Serious Illness Conversation Helps Patients Choose What Matters
MAKING CHOICES WHEN FACED WITH SERIOUS ILLNESS
An aging U.S. population means more people are living longer with chronic illness.1 It can be challenging for patients with serious, life-threatening illnesses to make choices about the treatment they would prefer.2 Often, discussions happen late, and occur when patients are already in crisis or when they are unable to speak for themselves.3 Technology-heavy end-of-life care is associated with poorer quality of life, decreased patient satisfaction, and increased anxiety and depression for family members.1
Partners HealthCare is a not-for-profit, integrated healthcare system based in Boston, Massachusetts. The Partners HealthCare network includes hospitals, community health centers, physician practices and post-acute care facilities. To help patients, families, and their care teams have productive and meaningful conversations about serious illness care, Partners has leveraged the Serious Illness Conversation Guide, developed by Ariadne Labs in collaboration with clinicians from Brigham and Women’s Hospital and Dana-Farber Cancer Institute. The implementation across the Partners system was managed by its Population Health team.
Partners Population Health is a team of teams dedicated to researching and redesigning clinical care in a way that focuses on the whole patient. They design population health management strategies, programs, and tools. To identify and test meaningful interventions, Partners Population Health collaborates closely with frontline clinicians. A central team works with staff across the Partners system to develop, implement, and manage a systemwide value-based care strategy for all patient populations.
UNDERSTANDING THEIR OPTIONS
Partners recognized that less than one-third of patients with an advanced, serious illness discussed their goals and preferences with their clinicians. When the conversations did occur, they often took place late in the course of illness when there was little time to take meaningful action. In general, clinicians did not feel prepared to have these conversations. Partners committed to supporting patients with serious illnesses, and their families, by providing the opportunity to discuss treatment preferences earlier, increasing the likelihood that patients would be given the care they wanted to receive.
SERIOUS ILLNESS CONVERSATIONS
To help patients and families discuss what matters most when facing a serious illness, Partners adopted the Serious Illness Conversation Guide to prepare providers to integrate these conversations into the plan of care for patients in the integrated care management program.
The guide provides Partners primary care team members with training and guidance that enables productive conversations about health care options in the face of serious illness and includes instructions on how to:
- Set up the conversation.
- Assess the patient’s understanding of their illness and information preferences.
- Share the prognosis.
- Explore key topics.
- Close and document the conversation.
When a patient has a severe, chronic illness, or multiple conditions such as cancer, congestive heart failure, end stage renal disease, chronic obstructive pulmonary disease, Alzheimer’s, and/or stroke, the primary care team can use the guide to help instigate the serious illness conversation.
Clinicians document the conversation in the EMR. Notes are collected and can be easily accessed with a single click in the patient’s digital record. Information is available across the Partners system, ensuring subsequent providers have access to view previous conversations and continue to explore what matters most to a patient over time and in different settings. On average, serious illness conversations take nine months to complete.
Partners uses technology, including the Health Catalyst® Analytics Platform and broad suite of analytics applications and the EMR, to collect data about serious illness conversations, and to evaluate the impact of those conversations on trends at the end of life. The analytics platform aggregates clinical and financial data, so Partners can complete a comprehensive evaluation of the effectiveness of the Serious Illness Conversation Guide.
Having serious illness conversations has helped primary care physicians identify what matters most to patients and has positively impacted the end-of-life experience for patients at Partners. Using data from the initial pilot at Brigham and Women’s, outcomes have shown:
- 53 percent of the patients with clinicians who used the Serious Illness Conversation Guide used hospice in the last six months of life. Only 42 percent of patients in the control group (those who did not participate in a serious illness conversation) used hospice in the last six months of life.
- On average, the patients who participated in a serious illness conversation were in hospice for 27.8 and control patients for 12.3 days.
- $15,588 savings in total medical expense in the last six months of life.
- Reductions occurred primarily in the last three months of life. Reductions were in both inpatient medical expense and emergency department expense.
Partners will continue Serious Illness Conversation training, increasing the number of clinicians who feel prepared to have these conversations with patients, helping empower patients to live satisfying lives despite having a serious illness.
- You, J. J., Fowler, R. A., & Heyland, D. K. (2014). Just ask: discussing goals of care with patients in hospital with serious illness. CMAJ: Canadian Medical Association Journal, 186(6), 425–432. Retrieved from https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC3971028/
- LeBlanc, T. W., & Tulsky, J. (2018). Discussing goals of care. UpToDate. Retrieved from https://www.uptodate.com/contents/discussing-goals-of-care
- Bernacki, R., Hutchings, M., Vick, J., Smith, G., Paladino, J., Lipsitz, S., . . . Block, S.D. (2015). Development of the serious illness care program: A randomised controlled trial of a palliative care communication intervention. BMJ Open. Retrieved from https://bmjopen.bmj.com/content/5/10/e009032