Care concordant with patient goals of care (GOC) is a central component of quality. Communication about GOC is associated with improved quality of life, reduced resource utilization, and optimized end-of-life (EOL) care. Prior literature has focused on outpatient populations, with little knowledge based on preferences elicited from patients hospitalized for serious acute illness.1 The consequent knowledge gap relates to a dimension of practice through which hospitalists can improve patient-centered care by clarifying patient preferences for goal-directed treatments both during and following hospitalization.2 Implementing interventions that optimize shared decision-making through a personalized serious- illness care plan is a high-priority research area.2
In this issue, to estimate how frequently GOC are assessed during hospitalization for serious illness and the concordance between identified goals and postdischarge care, Taylor et al3 retrospectively evaluated a cohort of sepsis survivors through electronic health record (EHR) review. A standardized EHR care alignment tool and a comprehensive EHR assessment demonstrated that only 19% and 40% of patients, respectively, had identifiable GOC documented. Goal-concordant care was subsequently observed among 68% of patients with identified goals, consistent with prior work demonstrating goal-concordance in this range.1 Data on EOL care provided to decedents in an integrated health system notably showed that 89% received goal-concordant treatments.4 This difference may stem from clinicians’ emphasis on goal ascertainment at the EOL, a propensity reflected in the comparative characteristics of patients with goals documented in the current study’s Table.3 Investigators took advantage of unique inpatient and postdischarge clinical information from a sepsis patient sample to provide novel insights into the inadequacy of patient preference assessment and the substantial frequency of goal-discordant care resulting from insufficient attention to GOC.
This study suggests a critical need to improve practices related to identification of GOC in patients hospitalized with serious illness. After adjusting for relevant confounding characteristics, completion of a standardized EHR care alignment tool was strongly associated with receipt of goal-concordant care following discharge.3 Although this tool was only completed in 19% of patients, this finding suggests that elicitation of patient preferences is an under-addressed step in facilitating patient-centered transitions of care. In particular, the low 39% rate of goal-concordant care among patients prioritizing comfort over longevity is noteworthy, but consistent with prior literature.1 This degree of discordance highlights provision of goal-concordant care following hospitalization as a key, yet unfulfilled, patient-centered-care quality metric.
The identified shortcomings in communication and care represent an important opportunity for hospitalists to enhance the extent to which survivors of critical illness receive care respectful of their preferences and values. Given the importance of effective discharge handoff practices in hospital medicine,2 future work should address assertively incorporating GOC into transitions after serious acute illness. Enhancing communication of these goals at discharge may benefit patients at high risk of readmission and other postdischarge adverse events, particularly for patients with comfort-focused GOC.
The study is limited in its derivation from trial participants with a specific clinical syndrome in a single health system. Also, investigators’ classification of a single patient goal does not reflect the multifactorial objectives of health interventions. In addition, since patient-reported GOC discussions correlate more highly with goal-concordant care than those identified through EHRs,5 future work should ascertain the generalizability of the identified gaps in practice.
The findings of this study underscore the need for clinicians to promote GOC assessment and documentation during hospitalization for high-risk conditions, such as sepsis. Tracking rates of GOC elicitation and goal-concordant care following discharge should be incorporated into quality measurement systems as important patient-centered dimensions of care. Hospitalists can fill a critical void by helping to correct the deficiencies that exist in respecting the preferences of survivors of serious acute illness.