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1. Describe a method to identify and classify patients’ goals of care (GOCs) from documented conversations in the electronic health record (EHR)
2. Understand the general trend of change in GOCs toward comfort-focused care for a cohort of seriously ill inpatients
Previous studies assessing patients’ goals of care (GOCs) have been limited by reliance on code status or presence of physician orders for life-sustaining treatments. We used a novel framework to classify patients’ GOCs from documented conversations in the electronic health record (EHR) and to describe trajectory of GOCs over time among seriously ill inpatients.
Classify patients’ GOCs through review of longitudinal EHR data to describe GOC trajectory among seriously ill inpatients.
We randomly selected 109 patients with ≥50% predicted 6-month mortality risk admitted to one of three urban hospitals between July 1 and October 31, 2019. Two coders independently reviewed EHR notes from 6 months before through 6 months after admission to identify the most recent documented GOCs prior to admission and all subsequent GOC conversations through 6 months or death. For each GOC conversation, we classified GOCs into one of four categories: comfort-focused care, maintain or improve function, life extension, or unable to determine.
Median age was 70 years (interquartile range [IQR] 63, 79), 49% were women, and 42% were non-White. Median Elixhauser index was 6 (4, 8). Fifty (46%) patients died during the study period. Interrater reliability of GOC classification between coders was substantial (kappa = 0.67). Eighty-five (78%) patients had at least 1 GOC conversation documented. Median number of GOC conversations per patient was 3 (IQR 1, 5). Among the 77 (71%) patients with ≥2 documented GOC conversations, 66 (86%) changed goals over time. Among these, 49 (74%) changed to comfort-focused care.
Patients’ GOCs can be identified and classified from the EHR by trained reviewers. Patients with multiple GOC conversations commonly changed their goals over time to comfort-focused care, probably reflecting selection effects.
Using the EHR to classify GOCs is an essential step toward systematically promoting goal-concordant care and can facilitate reliable outcome measurement in research studies.
© 2022 Published by Elsevier Inc.