Download

GIM Practice

A Quality Improvement Initiative to Implement the Serious Illness Care Program on Hospital Medical Wards: Impact on Patient and Clinician Experience

John J. You1*, Japteg Singh2, Jessica Simon3, Irene W. Y. Ma4, Joanna Paladino5, Marilyn Swinton6, Daniel Kobewka7, Peter Munene8, Dev Jayaraman9, Fiona Dunne10, Andrew Lagrotteria11, Rachelle Bernacki5

1Division of General Internal and Hospitalist Medicine, Trillium Health Partners, Mississauga, Ontario, Canada;

2Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada;

3Departments of Oncology, Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada;

4Division of General Internal Medicine, Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada;

5Harvard Medical School, Dana Farber Cancer Institute, Boston, MA, USA;

6Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada;

7The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada;

8Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada;

9Departments of Medicine and Critical Care, McGill University, Montreal, Quebec, Canada;

10Division of General Internal Medicine, Department of Medicine, University of Calgary, Calgary, Alberta, Canada;

11Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada

Abstract

Background: The Serious Illness Care Program (SICP) is a communication intervention that builds clinician capacity to have earlier, more values-based conversations about goals of care with patients experiencing life-limiting illness. We report the impact of its implementation on hospital wards.

Methods: In this quality improvement initiative on the medical wards of two Canadian teaching hospitals, we trained physicians, nurse practitioners, and social workers in the use of the Serious Illness Conversation Guide. Between February 2017 and September 2020, we prompted trained clinicians to have serious illness conversations with hospitalized patients or their family member(s), for patients at high risk of dying. Outcomes were the number of clinicians trained, the number of conversations delivered, patient or family experience, including the extent to which they felt heard and understood, and clinician experience.

Results: We trained 57 (92%) of 62 eligible clinicians. We delivered conversations to 334 (29%) of 1158 eligible patients (or family members) and documented 274 (82%) of these in the medical record. After a serious illness conversation, 80% of patients or families rated the conversations as mostly or extremely worthwhile and felt more heard and understood (+0.2 on 5-point scale, P = 0.04). The majority (95%) of clinicians agreed (somewhat, mostly, or completely) that conversations could be done in an appropriate amount of time and 97% agreed (somewhat, mostly, or completely) that the Guide provided information that enhances clinical care.

Interpretation: The SICP can be implemented on medical wards of hospitals and can have a positive impact on patient and clinician experience.

Résumé

Contexte: Le Serious Illness Care Program (SICP) est une intervention de communication qui renforce la capacité du clinicien à avoir des conversations plus précoces et davantage axées sur les valeurs concernant les objectifs des soins avec les patients atteints d’une maladie limitant leur espérance de vie. Nous présentons les répercussions de sa mise en œuvre dans les services hospitaliers.

Méthodologie: Dans cette initiative sur l’amélioration de la qualité dans les services médicaux de deux hôpitaux universitaires canadiens, nous avons formé des médecins, des infirmières praticiennes et des travailleurs sociaux à l’utilisation du guide de conversation sur les maladies graves. Entre février 2017 et septembre 2020, nous avons incité les cliniciens formés à avoir des conversations sur les maladies graves avec des patients hospitalisés présentant un risque élevé de décès ou des membres de leur famille. Les critères d’évaluation étaient le nombre de cliniciens formés, le nombre de conversations effectuées, l’expérience des patients ou de leur famille, y compris la mesure dans laquelle ils se sont sentis écoutés et compris, et l’expérience des cliniciens.

Résultats: Nous avons formé 57 (92 %) des 62 cliniciens admissibles. Des conversations ont été réalisées auprès de 334 (29 %) des 1158 patients (ou membres de la famille) admissibles et 274 (82 %) de ces conversations ont été consignées dans le dossier médical. Après une conversation sur les maladies graves, 80 % des patients ou de leur famille ont évalué les conversations comme étant plutôt ou extrêmement utiles et ils se sont sentis plus écoutés et compris (+ 0,2 sur une échelle de 5 points, P = 0,04). La majorité (95 %) des cliniciens sont d’accord (quelque peu, plutôt ou complètement) sur le fait que les conversations ont pu avoir lieu dans un laps de temps approprié et 97 % sont d’accord (quelque peu, plutôt ou complètement) sur le fait que le guide fournit des renseignements qui améliorent les soins cliniques.

Interprétation: Le SICP peut être mis en œuvre dans les services médicaux des hôpitaux et peut avoir des répercussions positives sur l’expérience des patients et des cliniciens.

Key words: advance care planning, hospital medicine, palliative care, quality improvement

Corresponding Author: Dr. John J. You: John.You@thp.ca

Submitted: 22 February 2021; Accepted: 15 May 2021; Published: 9 February 2022

Doi: http://dx.doi.org/10.22374/cjgim.v17i1.528

All articles published in DPG Open Access journals
This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0)(https://creativecommons.org/licenses/by-nc/4.0/).

Introduction

Improvements in serious illness communication are a key priority to improve the quality of serious illness care in Canada. In a multicenter survey of 363 patients experiencing life-limiting illness at 7 Canadian hospitals, participants stated that clear, honest communication with their physicians, feeling heard and understood as a person, receiving emotional support, and feelings of peace are the aspects of their care they were least satisfied with but that were most important to them.1 However, hospital-based clinicians often do not engage in these conversations: in a subsequent multicenter audit of communication practices with 233 seriously ill patients in the medical wards of 9 Canadian hospitals, we found that guideline-recommended elements of goals-of-care discussions (e.g., disclosing prognosis, eliciting values, fears or concerns, and preferences for care) were addressed infrequently by hospital-based clinicians (range 1–32%). Furthermore, addressing more elements was associated with both greater concordance between patients’ preferences and prescribed goals of care, and greater patient satisfaction.2,3 In this study, we define a serious illness conversation as a discussion between a practitioner and a patient with a life- limiting illness, or their substitute decision maker(s), regarding their illness understanding, prognosis, values, goals, fears, and sources of strength.4 Commonly cited barriers to these conversations include a need for patients to have a better illness understanding, lack of time, and clinicians’ uncertainty about their own skills, to the point where some clinicians actively avoid these discussions.58

To address these barriers and the gaps in communication practice identified in our previous work,13 we undertook a quality improvement initiative to adapt and implement the Serious Illness Care Program (SICP) on the medical wards of several hospitals in Canada.9 The SICP is a system-based communication intervention designed to improve the timing, quality, and frequency of conversations about values and goals with patients facing life-limiting illness.10 In a cluster randomized controlled trial conducted in an outpatient oncology setting, the program resulted in earlier and more frequent conversations with patients and sustained reductions in patient anxiety and depression.4,11 We hypothesized that the program was well-suited to address the aforementioned barriers and could be adapted for use in an inpatient setting. In this study, we report the impact of the SICP on patient and clinician experience when adapted and implemented on the medical wards of two teaching hospitals in Canada.

Methods

Setting

Medical wards of two Canadian teaching hospitals: Hamilton General Hospital, Hamilton, Ontario and Foothills Medical Centre, Calgary, Alberta (Table 1).

Table 1. Characteristics of and implementation processes at participating sites

Hamilton General Hospital Foothills Medical Center
Site characteristics
Number of participating medical wards 3 1
Number of patient beds 100 28
Number of attending physicians working at a given time 6 3
Implementation processes
Clinician training 2.5 h interactive skills practice session using the Serious Illness Conversation Guide (3:1 ratio of learners to expert facilitators; typically 6 learners per session)
Patient identification InterRAI ED screener score of 5 or 6 and hospitalized for at least 48 h, or clinician selected14 Age ≥ 65 years and hospitalized for ≥5 days, or clinician selected
Cueing clinicians for conversations Unit Champion contacts clinicians via text message, phone, or in person Unit Champion on the ward during morning rounds
Preparing eligible patients or family members for conversations Scripted or structured conversation
Delivering conversations* Private meeting room
Documentation of conversations Dictated structured notes transcribed into EMR Advance Care Planning and Goals of Care Tracking Record in EMR

EMR, electronic medical record.

*Residents or medical students were invited to attend serious illness conversations at the discretion of the attending physician. Occasionally, senior residents who had received skills practice training using the Serious Illness Conversation Guide (through separate training sessions offered through their residency training program) facilitated the conversation under the supervision of the attending physician.

Design

Multisite quality improvement study.12

Intervention

Details of our adaptation and implementation of the SICP are reported elsewhere.9 The program consists of three main components: tools for clinicians, an educational component, and a system change component. Tools include a Previsit Letter for patients, the Serious Illness Conversation Guide and Clinician Reference Guide for clinicians, and a Family Communication Guide for patients and their families. The central communication tool is the Serious Illness Conversation Guide, hereafter referred to as the Guide, that is based on best practices in palliative care and provides patient-tested language for clinicians (Appendix 1).13 The Guide addresses illness understanding, decision-making and information preferences, prognostic disclosure, patient goals, values and fears, views on acceptable function and trade-offs, and desires for family involvement. The educational component consists of a 2.5-h clinician training workshop that includes reflection, didactic teaching, skills practice using the Guide with standardized patients, and direct observation and feedback from expert faculty. Clinicians were eligible for training if they were attending physicians or social workers (or nurse practitioners, Hamilton site) on participating medical wards. System change refers to embedding processes in and making adjustments to existing workflow to enable these conversations in practice: identifying suitable patients, triggering clinicians to have serious illness conversations with eligible patients, delivering the conversation using the Guide, documenting the conversations in the medical record, giving participants the Family Communication Guide (Appendix 2) to support postconversation dialogue with family. The program acknowledges that clinicians are busy, and therefore emphasizes the need for system change to create “protected time” for clinicians, that is, the frontline clinicians only need to focus on delivering and documenting the conversations. Table 1 summarizes the local adaptations of these processes at the two sites.

Patients were eligible if they were: (1) Hamilton site— hospitalized for at least 48 h with an interRAI Emergency Department Screener score of five or six (maximum score 6)1416; (2) Calgary site—65 years or older and hospitalized for 5 days or more. Patients were also eligible if the attending physician believed that a serious illness conversation was a high priority. When patients did not have capacity to participate, substitute decision maker(s) were invited instead.

Quality improvement measures and data sources

Process measures

Unit champions collected real-time data on the number of eligible clinicians trained, number of eligible patients identified, number of eligible patients for whom we delivered a serious illness conversation, and number of conversations documented in the medical record.

Patient experience measures

We used the single-item measure “In the last 2 days, how much have you felt heard and understood by the doctors, nurses, and hospital staff?” that has been validated to evaluate palliative care quality improvement interventions. Response options were not at all, slightly, moderately, quite a bit, or completely.17 In addition, we used a seven-item questionnaire designed by the developers of the SICP to assess patient experience, in which patients (or family members) reported the impact of serious illness conversations on their understanding of what their health might be like in the future, sense of control over medical decisions, peacefulness, hopefulness about quality of life, and sense of closeness with their clinician (response options were: decreased a lot, decreased somewhat, decreased a little, neither increased nor decreased, increased a little, increased somewhat, increased a lot). Patients also reported the extent to which the conversation was worthwhile (not at all, somewhat, mostly, extremely). These survey items (and those on the clinician survey, see below) were derived from extensive literature review, and were reviewed for face and content validity by experts in palliative care, psychiatry, geriatrics, and survey methods.18 We obtained these measures by administering questionnaires to patients (or family members) before and 48 h after a serious illness conversation (Appendix 3).

Clinician experience measures

In the nine-item clinician survey, clinicians rated ease of use of the Guide, and the extent to which the Guide allowed them to gather important information, understand patients’ values and goals of care, provided information that enhanced clinical care, helped build trust in the clinician–patient relationship, and could be done in an appropriate amount of time (do not agree, somewhat agree, mostly agree, agree). Further, clinicians reported impact of the Guide on their anxiety in having these discussions, their patients’ emotional state (much worse, worse, slightly worse, neither worse nor better, slightly better, better, much better), and satisfaction with their role in patient care (greatly decreased, decreased, slightly decreased, neither increased nor decreased, slightly increased, increased, greatly increased). We collected clinician-reported measures by emailing trained clinicians an invitation to an online questionnaire, at least 6 months after they had completed their training (Appendix 4). We also conducted qualitative interviews with participating clinicians, the results of which are reported elsewhere.19

Assessing contextual elements affecting implementation

We used the National Health Service Sustainability Model self-assessment tool to identify local factors that may influence the likelihood of continued project success at each site.20 The model consists of 10 factors related to process, staff, and organizational issues (Appendix 5). An overall score ≥ 55 suggests that a system intervention will have a high likelihood of sustained success, whereas a score <35 suggests that there are significant barriers to sustainability. To determine scores on the National Health Service Sustainability Model self-assessment tool, the implementation committees at each site led a face-to-face structured discussion, chaired by the site lead, to reach consensus on each item.

Statistical analysis

We used descriptive statistics to summarize patient and clinician characteristics. To assess change in responses to the “feeling heard and understood” question before and after a serious illness conversation, we used a paired t-test, as defined a priori, assigning the following values to the response options (1 = not at all, 2 = slightly, 3 = moderately, 4 = quite a bit, 5 = completely).9 We used counts and proportions to describe the distribution of responses to the questions on the patient and clinician experience questionnaires. In this study, we report data from two sites. We conducted exploratory subgroup analyses to examine differences in outcome measures between sites.

Although we implemented the program at four sites, one site ultimately developed different site-specific evaluation measures, which will be published elsewhere. The other site began work later and could not conduct formal evaluation because it first needed to channel resources into implementation and was then hampered by the global coronavirus pandemic.

Ethics approval

The Hamilton Integrated Research Ethics Board granted a formal written exemption from full review because the primary aim was deemed to be quality improvement. The initiative was fully reviewed and approved by Calgary’s Conjoint Health Research Ethics Board.

Results

In Hamilton, implementation began in February 2017 and ended in September 2018. In Calgary, implementation began in March 2018 and ended in December 2020.

Implementation process measures

Of 62 eligible clinicians (55 attending physicians, 4 nurse practitioners, 3 social workers), 57 (92%; 50 attending physicians, 4 nurse practitioners, and 3 social workers) completed clinician training. We delivered serious illness conversations for 334 (29%) of 1158 eligible patients. The following types of clinicians led the conversations: attending physicians 262 (78%), nurse practitioners 52 (16%), senior medical residents who had received training within their residency program and were supervised by trained attending physicians 16 (5%), social worker 1 (0.3%), unknown 3 (1%). Most conversations (n = 274, 82%) were documented in the medical record (Figure 1).

Figure 1. Study flow diagram.

EMR, electronic medical record.

Patient and family member experience

The characteristics of the 334 eligible patients are reported in Table 2. In the majority of cases (n = 226, 68%), the patient was able to participate in the serious illness conversations, whereas 93 (28%) conversations were held with family member(s) alone (Table 3). Of the 334 conversations, a postconversation questionnaire was completed in 106 (32%) cases. Most of the respondents (80%) reported that conversations were worthwhile (mostly or extremely) and that they increased (a little, somewhat, a lot) their sense of control over their medical decisions (61%), peacefulness (60%), understanding of their life expectancy (65%), their sense of closeness to their clinician (62%), and understanding of what their health may be like in the future (75%). Approximately half (52%) of the respondents reported an increase in hopefulness, whereas 21% reported a decrease in hopefulness after the conversation (Figure 2).

Table 2. Characteristics of 334 eligible patients for whom the patient and/or family member received a serious illness conversation

Eligible patients (N = 334)
Age, years, Mean (SD), (n = 334) 75.6 (11.8) [range 32 to 97]
Gender, n (%)
Male 148 (44)
Female 128 (37)
Missing 63 (19)
Frailty score*, median (IQR), (n = 269) 5 (4, 6)
English speaking, n (%)
Yes 281 (84)
No 52 (16)
Missing 1 (0.3)
Cognition, n (%)
Oriented 229 (69)
Not oriented** 104 (31)
Missing 1 (0.3)
Patient living alone, n (%)
Yes 112 (34)
No 156 (47)
Missing 66 (20)
Marital status, n (%)
Never married 9 (3)
Married or living as married or common-law 119 (36)
Widowed 78 (23)
Divorced, separated, or never married 26 (8)
Missing 102 (31)

*Clinical Frailty Score by Rockwood et al.27 1 = very fit, 2 = fit, 3 = managing well, 4 = living with very mild frailty, 5 = living with mild frailty, 6 = living with moderate frailty, 7 = living with severe frailty, 8 = living with very severe frailty, 9 = terminally ill. **Substitute decision makers participated in conversations if the patient lacked capacity.

Table 3. Participants in serious illness conversations

Conversations (N = 334)
Patient alone 55 (16)
Patient and family member(s) 171 (51)
Family member(s) alone 93 (28)
Missing information 15 (5)

All data are reported as numbers (%).

Figure 2. Responses to patient (or family) postconversation questionnaire.

The pre- and postconversation ratings of the heard and understood item were completed in 99 (30%) of 334 cases. Mean ratings before and after were 3.9 and 4.1, respectively (1 = not at all, 5 = completely), corresponding to a mean increase of 0.2 (95% CI 0.0 to +0.4, P = 0.04) after the serious illness conversation (Figure 3).

Figure 3. Patient (or family) responses to heard and understood questions before and after serious illness conversation.

In exploratory subgroup analyses, we did not find appreciable differences in patient experience responses between sites (data not shown); however, we did find a significantly different effect of conversations on feeling heard and understood between sites; in Hamilton, mean scores before and after were 3.2 and 4.0, respectively (mean change +0.8, 95% CI +0.4 to +1.3, P = 0.002), versus in Calgary, mean scores before and after were 4.1 and 4.1, respectively (mean change 0.0, 95% CI −0.2 to +0.2, P = 0.90) (P = 0.001 for interaction).

Clinician experience

Of the 57 clinicians who received training, 39 (68%) completed the clinician experience questionnaire (33 attending physicians, 3 nurse practitioners, and 3 social workers). All clinicians agreed that the Guide was easy to use, with 95% agreeing (somewhat, mostly, fully) that the Guide can be used in an appropriate amount of time. Clinicians also agreed that the Guide allowed them to gather important information (100%), helped them understand patients’ values and goals of care (100%), helped build a trusting clinician–patient relationship (100%), and provided information that enhanced clinical care of their patients (97%). Clinicians perceived that, in general, discussions using the Guide improved their patients’ emotional state (73%). Overall, 82% of clinicians reported that their satisfaction of their role in their patients’ care increased (Figure 4). There were no appreciable differences in clinician experience by site (data not shown).

Figure 4. Responses to clinician experience questionnaire.

National Health Service Sustainability Model

Figure 5 and Appendix 5 show site scores on the National Health Service Sustainability Model. Total sustainability scores were 46.4 in Hamilton and 59.4 in Calgary (an overall score ≥55 suggests that a system intervention will have a high likelihood of sustained success, whereas a score <35 suggests that there are significant barriers to sustainability). At both sites, the factors with the lowest scores indicating the greatest opportunity for improvement were senior leadership engagement and support, and infrastructure for sustainability.

Figure 5. Summary of scores on the National Health System Sustainability Model at the (a) Hamilton site and (b) Calgary site.

Discussion

We found that the SICP can be adapted and implemented on medical wards of hospitals. Clinicians found the Guide was easy to use, feasible to complete in an appropriate amount of time and had a positive impact on clinical care. Patients and families who responded to study questionnaires found the conversations worthwhile, with increase in illness understanding, peacefulness, sense of control over medical decisions, closeness with their clinician and, in some cases, feeling more heard and understood.

In contrast to most other communication tools in the field of advance care planning,21 the SICP has high quality evidence to support its effectiveness, with a cluster randomized controlled trial in outpatient oncology demonstrating more frequent, higher quality and earlier conversations, and sustained reductions in patient anxiety and depression compared to usual care.4,11 Further analyses also found the intervention was acceptable and useful to clinicians and improved patient experience.18 However, the hospital differs in important ways from the outpatient clinic. For instance, most hospital clinicians do not have a longitudinal relationship with their patients, requiring rapid rapport-building to engage in serious illness conversations. Also, because of acute symptoms, hospitalized patients may be less able to participate in these conversations, and families’ attention may be more focused on treatment of the acute problem. Therefore, the benefits of the SICP cannot be assumed to generalize to the inpatient setting.

However, in a chart review of early data from our hospital-based implementation, we found that serious illness conversations during the intervention phase were of higher quality than among historical controls.22 Our current findings suggest that the SICP is adaptable to hospital medical wards without compromising known benefits to patient and clinician experience.4,18 Our study also extends previous studies by showing that serious illness conversations delivered by hospital teams (not palliative care consultants) can result in an improvement in patients feeling heard and understood, a validated quality measure for palliative care.17

Clinicians often cite lack of time and training, a fear of destroying patients’ hope and increasing their anxiety as barriers to serious illness conversations.58 However, our findings suggest that the Guide can be completed in an appropriate amount of time. Although we did not measure conversation duration, others reported a median duration of 14 min (from audio-recorded conversations in the original trial),23 and clinician-reported durations of 22 min (physician-led) to 26 min (nurse-led) in primary care,24 which is anecdotally similar to our experience. In addition, more important than the absolute duration of the conversations is their acceptability to clinicians. In our study, a majority (95%) of clinicians agreed (somewhat, mostly, or completely) that conversations could be done in an appropriate amount of time. Importantly, in our study, most patients reported feeling more hopeful, more peaceful and, in some cases, more heard and understood after having serious illness conversations with their hospital clinician. While the majority reported positive experiences, 21% did report a decrease in hopefulness, consistent with the implementation of this program in the oncology setting18; however, the oncology trial also found sustained, statistically significant, and clinically meaningful reductions in patient anxiety and depression at 6-months follow-up, suggesting that initial reports of decreased hopefulness are either transient, are outweighed by other benefits of the conversation, or that there may still be an opportunity to further enhance the positive impact of these conversations (e.g., by providing longitudinal communication skills coaching to clinicians after initial training).18 Nevertheless, the overall positive impact we observed demonstrates that clinicians who do not have a prior relationship with patients can nonetheless develop rapport rapidly using the tool and that this is not a barrier to meaningful conversations.7

At a health system level, the RE-AIM framework offers one approach to assess our efforts to translate research into action. The framework delineates five domains: reach, effectiveness, adoption, implementation, and maintenance.25 We were able to generate high rates of clinician participation in training and adoption of the Guide in practice. When used, we observed more accessible documentation of conversations in the medical record, and, among survey responders, positive experiences on clinicians, patients, and families. Yet, conversations reached only one-third of the eligible population. Very few eligible patients declined to engage in a serious illness conversation when invited. Therefore, there were other reasons for the limited participation of all eligible patients. First, although we found personal “nudges” from Unit Champions were effective in prompting conversations, we needed to balance this with alert fatigue and a need to maintain collaborative relationships with frontline clinicians. Second, although clinicians rated the Guide as feasible to complete, the full process of identifying an eligible patient, prompting the clinician, scheduling, and delivering the conversation still take time, and sometimes were interrupted by patient discharge, transfer to another unit, attending physician leaving the service or, rarely, death of the eligible patient. Finally, despite excellent uptake of clinician training (92%), once on the ward, clinicians ranged from high adopters to avoidant which limited our reach to all eligible patients. Although we did approach our initial goal of clinicians having one conversation per week, our reach to 30% of eligible patients highlights that the number of patients who could potentially benefit may outstrip the capacity to have these conversations in a hospital setting. It may be more useful to view these conversations as part of an ongoing process, requiring additional engagement of primary care and outpatient practitioners. Finally, to maximize sustainability, we found that both sites need to focus on senior leadership engagement and support, and infrastructure for sustainability. There are considerable resources needed for training and identification of patients which need leadership support. For instance, our implementation relied on external funding of a Unit Champion (0.5 to 1.0 full-time equivalent of a ward nurse’s salary) to facilitate various key processes, including identifying eligible patients, nudging clinicians to have serious illness conversations, and scheduling a time for the conversations to occur. Our experience so far suggests that senior leadership is very willing to voice moral support and affirmation about the importance of this work; however, ongoing commitment of organizational resources to ensure sustainability is less clear. Although one conceptually attractive option is to embed processes and roles into the existing envelope of funding for medical programs, it is unclear whether the impacts we observed could be achieved without some minimum amount of funding. Future work could examine strategies to maximize the feasibility and efficiency of implementation to create opportunity for larger scale spread and impact of this intervention.

Our study has limitations. First, the patient or family member response rate to questionnaires was approximately 30%. Although missing responses were often due to factors unlikely to correlate with patient experience measures (e.g., discharge, transfer to another service, death), it remains possible that nonresponders were systematically different from responders. Second, we observed a ceiling effect on the feeling heard and understood measure, suggesting that other outcome measures may be required to determine the impact on patient experience. Third, we did not measure the impact of the program on behavioral outcomes such as greater engagement in advance care planning activities. This could be an area for future research. Fourth, we did not measure impact of the conversations on subsequent system outcomes, such as readmission rates and emergency room use.26 Finally, we conducted our implementation at Canadian teaching hospitals, so our experience may not be generalizable to other hospitals or settings.

In conclusion, the SICP, originally designed for outpatient oncology setting, can be adapted and implemented on medical wards of hospitals and can have a positive impact on patient and clinician experience. Further work is warranted to determine how to efficiently implement, spread, and sustain this intervention in other hospitals.

Acknowledgments

The authors would like to thank Shelley Weniger and Jocelyn Semenchuk for all the time and energy they devoted to the implementation of the Serious Illness Care Program as Unit Champions on their respective medical wards.

Author Contributions

You, Simon, Swinton, Ma, Dunne, Jayaraman, Kobewka, and Munene contributed to the conception or design of the work. Singh, Swinton, Lagrotteria, Paladino, and Bernacki contributed to acquisition, analysis, and interpretation of data. You and Singh were involved in the drafting of the work, and Simon, Swinton, Ma, Dunne, Jayaraman, Kobewka, Munene, Lagrotteria, Paladino, and Bernacki contributed to the critical revision for important intellectual content. All authors gave final approval of the version submitted for publication.

Disclosures

None of the authors have conflicts of interest to disclose.

Funding

This work received funding support from the Canadian Frailty Network and Hamilton Health Sciences Research Administration. Dr. Irene Ma is funded as the Chair Holder of the John A. Buchanan Chair of General Internal Medicine at the University of Calgary. None of the funders had any role in the design or implementation of the study, interpretation of the data, preparation of the manuscript, or the decision to publish.

REFERENCES

1. Heyland DK, Cook DJ, Rocker GM, Dodek PM, Kutsogiannis DJ, Skrobik Y, et al. Defining priorities for improving end-of-life care in Canada. CMAJ. 2010;182:E747–52. 10.1503/cmaj.100131

2. Heyland DK, Barwich D, Pichora D, Dodek P, Lamontagne F, You JJ, et al. Failure to engage seriously ill hospitalized patients and their families in advance care planning: Results of a multi-center prospective study. JAMA Intern Med. 2013;173:778–87. 10.1001/jamainternmed.2013.180

3. You JJ, Dodek P, Lamontagne F, Downar J, Sinuff T, Jiang X, et al. What really matters in end-of-life discussions? Perspectives of patients in hospital with serious illness and their families. CMAJ. 2014;186:E679–87. 10.1503/cmaj.140673

4. Bernacki R, Paladino J, Neville BA, Hutchings M, Kavanagh J, Geerse OP, et al. Effect of the serious illness care program in outpatient oncology: A cluster randomized clinical trial. JAMA Intern Med. 2019;179:751–9. 10.1001/jamainternmed.2019.0077

5. You JJ, Downar J, Fowler RA, Lamontagne F, Ma IWY, Jayaraman D, et al. Barriers to goals of care discussions with seriously ill hospitalized patients and their families: A multi-center survey of clinicians. JAMA Intern Med. 2015;175:549–56. 10.1001/jamainternmed.2014.7732

6. Bergenholtz H, Timm HU, Missel M. Talking about end of life in general palliative care–What’s going on? A qualitative study on end-of-life conversations in an acute care hospital in Denmark. BMC Palliat Care. 2019;18:62. 10.1186/s12904-019-0448-z

7. Simon J, Porterfield P, Bouchal SR, Heyland D. “Not yet” and “Just ask”: Barriers and facilitators to advance care planning—A qualitative descriptive study of the perspectives of seriously ill, older patients and their families. BMJ Support Palliat Care. 2015;5:54–62. 10.1136/bmjspcare-2013-000487

8. Lovell A, Yates P. Advance care planning in palliative care: A systematic literature review of the contextual factors influencing its uptake 2008–2012. Palliat Med. 2014;28:1026–35. 10.1177/0269216314531313

9. Singh J, Simon J, Ma I, Dunne F, Dugan A, Wooller K, et al. Implementation of the serious illness care program on hospital medical wards: Methodology for a multi-site quality improvement initiative. Can J Gen Intern Med. 2021;16(3):e40–59. 10.22374/cjgim.v16i3.484

10. Bernacki R, Hutchings M, Vick J, Smith G, Paladino J, Lipsitz S, et al. Development of the serious illness care program: A randomised controlled trial of a palliative care communication intervention. BMJ Open. 2015;5:e009032. 10.1136/bmjopen-2015-009032

11. Paladino J, Bernacki R, Neville BA, Kavanagh J, Miranda SP, Palmor M, et al. Evaluating an intervention to improve communication between oncology clinicians and patients with life-limiting cancer: A cluster randomized clinical trial of the serious illness care program. JAMA Oncol. 2019;5:801–9. 10.1001/jamaoncol.2019.0292

12. Ogrinc G, Davies L, Goodman D, Batalden P, Davidoff F, Stevens D. SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process.BMJ Qual Saf. 2016;25:986–92. 10.1136/bmjqs-2015-004411

13. Bernacki RE, Block SD. Communication about serious illness care goals: A review and synthesis of best practices. JAMA Intern Med. 2014;174:1994–2003. 10.1001/jamainternmed.2014.5271

14. Declercq A, Hirdes J, Curtin-Telegdi N, Poss JW, Gray L, Berg K, et al. InterRAI contact assessment (CA) form and user’s manual: A screening level assessment for emergency department and intake from community/hospital. Version 9.2. Washington, DC: InterRAI; 2009.

15. Hirdes JP, Ljunggren G, Morris JN, Frijters DHM, Soveri HF, Gray L, et al. Reliability of the interRAI suite of assessment instruments: A 12-country study of an integrated health information system. BMC Health Serv Res. 2008;8:277. 10.1186/1472-6963-8-277

16. Wellens NI, Deschodt M, Boonen S, Flamaing J, Gray L, Moons P, et al. Validity of the interRAI acute care based on test content: A multi-center study. Aging Clin Exp Res. 2011;23:476–86. 10.1007/BF03325244

17. Gramling R, Stanek S, Ladwig S, Gajary-Coots E, Cimino J, Anderson W, et al. Feeling heard and understood: A patient-reported quality measure for the inpatient palliative care setting. J Pain Symptom Manage. 2016;51:150–4. 10.1016/j.jpainsymman.2015.10.018

18. Paladino J, Koritsanszky L, Nisotel L, Neville BA, Miller K, Sanders J, et al. Patient and clinician experience of a serious illness conversation guide in oncology: A descriptive analysis. Cancer Med. 2020;9:4550–60. 10.1002/cam4.3102

19. Lagrotteria A, Swinton M, Simon J, King S, Boryski G, Ma IWY, Dunne F, Singh J, Bernacki RE, You JJ. Clinicians’ Perspectives After Implementation of the Serious Illness Care Program: A Qualitative Study. JAMA Netw Open. 2021 Aug 2;4(8):e2121517. 10.1001/jamanetworkopen.2021.21517. PMid: 34406399; PMCID: PMC8374609.

20. Maher L, Gustafson PD, Evans A. National health service sustainability model and guide [Internet]. 2010 [cited 2020 Dec 18]. Available from: https://improvement.nhs.uk/resources/Sustainability-model-and-guide/

21. Butler M, Ratner E, McCreedy E, Shippee N, Kane RL. Decision aids for advance care planning: An overview of the state of the science. Ann Intern Med. 2014;161:408–18. 10.7326/M14-0644

22. Ma C, Riehm LE, Bernacki R, Paladino J, You JJ. Quality of clinicians’ conversations with patients and families before and after implementation of the serious illness care program in a hospital setting: A retrospective chart review study. CMAJ Open. 2020;8:E448–54. 10.9778/cmajo.20190193

23. Geerse OP, Lamas DJ, Sanders JJ, Paladino J, Kavanagh J, Henrich NJ, et al. A Qualitative study of serious illness conversations in patients with advanced cancer. J Palliat Med. 2019;22:773–81. 10.1089/jpm.2018.0487

24. Lakin JR, Koritsanszky LA, Cunningham R, Maloney FL, Neal BJ, Paladino J, et al. A systematic intervention to improve serious illness communication in primary care. Health Aff (Millwood). 2017;36:1258–64. 10.1377/hlthaff.2017.0219

25. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: The RE-AIM framework. Am J Public Health. 1999;89:1322–7. 10.2105/ajph.89.9.1322

26. Sudore RL, Heyland DK, Lum HD, Rietjens JAC, Korfage IJ, Ritchie CS, et al. Outcomes that define successful advance care planning: A delphi panel consensus. J Pain Symptom Manage. 2018;55:245–55.e8. 10.1016/j.jpainsymman.2017.08.025

27. Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173:489–95. 10.1503/cmaj.050051

Appendix 1. Serious Illness Conversation Guide

Serious Illness Conversation Guide

Appendix 2. Family Communication Guide

Talking about your illness with loved ones and caregivers

Appendix 3. Patient survey instrument

Appendix 4. Clinician survey instrument

Appendix 5. National Health Service Sustainability Model scores for each site

Domain Factor Calgary Hamilton Maximumscore
Process Benefits beyond helping patients 4.0 4.7 8.5
Credibility of the evidence 6.3 6.3 9.1
Adaptability of improved process 3.4 2.4 7
Effectiveness of the system to monitorprogress 3.3 2.4 6.5
Overall Process Domain Score 17 15.8 31.1
Staff Staff involvement and training to sustainthe process 6.3 6.3 11.4
Staff behaviours towards sustaining thechange 5.1 5.1 11
Senior leadership engagement andsupport 5.7 5.7 15
Clinical leadership engagement andsupport 15 6.7 15
Overall Staff Domain Score 32.1 23.8 52.4
Organization Fit with the organization’s strategic aimsand culture 7 3.5 7
Infrastructure for sustainability 3.3 3.3 9.5
Overall Organizational Domain Score 10.3 6.8 16.5
Total Sustainability Score 59.4 46.4 100