planning (ACP) in nursing homes (NH) due to rapid aging and burden of multimorbidity. This study examines differences in the characteristics and outcomes of NH residents enrolled in a palliative care programme who have completed ACP and those who did not. METHOD: We conducted a retrospective cohort analysis of 294 deceased residents enrolled into a palliative programme from 8 nursing homes in Singapore. Comparison was made between residents who completed an ACP and those who did not. Treatment preferences and place of death preferences were examined and concordance to these preferences were analyzed. RESULTS: ACP completion rate was 81% in the cohort. Residents opting for comfort measures only had high concordance (92%) for their preferred place of death (PPOD). However, residents opting for limited intervention showed lower PPOD concordance (77%), with many dying in hospitals despite a preference for dying in the NH. Residents with ACP were significantly more likely to die in NH (68.2% vs. 36.4%) and had a longer median programme enrolment duration (131 vs. 53 days) compared to those who did not complete ACP. CONCLUSION: Despite high ACP completion rate in our cohort, challenges remain in aligning treatment preferences with actual care provided, particularly for residents opting for limited intervention. Future efforts should focus on increasing ACP participation and addressing systemic barriers to improve end-of-life care outcomes for NH residents.

Advance Care Planning Bundle: Using Technical and Adaptive Solutions to Promote Goal Concordant Care.

BACKGROUND: Advance Care Planning (ACP) is critical to achieve goal-aligned care for patients. However, optimal implementation requires complex coordination and alignment across a healthcare system. MEASURES: A survey of rapid response providers assessed usefulness of the ACP quality improvement bundle and perceptions of use and adherence. INTERVENTION: We implemented a bundle of advance care planning tools and interventions using the technical-adaptive framework. These included orders, documentation templates and processes, and standard education. OUTCOMES: Ninety-three rapid response providers completed the survey. 80.5% reported that overall, these quality improvement efforts have been very helpful or somewhat helpful in improving their ability to provide care consistent with the patient's goals. CONCLUSIONS/LESSONS LEARNED: Implementation of technical and adaptive tools as a bundle for Advance Care Planning shows promise to improve and sustain goal-aligned care. Quality Improvement in ACP is a complex, iterative process involving both structural change and behavioral adaptation.

The Progression of End-of-Life Wishes and Concordance with End-of-Life Care: An Update.

Importance: Concordance between physician orders for life-sustaining treatment (POLST) preferences and treatment at end-of-life is an important outcome measure of providing patient-centered care. Objectives: We determine whether the COVID pandemic affected clinician ability to provide goal concordant care and replicate our previous report on care concordance and change in patient preferences over time with a larger sample size. We also investigate the quality of POLST completion to determine the number of documents completed with an advance care planning (ACP) conversation or a decision maker present. Methods: Chart abstraction via structured questionnaire of 796 randomly selected patients who died in 2020 with a POLST on file. Results: We found 99% concordance in the last setting of death between a patient's POLST preferences and the care they received. We confirm our previous finding that patients' wishes shift towards a preference for lower treatment intensity at end-of-life. We found that 82% of POLSTs were created in the context of an ACP conversation, 77% with a decision maker present. Conclusion: High levels of goal concordant care were maintained during the pandemic. Because patient wishes evolve over time, clinicians should be trained and supported to revisit care preferences across the illness trajectory.

Respecting Faith, Hope, and Miracles in African American Christian Patients at End-of-Life: Moving from Labeling Goals of Care as "Aggressive" to Providing Equitable Goal-Concordant Care.

In this article, we demonstrate first how the term "aggressive care," used loosely by clinicians to denote care that can negatively impact quality of life in serious illness, is often used to inappropriately label the preferences of African American patients, and discounts, discredits, and dismisses the deeply held beliefs of African American Christians. This form of biased communication results in a higher proportion of African Americans than whites receiving care that is non-goal-concordant and contributes to the prevailing lack of trust the African American community has in our healthcare system. Second, we invite clinicians and health care centers to make the perspectives of socially marginalized groups (in this case, African American Christians) the central axis around which we find solutions to this problem. Based on this, we provide insight and understanding to clinicians caring for seriously ill African American Christian patients by sharing their beliefs, origins, and substantive importance to the African American Christian community. Third, we provide recommendations to clinicians and healthcare systems that will result in African Americans, regardless of religious affiliation, receiving equitable levels of goal-concordant care if implemented. KEY MESSAGE: Labeling care at end-of-life as "aggressive" discounts the deeply held beliefs of African American Christians. By focusing on the perspectives of this group clinicians will understand the importance of respecting their religious values. The focus on providing equitable goal-concordant care is the goal.