Implementing standardized documentation for goals of care among advanced stage cancer patients.

Abstract

e23236 Background: Early goals of care (GOC) discussions are associated with better health outcomes and quality of life for patients with advanced cancer. We describe a quality improvement initiative to improve documentation of GOC discussions. Methods: Using a Plan-Do-Study-Act model, we promoted use of a concise GOC documentation form developed by Cancer Care Ontario (CCO) among oncologists at a single institution. In stage 1, we established baseline data for 3 metrics within 60 days of initial consult: documented GOC discussions, documentated resuscitation status, and palliative care referral rates . Patients were identified by searching the hospital’s cancer activity level reporting database using ICD-10 codes for metastatic solid tumors and hematologic malignancies as well as the cases prescribed palliative systemic therapy. Corresponding patient charts were selected from the electronic health record (EHR) system and manually reviewed. In stage 2, the GOC documentation form was created with stakeholder input from patients, oncologists, nurses, social workers and palliative care physicians and implemented. In stage 3, we repeated the same approach as in stage 1 to obtain data for our metrics following implementation of the initiative and solicited feedback from patients and physicians. GOC forms in the EHR were manually reviewed to identify and track palliative referral status and resuscitation status completion. Results: At baseline, only 15 of 283 (5%) patients with incurable cancer had documented GOC discussions within 60 days of initial consult. 7 (2%) had DNR statuses documented and 11 (4%) consults were referred to palliative care. 83% of oncologist surveyed identified time-pressures as a reason for poor documentation rates. Following implementation, only 14 (2%) of 720 new consults had forms completed within 60 days. Patients who had the GOC form completed had a higher rate of palliative care referrals than those who did not (4.8% vs. 33%, p = 0.121). 140 GOC forms were completed in total. Among them, 90(64.3%) had a documented DNR and 48 (40.7%) had new palliative care referrals. Among 40 patients surveyed on their GOC discussion experience, 28 (70%) had discussions prior to treatment onset, 30 (75%) felt satisfied with the discussion timing, and 28 (70%) found GOC discussions beneficial. Conclusions: Among patients with advanced cancers, use of a documentation form for GOC documentation was associated with higher palliative care referral rates compared to cases when the form was not used. GOC discussions were met with overall satisfaction by patients. However, early documentation remained poor among oncologists despite implementation. Our study is limited by the single-center design, potential selection bias in patient surveys (40 respondents), and manual chart review errors. Future efforts will include electronic prompting and qualitative assessments of barriers among oncologists.