Quality of clinicians’ conversations with patients and families before and after implementation of the Serious Illness Care Program in a hospital setting: a retrospective chart review study

Christina Ma; Lauren E. Riehm; Rachelle Bernacki; Joanna Paladino; John J. You

doi:10.9778/cmajo.20190193

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Figure 1:
Median scores for quality of conversations about serious illness in the intervention and control groups. Life-sustaining treatments scored on a scale of 0–2, prognosis and illness understanding scored on a scale of 0–4, values and goals scored on a scale of 0–7, and end-of-life care planning scored on a scale of 0–4 (total 17). Note: NS = not significant. *p = 0.03, †p < 0.001.

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Table 1:

Adaptation of the Serious Illness Care Program to the hospital medical ward setting

Component	Original in oncology clinic	Adaptation to hospital medical ward
Tools	Previsit letter	Script adjusted to reflect hospital setting rather than clinic visit
	Serious Illness Conversation Guide	No changes
	Clinician Reference Guide	No changes
	Family communication guide	No changes
Clinician training	2.5-h workshop including reflection; didactic teaching skills practice involving role play using the Serious Illness Conversation Guide with standardized patients; and direct observation and feedback from expert faculty	No changes
System change
Patient identification	“No” response to question “Would you be surprised if this patient died in the next year?”	Leveraged an existing hospital initiative to screen all patients in the emergency department aged ≥ 65 yr at the time of admission with the interRAI Emergency Department Screener; patients with a score of 5 or 6 who had a stay of at least 48 h on the medical ward were eligible
Reminding clinicians	Email sent the day before the clinic visit notifying the clinician that the patient is due for a conversation about serious illness; on the day of the visit, the Serious Illness Conversation Guide is placed with the face sheet that is given to clinicians before each patient visit	Hired a unit champion (former bedside nurse from the medical ward), who reminded clinicians in person, by telephone or by text message to have a conversation about serious illness with eligible inpatients under their care
Patient preparation	Previsit letter mailed to eligible patients	Unit champion prepared patients/families in hospital using the script adapted from the previsit letter
Conversation using Serious Illness Conversation Guide	During outpatient visit in clinic room	During hospital stay, in a private meeting room on the ward
Documentation of conversation	Electronic medical record module using a structured format that aligns with the items in the Serious Illness Conversation Guide	Dictated, structured clinical note that aligned with the items in the Serious Illness Conversation Guide; the transcribed note was placed in the patient’s electronic medical record and automatically faxed to the patient’s primary care physician (e.g., using the same workflow as for consultation notes and discharge summaries)
Patient and family support	After the conversation, the clinician gives the patient the Family Communication Guide	After the conversation (typically 24–48 h), the unit champion gave patients/families the Family Communication Guide and also provided in-person support and debriefing

Table 2:

Baseline characteristics of inpatients who took part in the Serious Illness Care Program and the control group

Variable	Group; mean ± SD^*		p value
Variable	Intervention n = 56	Control n = 56	p value
Age at time of conversation about serious illness, yr	76.2 ± 11.8	80.1 ± 11.4	0.08
Male sex, no. (%)	26 (46)	25 (45)	0.8
Charlson Comorbidity Index score	0.9 ± 1.5	1.1 ± 1.3	0.9
No. of emergency department visits in previous year	2.7 ± 2.7	3.6 ± 4.3	0.2
Arrived in emergency department by ambulance, no. (%)	41 (73)	50 (89)	0.05
Seen in cancer clinic in previous 6 mo, no. (%)	8 (14)	2 (4)	0.09
Laboratory values^†
Hematocrit	0.34 ± 0.08	0.35 ± 0.06	0.4
Creatinine level, μmol/L	145 ± 114	162 ± 152	0.5
Albumin level, g/L	28 ± 5.9	29 ± 5.7	0.2
Bilirubin level, μmol/L	16 ± 13	18 ± 20	0.7
High-sensitivity troponin I level, ng/L, median (IQR)	20 (9–71)	31 (12–66)	0.6^‡

Note: IQR = interquartile range, SD = standard deviation.
↵* Except where noted otherwise.
↵† The most abnormal result from 48 hours before hospital admission to 6 hours after.
↵‡ Mann–Whitney test used since data were not distributed normally (highly skewed).

Table 3:

Quality of conversations about serious illness in the intervention and control groups, stratified by the type of clinician who led the conversation

Type of clinician	Group; total score,^* median (IQR)		p value
Type of clinician	Intervention n = 55	Control n = 28	p value
Attending physician	9.0 (7.0–12.0)	4.0 (3.8–6.0)	< 0.001
Resident or nurse practitioner	8.0 (7.0–9.0)	4.5 (2.8–5.3)	0.008

Note: IQR = interquartile range.
↵* Maximum 17.