New Studies Guide When to Have End-of-Life Care Conversations

Researchers recently found that “trigger systems” signaling when a patient may need palliative care can boost utilization of those services, as well as advance care planning and hospice admissions.

The American Journal of Managed Care recently examined the impacts of two studies published in the Journal of Clinical Oncology that explored ways to help providers recognize when to have goals-of-care conversations with their patients, as well as when they may need palliative care.

Both studies found that establishing standardized parameters helped providers identify patients’ needs earlier in their health trajectories.

Identifying triggers for palliative care

New Jersey-based Monmouth Medical Center recently developed a set of triggers to help clinicians identify patients most likely to benefit from palliative care. Triggers included a list of symptoms at the time of patient admission, presence of comorbidities, age and illness requirements, and availability of social and caregiver support.

The hospital’s nursing staff used this trigger system to assess patients’ eligibility for palliative care and tracked the outcomes as part of a multidisciplinary study. If patients met even one of the triggers, care teams flagged them for a palliative consultation.

“Application of trigger-based pathways leads to early and increased utilization of palliative care services for all patients by identifying patients to benefit from early palliative care consultations,” researchers concluded.

The study spanned a three-month period earlier this year, including a one-month pre-intervention phase. In total, nurses recommended palliative care consultations for nearly 350 patients during the course of the study. The bulk of these (223) occurred within the first month.

After implementing the trigger system, palliative care referrals rose to 62.3%, up from close to 29% pre-intervention, the study indicated.

The Monmouth study researchers stated that the trigger system led to “improvement in utilization of hospice services and clarification of their code status at the time of discharge,” particularly among cancer patients. Ten cancer patients were discharged to home hospice during the intervention phase of the study, compared to none in the pre-intervention phase. More than half of these were referred from hospital-based intensive care units, while four were from medical floors.

Further studies are needed to standardize referral processes and increase integration of palliative care into hospital-based clinical care models, according to the researchers.

Signals for goals of care conversations

Other recent research has dug into methodologies that improve access to and understanding of advance care planning.

The pandemic has led to a rise of public recognition around the value of advance care planning, but thus far this has not translated into increased utilization.

More than two-thirds (68%) of Americans indicated that discussing end-of-life care plans with their loved ones is important in a recent survey from Ethos, a life insurance provider and global technology company. Yet, less than half (47%) of these individuals followed through with conversations or preparations, according to the survey findings.

One contributing factor is a lack of training among health care professionals around how and when to conduct goals-of-care conversations.

Massachusetts-based Dana-Farber Cancer Institute developed a platform aimed at helping to alert clinicians of when to initiate those discussions.

“A clinical pathways platform can be a key tool in designating clinical scenarios associated with poor prognosis and identifying patients who may be particularly at risk,” the study’s authors wrote.

Throughout the course of the 15-month study, researchers from the institute asked oncologists to identify characteristics of lung cancer patients with an estimated life expectancy prognosis of less than 12 months. Researchers then embedded these factors into a “pathway platform” designed for those who were at risk of poor outcomes and could benefit from advance care planning.

Clinicians used the platform to guide 264 care navigations for 205 patients with lung cancer.

“By embedding this into the pathways data model, we aim to alert physicians to conduct goals-of-care conversations, offer supportive care resources and match patients to appropriate treatment options and clinical trials,” authors stated.