Timing and content of serious illness conversations for patients with advanced heart failure in a specialty-aligned palliative care service.

Background: Patients with advanced heart failure (AHF) desire communication around values and goals prior to treatment decisions.

Objectives: To evaluate the timing and content of the first serious illness communication (SI conversation) for patients with AHF after referral to a specialist palliative care (PC) team (HeartPal).

Methods: In this retrospective cohort study, we used electronic health records to identify patients referred to HeartPal and their first SI conversations at a tertiary care hospital between October 2018 and September 2021.

Feasibility of a Serious Illness Communication Program for Pediatric Advance Care Planning.

Importance: Pediatric advance care planning (ACP), which aims to ensure care is aligned with family goals and values, is associated with better end-of-life outcomes; however, ACP in pediatrics remains uncommon.

Objectives: To determine the feasibility and acceptability of the Pediatric Serious Illness Communication Program (PediSICP) and explore family-centered outcomes.

Design, Setting, And Participants: This cohort study was a single-group pilot study of the PediSICP in adolescents and young adults (AYAs; age ≥13 y) with serious illness, parents of seriously ill children, and interprofessional clinicians from April 2021 to March 2023 in a quaternary care pediatric hospital.

Racial and Ethnic Disparities in Serious Illness Conversation Quality during the COVID-19 Pandemic.

Context: The COVID-19 pandemic disproportionately impacted non-Hispanic Black and Hispanic patients. However, little is known about the quality of serious illness communication in these communities during this time.

Objective: We aimed to determine whether racial and ethnic disparities manifested in serious illness conversations during the pandemic.

Provider Perceptions Regarding Cardiopulmonary Resuscitation in Surgical Patients with Frailty.

Objective: To characterize the perceptions of surgeons, anesthesiologists, and geriatricians regarding perioperative CPR in surgical patients with frailty.

Summary Background Data: The population of patients undergoing surgery is growing older and more frail. Despite a growing focus on goal-concordant care, frailty assessment, and debate regarding the appropriateness of cardiopulmonary resuscitation (CPR) in patients with frailty, providers' views regarding frailty and perioperative CPR are unknown.

Feasibility of frailty screening among patients with advanced heart failure.

Background: Frailty is common among patients with advanced heart failure (HF), and screening for frailty to guide care is recommended. Although multiple tools are available to screen for frailty, the feasibility of routinely incorporating frailty screening into daily clinical practice among hospitalised advanced HF patients has not been rigorously tested.

Methods: This was a prospective, single-centre, quality improvement study.

Frailty and Outcomes Following Cardiopulmonary Resuscitation for Perioperative Cardiac Arrest.

Importance: Frailty is associated with mortality following surgery and cardiopulmonary resuscitation (CPR) for in-hospital cardiac arrest. Despite the growing focus on frailty as a basis for preoperative risk stratification and concern that CPR in patients with frailty may border on futility, the association between frailty and outcomes following perioperative CPR is unknown.

Objective: To determine the association between frailty and outcomes following perioperative CPR.

Preoperative Code Status Discussion Workflows: Targets for Improvement in Multidisciplinary Pathways.

Context: Discussion of perioperative code status is an important element of preoperative care and a component of the American College of Surgeons' Geriatric Surgery Verification (GSV) program. Evidence suggests code status discussions (CSDs) are not routinely performed and are inconsistently documented.

Objectives: Because preoperative decision making is a complex process spanning multiple providers, this study aims to utilize process mapping to highlight challenges associated with CSDs and inform efforts to improve workflows and implement elements of the GSV program.

Adaptations within Palliative Care Delivery Models Due to the COVID-19 Pandemic at a Tertiary Care Hospital.

Since the onset of the COVID-19 pandemic, all facets of palliative care provision for patients with serious illness have faced unparalleled challenges. We describe our palliative care program's response to the increased clinical volume associated with the pandemic by adapting workflows for inpatient and outpatient palliative care teams caring for oncology and nononcology populations. During the initial surge, the demand for palliative care consultation for patients affected by SARS-CoV-2 was high, accounting for 75% of all inpatient palliative care referral requests for oncology and nononcology patients.

A Pilot Study of the Serious Illness Conversation Guide in a Dialysis Clinic.

Clinician-led conversations about future care priorities occur infrequently with end-stage renal disease (ESRD) patients on dialysis. This was a pilot study of structured serious illness conversations using the Serious Illness Conversation Guide (SICG) in a single dialysis clinic to assess acceptability of the approach and explore conversation themes and potential outcomes among patients with ESRD. Twelve individuals with ESRD on dialysis from a single outpatient dialysis clinic participated in this study.

Evaluation of interdisciplinary care pathway implementation in older elective surgery patients.

Background: The American College of Surgeons Geriatric Surgery Verification Program outlines best practices for surgical care in older adults. These recommendations have guided institutions to create workflows to better support needs specific to older surgical patients. This qualitative study explored clinician experiences to understand influences on implementation of frailty screening and an interdisciplinary care pathway in older elective colorectal surgery and neurosurgery patients.

Surgeon-reported Factors Influencing Adoption of Quality Standards for Goal-concordant Care in Patients With Advanced Cancer: A Qualitative Study.

Objective: This study explored surgical oncologists' perspectives on factors influencing adoption of quality standards in patients with advanced cancer.

Background: The American College of Surgeons Geriatric Surgery Verification Program includes communication standards designed to facilitate goal-concordant care, yet little is known about how surgeons believe these standards align with clinical practice.

Methods: Semistructured video-based interviews were conducted from November 2020 to January 2021 with academic surgical oncologists purposively sampled based on demographics, region, palliative care certification, and years in practice.

Geriatric surgical service interventions in older emergency general surgery patients: Preliminary results.

Background: Older adults comprise an increasing proportion of emergency general surgery (EGS) admissions and face high morbidity and mortality. We created a geriatric surgical service with geriatric and palliative expertise to mitigate risks of hospitalization most hazardous to older patients. We sought to identify geriatric surgical service interventions most relevant to EGS patients.

Which Geriatric Variables Most Strongly Inform Discharge Disposition After Emergency Surgery?

Introduction: Older adults account for an increasing proportion of emergency surgical procedures and have longer hospital lengths of stay than their elective counterparts. Identifying those at greatest risk of discharge to a postacute care facility would improve postoperative planning. We aimed to examine the role of preoperative cognitive and functional status on discharge disposition after emergency surgery in older adults.

Understanding the role of informal caregivers in postoperative care transitions for older patients.

Background: Older adults may have new care needs and functional limitations after surgery. Many rely on informal caregivers (unpaid family or friends) after discharge but the extent of informal support is unknown. We sought to examine the role of informal postoperative caregiving on transitions of care for older adults undergoing routine surgical procedures.

Beyond the Do-not-resuscitate Order: An Expanded Approach to Decision-making Regarding Cardiopulmonary Resuscitation in Older Surgical Patients.

American Society of Anesthesiologists guidelines recommend that anesthesiologists revisit do-not-resuscitate orders preoperatively and revise them if necessary based on patient preferences. In patients without do-not-resuscitate orders or other directives limiting treatment however, "full code" is the default option irrespective of clinical circumstances and patient preferences. It is time to revisit this approach based on (1) increasing understanding of the power of default options in healthcare settings, (2) changing demographics and growing evidence suggesting that an expanding subset of patients is vulnerable to poor outcomes after perioperative cardiopulmonary resuscitation (CPR), and (3) recommendations from multiple societies promoting risk assessment and goal-concordant care in older surgical patients.

Clinicians' Perspectives After Implementation of the Serious Illness Care Program: A Qualitative Study.

Importance: Discussions about goals of care with patients who are seriously ill typically occur infrequently and late in the illness trajectory, are of low quality, and focus narrowly on the patient's resuscitation preferences (ie, code status), risking provision of care that is inconsistent with patients' values. The Serious Illness Care Program (SICP) is a multifaceted communication intervention that builds capacity for clinicians to have earlier, more frequent, and more person-centered conversations.

Objective: To explore clinicians' experiences with the SICP 1 year after implementation.

Development, Implementation, and Outcomes of a Serious Illness Care Community of Practice.

Context: Communities of Practice (CoP) can help geographically separated individuals who share a joint enterprise, mutual engagement, and a repertoire of tools to gain, maintain, and implement new skills, including serious illness communication.

Objectives: To investigate the health system uptake, implementation and outcomes of the Serious Illness Community of Practice (SICoP).

Methods: Participants included members of the online SICoP, including participants from all 50 states in the United States and 44 countries, interested in implementation of the Serious Illness Care Program.

Early serious illness communication in hospitalized patients: A study of the implementation of the Speaking About Goals and Expectations (SAGE) program.

Background: Early conversations about patients' goals and values in advancing serious illness (serious illness conversations) can drive better healthcare. However, these conversations frequently happen during acute illness, often near death, without time to realize benefits of early communication.

Methods: The Speaking About Goals and Expectations (SAGE) Program, adapted from the Serious Illness Care Program, is a multicomponent intervention designed to foster earlier and more comprehensive serious illness conversations for patients admitted to the hospital.

Launching a Geriatric Surgery Center: Recommendations from the Society for Perioperative Assessment and Quality Improvement.

To prepare for the increasing numbers of older adults undergoing surgery, the American College of Surgeons (ACS) has recently launched the Geriatric Surgery Verification Program with the goal of encouraging the creation of centers of geriatric surgery. Meanwhile, the Society for Perioperative Assessment and Quality Improvement (SPAQI) has published recommendations for the preoperative management of frailty, which state that teams should actively screen for frailty before surgery and that pathways, including geriatric comanagement, shared decision-making, and multimodal prehabilitation, should be embedded in routine care to help improve patient outcomes. Both SPAQI and the ACS advocate for a multidisciplinary approach to improve the value of care for older adults undergoing surgery.

Adherence and Concordance between Serious Illness Care Planning Conversations and Oncology Clinician Documentation among Patients with Advanced Cancer.

Serious illness conversations are part of advance care planning (ACP) and focus on prognosis, values, and goals in patients who are seriously ill. To be maximally effective, such conversations must be documented accurately and be easily accessible. The two coprimary objectives of the study were to assess concordance between written documentation and recorded audiotaped conversations, and to evaluate adherence to the Serious Illness Conversation Guide questions.

A systematic intervention to improve serious illness communication in primary care: Effect on expenses at the end of life.

Background: At a population level, conversations between clinicians and seriously ill patients exploring patients' goals and values can drive high-value healthcare, improving patient outcomes and reducing spending.

Methods: We examined the impact of a quality improvement intervention to drive better communication on total medical expenses in a high-risk care management program. We present our analysis of secondary expense outcomes from a prospective implementation trial of the Serious Illness Care Program, which includes clinician training, coaching, tools, and system interventions.

When the Dust Settles: Preventing a Mental Health Crisis in COVID-19 Clinicians.

This essay describes timely and targeted actions that clinicians can take during the COVID-19 pandemic to support fellow clinicians.

Engaging Hospices in Quality Measurement and Improvement: Early Experiences of a Large Integrated Health Care System.

The quality of hospice care remains highly variable in the U.S. Patients, providers, and health care systems lack a comprehensive method of measuring the quality of care provided by an individual hospice.