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ImportanceDiscussions about goals of care are important for high-quality palliative care yet are often lacking for hospitalized older patients with serious illness.ObjectiveTo evaluate a communication-priming intervention to promote goals-of-care discussions between clinicians and hospitalized older patients with serious illness.Design, Setting, and ParticipantsA pragmatic, randomized clinical trial of a clinician-facing communication-priming intervention vs usual care was conducted at 3 US hospitals within 1 health care system, including a university, county, and community hospital. Eligible hospitalized patients were aged 55 years or older with any of the chronic illnesses used by the Dartmouth Atlas project to study end-of-life care or were aged 80 years or older. Patients with documented goals-of-care discussions or a palliative care consultation between hospital admission and eligibility screening were excluded. Randomization occurred between April 2020 and March 2021 and was stratified by study site and history of dementia.InterventionPhysicians and advance practice clinicians who were treating the patients randomized to the intervention received a 1-page, patient-specific intervention (Jumpstart Guide) to prompt and guide goals-of-care discussions.Main Outcomes and MeasuresThe primary outcome was the proportion of patients with electronic health record–documented goals-of-care discussions within 30 days. There was also an evaluation of whether the effect of the intervention varied by age, sex, history of dementia, minoritized race or ethnicity, or study site.ResultsOf 3918 patients screened, 2512 were enrolled (mean age, 71.7 [SD, 10.8] years and 42% were women) and randomized (1255 to the intervention group and 1257 to the usual care group). The patients were American Indian or Alaska Native (1.8%), Asian (12%), Black (13%), Hispanic (6%), Native Hawaiian or Pacific Islander (0.5%), non-Hispanic (93%), and White (70%). The proportion of patients with electronic health record–documented goals-of-care discussions within 30 days was 34.5% (433 of 1255 patients) in the intervention group vs 30.4% (382 of 1257 patients) in the usual care group (hospital- and dementia-adjusted difference, 4.1% [95% CI, 0.4% to 7.8%]). The analyses of the treatment effect modifiers suggested that the intervention had a larger effect size among patients with minoritized race or ethnicity. Among 803 patients with minoritized race or ethnicity, the hospital- and dementia-adjusted proportion with goals-of-care discussions was 10.2% (95% CI, 4.0% to 16.5%) higher in the intervention group than in the usual care group. Among 1641 non-Hispanic White patients, the adjusted proportion with goals-of-care discussions was 1.6% (95% CI, −3.0% to 6.2%) higher in the intervention group than in the usual care group. There was no evidence of differential treatment effects of the intervention on the primary outcome by age, sex, history of dementia, or study site.Conclusions and RelevanceAmong hospitalized older adults with serious illness, a pragmatic clinician-facing communication-priming intervention significantly improved documentation of goals-of-care discussions in the electronic health record, with a greater effect size in racially or ethnically minoritized patients.Trial RegistrationClinicalTrials.gov Identifier: NCT04281784

IMPORTANCE: A meta-analysis of outcomes during the 6 months after intensive care unit (ICU) discharge indicate a prevalence for clinically important posttraumatic stress disorder (PTSD) symptoms of 25%. OBJECTIVE: To determine whether a nurse-led preventive, complex psychological intervention, initiated in the ICU, reduces patient-reported PTSD symptom severity at 6 months. DESIGN, SETTING, AND PARTICIPANTS: A multicenter, parallel-group, cluster-randomized clinical trial with integrated economic and process evaluations conducted in 24 ICUs in the United Kingdom. Participants were critically ill patients who regained mental capacity following receipt of level 3 (intensive) care. A total of 2961 eligible patients were identified from September 2015 to January 2017. A total of 2048 were approached for participation in the ICU, of which 1458 provided informed consent. Follow-up was completed December 2017. INTERVENTIONS: Twenty four ICUs were randomized 1:1 to the intervention or control group. Intervention ICUs (n = 12; 669 participants) delivered usual care during a baseline period followed by an intervention period. The preventive, complex psychological intervention comprised promotion of a therapeutic ICU environment plus 3 stress support sessions and a relaxation and recovery program delivered by trained ICU nurses to high-risk (acutely stressed) patients. Control ICUs (n = 12; 789 participants) delivered usual care in both baseline and intervention periods. MAIN OUTCOMES AND MEASURES: The primary clinical outcome was PTSD symptom severity among survivors at 6 months measured using the PTSD Symptom Scale–Self-Report questionnaire (score range, 0-51, with higher scores indicating greater symptom severity; the minimal clinically important difference was considered to be 4.2 points). RESULTS: Among 1458 enrolled patients (mean [SD] age, 58 [16] years; 599 women [41%]), 1353 (93%) completed the study and were included in the final analysis. At 6 months, the mean PTSD Symptom Scale–Self-Report questionnaire score in intervention ICUs was 11.8 (baseline period) compared with 11.5 (intervention period) (difference, −0.40 [95% CI, −2.46 to 1.67]) and in control ICUs, 10.1 (baseline period) compared with 10.2 (intervention period) (difference, 0.06 [95% CI, −1.74 to 1.85]) between periods. There was no significant difference in PTSD symptom severity at 6 months (treatment effect estimate [difference in differences] of −0.03 [95% CI, −2.58 to 2.52]; P = .98). CONCLUSIONS AND RELEVANCE: Among critically ill patients in the ICU, a nurse-led preventive, complex psychological intervention did not significantly reduce patient-reported PTSD symptom severity at 6 months. These findings do not support the use of this psychological intervention. TRIAL REGISTRATION: ISRCTN53448131

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.

Importance Misperceptions about prognosis by individuals making decisions for incapacitated critically ill patients (surrogates) are common and often attributed to poor comprehension of medical information. Objective To determine the prevalence of and factors related to physician-surrogate discordance about prognosis in intensive care units (ICUs). Design, Setting, and Participants Mixed-methods study comprising quantitative surveys and qualitative interviews conducted in 4 ICUs at a major US medical center involving surrogate decision makers and physicians caring for patients at high risk of death from January 4, 2005, to July 10, 2009. Main Outcomes and Measures Discordance about prognosis, defined as a difference between a physician’s and a surrogate’s prognostic estimates of at least 20%; misunderstandings by surrogates (defined as any difference between a physician’s prognostic estimate and a surrogate’s best guess of that estimate); differences in belief (any difference between a surrogate’s actual estimate and their best guess of the physician’s estimate). Results Two hundred twenty-nine surrogate decision makers (median age, 47 [interquartile range {IQR}, 35-56] years; 68% women) and 99 physicians were involved in the care of 174 critically ill patients (median age, 60 [IQR, 47-74] years; 44% women). Physician-surrogate discordance about prognosis occurred in 122 of 229 instances (53%; 95% CI, 46.8%-59.7%). In 65 instances (28%), discordance was related to both misunderstandings by surrogates and differences in belief about the patient’s prognosis; 38 (17%) were related to misunderstandings by surrogates only; 7 (3%) were related to differences in belief only; and data were missing for 12. Seventy-five patients (43%) died. Surrogates’ prognostic estimates were much more accurate than chance alone, but physicians’ prognostic estimates were statistically significantly more accurate than surrogates’ (C statistic, 0.83 vs 0.74; absolute difference, 0.094; 95% CI, 0.024-0.163;P = .008). Among 71 surrogates interviewed who had beliefs about the prognosis that were more optimistic than that of the physician, the most common reasons for optimism were a need to maintain hope to benefit the patient (n = 34), a belief that the patient had unique strengths unknown to the physician (n = 24), and religious belief (n = 19). Conclusions and Relevance Among critically ill patients, discordant expectations about prognosis were common between patients’ physicians and surrogate decision makers and were related to misunderstandings by surrogates about physicians’ assessments of patients’ prognoses and differences in beliefs about patients’ prognoses.

Studies suggest that many survivors of critical illness experience long-term cognitive impairment but have not included premorbid measures of cognitive functioning and have not evaluated risk for dementia associated with critical illness.To determine whether decline in cognitive function was greater among older individuals who experienced acute care or critical illness hospitalizations relative to those not hospitalized and to determine whether the risk for incident dementia differed by these exposures.Analysis of data from a prospective cohort study from 1994 through 2007 comprising 2929 individuals 65 years old and older without dementia at baseline residing in the community in the Seattle area and belonging to the Group Health Cooperative. Participants with 2 or more study visits were included, and those who had a hospitalization for a diagnosis of primary brain injury were censored at the time of hospitalization. Individuals were screened with the Cognitive Abilities Screening Instrument (CASI) (score range, 0-100) every 2 years at follow-up visits, and those with a score less than 86 underwent a clinical examination for dementia.Score on the CASI at follow-up study visits and incident dementia diagnosed in study participants, adjusted for baseline cognitive scores, age, and other risk factors.During a mean (SD) follow-up of 6.1 (3.2) years, 1601 participants had no hospitalization, 1287 had 1 or more noncritical illness hospitalizations, and 41 had 1 or more critical illness hospitalizations. The CASI score was assessed more than 45 days after discharge for 94.3% of participants. Adjusted CASI scores averaged 1.01 points lower for visits following acute care illness hospitalization compared with follow-up visits not following any hospitalization (95% confidence interval [CI], -1.33 to -0.70; P.001) and 2.14 points lower on average for visits following critical illness hospitalization (95% CI, -4.24 to -0.03; P = .047). There were 146 cases of dementia among those not hospitalized, 228 cases of dementia among those with 1 or more noncritical illness hospitalizations, and 5 cases of dementia among those with 1 or more critical illness hospitalizations. The adjusted hazard ratio for incident dementia was 1.4 following a noncritical illness hospitalization (95% CI, 1.1 to 1.7; P = .001) and 2.3 following a critical illness hospitalization (95% CI, 0.9 to 5.7; P = .09).Among a cohort of older adults without dementia at baseline, those who experienced acute care hospitalization and critical illness hospitalization had a greater likelihood of cognitive decline compared with those who had no hospitalization. Noncritical illness hospitalization was significantly associated with the development of dementia.

Chronic liver disease results in more than 1 million physician visits and more than 300 000 hospitalizations per year in the United States. More than 27 000 patients annually progress to end-stage liver disease (ESLD), liver failure, or death. Patients with ESLD experience such complications as encephalopathy, malnutrition, muscle wasting, ascites, esophagogastric variceal hemorrhage, spontaneous bacterial peritonitis, fatigue, and depression. Despite significant improvements in palliation, patients' quality of life diminishes and their disease will often inexorably progress. Liver transplantation, a valid treatment option, increases life and reduces many symptoms. With the current shortage of organs, up to 10% to 15% of these patients die without receiving an organ. Many patients also are not candidates for transplantation due to comorbid illness. In addition, some patients receive a transplant but succumb to complications of the transplant itself. Such patients and families face the conundrum of a potentially treatable yet often fatal illness. Through the case of a 55-year-old woman with a life-long history of hepatitis B virus infection who is awaiting transplant, we discuss the transplant eligibility process and the struggle with maintaining hope for a cure in the face a life-threatening illness. In all of these circumstances, the health care team must combine elements of palliative care with life-sustaining therapy to maximize the patient's quality and quantity of life.

Importance Communication about end-of-life care is a core clinical skill. Simulation-based training improves skill acquisition, but effects on patient-reported outcomes are unknown. Objective To assess the effects of a communication skills intervention for internal medicine and nurse practitioner trainees on patient- and family-reported outcomes. Design, Setting, and Participants Randomized trial conducted with 391 internal medicine and 81 nurse practitioner trainees between 2007 and 2013 at the University of Washington and Medical University of South Carolina. Intervention Participants were randomized to an 8-session, simulation-based, communication skills intervention (N = 232) or usual education (N = 240). Main Outcomes and Measures Primary outcome was patient-reported quality of communication (QOC; mean rating of 17 items rated from 0-10, with 0 = poor and 10 = perfect). Secondary outcomes were patient-reported quality of end-of-life care (QEOLC; mean rating of 26 items rated from 0-10) and depressive symptoms (assessed using the 8-item Personal Health Questionnaire [PHQ-8]; range, 0-24, higher scores worse) and family-reported QOC and QEOLC. Analyses were clustered by trainee. Results There were 1866 patient ratings (44% response) and 936 family ratings (68% response). The intervention was not associated with significant changes in QOC or QEOLC. Mean values for postintervention patient QOC and QEOLC were 6.5 (95% CI, 6.2 to 6.8) and 8.3 (95% CI, 8.1 to 8.5) respectively, compared with 6.3 (95% CI, 6.2 to 6.5) and 8.3 (95% CI, 8.1 to 8.4) for control conditions. After adjustment, comparing intervention with control, there was no significant difference in the QOC score for patients (difference, 0.4 points [95% CI, −0.1 to 0.9];P = .15) or families (difference, 0.1 [95% CI, −0.8 to 1.0];P = .81). There was no significant difference in QEOLC score for patients (difference, 0.3 points [95% CI, −0.3 to 0.8];P = .34) or families (difference, 0.1 [95% CI, −0.7 to 0.8];P = .88). The intervention was associated with significantly increased depression scores among patients of postintervention trainees (mean score, 10.0 [95% CI, 9.1 to 10.8], compared with 8.8 [95% CI, 8.4 to 9.2]) for control conditions; adjusted model showed an intervention effect of 2.2 (95% CI, 0.6 to 3.8;P = .006). Conclusions and Relevance Among internal medicine and nurse practitioner trainees, simulation-based communication training compared with usual education did not improve quality of communication about end-of-life care or quality of end-of-life care but was associated with a small increase in patients’ depressive symptoms. These findings raise questions about skills transfer from simulation training to actual patient care and the adequacy of communication skills assessment. Trial Registration clinicaltrials.gov Identifier:NCT00687349

QUALITY AND SAFETY ARE CRITICAL ISSUES FOR health care systems around the world and have appropriately been highlighted in ongoing efforts to reform and improve health care. Care of critically ill patients is a domain in which issues of quality and safety take on monumental importance because of the severity of illness and the complexity of providing highquality critical care. In this issue of JAMA, Scales and colleagues report the results of an important study designed to evaluate the effectiveness of quality improvement efforts in communitybased critical care units in Ontario. The authors use a multifaceted “knowledge transfer” intervention including education, dissemination of algorithms, and audit and feedback, transferred through an interactive telecommunication strategy. The goal of the intervention was to increase adherence to 6 quality measures that have been documented to improve patient outcomes: prevention of ventilator-associated pneumonia (VAP), prophylaxis for deep venous thrombosis (DVT), daily spontaneous breathing trials, prevention of catheter-related bloodstream infections, early enteral feeding, and prevention of decubitus ulcers. Although debate remains about some of the evidence supporting these measures, there is general consensus that appropriate implementation of each measure can decrease risk of harm for critically ill patients. Numerous studies have investigated the value and implementation of these quality measures, but the study by Scales and colleagues has several notable features. First, the design and implementation reflect state-of-the art methods for a study evaluating quality improvement and advancing the state of science. Second, the study design, knowledge transfer intervention, and analyses are extremely complex but appropriate to the complex phenomenon under study. Third, the results were positive, documenting significant improvement in quality, although benefits were modest. Fourth, this study—with its state-of-the-art, complex methods—was funded by the Ontario health care delivery system rather than a research funding agency, which has important policy implications for improving health care in North America and beyond. Each of these 4 points warrants further discussion. Many studies have been designed to improve health care quality, but relatively few are randomized trials. Although much can be learned from nonrandomized and nonexperimental studies, the authors’ use of a randomized design with an appropriate control group improves their ability to control for bias and greatly enhances the ability to draw causal inferences. An observational study with historical controls would be unable to exclude temporal change as an explanation for the findings. These authors also addressed the problems that result from having the control group receive no intervention by using the same knowledge transfer intervention targeting different quality measures in pairs. Each intensive care unit was randomly assigned to simultaneously be the experimental group receiving the knowledge transfer intervention for one quality measure (eg, VAP prevention) and the control group receiving no knowledge transfer intervention for the other measure of the pair (eg, DVT prophylaxis). Additional innovative methods included a “decay-monitoring period” demonstrating that the improvements persist and qualitative interviews with participants to explore mechanisms of action and facilitators of success. Another feature of this study is its complexity. Rather than using the standard scientific method of changing one variable and examining its effect, the authors designed a multifaceted knowledge transfer intervention. Yet this complexity is not only appropriate; it is essential. Years of research suggest that multifaceted interventions are needed to change clinician behavior and transfer knowledge of best practices into the complicated health care system. The cluster randomized design is appropriate for an intervention targeting the hospital, yet requires complex statistical approaches to account for clustering by center, can significantly reduce effective sample sizes (if intracluster correlations are high), and substantially reduces effectiveness of randomization, thereby increasing risk of randomization imbal

ContextHealth-related quality of life (HRQL) is reduced in patients who survive acute respiratory distress (ARDS), but whether this decline in HRQL is caused by ARDS or other aspects of the patient's illness or injury is unknown.ObjectiveTo determine if there are differences in the HRQL of ARDS survivors and comparably ill or injured controls without ARDS.DesignProspective, matched, parallel cohort study.SettingA 411-bed municipal medical and regional level I trauma center.PatientsSeventy-three pairs of ARDS survivors and severity-matched controls with the clinical risk factors for ARDS of sepsis and trauma admitted between January 1, 1994, and July 30, 1996.Main Outcome MeasuresThe HRQL of ARDS survivors and controls, assessed by generic and pulmonary disease–specific HRQL instruments (Medical Outcomes Study 36-Item Short Form Health Survey, Standard Form [SF-36] and St George's Respiratory Questionnaire [SGRQ], respectively).ResultsClinically meaningful and statistically significant reductions in HRQL scores of ARDS survivors (n=73) were seen in 7 of 8 SF-36 domains and 3 of 3 SGRQ domains compared with matched controls (PP≤.02) and 3 of 3 SGRQ domains (P≤.003). Analysis of sepsis-matched pairs (n=27) revealed significant reductions in 6 of 8 SF-36 domains (P≤.05) and 3 of 3 SGRQ domains (P≤.002).ConclusionsSurvivors of ARDS have a clinically significant reduction in HRQL that appears to be caused exclusively by ARDS and its sequelae. Reductions were primarily noted in physical functioning and pulmonary disease–specific domains.

The quality of medical care at the end of life is receiving increased attention in both the popular press 1 and professional journals. 2,3 This interest has developed in part because of the perception that people die with ineffective, painful, expensive, and unwanted medical interventions that deprive them of their dignity, personal interactions, and family savings. This perception is not wholly unfounded. Approximately 60% of Americans die in hospitals. 4 Among the deaths of hospitalized patients in the SUPPORT study, 5 half died after receiving mechanical ventilation for more than 1 week. Many families of dying patients report that their loved ones experience moderate to severe pain during most or all of the loved ones' last few days. Many of the families of dying patients experience severe caregiving and financial burdens. 6 Efforts to improve the quality of end-of-life care through advance directives, education, and more accurate prognostic information have

Objective. —To describe the use of the medical futility rationale in do-not-attempt-resuscitation (DNAR) orders written for medical inpatients. Design. —Structured interviews with medical residents. Methods. —Second- and third-year internal medicine residents (n=44) were telephoned weekly and briefly interviewed about each patient who received a DNAR order in the preceding week. Setting. —Two university-affiliated hospitals: a veterans affairs medical center and a municipal hospital. Patients. —One hundred forty-five medical inpatients for whom DNAR orders were written during their hospitalization. Results. —Residents stated that the medical futility rationale applied for 91 patients (63%), but this rationale was invoked independent of patient or surrogate choice for only 17 patients (12%). Of the 91 patients for whom futility applied, both quantitative futility (low probability of success) and qualitative futility (poor quality of life if cardiopulmonary resuscitation [CPR] were performed) applied to 45 (49%), quantitative futility alone to 30 (33%), and qualitative futility alone to 16 (18%). Residents report that they discussed resuscitation issues with all communicative patients for whom the medical futility rationale was invoked. Among patients for whom quantitative futility applied, residents'predictions of the probability that patients would survive to hospital discharge after CPR varied from 0% (for 60% of patients) to 75%. For 32% of these patients, residents predicted survival at 5% or more. Logistic regression modeling showed that the presence of organ failure (odds ratio [OR], 8.9; 95% confidence interval [CI], 3.3 to 23.9), the residents' estimates of the probability of surviving CPR (OR, 0.94; 95% CI, 0.88 to 0.99), and nonwhite race (OR, 2.7; 95% CI, 1.1 to 6.3) were associated with the determination of quantitative futility. In one third of the cases where qualitative futility applied, residents made the judgment of qualitative futility without discussing quality of life with communicative patients. Logistic regression modeling showed immobility (OR, 3.2; 95% CI, 1.1 to 9.0) and age ≥75 years (OR, 0.3; 95% CI, 0.1 to 0.8) to be associated with the determination of qualitative futility. Conclusions. —While residents did not appear to use the medical futility rationale to avoid discussing DNAR issues with patients, we found evidence of important misunderstandings of the concepts of both quantitative and qualitative futility. If the futility rationale is to be applied to withholding or withdrawing medical interventions, practice guidelines for its use should be developed, and education about medical futility must be incorporated into medical school, residency training, and continuing medical education programs. ( JAMA . 1995;273:124-128)