More Than a Prompt May be Needed to Improve Palliative Care Discussions for Hospitalized Patients

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We read with interest the study published in a recent issue of Critical Care Medicine by Picker et al (1) which examined the use of an automated Early Warning Score alert to prompt palliative care discussions. The investigators randomized adult general medicine patients triggering the score into usual care or an intervention group in which the patient’s primary team received scripted recommendations for palliative-focused interventions. These recommendations included prompts to discuss and document advance directives and code status. We applaud this novel approach to improve communication with a population at risk for deterioration.
While we were encouraged to find that the intervention significantly improved the proportion of patients with advance directive documentation (37.1% vs 15.4%) and documentation of resuscitation status (36.0% vs 23.1%), we were discouraged by the low frequency of this documentation even in the intervention group. The medical record often does not reflect the true wishes of severely ill hospitalized patients and patients without accurate documentation are at risk for undesired care (2). In this study, identifying patients at high risk for deterioration and prompting their team to document an advance directive still left roughly two thirds of these patients without documented preferences.
Internal medicine residents and attendings often feel unprepared to discuss code status and fail to conduct high-quality discussions (3, 4). Prompting the general medicine team to engage in palliative discussions may not be enough to overcome these barriers in the absence of additional skills training. These findings may therefore present further evidence of the need to improve formal training for primary inpatient providers to communicate about code status and advance directives. Additionally, although the intervention recommendations included the option of palliative care consult, there was no significant increase in specialist palliative care utilization in this group. Perhaps, identification of the subset of this population with more complex palliative needs, followed by automated direct notification of the specialist palliative care service, could increase utilization of specialists for more difficult discussions. This proactive use of specialist palliative care has been effective in the ICU (5).
Picker et al (1) recognized the need for palliative-focused care among patients triggering Early Warning Scores and their intervention resulted in a significant improvement in the delivery of this care. Additional work should build upon this to increase the proportion of high-risk patients with advance directive and code status documentation.
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