Joshua R. Lakin

Improving Communication About Serious Illness in Primary Care: A Review

IMPORTANCE The Institute of Medicine recently called for systematic improvements in clinician-led conversations about goals, values, and care preferences for patients with serious and life-threatening illnesses. Studies suggest that these conversations are associated with improved outcomes for patients and their families, enhanced clinician satisfaction, and lower health care costs; however, the role of primary care clinicians in driving conversations about goals and priorities in serious illness is not well defined. OBJECTIVE To present a review of a structured search of the evidence base about communication in serious illness in primary care. EVIDENCE REVIEW MEDLINE was searched, via PubMed, on January 19, 2016, finding 911 articles; 126 articles were reviewed and selected titles were added from bibliography searches. FINDINGS Review of the literature informed 2 major topic areas: the role of primary care in communication about serious illness and clinician barriers and system failures that interfere with effective communication. Literature regarding the role that primary care plays in communication focused primarily on the ambiguity about whether primary care clinicians or specialists are responsible for initiating conversations, the benefits of primary care clinicians and specialists conducting conversations, and the quantity and quality of discussions. Timely and effective communication about serious illness in primary care is hampered by key clinician barriers, which include deficits in knowledge, skills, and attitudes; discomfort with prognostication; and lack of clarity about the appropriate timing and initiation of conversations. Finally, system failures in coordination, documentation, feedback, and quality improvement contribute to lack of conversations. CONCLUSIONS AND RELEVANCE Clinician and system barriers will challenge primary care clinicians and institutions to meet the needs of patients with serious illness. Ensuring that conversations about goals and values occur at the appropriate time for seriously ill patients will require improved training, validation, and dissemination of patient selection tools, systems for conducting and revisiting conversations, accessible documentation, and incentives for measurement, feedback, and continuous improvement.

Incentivizing Residents to Document Inpatient Advance Care Planning

develops web-based decision support for radiology test ordering. He serves on the board for SEA Medical Systems, which makes intravenous pump technology. He serves as an advisor to Calgary Scientific, which makes technologies that enable mobility within EHRs. He is on the clinical advisory board for Zynx Inc, which develops evidence-based algorithms, and Patient Safety Systems, which provides a set of approaches to help hospitals improve safety. He is a consultant for EarlySense, which makes patient safety monitoring systems.

High-sensitivity troponin: elevated without infarction, is the horse out of the barn?

Ischaemic heart disease persists as the worlds leading cause of mortality with serious consequences for unrecognised disease.1 Chest pain, the cardinal symptom of acute coronary syndromes (ACS), accounts for over six million adult emergency department (ED) visits in the USA and greater than 360 000 in England and Wales each year.2 ,3 If ACS is diagnosed early, there are effective interventions that improve outcomes. Therefore, increasing our diagnostic accuracy in ACS, specifically for acute myocardial infarctions (AMI), including both ST segment and non-ST segment elevation, is critical. A major part of these efforts is the use of biomarkers, primarily the serum troponin assay. To address the expanding clinical use of different troponin assays, the American College of Cardiology Foundation (ACCF) recently issued guidelines on interpreting troponin assays in the clinical setting.4 It notes several recent studies supporting high-sensitivity troponin (HS-Tn) assays as a mechanism to rapidly rule out AMI. These assays are quickly replacing troponin-I as the standard of care in routine clinical practice.4–8 However, these studies do not address one consequence of increasing sensitivity: the tradeoff of increased positive results in the absence of ACS and their associated patient health and financial costs. Several studies have demonstrated the ability of HS-Tn assays to rapidly ‘rule out’ AMI in their respective populations when coupled with standard clinical assessment and ECG.4–8 Achieving a ‘rapid rule-out,’ that is, quickly obtaining accurate negative results, is helpful for the process of safely excluding persons without AMI. A perfect test would achieve …

Something Just Doesn't Smell Quite Right

To the Editor: Sakamoto and colleagues generated a welldesigned, multisite, longitudinal randomized controlled trial to evaluate whether a lavender aromatherapy patch would reduce falls in elderly nursing home residents. The authors did an impeccable job of detailing important outcomes and variables such as functional ability, cognitive function, and behavioral and psychological concerns that could have revealed a failure of randomization. They also set out, using careful longitudinal monitoring of such variables, an interesting set of secondary outcomes, some of which showed significant benefit of lavender patches. Nevertheless, we are concerned about the selective presentation of results in the abstract and in the discussion that give readers a false impression of the primary outcome of the trial. In the abstract, the authors state that the results showed fewer fallers in the lavender group than in the placebo group. The authors failed to report at that point that there was no statistically significant difference in the main outcome of number of falls (P = .08), a critical point for interpreting the trial correctly. Furthermore, they failed to report the unadjusted hazard ratio for their primary outcome (0.67, 95% confidence interval = 0.40–1.10; P = .11). In the abstract, the authors report a significant hazard ratio yielded by an adjusted model (Model 2) without stating that they did so. Statistical significance was demonstrated only after adjustments for variables that appeared equal at baseline and theoretically controlled for by randomization (age, sex, fall history, Mini-Mental State Examination score, Cohen-Mansfield Agitation Inventory score, transfer status, visual status, and tranquilizer use). Although there are instances in which adjustment can be considered, the authors failed to describe in the Methods section why they adjusted for confounders. What was the reasoning for these adjustments? Was this analysis preplanned or completed after data collection? Table 1 did not show any significant differences in many of these particular variables; why then did the authors choose them for their models? Why did they feel that this information was appropriate to leave out of the abstract and instead be replaced by an adjusted model without describing the reasons for doing so? These adjustments and lack of clear and consistent labeling seem to cast a shadow on what was otherwise a well-designed and important trial assessing the effect of this low-risk, promising intervention.

Cancer Survivorship and Palliative Care: Shared Progress, Challenges, and Opportunities

Despite seeming superficially paradoxical, palliative care and survivorship care may have more in common than in opposition. An increased focus on collaboration and a pursuit of shared strategies may foster significant opportunities to both fields.

Modern Death, How Medicine Changed the End of Life—A Book Review

Haider Warraich’s recent book, Modern Death, How Medicine Changed the End of Life,1 is timely. At a time when we strive for simple answers to complex questions, often utter the phrase “I have an app for that,” and condense our thoughts into a 140-character bite, Warraich, a cardiovascular fellow at Duke, engages a complex topic: What does death look like in our modern medical world? He weaves his personal and clinical stories together with threads of history, law, ethics, and spirituality. The book is founded on Warraich’s interactions with individual patients and he constructs his narrative on a backbone of emotional clinical experiences. Onto these anecdotes, he layers an exploration of a complex topic, ranging broadly from the microscope to the intensive care unit, to the courtroom and on to Star Trek: The Next Generation. Through this construction, he presents an ambitious review of how the end of life interacts with our modern practice of medicine. One of Warraich’s key achievements is to disrupt death as a binary concept. Although it is usually easy to agree that a person is vitally and vibrantly alive, it is more difficult to be sure when a person is, indisputably, no longer living. Warraich demonstrates that being alive is in the eye of the beholder, and the lens of that beholder is more of a complicated prism than a pinhole; whether that beholder is patient, family, judge, jury, priest, physician, neighbor, concerned fellow citizen, or a 3-dimensional conglomerate of these melded together. Although death is often already a taboo subject in medicine, even when simplified to its most binary state, Warraich demonstrates how finance, law, politics, and religion make death an exponentially inaccessible topic for conversation. He helps the reader to see more clearly that trying to decide something that seems, with the quick glance that a taboo subject permits, as simple as knowing that life exists, is fraught with real challenges. Warraich then adds further complexity, taking his exploration beyond the debate about the definition of death. In describing the evolution of death, he highlights the challenge that medicine has created for itself—we have made such progress in our ability to postpone death that we now wrestle with the daunting task of relieving suffering in the context of longer lives with more complicated, meandering courses. Suffering may be an even more difficult target than death. As the end of life nears, we charge ourselves with addressing a range of discomforts, including those that are physical, emotional, existential, and even financial. In that context, we encounter difficulties as we strive to alleviate suffering. For many people, there are states worse than death and eliciting an understanding of those states is difficult.2 Those states are in many ways mirages for patients—changing with time, with distance from the subject, or when viewed through the filters of spirituality or religion. The struggle extends beyond the individual patient, impacting in substantial ways their caregivers and communities. Warraich highlights some of the tools we have for alleviating suffering associated with advancing illness—important activities, such as palliative care and the key task of exploring goals and values with patients and their families. However, he also points out that clinicians are not well-prepared for those explorations. For example, we have not learned how to handle the intensity of silence, knowing that holding a quiet space is in fact doing something significant and meaningful for a patient, and can be more so than prescribing a medicine or offering a procedure. Warraich engages thoughtfully with some controversial topics around suffering and control at the end of life, and I found myself ready to debate some of his suggestions. His description of his experience using the principle of “double effect”—tolerating the sedation effects of opioids when used to treat pain near the end of life—does not mirror my own in palliative care. I believe he underplays the importance of intention and the essential need for good symptom control, provided in lock step with a skillful exploration of the patients’ goals and preferences. Of course, stimulating debate about controversial topics at the intersection of death and modern medicine may be his intention. I agree with his ambition to shine a light on the issues in our historical and current medical practice around death. This book is needed for people experiencing and interacting with death throughout our modern medical system. It reminds us about the journey so far, the progress we have made, and the work that remains. We are complex and varied when it comes to our views of death in the context of ethics, spirituality, family, and society. As Warraich puts it, “the only way to make any real change is to tear away the vines of terror that creep up our legs whenever we talk about death and dying.”1 These vines may be hard to recognize, because they come in so many shapes, colors, textures, smells, and sensations. They can sometimes bear flowers and fruit that do not have an overwhelming scent of terror, but instead notes of tranquility. Maintaining our curiosity about the diversity of those vines when talking about death and dying is paramount to continuing to progress. Like death itself, few, if any, aspects of the vital and ongoing discussion about death in the world of modern medicine are binary. PERSPECTIVE

Can we improve the quality of documented end-of-life conversations using a structured, multicomponent intervention?

49 Background: Conversations about serious illness care goals are often inadequate and fail to address key elements of high-quality discussions. METHODS As part of a cluster-randomized trial of a multi-component communication intervention, we conducted a retrospective chart review of 147 deceased oncology patients to assess frequency and timing of documentation of end-of-life (EOL) conversations; charts of a subset of 20 intervention and 20 matched control patients underwent detailed review to assess quality. A systematically developed abstraction tool was used by two blinded researchers. The tool contained 25 elements reflecting four EOL conversation domains: goals/values, illness understanding/prognosis, EOL care planning, life-sustaining treatments. RESULTS Of 153 intervention patients, 44.4% died (n = 68); of 161 controls, 49.1% died (n = 79). Significantly more intervention patients than controls (92.7% vs 74.7%, p = 0.006) had at least 1 documented EOL discussion before death; intervention conversations occurred 3 months earlier (median 147 days vs 62 days, p = 0.003). 59.4% of intervention conversations were documented in a retrievable EHR location compared to 10.2% of controls (p = 0.001). In the detailed review, 85% (n = 17) of intervention and 40% (n = 8) of controls had at least 1 documented discussion about values/goals (p = 0.0001), with an average of 3.6 of 8 elements (0.7 of 8 for controls) (p = 0.0003). 85% percent (n = 17) of intervention and 30% (n = 6) of controls had at least 1 documented discussion about prognosis (p = 0.0014), with an average of 2.5 of 7 elements (0.5 of 7 for controls) (p = 0.001). 85% of intervention (n = 17) and 55% of controls (n = 11) had at least 1 documented discussion about EOL planning (p = 0.009). 55% of intervention and 30% of controls had at least 1 documented discussion about life-sustaining treatments (p = 0.20). CONCLUSIONS The intervention resulted in more, earlier and better documentation of serious illness care goals. Across 3 of 4 domains of quality, intervention patients had more detailed information about their EOL care preferences, demonstrating that the intervention results in more patient-centered, comprehensive discussions. CLINICAL TRIAL INFORMATION NCT01786811.

Opening It Up For More Questions: Racial Disparities in Hospice Use

more evenly serve our patients. The study by Johnson et al. focuses on differences in hospice use between black and white patients. Prior research has shown wide geographic variation in hospice use among racial groups. This study evaluated whether racial variation held true at the county level in the Carolinas. What they found was a statistically significant racial variation in just under a third of the counties studieddthis was not particularly surprising. What was surprising and interesting was the finding that, in counties with black-white disparities, there was a significant association with a greater number of hospital beds, physicians per older person, hospices, and a higher proportion of nongeneralist physicians. Fewer blacks used hospice in counties where specialists and hospitals were highly available. As the authors note, key questions remain unanswered. How do patient preferences and clinician behaviors influence observed disparities? How does the matching of treatment to goals influence patient satisfaction? The authors attribute this difference to previously documented variance in preference for using hospital resources when available, but there