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Au DH (Northwest HSR&D Center of Excellence and University of Washington), Udris EM
(Northwest HSR&D Center of Excellence), Diehr P
(Northwest HSR&D Center of Excellence and University of Washington), Engelberg RA
(University of Washington), Curtis JR
(University of Washington)
Objectives:
COPD, the leading cause of respiratory death in the United States, is 4 times more prevalent within VA primary care than the US population. At the end of life, patients with COPD receive care directed at preservation of life when palliation of symptoms was preferred. We hypothesized a multifaceted intervention would improve the occurrence and quality of communication about end-of-life care.
Methods:
We performed a clustered randomized trial of providers and their patients with COPD. The intervention was designed to fit within usual outpatient clinic visits at the VA Puget Sound Health Care System. We assessed patient’s COPD severity, preferences for communication, life-sustaining therapy, and facilitators and barriers to end-of-life communication. A one page form with patient-derived information was given to providers and patients/surrogates. Patient-reported occurrence of advanced care planning discussions and the quality of the communication about end-of-life care (QOC) was assessed within 2 weeks of a target visit. The QOC ranges between 0-10 with higher scores indicating higher quality communication. Intention to treat analyses were performed using GEE to account for clustering.
Results:
92 providers contributed 376 patients. Randomization produced good balance between groups. Before and after adjustment for pre-specified characteristics, patients in the intervention arm reported having significantly more discussion with both providers (unadjusted: 30% vs 11%, p < 0.001) and their surrogates (unadjusted: 85% vs 74%, p < 0.01). The overall baseline quality of communication was poor (mean 2.1, sd 2.3). Patients in the intervention arm reported small improvements in their quality of communication (difference post-intervention QOC score = 0.49, SD 2.7, p = 0.11: Cohen effect size 0.21) that achieved statistical significance in some, but not all analyses.
Implications:
A practical multifaceted intervention that incorporated patients' preferences for communication and care improved the occurrence of discussions about advanced care planning, but had small effects on the quality of communication.
Impacts:
We have tested a clinically applicable intervention that stimulates discussions about preferences for care at the end of life. These discussions may improve quality of care at the end of life by ensuring that care received is consistent with stated preferences.
