IMPORTANCE: Despite the benefits of goals-of-care (GOC) communication, many hospitalized individuals never communicate their goals or preferences to clinicians.
OBJECTIVE: To assess whether a GOC video intervention delivered by palliative care educators (PCEs) increased the rate of GOC documentation.
DESIGN, SETTING, AND PARTICIPANTS: This pragmatic, stepped-wedge cluster randomized clinical trial included patients aged 65 years or older admitted to 1 of 14 units at 2 urban hospitals in New York and Boston from July 1, 2021, to October 31, 2022.
INTERVENTION: The intervention involved PCEs (social workers and nurses trained in GOC communication) facilitating GOC conversations with patients and/or their decision-makers using a library of brief, certified video decision aids available in 29 languages. Patients in the control period received usual care.
MAIN OUTCOME AND MEASURES: The primary outcome was GOC documentation, which included any documentation of a goals conversation, limitation of life-sustaining treatment, palliative care, hospice, or time-limited trials and was obtained by natural language processing.
RESULTS: A total of 10?802 patients (mean [SD] age, 78  years; 51.6% male) were admitted to 1 of 14 hospital units. Goals-of-care documentation during the intervention phase occurred among 3744 of 6023 patients (62.2%) compared with 2396 of 4779 patients (50.1%) in the usual care phase (P < .001). Proportions of documented GOC discussions for Black or African American individuals (865 of 1376 [62.9%] vs 596 of 1125 [53.0%]), Hispanic or Latino individuals (311 of 548 [56.8%] vs 218 of 451 [48.3%]), non-English speakers (586 of 1059 [55.3%] vs 405 of 863 [46.9%]), and people living with Alzheimer disease and related dementias (520 of 681 [76.4%] vs 355 of 570 [62.3%]) were greater during the intervention phase compared with the usual care phase.
CONCLUSIONS AND RELEVANCE: In this stepped-wedge cluster randomized clinical trial of older adults, a GOC video intervention delivered by PCEs resulted in higher rates of GOC documentation compared with usual care, including among Black or African American individuals, Hispanic or Latino individuals, non-English speakers, and people living with Alzheimer disease and related dementias. The findings suggest that this form of patient-centered care delivery may be a beneficial decision support tool.
TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04857060.
GOC conversations occur regularly in an ED setting, even before decision to admit. This information is necessary for clinical staff as it clearly prescribes a trajectory that is determined by the patient/SDM. Ultimately, this preserves dignity and autonomy. Any intervention used to facilitate this is a win. With that said, it's surprising to read that GOC video conferencing is considered to improve completion rates of this important document, in 2 urban hospitals (Boston and New York). In any event, I believe this paper adds to the body of literature on this topic. Certainly, video conferencing should be used to facilitate GOC conversations at any point during an acute care hospitalization. One concern is that an admitting service generally assumes completion of this document -- by necessity, the MRP or team delegate. For that reason, it is unclear to me if the trained Palliative Care Educator (PCE) facilitating the conversation was a member of the patients' health care team.
Any intervention that improves discussion around palliative and EOL care should clearly be investigated and implemented. This seems a fairly straightforward and feasible intervention.
As a Nurse practitioner working in long-term care, I was not surprised that introducing palliative care educators onto inpatient units increased documentation of goals of care conversations. It was not clear if the standardized video component made an impact in documentation rates or the educators, but any research that supports improved GOC conversations is welcomed.
This seems like an easily adoptable and inexpensive intervention that I would like to have available on my hospital service.
Goals of care discussion, documentation, and implementation remains standard care in geriatrics. These aspects have not been applied successfully. This study has shown a way forward.