Professional Abstract

Objective

To evaluate whether an intervention that prepares patients with serious, life-limiting illnesses to have a conversation about care goals with their clinician enhances communication about care preferences and improves achievement of patient goals

Study Design

Design Elements	Description
Design	Randomized controlled trial
Population	132 clinicians and 537 patients with serious, life-limiting illnesses
Interventions/ Comparators	Patients complete a questionnaire reporting their goals for serious illness care and their preferences for communicating those goals; before a routine clinic visit, the researchers present patients, clinicians, and family members with tailored forms based on that information Patients complete the questionnaire but do not receive a tailored report based on their responses
Outcomes	Primary: patient-reported occurrence of patient-clinician communication about care goals Secondary: clinician documentation of a care goals conversation in the health record, patient-reported quality of communication, patient reports of goal-concordant care, patient-reported symptoms of depression and anxiety
Timeframe	2-week follow-up, or until the patient’s death, for primary outcome

This randomized controlled trial tested an intervention to improve clinician-patient communication about patients’ goals for serious illness care. Patients with serious illnesses completed a questionnaire that included questions about their preferences for communication about goals of care, such as whether the patient wanted the doctor to initiate the discussion. The questionnaire also asked about patient preferences for care intensity and about communication barriers and facilitators.

Researchers randomly assigned clinicians to the intervention or comparison group. In the intervention group, researchers prepared a tailored report for the patient, family members, and clinician based on the information in the questionnaire and provided it to them before the visit. In the comparison group, researchers did not share information from the questionnaire.

• Patients in both groups completed a follow-up survey at two weeks about whether they had a conversation about goals of care with their clinician.

At two weeks, three months, and six months after the clinic visit, patients completed surveys about

• The quality of communication with their doctor
• If the care they received matched their goals for care
• Their symptoms of depression and anxiety

The study included 537 patients with serious illnesses and 132 clinicians. Clinicians in the study included primary care doctors, specialists, and nurse practitioners. Researchers recruited patients and clinicians from outpatient clinics in Washington state. Of the patients, 79% were white, 12% were black, 3% were Asian, 6% were mixed or other races. Also, 1% were Hispanic. The average age was 74 and 52% were males. Patients in the study had cancer, lung disease, or other chronic or life-limiting conditions.

A community advisory board, including patients with serious illnesses, caregivers, clinicians, and community members, provided feedback on study materials.

Results

Compared with the comparison group, the intervention group had higher rates of patient-reported communication about care goals at their visits (74% versus 31%, p<0.001), and clinicians also documented more communication with patients about care goals (62% versus 17%; p<0.001). Patient-rated quality of communication was also higher in the intervention group (p=0.01) than in the comparison group.

Among all patients, goal-concordant care was not significantly different between the intervention and comparison groups. However, among patients whose goals were stable between two-week and three-month follow-ups (71%), those in the intervention group were more likely to report greater goal-concordant care (p=0.029) than those in the comparison group.

Depression and anxiety symptoms did not differ significantly between groups at three or six months. Clinicians referred the groups to palliative care at the same rate.

Limitations

The study took place in a single state; results may be different in other places. The clinicians and patients who were willing to participate may not reflect the respective general populations. Only 22% of patients had a family member who participated. Finally, it may have been difficult for patients to discern whether their care was goal-concordant.

Conclusions and Relevance

The study results suggest that preparing patients and clinicians to talk about care goals can increase the occurrence, documentation, and quality of that communication between patients with serious illnesses and their clinicians. Although increased communication did not result in increased goal-concordant care overall, patients with stable goals reported an increase in goal-concordant care.

Clinicians or clinic administrators may implement a communication feedback form to promote discussions about care goals to improve care for patients with serious illnesses.

Future Research Needs

Future research could simplify the communication form and assess its impact in patient and clinician subgroups. Researchers could also investigate barriers to family participation.