A team of researchers has developed a standardized goals-of-care note to document patient wishes in the electronic medical record.

Many patients do not experience goals-of-care conversations in a timely manner. But even among those who have, their wishes can get lost if they are not documented. The standardized note created by a research team from the Regenstrief Institute, the Indiana University School of Medicine and Indiana University Health can help health care providers be aware of and access patients’ goals of care, according to lead investigator Dr. Alexia Torke.

“One of the main purposes of having conversations with patients and families about their preferences is to inform their future medical care. But some of the time we have those conversations — they may be very rich conversations — but they’re not written down,” Torke told Palliative Care News. “The information is actually needed at a later time, like when the person is having an emergency, and it’s extremely important that we be able to access that information in a timely fashion.”

The research on the note was published in the American Journal of Medicine.

During the first year following implementation of the note, 944 patients had their goals of care documented in their EMR. The research team then examined the notes written by palliative care clinicians and a random selection of other providers. They found some differences between those notes prepared by the palliative teams and those written by others.

Key findings include:

• Palliative clinicians documented patient preferences, values and religion more often than other clinicians in goal of care notes (75% versus 32%).
• Palliative care clinicians documented a patient capacity to make medical decisions more often than other clinicians (74% versus 33%).
• Palliative care clinicians identified the patient’s legal decision maker more often than other clinicians (70% versus 32%).
• Hospice was discussed more by palliative care clinicians than other clinicians (50% versus 27%). 
• Palliative care discussions yielded higher hospice enrollments, indicating selection of comfort care before death (50% versus 35%)
• Among the patients who died during the study, other clinicians wrote goals-of-care notes closer to death compared to palliative care clinicians (4 days before death versus 19 days). 

Intensive care unit clinicians and hospital medicine clinicians were the second most likely to document goals of care after palliative care clinicians.

“Talking about goals of care and documenting is a core skill of palliative care, and so we really shouldn’t be surprised that the notes from palliative care are more detailed,” Torke said. “This is really critical to what we do, but it also does point to education that we can do to other types of clinicians who have these conversations on a regular basis.”