Best Practices To Increase Goals of Care Conversations in Primary Care

Motivation

It’s Not a Matter of Why But When…

To have the (goals of care) conversations…
-Life-sustaining treatment decisions

-Elicit, document, and honor values, goals, and preferences

There’s never a good time…
-And yet it must be done
-But when?

-Outpatient setting - patients are lucid?

-Inpatient setting - patients closer to an adverse event or death?
-Moving target - preferences change…you never know until closer to the end

Earlier is better (in theory)

Project Aim

Identifying the Pain Points

If sooner is better than later, then why are conversations not taking place?
1. Why bother
-Limited physician time with many competing demands ~ 20 minutes per visit
-COVID-19: bottleneck due to delayed care
-Notes of conversations are not used later
-Patients change their minds

2. An intense conversation that requires bedside manners
-Trust between physicians and patients
-Physician know-how
-Prompts patients to think that they will die soon

3. Who should have the conversation?
-Physicians, social workers, nurses, or nursing assistants.

Methods and My Role

Research Questions

Qualitative
What are the barriers and facilitators, and what is the context of the goals of care conversation?

Quantitative
What are physician characteristics and perceptions related to carrying out goals of care conversations with seriously ill patients?

Research Plan

Qualitative Methods
(My role) Conducted semi-structured interviews with physicians and executives throughout a 24-month period at 3 hospitals.

Quantitative Methods
(My role) Develop & fielded physician surveys administered at baseline and 6-12 months later at 3 hospitals.

Insights and Deliverables

Insights

-A case of kicking the can down the road but (hopefully) not too far:
-Primary care vs specialist physicians.

-Patient preferences change with changing prognosis.

-Medicine is at its most artful – trust, bedside manners, tack.

Deliverables

1. Develop a facilitation “playbook” for scale-up: implementation strategies.

2. Research repository of data/artifacts for future work.

3. Slide deck presentations of insights for leadership.

4. Periodic comprehensive written reports to funders.

5. Numerous conference products.

6. Peer-reviewed journal publications of key finding.

Impacts

1. Identify when and how goals of care are or should be carried out in primary care settings.

2. Increase goals of care conversations across different hospitals.

3. Return to the mission of medicine- healthcare delivery aligning with patient preferences and wishes.