Use and Meaning of "Goals of Care" in the Healthcare Literature: a Systematic Review and Qualitative Discourse Analysis.

BACKGROUND: The specific phrase "goals of care" (GOC) is pervasive in the discourse about serious illness care. Yet, the meaning of this phrase is ambiguous. We sought to characterize the use and meaning of the phrase GOC within the healthcare literature to improve communication among patients, families, clinicians, and researchers. METHODS: A systematic review of the English language healthcare literature indexed in MEDLINE/PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus was performed in October of 2018. We searched for all publications with the exact phrase "goals of care" within the title or abstract; no limitations on publication date or format were applied; conference abstracts were excluded. We used qualitative, discourse analysis to identify key themes and generate an operational definition and conceptual model of GOC. RESULTS: A total of 214 texts were included in the final analysis. Use of GOC increased over time with 87% of included texts published in the last decade (2009-2018). An operational definition emerged from consensus within the published literature: the overarching aims of medical care for a patient that are informed by patients' underlying values and priorities, established within the existing clinical context, and used to guide decisions about the use of or limitation(s) on specific medical interventions. Application of the GOC concept was described as important to the care of patients with serious illness, in order to (1) promote patient autonomy and patient-centered care, (2) avoid unwanted care and identify valued care, and (3) provide psychological and emotional support for patients and their families. DISCUSSION: The use of the phrase "goals of care" within the healthcare literature is increasingly common. We identified a consensus, operational definition that can facilitate communication about serious illness among patients, families, and clinicians and provide a framework for researchers developing interventions to improve goal-concordant care.

Improving residents' code status discussion skills: a randomized trial.

BACKGROUND: Inpatient Code Status Discussions (CSDs) are commonly facilitated by resident physicians, despite inadequate training. We studied the efficacy of a CSD communication skills training intervention for internal medicine residents. METHODS: This was a prospective, randomized controlled trial of a multimodality communication skills educational intervention for postgraduate year (PGY) 1 residents. Intervention group residents completed a 2 hour teaching session with deliberate practice of communication skills, online modules, self-reflection, and a booster training session in addition to assigned clinical rotations. Control group residents completed clinical rotations alone. CSD skills of residents in both groups were assessed 2 months after the intervention using an 18 item behavioral checklist during a standardized patient encounter. Average scores for intervention and control group residents were calculated and between-group differences on the CSD skills assessment were evaluated using two-tailed independent sample t tests. RESULTS: Intervention group residents displayed higher overall scores on the simulated CSD (75.1% versus 53.2%, p<0.0001) than control group residents. The intervention group also displayed a greater number of key CSD communication behaviors and facilitated significantly longer conversations. The training, evaluation, and feedback sessions were rated highly. CONCLUSION: A focused, multimodality curriculum can improve resident performance of simulated CSDs. Skill improvement lasted for at least 2 months after the intervention. Further studies are needed to assess skill retention and to set minimum performance standards.

Using an online forum to encourage reflection about difficult conversations in medicine.

OBJECTIVE: Medical students encounter many challenging communication situations during the clinical clerkships. We created the Difficult Conversations Online Forum (DC Forum) to give students an opportunity to reflect, debrief, and respond to one another about their experiences. METHODS: The DC Forum is a web-based application with structured templates for student posts and responses, along with a mechanism for faculty feedback. It became a required part of the curriculum for third-year medical students in 2003. We content analyzed data collected during the 2003-2004 and 2004-2005 academic years (N=315). All open-ended responses were coded by two members of the research team; the few disagreements were resolved via discussion. RESULTS: While posts addressed a wide range of topics, more than one-third (35.6%) of students addressed delivering bad news. Nearly half (49.4%) of the students reported they had talked with someone about their difficult conversation, most frequently a resident physician; the suggestions they received varied in terms of helpfulness. Only a small percentage of students (4.7%) reported accessing other resources. CONCLUSION: The DC Forum provides a template that encourages reflection and dialogue about challenging communication situations. The online design is feasible, and enables a virtual discussion that can be joined by students regardless of their clerkship schedule or clinical site. PRACTICE IMPLICATIONS: A structured approach for reflection and a simple, safe mechanism for feedback are essential components of the learning process regarding difficult conversations. While the DC Forum was created for medical students, the online approach may prove useful across the continuum of medical education.