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Context: Interventions to promote serious illness conversations have shown promise in promoting high-quality care. However, in randomized trials, some participants may benefit more from the intervention than others.Objectives: To examine heterogeneity of treatment effect and identify subgroups of patients with serious illness who might benefit most from interventions to enhance communication about goals of care.Methods: We used data from a multi-center cluster-randomized trial evaluating a communication intervention to increase goals-of-care discussions in the outpatient setting. Patients (n = 249 intervention, n = 288 usual care) had serious illness with an expected median survival of two years. Using model-based recursive partitioning, we tested heterogeneity of the intervention's effect on the occurrence of patient-reported goals-of-care discussions, electronic health record documentation of goals-of-care discussions, patients' ratings of quality of communication, and patients' symptoms of psychological distress at three and six months.Results: We found two significant interactions. For patients' overall rating of clinician communication (n = 251), the intervention effect was positive for patients with higher household income, but not those with lower income (P < 0.001). For patients' symptoms of depression at six months (n = 288), the intervention was associated with fewer symptoms of depression among those whose self-assessed health was poor, but not among those with fair to excellent health (P < 0.001).Conclusions: Identifying heterogeneity of treatment effect can be a valuable exercise following completion of a randomized trial. Interactions between the intervention and patient income and self-assessed health suggest these factors could be used to design more effective interventions to enhance communication about goals of care. [ABSTRACT FROM AUTHOR]

For a hospitalized patient, transitioning to comfort measures only (CMO) involves discontinuation of life-prolonging interventions with a goal of allowing natural death. Nurses play a pivotal role during the provision of CMO, caring for both the dying patient and their family. To examine the experiences of ICU nurses caring for patients receiving CMO. Between October 2020 and June 2021, nurses in the neuro- and medical-cardiac intensive care units at Harborview Medical Center in Seattle, WA, completed surveys about their experiences providing CMO. Surveys addressed involvement in discussions about CMO and questions asked by family members of dying patients. We also assessed nurses' moral distress related to CMO and used ordinal logistic regression to examine predictors of moral distress. Surveys were completed by 82 nurses (response rate 44%), with 79 (96%) reporting experience providing CMO in the previous year. Most preferred to be present for discussions between physicians or advanced practice providers and family members about transitioning to CMO (89% most of the time or always); however, only 31% were present most of the time or always. Questions from family about time to death, changes in breathing, and medications to relieve symptoms were common. Most nurses reported moral distress at least some of the time when providing CMO (62%). Feeling well-prepared to answer specific questions from family was associated with less moral distress. There is discordance between nurses' preferences for inclusion in discussions about the transition to CMO and their actual presence. Moral distress is common for nurses when providing CMO and feeling prepared to answer questions from family members may attenuate distress. [ABSTRACT FROM AUTHOR]

1. Increase learners' knowledge of the long-term outcomes of patients who opt for conservative management of their advanced kidney disease 2. Orient learners to potential research priorities to improve care for patients with advanced kidney disease who forgo maintenance dialysis that is supported by the findings of our systematic review Greater understanding of the clinical trajectory of patients with advanced kidney disease who do not undergo maintenance dialysis is needed to improve care practices for this population. To evaluate the long-term outcomes of conservatively managed patients with advanced kidney disease. We searched Medline, Embase, and CINAHL from inception through January 27, 2020 for all English-language cohort studies of adults for whom there was an explicit decision not to pursue maintenance dialysis. Two reviewers independently reviewed all studies and selected those reporting survival, healthcare utilization, and changes in quality of life or end-of-life care during follow-up. One author abstracted all study data, of which 14% was independently adjudicated by a second author (<1% error rate). Because of the heterogeneity in patient populations, approaches to conservative kidney management, and measures used across studies, we opted to provide a narrative synthesis of reported outcomes. 36 studies comprising 4,327 patients (n = 11-812) were included in this review. Median survival of cohorts ranged from 1 to 41 months as measured from a baseline mean estimated glomerular filtration rate ranging from 7 to 19 mL/min/1.73 m2. Patients generally experienced 1 or 2 hospital admissions, 4-11 in-hospital days, 7 or 8 clinic visits, and 2 emergency room visits per person-year. Over an 8- to 24-month observation period, mental well-being improved, and physical well-being and overall quality of life remained largely unchanged until late in the illness course. Among patients who died during follow-up, 20-76% had enrolled in hospice, 27-47% died in a hospital setting, 12-71% died at home, and 4-47% received invasive procedures during the final month of life. Many conservatively managed patients survived several years after their decision to forgo dialysis and experienced sustained quality of life until late in the illness course. Nonetheless, use of acute care services was common and intensity of end-of-life care highly variable across cohorts. Our findings underscore the need to develop best practices, models of care, and the care infrastructure that optimize outcomes for members of this population. PROSPERO CRD42020156086. [ABSTRACT FROM AUTHOR]

1. Identify how frequently family and family members ask nurses about certain elements of end-of-life care 2. Recognize how often nurses prefer to be included in discussions about comfort care with providers and patients and their family members compared to how often nurses were present during these discussions 3. State how frequently certain elements of end-of-life care caused nursing moral distress Transitions to comfort measures only (CMO) involve discontinuation of life-prolonging interventions with a goal of allowing a natural death. Despite frequent use of CMO in hospitals, little is known about involvement of nurses in discussions about CMO, questions nurses are asked by family about CMO, or whether those questions affect moral distress. To examine experiences of nurses caring for patients receiving CMO. Nurses in the neuro- and medical-cardiac ICUs at Harborview Medical Center in Seattle, WA, were invited to complete an online survey addressing their experiences caring for patients receiving CMO. Surveys were completed by 81 nurses (response rate 42%). Most nurses preferred to be present for discussions about initiating CMO (85% at least most of the time or always); however, only 30% reported being present this frequently. Questions from family about time to death, changes in breathing, and symptom management were common, and questions about nutrition and hydration were less so. Most nurses reported moral distress at least some of the time (53%) when providing CMO, but questions from family were not a source of distress for most. Nurses are infrequently present when providers discuss transitions to CMO with patients and their family, despite a preference to participate. Family members ask a variety of questions about CMO, most about features of the dying process and symptom management. Moral distress was common for nurses providing CMO, although questions from family members did not appear to be a primary driver of distress. Additional efforts are needed to actively involve nurses in discussions with families about CMO. Conversations with patients and their family members should be tailored to address common questions. More research is needed to elucidate contributors to moral distress experienced by nurses caring for patients at the end of life. [ABSTRACT FROM AUTHOR]