Publications by authors named "Erin K Kross"

70 Publications

Improving communication about goals of care for hospitalized patients with serious illness: Study protocol for two complementary randomized trials.

Contemp Clin Trials 2022 Aug 10:106879. Epub 2022 Aug 10.

Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America.

Background: Although goals-of-care discussions are important for high-quality palliative care, this communication is often lacking for hospitalized older patients with serious illness. Electronic health records (EHR) provide an opportunity to identify patients who might benefit from these discussions and promote their occurrence, yet prior interventions using the EHR for this purpose are limited. We designed two complementary yet independent randomized trials to examine effectiveness of a communication-priming intervention (Jumpstart) for hospitalized older adults with serious illness.

Methods: We report the protocol for these 2 randomized trials. Trial 1 has two arms, usual care and a clinician-facing Jumpstart, and is a pragmatic trial assessing outcomes with the EHR only (n = 2000). Trial 2 has three arms: usual care, clinician-facing Jumpstart, and clinician- and patient-facing (bi-directional) Jumpstart (n = 600). We hypothesize the clinician-facing Jumpstart will improve outcomes over usual care and the bi-directional Jumpstart will improve outcomes over the clinician-facing Jumpstart and usual care. We use a hybrid effectiveness-implementation design to examine implementation barriers and facilitators.

Outcomes: For both trials, the primary outcome is EHR documentation of a goals-of-care discussion within 30 days of randomization; additional outcomes include intensity of end-of-life care. Trial 2 also examines patient- or family-reported outcomes assessed by surveys targeting 3-5 days and 4-8 weeks after randomization including quality of goals-of-care communication, receipt of goal-concordant care, and psychological symptoms.

Conclusions: This novel study incorporates two complementary randomized trials and a hybrid effectiveness-implementation approach to improve the quality and value of care for hospitalized older adults with serious illness.

Clinical Trials Registration: STUDY00007031-A and STUDY00007031-B.
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http://dx.doi.org/10.1016/j.cct.2022.106879DOI Listing
August 2022

Admission Code Status and End-of-life Care for Hospitalized Patients With COVID-19.

J Pain Symptom Manage 2022 Jun 25. Epub 2022 Jun 25.

Cambia Palliative Care Center of Excellence (WA.K., L.R.P., C.J.C., E.K.K., J.R.C., N.K.), University of Washington, Seattle, WA, USA; Department of Anesthesiology and Pain Medicine (N.K.), University of Washington, Seattle, WA, USA.

Context: The COVID-19 pandemic has highlighted variability in intensity of care. We aimed to characterize intensity of care among hospitalized patients with COVID-19.

Objectives: Examine the prevalence and predictors of admission code status, palliative care consultation, comfort-measures-only orders, and cardiopulmonary resuscitation (CPR) among patients hospitalized with COVID-19.

Methods: This cross-sectional study examined data from an international registry of hospitalized patients with COVID-19. A proportional odds model evaluated predictors of more aggressive code status (i.e., Full Code) vs. less (i.e., Do Not Resuscitate, DNR). Among decedents, logistic regression was used to identify predictors of palliative care consultation, comfort measures only, and CPR at time of death.

Results: We included 29,923 patients across 179 sites. Among those with admission code status documented, Full Code was selected by 90% (n = 15,273). Adjusting for site, Full Code was more likely for patients who were of Black or Asian race (ORs 1.82, 95% CIs 1.5-2.19; 1.78, 1.15-3.09 respectively, relative to White race), Hispanic ethnicity (OR 1.89, CI 1.35-2.32), and male sex (OR 1.16, CI 1.0-1.33). Of the 4951 decedents, 29% received palliative care consultation, 59% transitioned to comfort measures only, and 29% received CPR, with non-White racial and ethnic groups less likely to receive comfort measures only and more likely to receive CPR.

Conclusion: In this international cohort of patients with COVID-19, Full Code was the initial code status in the majority, and more likely among patients who were Black or Asian race, Hispanic ethnicity or male. These results provide direction for future studies to improve these disparities in care.
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http://dx.doi.org/10.1016/j.jpainsymman.2022.06.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9233554PMC
June 2022

Seriously Ill Patients' Prioritized Goals and Their Clinicians' Perceptions of Those Goals.

J Pain Symptom Manage 2022 Jun 11. Epub 2022 Jun 11.

Division of Pulmonary (R.A.E., E.L.N., J.R.C., E.K.K.), Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (R.A.E., E.L.N., L.C.B., J.R.C., E.K.K.), University of Washington, Seattle, Washington, USA.

Context: Seriously ill patients whose prioritized healthcare goals are understood by their clinicians are likely better positioned to receive goal-concordant care.

Objectives: To examine the proportion of seriously ill patients whose prioritized healthcare goal is accurately perceived by their clinician and identify factors associated with accurate perception.

Methods: Secondary analysis of a multicenter cluster-randomized trial of outpatients with serious illness and their clinicians. Approximately two weeks after a clinic visit, patients reported their current prioritized healthcare goal- extending life over relief of pain and discomfort, or relief of pain and discomfort over extending life - and clinicians reported their perception of their patients' current prioritized healthcare goal; matching these items defined accurate perception.

Results: Of 252 patients with a prioritized healthcare goal, 60% had their goal accurately perceived by their clinician, 27% were cared for by clinicians who perceived prioritization of the alternative goal, and 13% had their clinician answer unsure. Patients who were older (OR 1.03 per year; 95%CI 1.01, 1.05), had stable goals (OR 2.52; 95%CI 1.26, 5.05), and had a recent goals-of-care discussion (OR 1.78, 95%CI 1.00, 3.16) were more likely to have their goals accurately perceived.

Conclusion: A majority of seriously ill outpatients are cared for by clinicians who accurately perceive their patients' prioritized healthcare goals. However, a substantial portion are not and may be at higher risk for goal-discordant care. Interventions that facilitate goals-of-care discussions may help align care with goals, as recent discussions were associated with accurate perceptions of patients' prioritized goals.
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http://dx.doi.org/10.1016/j.jpainsymman.2022.06.004DOI Listing
June 2022

Evolution of Investigating Informed Assent Discussions about CPR in Seriously Ill Patients.

J Pain Symptom Manage 2022 06;63(6):e621-e632

Pulmonary, Critical Care & Sleep Medicine, Cambia Palliative Care Center of Excellence at UW Medicine (R.A.E.), University of Washington, Seattle, Seattle, Washington, USA.

Context: Outcomes after cardiopulmonary resuscitation (CPR) remain poor. We have spent 10 years investigating an "informed assent" (IA) approach to discussing CPR with chronically ill patients/families. IA is a discussion framework whereby patients extremely unlikely to benefit from CPR are informed that unless they disagree, CPR will not be performed because it will not help achieve their goals, thus removing the burden of decision-making from the patient/family, while they retain an opportunity to disagree.

Objectives: Determine the acceptability and efficacy of IA discussions about CPR with older chronically ill patients/families.

Methods: This multi-site research occurred in three stages. Stage I determined acceptability of the intervention through focus groups of patients with advanced COPD or malignancy, family members, and physicians. Stage II was an ambulatory pilot randomized controlled trial (RCT) of the IA discussion. Stage III is an ongoing phase 2 RCT of IA versus attention control in in patients with advanced chronic illness.

Results: Our qualitative work found the IA approach was acceptable to most patients, families, and physicians. The pilot RCT demonstrated feasibility and showed an increase in participants in the intervention group changing from "full code" to "do not resuscitate" within two weeks after the intervention. However, Stages I and II found that IA is best suited to inpatients. Our phase 2 RCT in older hospitalized seriously ill patients is ongoing; results are pending.

Conclusions: IA is a feasible and reasonable approach to CPR discussions in selected patient populations.
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http://dx.doi.org/10.1016/j.jpainsymman.2022.03.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9179950PMC
June 2022

J. Randall Curtis's Legacy and Scientific Contributions to Palliative Care in Critical Care.

J Pain Symptom Manage 2022 06;63(6):e587-e593

Cambia Palliative Care Center of Excellence at UW Medicine (S.E.M., E.K.K.), Seattle, Washington State, USA; Division of Pulmonary (E.K.K.), Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington State, USA.

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http://dx.doi.org/10.1016/j.jpainsymman.2022.02.335DOI Listing
June 2022

Efficacy of a Communication-Priming Intervention on Documented Goals-of-Care Discussions in Hospitalized Patients With Serious Illness: A Randomized Clinical Trial.

JAMA Netw Open 2022 04 1;5(4):e225088. Epub 2022 Apr 1.

Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle.

Importance: High-quality goals-of-care communication is critical to delivering goal-concordant, patient-centered care to hospitalized patients with chronic life-limiting illness. However, implementation and documentation of goals-of-care discussions remain important shortcomings in many health systems.

Objective: To evaluate the efficacy, feasibility, and acceptability of a patient-facing and clinician-facing communication-priming intervention to promote goals-of-care communication for patients hospitalized with serious illness.

Design, Setting, And Participants: This randomized clinical trial enrolled patients from November 6, 2018, to February 18, 2020. The setting was 2 hospitals in an academic health care system in Seattle, Washington. Participants included hospitalized adults with chronic life-limiting illness, aged 65 years or older and with markers of frailty, or aged 80 years or older. Data analysis was performed from August 2020 to August 2021.

Intervention: Patients were randomized to usual care with baseline questionnaires (control) vs the Jumpstart communication-priming intervention. Patients or surrogates in the intervention group and their clinicians received patient-specific Jumpstart Guides populated with data from questionnaires and the electronic health records (EHRs) that were designed to prompt and guide a goals-of-care discussion.

Main Outcomes And Measures: The primary outcome was EHR documentation of a goals-of-care discussion between randomization and hospital discharge. Additional outcomes included patient-reported or surrogate-reported goals-of-care discussions, patient-reported or surrogate-reported quality of communication, and intervention feasibility and acceptability.

Results: Of 428 eligible patients, this study enrolled 150 patients (35% enrollment rate; mean [SD] age, 59.2 [13.6] years; 66 women [44%]; 132 [88%] by patient consent and 18 [12%] by surrogate consent). Seventy-five patients each were randomized to the intervention and control groups. Compared with the control group, the cumulative incidence of EHR-documented goals-of-care discussions between randomization and hospital discharge was higher in the intervention group (16 of 75 patients [21%] vs 6 of 75 patients [8%]; risk difference, 13% [95% CI, 2%-24%]; risk ratio, 2.67 [95% CI, 1.10-6.44]; P = .04). Patient-reported or surrogate-reported goals-of-care discussions did not differ significantly between groups (30 of 66 patients [45%] vs 36 of 66 patients [55%]), although the intrarater consistency of patient and surrogate reports was poor. Patient-rated or surrogate-rated quality of communication did not differ significantly between groups. The intervention was feasible and acceptable to patients, surrogates, and clinicians.

Conclusions And Relevance: In this randomized clinical trial, a patient-facing and clinician-facing communication priming intervention for seriously ill, hospitalized patients promoted EHR-documented goals-of-care discussions before discharge with good feasibility and acceptability. Communication-priming interventions should be reexamined in a larger randomized clinical trial to better understand their effectiveness in the inpatient setting.

Trial Registration: ClinicalTrials.gov Identifier: NCT03746392.
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http://dx.doi.org/10.1001/jamanetworkopen.2022.5088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8976242PMC
April 2022

Mixed-methods evaluation of three natural language processing modeling approaches for measuring documented goals-of-care discussions in the electronic health record.

J Pain Symptom Manage 2022 06 16;63(6):e713-e723. Epub 2022 Feb 16.

Department of Medicine (A.M.U., J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine (A.M.U., J.R.C., R.A.E., L.C.B., Y.G., J.S., W.B.L., T.C., J.T., J.H., S.R.P., E.K.K., R.Y.L.), University of Washington, Seattle, WA; Division of Pulmonary, Critical Care, and Sleep Medicine (J.R.C., R.A.E., J.T., J.H., S.R.P., E.K.K., R.Y.L.), Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA.

Context: Documented goals-of-care discussions are an important quality metric for patients with serious illness. Natural language processing (NLP) is a promising approach for identifying goals-of-care discussions in the electronic health record (EHR).

Objectives: To compare three NLP modeling approaches for identifying EHR documentation of goals-of-care discussions and generate hypotheses about differences in performance.

Methods: We conducted a mixed-methods study to evaluate performance and misclassification for three NLP featurization approaches modeled with regularized logistic regression: bag-of-words (BOW), rule-based, and a hybrid approach. From a prospective cohort of 150 patients hospitalized with serious illness over 2018 to 2020, we collected 4391 inpatient EHR notes; 99 (2.3%) contained documented goals-of-care discussions. We used leave-one-out cross-validation to estimate performance by comparing pooled NLP predictions to human abstractors with receiver-operating-characteristic (ROC) and precision-recall (PR) analyses. We qualitatively examined a purposive sample of 70 NLP-misclassified notes using content analysis to identify linguistic features that allowed us to generate hypotheses underpinning misclassification.

Results: All three modeling approaches discriminated between notes with and without goals-of-care discussions (AUC: BOW, 0.907; rule-based, 0.948; hybrid, 0.965). Precision and recall were only moderate (precision at 70% recall: BOW, 16.2%; rule-based, 50.4%; hybrid, 49.3%; AUC: BOW, 0.505; rule-based, 0.579; hybrid, 0.599). Qualitative analysis revealed patterns underlying performance differences between BOW and rule-based approaches.

Conclusion: NLP holds promise for identifying EHR-documented goals-of-care discussions. However, the rarity of goals-of-care content in EHR data limits performance. Our findings highlight opportunities to optimize NLP modeling approaches, and support further exploration of different NLP approaches to identify goals-of-care discussions.
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http://dx.doi.org/10.1016/j.jpainsymman.2022.02.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9124686PMC
June 2022

Perceptions of Critical Care Shortages, Resource Use, and Provider Well-being During the COVID-19 Pandemic: A Survey of 1,985 Health Care Providers in Brazil.

Chest 2022 06 10;161(6):1526-1542. Epub 2022 Feb 10.

Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA; Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA; Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA. Electronic address:

Background: Brazil has been disproportionately affected by COVID-19, placing a high burden on ICUs.

Research Question: Are perceptions of ICU resource availability associated with end-of-life decisions and burnout among health care providers (HCPs) during COVID-19 surges in Brazil?

Study Design And Methods: We electronically administered a survey to multidisciplinary ICU HCPs during two 2-week periods (in June 2020 and March 2021) coinciding with COVID-19 surges. We examined responses across geographical regions and performed multivariate regressions to explore factors associated with reports of: (1) families being allowed less input in decisions about maintaining life-sustaining treatments for patients with COVID-19 and (2) emotional distress and burnout.

Results: We included 1,985 respondents (57% physicians, 14% nurses, 12% respiratory therapists, 16% other HCPs). More respondents reported shortages during the second surge compared with the first (P < .05 for all comparisons), including lower availability of intensivists (66% vs 42%), ICU nurses (53% vs 36%), ICU beds (68% vs 22%), and ventilators for patients with COVID-19 (80% vs 70%); shortages were highest in the North. One-quarter of HCPs reported that families were allowed less input in decisions about maintaining life-sustaining treatments for patients with COVID-19, which was associated with lack of intensivists (adjusted relative risk [aRR], 1.37; 95% CI, 1.05-1.80) and ICU beds (aRR, 1.71; 95% CI, 1.16-2.62) during the first surge and lack of N95 masks (aRR, 1.43; 95% CI, 1.10-1.85), noninvasive positive pressure ventilation (aRR, 1.56; 95% CI, 1.18-2.07), and oxygen concentrators (aRR, 1.50; 95% CI, 1.13-2.00) during the second surge. Burnout was higher during the second surge (60% vs 71%; P < .001), associated with witnessing colleagues at one's hospital contract COVID-19 during both surges (aRR, 1.55 [95% CI, 1.25-1.93] and 1.31 [95% CI, 1.11-1.55], respectively), as well as worries about finances (aRR, 1.28; 95% CI, 1.02-1.61) and lack of ICU nurses (aRR, 1.25; 95% CI, 1.02-1.53) during the first surge.

Interpretation: During the COVID-19 pandemic, ICU HCPs in Brazil experienced substantial resource shortages, health care disparities between regions, changes in end-of-life care associated with resource shortages, and high proportions of burnout.
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http://dx.doi.org/10.1016/j.chest.2022.01.057DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8828383PMC
June 2022

Truths, Principles, Maxims, and Other Smart Things We Learned From J. Randall Curtis.

J Pain Symptom Manage 2022 06 30;63(6):e595-e600. Epub 2021 Dec 30.

Cambia Palliative Care Center of Excellence at the University of Washington (A.R.R., R.E., E.K.K.), Seattle, Washington State, USA; Department of Medicine (R.E., E.K.K.), Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington School of Medicine, Seattle, Washington State, USA.

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http://dx.doi.org/10.1016/j.jpainsymman.2021.12.028DOI Listing
June 2022

Patient Identification of Lung Cancer Screening Follow-Up Recommendations and the Association with Adherence.

Ann Am Thorac Soc 2022 05;19(5):799-806

Division of Pulmonary, Critical Care and Sleep Medicine.

Adherence to follow-up lung cancer screening (LCS) in real-world settings is suboptimal. Patient understanding of screening results and anticipated follow-up may be crucial to adherence. To determine patient factors associated with identification of follow-up recommendations as a measure of patient understanding of screening results after LCS, and to determine whether misidentification of follow-up is associated with lower adherence to recommendations. We performed a prospective study of patients in the University of Washington/Seattle Cancer Care Alliance LCS registry who underwent an initial LCS examination between June 2017 and September 2019. We mailed potential participants a survey after the initial LCS examination, with additional data abstracted from the electronic health record and LCS registry. Participants were asked to identify the timing and next step for their follow-up, with answers corresponding to the lung imaging reporting and data system (Lung-RADS) recommendations. We examined associations between incorrect identification of recommended follow-up and patient-level characteristics, self-perceived benefit/harm of LCS, LCS knowledge, Lung-RADS score, and patient-reported method of LCS results communication (letter, telephone, or in-person). We used multivariable logistic regression to evaluate associations with incorrect identification of recommendations and assessed incorrect identification of recommendations as a potential mechanism for poor adherence in a separate regression model. One hundred eighty-eight participants completed the survey (response rate 44%); 47% misidentified their follow-up recommendation. Those with Lung-RADS scores ⩾3 had higher odds of incorrectly identifying follow-up recommendations than those with scores <3, as did those with lower educational attainment. However, there was no significant association between incorrect identification of follow-up and ultimate adherence to follow-up. Understanding of LCS follow-up appears to be poor, especially among those with lower education levels and positive findings. Among survey responders, incorrect identification of follow-up was not associated with poor adherence, suggesting that other factors, such as provider interventions, may be driving adherence behavior. These results can inform efforts to target improved patient education regarding follow-up for LCS.
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http://dx.doi.org/10.1513/AnnalsATS.202107-887OCDOI Listing
May 2022

The influence of POLST on treatment intensity at the end of life: A systematic review.

J Am Geriatr Soc 2021 12 22;69(12):3661-3674. Epub 2021 Sep 22.

Health Services Research & Development, VA Portland Health Care System, Portland, Oregon, USA.

Background: Despite its widespread implementation, it is unclear whether Physician Orders for Life-Sustaining Treatment (POLST) are safe and improve the delivery of care that patients desire. We sought to systematically review the influence of POLST on treatment intensity among patients with serious illness and/or frailty.

Methods: We performed a systematic review of POLST and similar programs using MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database for Systematic Reviews, and PsycINFO, from inception through February 28, 2020. We included adults with serious illness and/or frailty with life expectancy <1 year. Primary outcomes included place of death and receipt of high-intensity treatment (i.e., hospitalization in the last 30- and 90-days of life, ICU admission in the last 30-days of life, and number of care setting transitions in last week of life).

Results: Among 104,554 patients across 20 observational studies, 27,090 had POLST. No randomized controlled trials were identified. The mean age of POLST users was 78.7 years, 55.3% were female, and 93.0% were white. The majority of POLST users (55.3%) had orders for comfort measures only. Most studies showed that, compared to full treatment orders on POLST, treatment limitations were associated with decreased in-hospital death and receipt of high-intensity treatment, particularly in pre-hospital settings. However, in the acute care setting, a sizable number of patients likely received POLST-discordant care. The overall strength of evidence was moderate based on eight retrospective cohort studies of good quality that showed a consistent, similar direction of outcomes with moderate-to-large effect sizes.

Conclusion: We found moderate strength of evidence that treatment limitations on POLST may reduce treatment intensity among patients with serious illness. However, the evidence base is limited and demonstrates potential unintended consequences of POLST. We identify several important knowledge gaps that should be addressed to help maximize benefits and minimize risks of POLST.
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http://dx.doi.org/10.1111/jgs.17447DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8648994PMC
December 2021

Applying Human-Centered Design to Refinement of the Jumpstart Guide, a Clinician- and Patient-Facing Goals-of-Care Discussion Priming Tool.

J Pain Symptom Manage 2021 12 18;62(6):1283-1288. Epub 2021 Jun 18.

Cambia Palliative Care Center of Excellence at UW Medicine (N.C.A., S.E.M., K.G.H., J.T., J.H., R.A.E., E.K.K., J.R.C.), Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine (J.T., J.H., R.A.E., E.K.K., J.R.C.), University of Washington, Seattle, Washington, USA.

Context: Human-centered design provides a framework to understand the needs of patients and clinicians who are the target of goals-of-care discussion priming tools. Few studies employ human-centered design to develop and refine their tools.

Objectives: To describe how human-centered design can be applied to the development and refinement of clinician- and patient-facing inpatient goals-of-care discussion guides (Jumpstart guides).

Methods: Human-centered design was applied to the development and refinement of the inpatient Jumpstart guides in four phases: (1) discovering problems based on prior pilots, studies, and research team priorities; (2) further defining problems based on stakeholder and expert review of the current guides; (3) designing solutions based on consensus among stakeholders; and (4) validating solutions after research team review of stakeholder comments.

Results: Five initial problems were identified by the research team in phase 1. After expert and stakeholder review in phase 2, 30 additional problems were identified related to Jumpstart guide format, structure, and content. In phase 3, stakeholders proposed solutions to these 35 problems and reached consensus on 32 of these. There was disagreement in 3 areas, including how to frame discussions around cardiopulmonary resuscitation and 2 perceived barriers to inpatient goals-of-care discussions. In phase 4, the research team reviewed all stakeholder input and reached final consensus on solutions to all of the identified problems.

Conclusion: Human-centered design is a useful tool for enhancing communication interventions in serious illness and can easily be integrated in future development and refinement of clinician- and patient-facing interventions to enhance goals-of-care discussions.
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http://dx.doi.org/10.1016/j.jpainsymman.2021.06.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8648905PMC
December 2021

Provision of Smoking Cessation Resources in the Context of In-Person Shared Decision-Making for Lung Cancer Screening.

Chest 2021 08 18;160(2):765-775. Epub 2021 Mar 18.

University of Washington, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA; Clinical Research Division, Fred Hutchinson Cancer Research Center and Department of Medicine, University of Washington, Seattle, WA. Electronic address:

Background: Lung cancer screening (LCS) is effective at reducing mortality for high-risk smokers. Mortality benefits go beyond early cancer detection, because shared decision-making (SDM) may present a "teachable moment" to reinforce cessation and provide resources.

Research Question: How well is smoking cessation performed during LCS SDM encounters, and what patient and provider characteristics are associated with smoking cessation assistance?

Study Design And Methods: This is a retrospective cohort study of current smokers participating in initial LCS SDM through a multisite program in Seattle, Washington, between 2015-2018. The LCS tracking database and electronic health record were reviewed for demographics, comorbidity data, and clinical encounter information. The primary outcome was provision of a smoking cessation resource, defined as referral to cessation resources, recommendation for nicotine replacement, or prescription for cessation medication. Participant and provider factor associations with the outcome were evaluated using χ testing and multivariable logistic regression.

Results: Most of the 423 study participants were men (70%), with a median age of 61 (IQR, 58-66) years and median of 50 (41-72) pack-years of smoking. Only 26% of encounters had documentation consistent with SDM. Thirty-nine percent of participants received at least one smoking cessation resource, and only 5% received both counseling referrals and medication. In a multivariable model, the provision of any smoking cessation resource was half as likely in participants with higher levels of comorbidity (Charlson Index >2; OR, 0.53; 95% CI, 0.31-0.81), and half as likely if the ordering provider was not the patient's PCP or their specialist (OR, 0.55; 95% CI, 0.32-0.96).

Interpretation: Overall provision of smoking cessation resources was moderate during SDM encounters for LCS, and lower in patients with more comorbidities and when not performed by the patient's PCP or specialist. Interventions are needed to improve smoking cessation counseling and resource utilization at the time of LCS encounters.
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http://dx.doi.org/10.1016/j.chest.2021.03.016DOI Listing
August 2021

Parent Perspectives after the PRISM-P Randomized Trial: A Mixed-Methods Analysis.

J Palliat Med 2021 09 15;24(10):1505-1515. Epub 2021 Mar 15.

Palliative Care and Resilience Research Laboratory, Center for Clinical and Translational Research, Epidemiology, and Analytics in Research Program, Seattle Children's Research Institute, Seattle, Washington, USA.

Parents experience high distress following their child's diagnosis of cancer. We previously tested two delivery models (group and one-on-one) of the "Promoting Resilience in Stress Management for Parents" (PRISM-P) intervention in a randomized trial: one-on-one delivery improved resilience and benefit finding at three months when compared to usual care (UC). The objective of this analysis was to evaluate quantitative and qualitative outcomes at six months. In this single-center, phase 2, parallel, 1:1:1 randomized trial conducted December 2016 to December 2018, English-speaking parents with a 2-24 year-old child diagnosed with new cancer were randomly assigned to UC, one-on-one, or group PRISM-P, a brief, skill-based curriculum targeting stress management, goal setting, cognitive reframing, and meaning making. We collected parent-reported outcomes (resilience, benefit finding, and psychological distress) at baseline and three and six months. We applied linear mixed-effects regression models to examine six-month outcomes among all participants and conducted directed content analyses of exit interviews with the first 12 parents to complete each study arm. The 94 participating parents were median aged 35-38 years and predominantly white, college-educated mothers. At six months, there was no statistically significant difference in parent-reported outcomes. Exit interviews ( = 36) suggested that PRISM-P was highly valued: 100% of interviewed recipients recommended it for other parents. Most suggested more coaching would help them retain skills, and almost all endorsed a combined one-on-one and group program. Although the PRISM-P benefits observed at three months were not sustained for six months, all interviewed parents found it valuable. Additional opportunities to strengthen and sustain resilience resources include longer follow-up, flexible format, and skill reinforcement. NCT02998086.
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http://dx.doi.org/10.1089/jpm.2020.0720DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9206468PMC
September 2021

The National Postdoctoral Palliative Care Research Training Collaborative: History, Activities, Challenges, and Future Goals.

J Palliat Med 2021 04 21;24(4):545-553. Epub 2020 Sep 21.

Division of General Internal Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA.

Palliative care-related postdoctoral training opportunities are critical to increase the quantity and quality of palliative care research. To describe the history, activities, challenges, and future goals of the National Postdoctoral Palliative Care Research Training Collaborative. National web-based survey of participating program leaders. Information about participating programs, trainees, challenges faced, and future goals. Nine participating programs at academic institutions across the United States focus on diverse aspects of palliative care research. The majority of 73 current and former fellows are female (75%) and white (84%). In total, 38% of fellows ( = 28) have MD backgrounds, of whom less than half ( = 12) completed hospice and palliative medicine fellowships. An additional 38% of fellows ( = 28) have nursing PhD backgrounds and 23% ( = 17) have other diverse types of PhD backgrounds. Key challenges relate to recruiting diverse trainees, fostering a shared identity, effectively advocating for trainees, and securing funding. Future goals include expanding efforts to engage clinician and nonclinician scientists, fostering the pipeline of palliative care researchers through expanded mentorship of predoctoral and clinical trainees, increasing the number of postdoctoral palliative care training programs, and expanding funding support for career development grants. The National Postdoctoral Palliative Care Research Training Collaborative fills an important role in creating a community for palliative care research trainees and developing strategies to address shared challenges.
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http://dx.doi.org/10.1089/jpm.2020.0411DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8182655PMC
April 2021

Conflicting Orders in Physician Orders for Life-Sustaining Treatment Forms.

J Am Geriatr Soc 2020 12 16;68(12):2903-2908. Epub 2020 Sep 16.

Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.

Background/objectives: Many older persons with chronic illness use Physician Orders for Life-Sustaining Treatment (POLST) to document portable medical orders for emergency care. However, some POLSTs contain combinations of orders that do not translate into a cohesive care plan (eg, cardiopulmonary resuscitation [CPR] without intensive care, or intensive care without antibiotics). This study characterizes the prevalence and predictors of POLSTs with conflicting orders.

Design: Retrospective cohort study.

Setting: Large academic health system.

Participants: A total of 3,123 POLST users with chronic life-limiting illness who died between 2010 and 2015 (mean age = 69.7 years).

Measurements: In a retrospective review of all POLSTs in participants' electronic health records, we describe the prevalence of POLSTs with conflicting orders for cardiac arrest and medical interventions, and use clustered logistic regression to evaluate potential predictors of conflicting orders. We also examine the prevalence of conflicts between POLST orders for antibiotics and artificial nutrition with orders for cardiac arrest or medical interventions.

Results: Among 3,924 complete POLSTs belonging to 3,123 decedents, 209 (5.3%) POLSTs contained orders to "attempt CPR" paired with orders for "limited interventions" or "comfort measures only"; 745/3169 (23.5%) POLSTs paired orders to restrict antibiotics with orders to deliver non-comfort-only care; and, 170/3098 (5.5%) POLSTs paired orders to withhold artificial nutrition with orders to deliver CPR or intensive care. Among POLSTs with orders to avoid intensive care, orders to attempt CPR were more likely to be present in POLSTs completed earlier in the patient's illness course (adjusted odds ratio = 1.27 per twofold increase in days from POLST to death; 95% confidence interval = 1.18-1.36; P < .001).

Conclusion: Although most POLSTs are actionable by clinicians, 5% had conflicting orders for cardiac arrest and medical interventions, and 24% had one or more conflicts between orders for cardiac arrest, medical interventions, antibiotics, and artificial nutrition. These conflicting orders make implementation of POLST challenging for clinicians in acute care settings.
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http://dx.doi.org/10.1111/jgs.16828DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7744421PMC
December 2020

The Coronavirus Disease 2019 Pandemic's Effect on Critical Care Resources and Health-Care Providers: A Global Survey.

Chest 2021 02 11;159(2):619-633. Epub 2020 Sep 11.

Department of Neurology, Harborview Medical Center, University of Washington, WA; Cambia Palliative Care Center of Excellence, University of Washington, WA; Cambia Health Foundation.

Background: The coronavirus disease 2019 (COVID-19) pandemic has severely affected ICUs and critical care health-care providers (HCPs) worldwide.

Research Question: How do regional differences and perceived lack of ICU resources affect critical care resource use and the well-being of HCPs?

Study Design And Methods: Between April 23 and May 7, 2020, we electronically administered a 41-question survey to interdisciplinary HCPs caring for patients critically ill with COVID-19. The survey was distributed via critical care societies, research networks, personal contacts, and social media portals. Responses were tabulated according to World Bank region. We performed multivariate log-binomial regression to assess factors associated with three main outcomes: limiting mechanical ventilation (MV), changes in CPR practices, and emotional distress and burnout.

Results: We included 2,700 respondents from 77 countries, including physicians (41%), nurses (40%), respiratory therapists (11%), and advanced practice providers (8%). The reported lack of ICU nurses was higher than that of intensivists (32% vs 15%). Limiting MV for patients with COVID-19 was reported by 16% of respondents, was lowest in North America (10%), and was associated with reduced ventilator availability (absolute risk reduction [ARR], 2.10; 95% CI, 1.61-2.74). Overall, 66% of respondents reported changes in CPR practices. Emotional distress or burnout was high across regions (52%, highest in North America) and associated with being female (mechanical ventilation, 1.16; 95% CI, 1.01-1.33), being a nurse (ARR, 1.31; 95% CI, 1.13-1.53), reporting a shortage of ICU nurses (ARR, 1.18; 95% CI, 1.05-1.33), reporting a shortage of powered air-purifying respirators (ARR, 1.30; 95% CI, 1.09-1.55), and experiencing poor communication from supervisors (ARR, 1.30; 95% CI, 1.16-1.46).

Interpretation: Our findings demonstrate variability in ICU resource availability and use worldwide. The high prevalence of provider burnout and its association with reported insufficient resources and poor communication from supervisors suggest a need for targeted interventions to support HCPs on the front lines.
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http://dx.doi.org/10.1016/j.chest.2020.09.070DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7484703PMC
February 2021

Health-care Professionals' Perceptions of Critical Care Resource Availability and Factors Associated With Mental Well-being During Coronavirus Disease 2019 (COVID-19): Results from a US Survey.

Clin Infect Dis 2021 05;72(10):e566-e576

Department of Neurology, Harborview Medical Center, University of Washington, Seattle, Washington, USA.

Background: Assessing the impact of coronavirus disease 2019 (COVID-19) on intensive care unit (ICU) providers' perceptions of resource availability and evaluating the factors associated with emotional distress/burnout can inform interventions to promote provider well-being.

Methods: Between 23 April and 7 May 2020, we electronically administered a survey to physicians, nurses, respiratory therapists (RTs), and advanced practice providers (APPs) caring for COVID-19 patients in the United States. We conducted a multivariate regression to assess associations between concerns, a reported lack of resources, and 3 outcomes: a primary outcome of emotional distress/burnout and 2 secondary outcomes of (1) fear that the hospital is unable to keep providers safe; and (2) concern about transmitting COVID-19 to their families/communities.

Results: We included 1651 respondents from all 50 states: 47% were nurses, 25% physicians, 17% RTs, and 11% APPs. Shortages of intensivists and ICU nurses were reported by 12% and 28% of providers, respectively. The largest supply restrictions reported were for powered air purifying respirators (56% reporting restricted availability). Provider concerns included worries about transmitting COVID-19 to their families/communities (66%), emotional distress/burnout (58%), and insufficient personal protective equipment (PPE; 40%). After adjustment, emotional distress/burnout was significantly associated with insufficient PPE access (adjusted relative risk [aRR], 1.43; 95% confidence interval [CI], 1.32-1.55), stigma from community (aRR, 1.32; 95% CI, 1.24-1.41), and poor communication with supervisors (aRR, 1.13; 95% CI, 1.06-1.21). Insufficient PPE access was the strongest predictor of feeling that the hospital is unable to keep providers safe and worries about transmitting infection to their families/communities.

Conclusions: Addressing insufficient PPE access, poor communication from supervisors, and community stigma may improve provider mental well-being during the COVID-19 pandemic.
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http://dx.doi.org/10.1093/cid/ciaa1311DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7499503PMC
May 2021

Identifying Goals of Care Conversations in the Electronic Health Record Using Natural Language Processing and Machine Learning.

J Pain Symptom Manage 2021 01 25;61(1):136-142.e2. Epub 2020 Aug 25.

Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA; Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, Washington, USA; Department of Bioethics and Humanities, University of Washington, Seattle, Washington, USA. Electronic address:

Context: Goals-of-care discussions are an important quality metric in palliative care. However, goals-of-care discussions are often documented as free text in diverse locations. It is difficult to identify these discussions in the electronic health record (EHR) efficiently.

Objectives: To develop, train, and test an automated approach to identifying goals-of-care discussions in the EHR, using natural language processing (NLP) and machine learning (ML).

Methods: From the electronic health records of an academic health system, we collected a purposive sample of 3183 EHR notes (1435 inpatient notes and 1748 outpatient notes) from 1426 patients with serious illness over 2008-2016, and manually reviewed each note for documentation of goals-of-care discussions. Separately, we developed a program to identify notes containing documentation of goals-of-care discussions using NLP and supervised ML. We estimated the performance characteristics of the NLP/ML program across 100 pairs of randomly partitioned training and test sets. We repeated these methods for inpatient-only and outpatient-only subsets.

Results: Of 3183 notes, 689 contained documentation of goals-of-care discussions. The mean sensitivity of the NLP/ML program was 82.3% (SD 3.2%), and the mean specificity was 97.4% (SD 0.7%). NLP/ML results had a median positive likelihood ratio of 32.2 (IQR 27.5-39.2) and a median negative likelihood ratio of 0.18 (IQR 0.16-0.20). Performance was better in inpatient-only samples than outpatient-only samples.

Conclusion: Using NLP and ML techniques, we developed a novel approach to identifying goals-of-care discussions in the EHR. NLP and ML represent a potential approach toward measuring goals-of-care discussions as a research outcome and quality metric.
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http://dx.doi.org/10.1016/j.jpainsymman.2020.08.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7769906PMC
January 2021

Physician Orders for Life-Sustaining Treatment and ICU Admission Near the End of Life-Reply.

JAMA 2020 08;324(6):608-609

Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle.

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http://dx.doi.org/10.1001/jama.2020.8654DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7891929PMC
August 2020

Patient-Reported Receipt of Goal-Concordant Care Among Seriously Ill Outpatients-Prevalence and Associated Factors.

J Pain Symptom Manage 2020 10 7;60(4):765-773. Epub 2020 May 7.

Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.

Context: Goal-concordant care is an important indicator of high-quality care in serious illness.

Objectives: To estimate the prevalence of patient-reported receipt of goal-concordant care among seriously ill outpatients and identify factors associated with the absence of patient-reported goal concordance.

Methods: Analysis of enrollment surveys from a multicenter cluster-randomized trial of outpatients with serious illness. Patients reported their prioritized health care goal and the focus of their current medical care; these items were matched to define receipt of goal-concordant care.

Results: Of 405 patients with a prioritized health care goal, 58% reported receipt of goal-concordant care, 17% goal-discordant care, and 25% were uncertain of the focus of their care. Patient-reported receipt of goal concordance differed by patient goal. For patients who prioritized extending life, 86% reported goal-concordant care, 2% goal-discordant care, and 12% were uncertain of the focus of their care. For patients who prioritized relief of pain and discomfort, 51% reported goal-concordant care, 21% goal-discordant care, and 28% were uncertain of the focus of their care. Patients who prioritized a goal of relief of pain and discomfort were more likely to report goal-discordant care than patients who prioritized a goal of extending life (relative risk ratio 22.20; 95% CI 4.59, 107.38).

Conclusion: Seriously ill outpatients who prioritize a goal of relief of pain and discomfort are less likely to report receipt of goal-concordant care than patients who prioritize extending life. Future interventions designed to improve receipt of goal-concordant care should focus on identifying patients who prioritize relief of pain and discomfort and promoting care aligned with that goal.
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http://dx.doi.org/10.1016/j.jpainsymman.2020.04.026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7508896PMC
October 2020

The Importance of Addressing Advance Care Planning and Decisions About Do-Not-Resuscitate Orders During Novel Coronavirus 2019 (COVID-19).

JAMA 2020 05;323(18):1771-1772

Larner College of Medicine, Division of Pulmonary and Critical Care Medicine, University of Vermont, Burlington.

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http://dx.doi.org/10.1001/jama.2020.4894DOI Listing
May 2020

Association of Physician Orders for Life-Sustaining Treatment With ICU Admission Among Patients Hospitalized Near the End of Life.

JAMA 2020 03;323(10):950-960

Cambia Palliative Care Center of Excellence, University of Washington, Seattle.

Importance: Patients with chronic illness frequently use Physician Orders for Life-Sustaining Treatment (POLST) to document treatment limitations.

Objectives: To evaluate the association between POLST order for medical interventions and intensive care unit (ICU) admission for patients hospitalized near the end of life.

Design, Setting, And Participants: Retrospective cohort study of patients with POLSTs and with chronic illness who died between January 1, 2010, and December 31, 2017, and were hospitalized 6 months or less before death in a 2-hospital academic health care system.

Exposures: POLST order for medical interventions ("comfort measures only" vs "limited additional interventions" vs "full treatment"), age, race/ethnicity, education, days from POLST completion to admission, histories of cancer or dementia, and admission for traumatic injury.

Main Outcomes And Measures: The primary outcome was the association between POLST order and ICU admission during the last hospitalization of life; the secondary outcome was receipt of a composite of 4 life-sustaining treatments: mechanical ventilation, vasopressors, dialysis, and cardiopulmonary resuscitation. For evaluating factors associated with POLST-discordant care, the outcome was ICU admission contrary to POLST order for medical interventions during the last hospitalization of life.

Results: Among 1818 decedents (mean age, 70.8 [SD, 14.7] years; 41% women), 401 (22%) had POLST orders for comfort measures only, 761 (42%) had orders for limited additional interventions, and 656 (36%) had orders for full treatment. ICU admissions occurred in 31% (95% CI, 26%-35%) of patients with comfort-only orders, 46% (95% CI, 42%-49%) with limited-interventions orders, and 62% (95% CI, 58%-66%) with full-treatment orders. One or more life-sustaining treatments were delivered to 14% (95% CI, 11%-17%) of patients with comfort-only orders and to 20% (95% CI, 17%-23%) of patients with limited-interventions orders. Compared with patients with full-treatment POLSTs, those with comfort-only and limited-interventions orders were significantly less likely to receive ICU admission (comfort only: 123/401 [31%] vs 406/656 [62%], aRR, 0.53 [95% CI, 0.45-0.62]; limited interventions: 349/761 [46%] vs 406/656 [62%], aRR, 0.79 [95% CI, 0.71-0.87]). Across patients with comfort-only and limited-interventions POLSTs, 38% (95% CI, 35%-40%) received POLST-discordant care. Patients with cancer were significantly less likely to receive POLST-discordant care than those without cancer (comfort only: 41/181 [23%] vs 80/220 [36%], aRR, 0.60 [95% CI, 0.43-0.85]; limited interventions: 100/321 [31%] vs 215/440 [49%], aRR, 0.63 [95% CI, 0.51-0.78]). Patients with dementia and comfort-only orders were significantly less likely to receive POLST-discordant care than those without dementia (23/111 [21%] vs 98/290 [34%], aRR, 0.44 [95% CI, 0.29-0.67]). Patients admitted for traumatic injury were significantly more likely to receive POLST-discordant care (comfort only: 29/64 [45%] vs 92/337 [27%], aRR, 1.52 [95% CI, 1.08-2.14]; limited interventions: 51/91 [56%] vs 264/670 [39%], aRR, 1.36 [95% CI, 1.09-1.68]). In patients with limited-interventions orders, older age was significantly associated with less POLST-discordant care (aRR, 0.93 per 10 years [95% CI, 0.88-1.00]).

Conclusions And Relevance: Among patients with POLSTs and with chronic life-limiting illness who were hospitalized within 6 months of death, treatment-limiting POLSTs were significantly associated with lower rates of ICU admission compared with full-treatment POLSTs. However, 38% of patients with treatment-limiting POLSTs received intensive care that was potentially discordant with their POLST.
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http://dx.doi.org/10.1001/jama.2019.22523DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7042829PMC
March 2020

Postdoctoral Research Training in Palliative Care: Lessons Learned From a T32 Program.

J Pain Symptom Manage 2020 03 24;59(3):750-760.e8. Epub 2019 Nov 24.

Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA. Electronic address:

Our aging population and advances in chronic disease management that prolong the time that patients live with a chronic illness have combined to create an enormous need for improved palliative care research across diverse diseases. In this article, we describe the structure and processes of a National Institutes of Health-funded T32 postdoctoral research fellowship at the University of Washington and our experiences in developing and implementing the program. We recognize a broad definition of palliative care research, including research focused on improving quality of life, minimizing symptoms, providing psychological and spiritual support, and improving communication about patients' values and goals of care, all in the context of a serious illness. We describe our four core principles for postdoctoral training in palliative care research, each with a number of specific approaches: 1) mastering a set of essential content and research skills; 2) structured mentoring and academic career development; 3) creating and supporting early success; and 4) interdisciplinary training and team science. In addition, we also describe our framework for the essential competencies necessary for a palliative care research training program, our methods for identification and selection of applicants, our outcomes to date, and our processes of continuous quality assessment and improvement. Our goal is to describe our successful postdoctoral research training program in palliative care to promote development of new programs and share information between programs to continue to build the field of collaborative and interdisciplinary palliative care research.
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http://dx.doi.org/10.1016/j.jpainsymman.2019.11.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7029795PMC
March 2020

Agreement With Consensus Statements on End-of-Life Care: A Description of Variability at the Level of the Provider, Hospital, and Country.

Crit Care Med 2019 10;47(10):1396-1401

Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel.

Objectives: To develop an enhanced understanding of factors that influence providers' views about end-of-life care, we examined the contributions of provider, hospital, and country to variability in agreement with consensus statements about end-of-life care.

Design And Setting: Data were drawn from a survey of providers' views on principles of end-of-life care obtained during the consensus process for the Worldwide End-of-Life Practice for Patients in ICUs study.

Subjects: Participants in Worldwide End-of-Life Practice for Patients in ICUs included physicians, nurses, and other providers. Our sample included 1,068 providers from 178 hospitals and 31 countries.

Interventions: None.

Measurements And Main Results: We examined views on cardiopulmonary resuscitation and withholding/withdrawing life-sustaining treatments, using a three-level linear mixed model of responses from providers within hospitals within countries. Of 1,068 providers from 178 hospitals and 31 countries, 1% strongly disagreed, 7% disagreed, 11% were neutral, 44% agreed, and 36% strongly agreed with declining to offer cardiopulmonary resuscitation when not indicated. Of the total variability in those responses, 98%, 0%, and 2% were explained by differences among providers, hospitals, and countries, respectively. After accounting for provider characteristics and hospital size, the variance partition was similar. Results were similar for withholding/withdrawing life-sustaining treatments.

Conclusions: Variability in agreement with consensus statements about end-of-life care is related primarily to differences among providers. Acknowledging the primary source of variability may facilitate efforts to achieve consensus and improve decision-making for critically ill patients and their family members at the end of life.
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http://dx.doi.org/10.1097/CCM.0000000000003922DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7446953PMC
October 2019

The Association of Physician Orders for Life-Sustaining Treatment With Intensity of Treatment Among Patients Presenting to the Emergency Department.

Ann Emerg Med 2020 02 24;75(2):171-180. Epub 2019 Jun 24.

Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, OR; Health Services Research and Development, VA Portland Health Care System, Portland, OR.

Study Objective: Physician Orders for Life-Sustaining Treatment (POLST) forms are intended to help prevent the provision of unwanted medical interventions among patients with advanced illness or frailty who are approaching the end of life. We seek to evaluate how POLST form completion, treatment limitations, or both influence intensity of treatment among patients who present to the emergency department (ED).

Methods: This was a retrospective cohort study of adults who presented to the ED at an academic medical center in Oregon between April 2015 and October 2016. POLST form completion and treatment limitations were the main exposures. Primary outcome was hospital admission; secondary outcomes included ICU admission and a composite measure of aggressive treatment.

Results: A total of 26,128 patients were included; 1,769 (6.8%) had completed POLST forms. Among patients with POLST, 52.1% had full treatment orders, and 6.4% had their forms accessed before admission. POLST form completion was not associated with hospital admission (adjusted odds ratio [aOR]=0.97; 95% confidence interval [CI] 0.84 to 1.12), ICU admission (aOR=0.82; 95% CI 0.55 to 1.22), or aggressive treatment (aOR=1.06; 95% CI 0.75 to 1.51). Compared with POLST forms with full treatment orders, those with treatment limitations were not associated with hospital admission (aOR=1.12; 95% CI 0.92 to 1.37) or aggressive treatment (aOR=0.87; 95% CI 0.5 to 1.52), but were associated with lower odds of ICU admission (aOR=0.31; 95% CI 0.16 to 0.61).

Conclusion: Among patients presenting to the ED with POLST, the majority of POLST forms had orders for full treatment and were not accessed by emergency providers. These findings may partially explain why we found no association of POLST with treatment intensity. However, treatment limitations on POLST forms were associated with reduced odds of ICU admission. Implementation and accessibility of POLST forms are crucial when considering their effect on the provision of treatment consistent with patients' preferences.
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http://dx.doi.org/10.1016/j.annemergmed.2019.05.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6928444PMC
February 2020

Enablers and Barriers to Implementing ICU Follow-Up Clinics and Peer Support Groups Following Critical Illness: The Thrive Collaboratives.

Crit Care Med 2019 09;47(9):1194-1200

Department of Medicine, Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, MA.

Objectives: Data are lacking regarding implementation of novel strategies such as follow-up clinics and peer support groups, to reduce the burden of postintensive care syndrome. We sought to discover enablers that helped hospital-based clinicians establish post-ICU clinics and peer support programs, and identify barriers that challenged them.

Design: Qualitative inquiry. The Consolidated Framework for Implementation Research was used to organize and analyze data.

Setting: Two learning collaboratives (ICU follow-up clinics and peer support groups), representing 21 sites, across three continents.

Subjects: Clinicians from 21 sites.

Measurement And Main Results: Ten enablers and nine barriers to implementation of "ICU follow-up clinics" were described. A key enabler to generate support for clinics was providing insight into the human experience of survivorship, to obtain interest from hospital administrators. Significant barriers included patient and family lack of access to clinics and clinic funding. Nine enablers and five barriers to the implementation of "peer support groups" were identified. Key enablers included developing infrastructure to support successful operationalization of this complex intervention, flexibility about when peer support should be offered, belonging to the international learning collaborative. Significant barriers related to limited attendance by patients and families due to challenges in creating awareness, and uncertainty about who might be appropriate to attend and target in advertising.

Conclusions: Several enablers and barriers to implementing ICU follow-up clinics and peer support groups should be taken into account and leveraged to improve ICU recovery. Among the most important enablers are motivated clinician leaders who persist to find a path forward despite obstacles.
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http://dx.doi.org/10.1097/CCM.0000000000003818DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6699486PMC
September 2019
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