How Well Do Documented Goals-of-Care Discussions for Patients with Stage IV Cancer Reflect Communication Best Practices?

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Natalie C. Ernecoff, Kathryn L. Wessell, William A. Wood, Gary S. Winzelberg, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-68860/v2 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 Mar, 2021 Read the published version in BMC Palliative Care → Version 2 posted 6 You are reading this latest preprint version Show more versions Abstract Background: Written clinical communication regarding patients’ disease understanding and values may facilitate goal-concordant care, yet little is known about electronic health record (EHR) goals-of-care documentation. We sought to (1) describe frequency of communication best practices in EHR-documented goals-of-care discussions, and (2) assess whether templated notes improve quality of documentation. Methods: We abstracted all EHR-documented goals-of-care discussions for hospitalized patients with Stage IV cancer from admission to 60-days follow-up. Goals-of-care documentation was operationalized to include discussion of: (a) prognosis and/or illness understanding; and (b) goals and/or treatment options. Investigators qualitatively coded text based on conceptual frameworks for communication best practices, including decision making documentation, and noted if a health system template was used. Results: Among 206 of 492 (42%) patients with documented goals-of-care discussions, clinicians frequently communicated cancer progression or incurability (89%), but rarely addressed prognosis for life expectancy (22%). Goals and values were documented for 83%, and a treatment decision for 82% of patients. Treatment preferences were assessed for 98% of patients; options discussed included cancer treatment (62%), hospice (62%), resuscitation (51%), or intensive care (38%). Clinicians made a treatment recommendation for 40% of patients. Attention to emotional and spiritual concerns was uncommon (15%). Use of a template increased documentation of patient goals and values (80% vs. 61%, p<0.01), but did not enhance other communication best practices. Conclusion: Insights from the study can be used to guide future training and research to study and improve the quality of written communication about goal of care, and its impact on goal-concordant care. Cancer Biology Oncology Metastatic Decision making Palliative care Electronic health record Background High-quality care for patients with serious illness requires skilled goals-of-care communication in order to be concordant with patients’ goals, values and preferences. 1,2 Observational research of in-person communication has helped define best practices for communication and decision-making. 3,4 Communication skills training has demonstrated capacity to improve skills for in-person clinician-patient communication. 5–7 While high-quality clinician-patient communication is important; written evidence of this communication in the health record may promote delivery of goal-concordant care. For example, in hospital written records of patients’ goals and values, key treatment decisions are used by clinicians covering at night or on weekends to guide treatment. Teaching best practices for in-person communication is not sufficient to ensure high quality documentation. 8 Providing goal-concordant care, a key outcome to improve serious-illness care, includes communication between clinicians in the form of high-quality documentation of goals-of-care discussion in the electronic health record (EHR). 9 The content of high-quality documentation may slightly differ from high-quality communication; for example, whether decisions were made and—perhaps more important for future decision-making communication—what goals and values the patient expressed to guide their choices. Very limited research explores how well goals-of-care communication is documented in the EHR, but existing evidence indicates it is insufficient. 10–13 Understanding how current documentation reflects communication best practices may be a first-step toward use of EHR documentation as a tool to promote goal-concordant care. In this study of hospitalized patients with Stage IV cancer, we sought (1) to describe frequency of communication best practices in EHR-documented goals-of-care discussions; and (2) to assess whether templated notes for Advance Care Planning (ACP) improve quality of documentation. Methods Study Design We abstracted (KLW and two other chart abstractors) and qualitatively coded (NCE, KLW) content of all documented goals-of-care discussions from clinician notes (generally oncology, palliative care, and medicine) in the EHR among hospitalized patients with Stage IV cancer. Chart reviews were part of a pre/post study of a collaborative model of oncology-palliative care among all patients with Stage IV cancer admitted to one inpatient medical oncology service at the University of North Carolina (UNC) Medical Center from June 01, 2017 to November 15, 2018. The UNC institutional review board approved all study procedures. Inclusion and Exclusion Criteria We included all adult patients with Stage IV solid-tumor cancer who were admitted to the inpatient Medical Oncology unit with an acute illness, and who received their primary outpatient oncology care at UNC Medical Center. We excluded those with a planned admission, or who were prisoners at the time of admission, requiring a different process for decision-making. Data Collection Chart Reviews : We conducted structured, systematic chart reviews from admission through 60 days post-admission date to abstract data from the inpatient and outpatient EHR (Epic) for each patient. Chart reviews included demographic and clinical characteristics, encounter details and utilization information, and elements of palliative care including pain and symptom screening and goals-of-care discussion. To ensure reliability, three trained researchers abstracted data from 20 patients and compared results five charts at a time, adjudicating any discrepancies. Decisions were logged in an operational guide to support consistency over time. The chart abstractors had high inter-rater reliability; the raters matched 100% percent by the final set (kappa=1.0). Then, they conducted the remaining chart reviews individually with frequent discussion to clarify uncertainties and prevent drift. Qualitative Analysis of Goals-of-Care Documentation Phase 1: To be considered goals-of-care documentation, a note had to include discussion of: (a) prognosis or illness understanding; and (b) goals or treatment options. Full text of all goals-of-care discussions were further characterized by: cancer stage understanding or curability; prognosis: life expectancy; prognosis: what will happen in the future; overall goal of care; cancer treatment options; code status or life-sustaining treatments; hospice; and emotional or spiritual needs. 5 The source of each goals-of-care documentation was collected, including whether it was documented in the formal, health system-wide, preexisting ACP Note template that included the following fields: patient has decisional capacity [yes/no]; surrogate decision maker [yes/no]; health care power of attorney [yes/no], name and contact information of surrogate; discussion participants; communication of medical status/prognosis; communication of treatment options/goals; and treatment decisions. Best practices for all clinicians included documenting goals-of-care conversations and decision making in a separate, easy to locate, place in the EHR such as an ACP Note. We compared best practices within and outside of ACP Notes. Phase 2: We used a template analysis approach to qualitative description, which is a qualitative method that incorporates deductive interpretations of data based on existing conceptual frameworks. 14 Our coding schema was based on existing frameworks for high-quality communication: Braddock et al.’s Informed Decision Making Criteria and Ariadne Labs’ Serious Illness Conversation Guide. 6,15 Best-practice communication included (1) discussion of prognosis and cancer stage understanding; (2) discussion of broad goals of care and specific treatment options; and (3) documentation of decision making. Through a series of investigator meetings, we developed consensus on the coding framework (NCE, KLW, GSW, LCH), which we modified iteratively until we reached thematic saturation. Two coders (NCE, KLW) were trained on the coding framework. Together, both coders reviewed all goals-of-care discussions and consensus coded using the final coding framework and adjudicated discrepancies with a physician-investigator (LCH). We used ATLAS.ti (Scientific Software Development GmbH) for qualitative data management. Quantitative Analysis We conducted univariate and bivariate statistics for demographic and clinical characteristics, dichotomized by whether or not patients had a documented goals-of-care discussion. We also conducted bivariate (t-test) analysis of the content of goals-of-care documentation when that documentation occurred in an ACP Note template versus elsewhere in the EHR. Results Participants We identified 492 eligible patients with Stage IV cancer, 206 (42%) of whom had any documented goals-of-care discussion. Forty-seven (9.6%) had a communication barrier due to confusion and sedation, or dementia, and included surrogate decision makers (Table 1). Elements of Goals-of-Care Documentation Among the 206 patients who had documented goals-of-care discussions, clinicians frequently documented overall prognosis, lack of curability, or cancer stage in communication about illness understanding (89%) but less commonly addressed life expectancy (22%) or future illness trajectory (10%). Broad goals (e.g., prolong life, support function, improve comfort) and values were documented for 83% of patients. At least one treatment preference was assessed for 98% of patients; options discussed included cancer treatment (62%), hospice (62%), resuscitation (51%), or intensive care (38%). Within this sample, 40% of clinicians documented making a recommendation as part of the discussion, and 15% documented the ways they addressed spiritual or emotional needs during communication. A clear treatment decision was documented for 82% of patients (Table 2). Qualitative Content of Goals-of-Care Documentation Domain 1: Documentation of Prognosis & Cancer Stage Understanding In this domain, communication about prognosis was commonly documented and often included language about cancer stage and lack of potential for cure (n=183, 89%). One clinician documented, “ Patient hopeful, but aware that her cancer is not curable. ” Less common was description of prognosis in terms of life expectancy, (n=46, 22%) as in this example: “ We reviewed poor prognosis measured in days to weeks. […] She and her daughters understand. ” Prognosis documentation also rarely described communication on what would happen in the future, (n=21, 10%); as one clinician noted, “ She understands that someday radiation and chemotherapy will not be able to fix her and that she will succumb to her cancer. ” Domain 2: Documentation of Decision Alternatives, including Broad Goals of Care & Treatment Options Category 1, Goals and Values: Clinicians frequently documented exploration of goals and values (n=171, 83%). This aspect of documentation most frequently took the form of exploring goals of care broadly (n=141, 68%), as in this example: “ He doesn't want her to suffer unnecessarily but still believes she is strong and has the will to live. He is open to hospice at home if she survives to discharge, but not ready to consider comfort care. ” Documentation of goals and values also included the more specific sub-categories: personal goals (n=87, 42%), such as this conversation about a time-limited goal, “ He would like to live long enough to see his grandchild born in December and articulates his desire to continue chemotherapy if he could meet this goal. ” Goals were also specified in terms of their corresponding tradeoffs (n=58, 28%), with different values-based conclusions, as was the case with these two different patients: In his mind, he is not sure if that extra time would be worth the suffering, especially since he is at peace with his relationship with God and knows that he will be saved. He acknowledges the reality that treatments carry risks and side effects and may cause discomfort. He is willing to accept discomfort in order to extend his life. Category 2, Treatment Preferences: Clinicians documented exploration of patients’ treatment preferences in nearly all cases of documented goals-of-care discussions (n=201, 98%) for several treatment types (sub-categories) including: Hospice (128, 62%): In this example quote, the clinician notes examination of the intersection of the patient’s priorities with treatment decisions, She expressed that she had been worried about being away from her home and being unable to communicate with non-Spanish speakers. She was delighted to learn that home hospice services for Spanish speakers can be provided though most agencies in her county. She requested to be discharged home with home hospice. Cancer treatment (n=127, 62%): In the example quote here, the clinician documents a discussion of a pause in chemotherapy to consider options, and contract further chemotherapy again best supportive care, Daughter states that given how poorly he's been feeling, he had been thinking about stopping further chemotherapy. We discussed that we will take one week off therapy to allow more time for recovery from chemo. If he still feels poorly, proceeding with best supportive care would be reasonable. Code status (n=105, 51%): Here, we see an example of a more robust discussion (compared to simply listing code status) that acknowledges malleability of goals and preferences over time, “ Patient wants to remain Full Code for now, but acknowledges she might consider DNR as she nears the end of life .” ICU or other life support (n=79, 38%): Here, the clinician’s note shares information about future life support treatment possibilities, “ We discussed my concerns that if her hypoxia worsened as a result of her cancer, intubating her and maintaining her on life support would be challenging as there would no one intervention to reverse her hypoxia and allow her to return to normal living. ” Surrogate decision making was explicitly discussed in 5% (n=10) of goals-of-care documentation, excluding a simple list of the surrogate decision maker name, relationship, and contact information. These conversations often took the form of establishing the decision maker, She is able to clearly answer questions when asked and has capacity to make decisions, but withdraws from the conversation when addressing goals of care. She would like her family to help make the decisions for her and trusts that they will have her best interest in mind. Category 3, Uncertainty: Clinicians infrequently documented discussion of uncertainty (n=8, 4%). When uncertainty was discussed, it took the form of assessing the nature of specific elements of the disease or complications, for example, We discussed that it will be important to determine the etiology of his acute renal failure. If no intervention, could potentially progress from a renal failure perspective, which could be life limiting on a shorter time-frame than his prostate cancer. Category 4, Make recommendations: Including notes that indicated treatment was no longer an option, clinicians documented discussion of recommendations in 82 (n=40%) cases. Recommendations were varied, from hospice, In-patient hospice recommended due to high symptom burden (mucous plugs and desaturations requiring deep suctioning, pain management) and frequent interventions (tube feeds, medications), to code status and specific treatments, I gave him my opinion that ventilator support and cardiac resuscitation as medical interventions were unlikely to make him live longer, and might impose significant suffering, although I certainly think it is reasonable to provide interventions short of this to cover all reversible causes. Goals-of-care documentation infrequently addressed spiritual and emotional needs (n=31, 15%). Information of this nature tended to demonstrate information sharing with future clinicians, for example, “ She states she is Muslim and declines chaplain services at this time. She reports continued communication with her therapist during her stay, which has been very helpful, ” and, “ Counseling and support with patient. Discussion of diagnosis, feelings of anger, fear and anxiety. Acknowledgement of loss of ability to drive, fish and to do the things he enjoys. ” Domain 3: Documentation of Decision Making Outcomes Decisions were documented in three ways. Categories were not mutually exclusive within each case, or with respect to different decisions. Category 1: Documentation included a clear decision or plan in 170 cases (82%). These notes included clear next-steps, such as, “ We will continue the aggressive measures we have already embarked on but will not intubate or resuscitate if she continues to decline. ” Category 2: Documentation included note of ongoing decision-making processes in 46 cases (22%), including the patient or family’s desire to continue the discussion with each other of the clinician at a later time, Best supportive care would be a very reasonable treatment decision, and indeed would probably be what I would recommend if the patient were my family member. His family understands this discussion, particularly since he has experienced significant toxicity with more benign medications that he has been on for long periods of time like his antiepileptics and antihypertensives. They would like to discuss over the holiday and follow up after molecular testing returns. Category 3: Clinicians documented that they provided information about options with unclear next steps, or provided no documentation of shared decision making (n=8, 4%). For example, “ She articulates a desire to explore the option of a large complicated operation vs hospice. […] She is frequently tearful on exam. ” Associations between Goals-of-Care Documentation and ACP Note Template Among patients with goals-of-care documentation (n=206), that documentation was in an ACP Note in 127 (41%). On average, documentation of goals-of-care discussions in ACP Notes included 8.7 (SD 1.98) categories, whereas documentation outside ACP Notes included 8.0 (SD 1.97) categories (p=0.01). Compared to documentation outside of ACP Notes, goals-of-care discussions that were documented in ACP Notes more frequently included exploration of goals and values (78% vs. 90%, p=0.02), particularly about broad goals of care (including longevity, function, comfort, and quality of life; 61% vs. 80%, p<0.01). Relatedly, discussion of code status was more often documented in ACP Notes than not (76% vs. 34%; p<0.01). Emotional and spiritual needs were more frequently included in notes documented outside ACP Notes (22% vs. 7%; p<0.01). There were no other significant differences in the content of goals-of-care documentation whether in ACP Notes or otherwise (Table 2). Discussion We have developed and applied an operational definition of clinical documentation of goals-of-care discussions, grounded in published conceptual frameworks of high-quality communication. 5,6,15 Fewer than half of patients with Stage IV cancer and acute hospitalization had a documented goals-of-care discussion. Among documented goals-of-care discussions, almost all explored patient treatment preferences and many explicitly addressed patient goals and values. Documentation of prognostic communication and attention to patient spiritual and emotional needs was less common. Documentation of goals-of-care discussions is an important component of high quality goals-of-care communication skills. High-quality documentation is necessary (though likely not sufficient, alone) to ensure that other clinicians can understand patient values, preferences and honor current treatment decisions, thus supporting clinical aspects of goal-concordant care. 16 However, we found very little guidance for frameworks and recommendations for goals-of-care documentation practices, instead we relied on best-practices for communication, an imperfect proxy. 6,15 One potential strategy to improve goals-of-care documentation is use of an ACP Note template. We found that use of this tool promoted more complete and detailed documentation. Templated EHR notes may also improve clinician-clinician communication in other ways, because: (1) the notes can then be systematically searched and reviewed for real-time decision making, and (2) templates include structure to prompt inclusion of important content, thus increasing the likelihood of including all information essential to decision making. 17 For example, because clinicians’ understanding of emotional and spiritual concerns is important to decision making, including explicit space for such information could enhance documentation. The purpose of documentation is to tell other clinicians the current preference-driven treatment plan, transmit an understanding of the patients’ goals and preferences, indicate current uncertainty or need for future decision-making, and other essential points to good communication with a specific patient (e.g., noting complex family dynamics or application of religious or spiritual beliefs to medical decision making). 18 These nuances can have large consequences on future communication and care transitions. If the next clinician cannot determine next steps, the current state of the decision-making process, or even find the note, it will likely negatively affect patient care, particularly when a patient’s decisions on not consistent with clinical defaults (generally for life prolongation). This is manifested in evidence that documentation of decisions for patients with cancer and other serious illness occurs infrequently, and often very near the end of life, potentially limiting access to treatments consistent with patient goals, including hospice. 19–21 This study was conducted among patients with Stage IV solid-tumor cancer, limiting its generalizability to decision-making in patients with earlier-stage disease. This study was also conducted at a single public hospital affiliated with an NCI Comprehensive Cancer Center; therefore the patient population is quite broad, though findings may not generalize to smaller or non-academic centers. Although ACP Note templates vary, our conclusions may still be applicable to different settings in terms of similar tools. We set a relatively high standard for inclusion of goals-of-care documentation in this analysis, and focused on goals-of-care rather than all advance care planning, unlike, for example, National Quality Forum (NQF) metrics for documentation of treatment preferences, that are generally more inclusive. 22 Considering low rates of some arguably important pieces of information, documentation corresponding to goals-of-care conversations can be more robust. Conclusion Just as there have been expert-defined and empirically-informed best practice guidelines for in-person communication with patients and their families, additional guidelines should define best-practices for documentation to maximize clinician-clinician communication without inducing undue documentation burden. 8 Additional empiric work can link documentation practices and patterns to whether patients receive goal-concordant care. Abbreviations electronic health record (EHR) Advance Care Planning (ACP) University of North Carolina (UNC) National Quality Forum (NQF) Declarations Ethics Approval and Consent to Participate: The University of North Carolina Institutional Review Board approved all study procedures. Consent for Publication: Not applicable. Availability of Data and Materials: The datasets used and analysed during the current study are available from the corresponding author on reasonable request. Competing Interests: Dr. Wood discloses consulting with Best Doctors, equity with Koneksa Health and Elektra Labs, and honorarium from ASH Research Collaborative. He receives research funding from Pfizer and Genentech. There are no other conflicts of interest to disclose. Funding: This work was supported by a grant from the University of North Carolina Lineberger Comprehensive Cancer Center. Author Contributions: NCE and KLW analyzed the data. NCE, KLW, and LCH interpreted the data. NCE and LCH were major contributors in writing the manuscript. All authors were major contributors to study design, and read and approved the final manuscript. Natalie C. Ernecoff, PhD, MPH 1 Kathryn L. Wessell, MPH 2 William A. Wood, MD, MPH 3 Gary S. Winzelberg, MD, MPH 4 Frances A. Collichio, MD 3 Laura C. Hanson, MD, MPH 2,4 Acknowledgements: Not applicable. References National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care . 4th ed. National Coalition for Hospice and Palliative Care; 2018. Gilligan T, Coyle N, Frankel RM, et al. Patient-Clinician Communication: American Society of Clinical Oncology Consensus Guideline. J Clin Oncol . 2017:Jco2017752311. doi:10.1200/jco.2017.75.2311 Parker SM, Clayton JM, Hancock K, et al. A Systematic Review of Prognostic/End-of-Life Communication with Adults in the Advanced Stages of a Life-Limiting Illness: Patient/Caregiver Preferences for the Content, Style, and Timing of Information. 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Defining Advance Care Planning for Adults: A Consensus Definition From a Multidisciplinary Delphi Panel. J Pain Symptom Manage . 2017. doi:10.1016/j.jpainsymman.2016.12.331 Geerse OP, Lamas DJ, Sanders JJ, et al. A Qualitative Study of Serious Illness Conversations in Patients with Advanced Cancer. J Palliat Med . 2019;22(7):773-781. doi:10.1089/jpm.2018.0487 Buck K, Detering KM, Pollard A, et al. Concordance Between Self-Reported Completion of Advance Care Planning Documentation and Availability of Documentation in Australian Health and Residential Aged Care Services. J Pain Symptom Manage . 2019;58(2):264-274. doi:10.1016/j.jpainsymman.2019.04.026 Wilson E, Bernacki R, Lakin JR, Alexander C, Jackson V, Jacobsen J. Rapid Adoption of a Serious Illness Conversation Electronic Medical Record Template: Lessons Learned and Future Directions. J Palliat Med . 2020;23(2):159-161. doi:10.1089/jpm.2019.0420 Geerse OP, Lamas DJ, Bernacki RE, et al. Adherence and Concordance between Serious Illness Care Planning Conversations and Oncology Clinician Documentation among Patients with Advanced Cancer. J Palliat Med . 2020;24(1). doi:10.1089/jpm.2019.0615 King N. Template analysis. In: Symon G, Cassell C, eds. Qualitative Methods and Analysis in Organizational Research: A Practical Guide. Thousand Oaks, CA: Sage Publications Ltd; 1998:118-134. Ariadne Labs: A Joint Center for Health Systems Innovation and Dana-Farber Cancer Institute. Serious Illness Conversation Guide. 2015. Butler J V., Pooviah PK, Cunningham D, Hasan M. Improving decision-making and documentation relating to do not attempt resuscitation orders. Resuscitation . 2003. doi:10.1016/S0300-9572(03)00029-7 Huber MT, Highland JD, Krishnamoorthi VR, Tang JWY. Utilizing the Electronic Health Record to Improve Advance Care Planning: A Systematic Review. Am J Hosp Palliat Med . 2018;35(3):532-541. doi:10.1177/1049909117715217 Lamas D, Panariello N, Henrich N, et al. Advance Care Planning Documentation in Electronic Health Records: Current Challenges and Recommendations for Change. J Palliat Med . 2018;21(4):522-528. doi:10.1089/jpm.2017.0451 Temel JS, Greer JA, Admane S, et al. Code status documentation in the outpatient electronic medical records of patients with metastatic cancer. J Gen Intern Med . 2010;25(2):150-153. doi:10.1007/s11606-009-1161-z Ernecoff NC, Wessell KL, Hanson LC, et al. Elements of Palliative Care in the Last 6 Months of Life: Frequency, Predictors, and Timing. J Gen Intern Med . 2019. doi:10.1007/s11606-019-05349-0 Ernecoff NC, Wessell KL, Hanson LC, et al. Does Receipt of Recommended Elements of Palliative Care Precede In-Hospital Death or Hospice Referral? J Pain Symptom Manage . 2020;0(0). doi:10.1016/j.jpainsymman.2019.11.011 National Quality Forum (NQF). Hospice and Palliative Care – Treatment Preferences (#1641). www.qualityforum.org. Published 2018. Accessed September 13, 2019. Tables Table 1. Characteristics of patients with Stage IV cancer and acute illness hospitalization, dichotomized by presence of EHR-documented goals-of-care discussion. Characteristic n(%) Total n = 492 Documented Goals-of-Care Discussion n = 206 No Documented Goals-of-Care Discussion n = 286 p Age, mean (range) 60.2 (21-93) 60.7 (21-90) 59.9 (22-93) 0.482 Female gender 252 (51) 103 (50) 149 (52) 0.646 Race/Ethnicity Caucasian 303 (62) 122 (60) 181 (64) 0.512 African American 143 (29) 59 (29) 84 (30) Latino/Hispanic 23 (5) 13 (6) 10 (4) Asian 9 (2) 5 (2) 4 (1) Other 8 (2) 4 (2) 4 (1) Primary cancer diagnosis Gastrointestinal 112 (23) 61 (30) 51 (18) 0.009 Genitourinary 91 (19) 40 (19) 51 (18) Breast 87 (18) 25 (12) 62 (22) Lung 80 (16) 38 (18) 42 (15) Head and Neck 53 (11) 17 (8) 36 (13) Melanoma 33 (7) 10 (5) 23 (8) Neuro 13 (3) 5 (2) 8 (3) Other 23 (5) 10 (5) 13 (5) Primary reason for hospitalization Acute medical illness 267 (54) 105 (51) 162 (57) 0.525 Uncontrolled symptoms 168 (34) 73 (35) 95 (33) Failure to thrive 35 (7) 18 (9) 17 (6) Acute confusion/ delirium 21 (4) 10 (5) 11 (4) Other 1 (0.2) 0 (0) 1 (0.4) Comorbidity (CCI)**, mean (range) 6.9 (2-15) 6.9 (2-13) 6.8 (2-15) 0.318 Nutritional insufficiency diagnosed within 3 days of hospitalization 226 (46) 115 (56) 111 (39) <0.001 Malnutrition 171 (35) 91 (44) 80 (28) <0.001 Unplanned weight loss 155 (32) 78 (38) 77 (27) 0.010 Failure to thrive 60 (12) 36 (17) 24 (8) 0.002 Cachexia 40 (8) 31 (15) 9 (3) <0.001 Serum albumin level within 3 days of hospitalization* , mean g/dL (range) 3.2 (1.2-5.4) 3.1 (1.2-4.8) 3.3 (1.7-5.4) <0.001 Length of stay, days mean (range) 5.2 (0-57) 6.2 (0-48) 4.5 (0-57) 0.002 Deaths 156 (32) 110 (53) 46 (16) <0.001 Survival, days median (range) 28 (3-60) 27 (3-57) 33 (3-60) 0.152 *missing for 14% of patients **CCI= Charleson Comorbidity Index; range 0-37; higher scores indicate higher disease burden Table 2. Qualitative coding framework, themes, and quantitative results. THEME n(%) Total N=206 Documented in ACP Note N=84 Not Documented in ACP Note N=122 p-value Section 1: Documentation of Prognosis & Disease Stage Understanding Assess illness understanding 183 (89) 76 (90) 107 (88) 0.54 Life expectancy 46 (22) 19 (23) 27 (22) 0.93 What will happen in the future 21 (10) 7 (8) 14 (11) 0.47 Section 2: Documentation of Decision Alternatives, including Broad Goals of Care & Treatment Options Explore goals and values 171 (83) 76 (90) 95 (78) 0.02* Broad goals of care (includes longevity, function, comfort) & QoL 141 (68) 67 (80) 74 (61) <0.01* Personal Goals (e.g., family, location/home, events) 87 (42) 36 (43) 51 (42) 0.88 Tradeoffs (including risks/benefits) 58 (28) 20 (24) 38 (31) 0.25 Explore patient treatment preferences 201 (98) 81 (96) 120 (98) 0.38 Hospice 128 (62) 52 (62) 76 (62) 0.96 Cancer treatment 127 (62) 48 (57) 79 (65) 0.27 Code status 105 (51) 64 (76) 41 (34) <0.01* ICU/life support/machines 79 (38) 37 (44) 42 (34) 0.16 Surrogate decision making 10 (5) 7 (8) 3 (2) 0.05 Discuss uncertainty (medical) 8 (4) 3 (4) 5 (4) 0.85 Make recommendations/treatment no longer an option 82 (40) 34 (40) 4 (39) 0.87 Address emotional/spiritual needs 31 (15) 6 (7) 27 (22) <0.01* Section 3: Documentation of Decision Making Document a clear decision/plan 170 (83) 70 (83) 100 (82) 0.80 Document ongoing decision making process 46 (22) 24 (29) 22 (18) 0.07 Provide information about options with unclear next steps; no documentation of shared decision making 8 (4) 2 (2) 6 (5) 0.36 Cite Share Download PDF Status: Published Journal Publication published 10 Mar, 2021 Read the published version in BMC Palliative Care → Version 2 posted Review # 1 received at journal 11 Feb, 2021 Reviewer # 1 agreed at journal 10 Feb, 2021 Reviewers invited by journal 09 Feb, 2021 Editor assigned by journal 09 Jan, 2021 Submission checks completed at journal 09 Jan, 2021 Editor invited by journal 09 Jan, 2021 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-68860","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":8054975,"identity":"fbde2303-faeb-4abc-8ec4-65d8688ad54c","order_by":0,"name":"Natalie C. Ernecoff","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDUlEQVRIiWNgGAWjYPACOX4IXSDBwM/A2ABiQkjcwFiyAazIQIJBsoGxseEACVoYGAwOABn4tPBLnz344EcF0HTp5ucPfhhYyBnfbm5//IHBRnbDAexaJPvykg17zgC1yBwzbOwxkDA2u3MQ5LA0Y1xaDM7wmEkztv2pY5BIMGzgMZBI3HYjEaTlcCIuLfZneMx/M7YBbZFI/9j4x0CifvMMsJb/OLUY8PCYMUO05Bg2A21JAFoE0nIApxaJMzzGkiC/sEnkFM6WMZAwnAH0y4wzBsnGM3Fo4e/hMfwACjF+ifQNH99U1Mnzz25/8KGiwk62D4cWOGBDWAx2MAHlaG4lSfUoGAWjYBSMAAAAjS9de5QgzQ8AAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0003-4753-8492","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Natalie","middleName":"C.","lastName":"Ernecoff","suffix":""},{"id":8054976,"identity":"cb405812-bd05-472f-82c7-24b5c65bf0f3","order_by":1,"name":"Kathryn L. Wessell","email":"","orcid":"","institution":"University of North Carolina at Chapel Hill","correspondingAuthor":false,"prefix":"","firstName":"Kathryn","middleName":"L.","lastName":"Wessell","suffix":""},{"id":8054977,"identity":"a2ac8a9b-0503-4353-a6c9-b4191dab0cfd","order_by":2,"name":"William A. Wood","email":"","orcid":"","institution":"University of North Carolina at Chapel Hill","correspondingAuthor":false,"prefix":"","firstName":"William","middleName":"A.","lastName":"Wood","suffix":""},{"id":8054978,"identity":"196f55db-b318-4895-acbb-1a73a5f7a249","order_by":3,"name":"Gary S. Winzelberg","email":"","orcid":"","institution":"University of North Carolina at Chapel Hill","correspondingAuthor":false,"prefix":"","firstName":"Gary","middleName":"S.","lastName":"Winzelberg","suffix":""},{"id":8054979,"identity":"01ea8b85-8abe-4206-8867-0dd1bc06c81a","order_by":4,"name":"Frances A. Collichio","email":"","orcid":"","institution":"University of North Carolina at Chapel Hill","correspondingAuthor":false,"prefix":"","firstName":"Frances","middleName":"A.","lastName":"Collichio","suffix":""},{"id":8054980,"identity":"2cc3032f-eb05-43da-a53f-90872344a958","order_by":5,"name":"Laura C. Hanson","email":"","orcid":"","institution":"University of North Carolina at Chapel Hill","correspondingAuthor":false,"prefix":"","firstName":"Laura","middleName":"C.","lastName":"Hanson","suffix":""}],"badges":[],"createdAt":"2020-08-30 12:24:55","currentVersionCode":2,"declarations":"","doi":"10.21203/rs.3.rs-68860/v2","doiUrl":"https://doi.org/10.21203/rs.3.rs-68860/v2","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12904-021-00733-2","type":"published","date":"2021-03-10T15:00:28+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":13647874,"identity":"af0c6089-6fd2-4708-8072-1dd798155e36","added_by":"auto","created_at":"2021-09-17 09:30:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":493715,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-68860/v2/9c750c0f-f24a-4190-9777-f6b6bfb9b36f.pdf"}],"financialInterests":"","formattedTitle":"How Well Do Documented Goals-of-Care Discussions for Patients with Stage IV Cancer Reflect Communication Best Practices?","fulltext":[{"header":"Background","content":"\u003cp\u003eHigh-quality care for patients with serious illness requires skilled goals-of-care communication in order to be concordant with patients\u0026rsquo; goals, values and preferences.\u003csup\u003e1,2\u003c/sup\u003e Observational research of in-person communication has helped define best practices for communication and decision-making.\u003csup\u003e3,4\u003c/sup\u003e Communication skills training has demonstrated capacity to improve skills for in-person clinician-patient communication.\u003csup\u003e5\u0026ndash;7\u003c/sup\u003e While high-quality clinician-patient communication is important; written evidence of this communication in the health record may promote delivery of goal-concordant care. For example, in hospital written records of patients\u0026rsquo; goals and values, key treatment decisions are used by clinicians covering at night or on weekends to guide treatment. Teaching best practices for in-person communication is not sufficient to ensure high quality documentation.\u003csup\u003e8\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eProviding goal-concordant care, a key outcome to improve serious-illness care, includes communication between clinicians in the form of high-quality documentation of goals-of-care discussion in the electronic health record (EHR).\u003csup\u003e9\u003c/sup\u003e The content of high-quality documentation may slightly differ from high-quality communication; for example, whether decisions were made and\u0026mdash;perhaps more important for future decision-making communication\u0026mdash;what goals and values the patient expressed to guide their choices. Very limited research explores how well goals-of-care communication is documented in the EHR, but existing evidence indicates it is insufficient.\u003csup\u003e10\u0026ndash;13\u003c/sup\u003e Understanding how current documentation reflects communication best practices may be a first-step toward use of EHR documentation as a tool to promote goal-concordant care.\u003c/p\u003e\n\u003cp\u003eIn this study of hospitalized patients with Stage IV cancer, we sought (1) to describe frequency of communication best practices in EHR-documented goals-of-care discussions; and (2) to assess whether templated notes \u0026nbsp;for Advance Care Planning (ACP) improve quality of documentation.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cem\u003eStudy Design\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe abstracted (KLW and two other chart abstractors) and qualitatively coded (NCE, KLW) content of all documented goals-of-care discussions from clinician notes (generally oncology, palliative care, and medicine) in the EHR among hospitalized patients with Stage IV cancer. Chart reviews were part of a pre/post study of a collaborative model of oncology-palliative care among all patients with Stage IV cancer admitted to one inpatient medical oncology service at the University of North Carolina (UNC) Medical Center from June 01, 2017 to November 15, 2018. The UNC institutional review board approved all study procedures.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eInclusion and Exclusion Criteria\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe included all adult patients with Stage IV solid-tumor cancer who were admitted to the inpatient Medical Oncology unit with an acute illness, and who received their primary outpatient oncology care at UNC Medical Center. We excluded those with a planned admission, or who were prisoners at the time of admission, requiring a different process for decision-making.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData Collection\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eChart Reviews\u003c/u\u003e: We conducted structured, systematic chart reviews from admission through 60 days post-admission date to abstract data from the inpatient and outpatient EHR (Epic) for each patient. Chart reviews included demographic and clinical characteristics, encounter details and utilization information, and elements of palliative care including pain and symptom screening and goals-of-care discussion. To ensure reliability, three trained researchers abstracted data from 20 patients and compared results five charts at a time, adjudicating any discrepancies. Decisions were logged in an operational guide to support consistency over time. The chart abstractors had high inter-rater reliability; the raters matched 100% percent by the final set (kappa=1.0). Then, they conducted the remaining chart reviews individually with frequent discussion to clarify uncertainties and prevent drift.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eQualitative Analysis of Goals-of-Care Documentation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003ePhase 1:\u003c/u\u003e To be considered goals-of-care documentation, a note had to include discussion of: (a) prognosis or illness understanding; and (b) goals or treatment options. Full text of all goals-of-care discussions were further characterized by: cancer stage understanding or curability; prognosis: life expectancy; prognosis: what will happen in the future; overall goal of care; cancer treatment options; code status or life-sustaining treatments; hospice; and emotional or spiritual needs.\u003csup\u003e5\u003c/sup\u003e The source of each goals-of-care documentation was collected, including whether it was documented in the formal, health system-wide, preexisting ACP Note template that included the following fields: patient has decisional capacity [yes/no]; surrogate decision maker [yes/no]; health care power of attorney [yes/no], name and contact information of surrogate; discussion participants; communication of medical status/prognosis; communication of treatment options/goals; and treatment decisions. Best practices for all clinicians included documenting goals-of-care conversations and decision making in a separate, easy to locate, place in the EHR such as an ACP Note. We compared best practices within and outside of ACP Notes.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003ePhase 2:\u003c/u\u003e We used a template analysis approach to qualitative description, which is a qualitative method that incorporates deductive interpretations of data based on existing conceptual frameworks.\u003csup\u003e14\u003c/sup\u003e Our coding schema was based on existing frameworks for high-quality communication: Braddock et al.\u0026rsquo;s Informed Decision Making Criteria and Ariadne Labs\u0026rsquo; Serious Illness Conversation Guide.\u003csup\u003e6,15\u003c/sup\u003e Best-practice communication included (1) discussion of prognosis and cancer stage understanding; (2) discussion of broad goals of care and specific treatment options; and (3) documentation of decision making. Through a series of investigator meetings, we developed consensus on the coding framework (NCE, KLW, GSW, LCH), which we modified iteratively until we reached thematic saturation. Two coders (NCE, KLW) were trained on the coding framework. Together, both coders reviewed all goals-of-care discussions and consensus coded using the final coding framework and adjudicated discrepancies with a physician-investigator (LCH). We used ATLAS.ti (Scientific Software Development GmbH) for qualitative data management.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eQuantitative Analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted univariate and bivariate statistics for demographic and clinical characteristics, dichotomized by whether or not patients had a documented goals-of-care discussion. We also conducted bivariate (t-test) analysis of the content of goals-of-care documentation when that documentation occurred in an ACP Note template versus elsewhere in the EHR.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eParticipants\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe identified 492 eligible patients with Stage IV cancer, 206 (42%) of whom had any documented goals-of-care discussion. Forty-seven (9.6%) had a communication barrier due to confusion and sedation, or dementia, and included surrogate decision makers (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eElements of Goals-of-Care Documentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the 206 patients who had documented goals-of-care discussions, clinicians frequently documented overall prognosis, lack of curability, or cancer stage in communication about illness understanding (89%) but less commonly addressed life expectancy (22%) or future illness trajectory (10%).\u003c/p\u003e\n\u003cp\u003eBroad goals (e.g., prolong life, support function, improve comfort) and values were documented for 83% of patients. At least one treatment preference was assessed for 98% of patients; options discussed included cancer treatment (62%), hospice (62%), resuscitation (51%), or intensive care (38%). Within this sample, 40% of clinicians documented making a recommendation as part of the discussion, and 15% documented the ways they addressed spiritual or emotional needs during communication.\u003c/p\u003e\n\u003cp\u003eA clear treatment decision was documented for 82% of patients (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative Content of Goals-of-Care Documentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDomain 1: Documentation of Prognosis \u0026amp; Cancer Stage Understanding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn this domain, communication about prognosis was commonly documented and often included language about cancer stage and lack of potential for cure (n=183, 89%). One clinician documented, \u0026ldquo;\u003cem\u003ePatient hopeful, but aware that her cancer is not curable.\u003c/em\u003e\u0026rdquo; Less common was description of prognosis in terms of life expectancy, (n=46, 22%) as in this example: \u0026ldquo;\u003cem\u003eWe reviewed poor prognosis measured in days to weeks. [\u0026hellip;] She and her daughters understand.\u003c/em\u003e\u0026rdquo; Prognosis documentation also rarely described communication on what would happen in the future, (n=21, 10%); as one clinician noted, \u0026ldquo;\u003cem\u003eShe understands that someday radiation and chemotherapy will not be able to fix her and that she will succumb to her cancer.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDomain 2: Documentation of Decision Alternatives, including Broad Goals of Care \u0026amp; Treatment Options\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCategory 1, Goals and Values:\u003c/u\u003e Clinicians frequently documented exploration of goals and values (n=171, 83%). This aspect of documentation most frequently took the form of exploring goals of care broadly (n=141, 68%), as in this example: \u0026ldquo;\u003cem\u003eHe doesn't want her to suffer unnecessarily but still believes she is strong and has the will to live. He is open to hospice at home if she survives to discharge, but not ready to consider comfort care.\u003c/em\u003e\u0026rdquo; Documentation of goals and values also included the more specific sub-categories: personal goals (n=87, 42%), such as this conversation about a time-limited goal, \u0026ldquo;\u003cem\u003eHe would like to live long enough to see his grandchild born in December and articulates his desire to continue chemotherapy if he could meet this goal.\u003c/em\u003e\u0026rdquo; Goals were also specified in terms of their corresponding tradeoffs (n=58, 28%), with different values-based conclusions, as was the case with these two different patients:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIn his mind, he is not sure if that extra time would be worth the suffering, especially since he is at peace with his relationship with God and knows that he will be saved.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHe acknowledges the reality that treatments carry risks and side effects and may cause discomfort. He is willing to accept discomfort in order to extend his life.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCategory 2, Treatment Preferences:\u003c/u\u003e Clinicians documented exploration of patients\u0026rsquo; treatment preferences in nearly all cases of documented goals-of-care discussions (n=201, 98%) for several treatment types (sub-categories) including:\u003c/p\u003e\n\u003cp\u003eHospice (128, 62%): In this example quote, the clinician notes examination of the intersection of the patient\u0026rsquo;s priorities with treatment decisions,\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eShe expressed that she had been worried about being away from her home and being unable to communicate with non-Spanish speakers. She was delighted to learn that home hospice services for Spanish speakers can be provided though most agencies in her county. She requested to be discharged home with home hospice.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCancer treatment (n=127, 62%): In the example quote here, the clinician documents a discussion of a pause in chemotherapy to consider options, and contract further chemotherapy again best supportive care,\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDaughter states that given how poorly he's been feeling, he had been thinking about stopping further chemotherapy. We discussed that we will take one week off therapy to allow more time for recovery from chemo. If he still feels poorly, proceeding with best supportive care would be reasonable.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCode status (n=105, 51%): Here, we see an example of a more robust\u0026nbsp; discussion (compared to simply listing code status) that acknowledges malleability of goals and preferences over time, \u0026ldquo;\u003cem\u003ePatient wants to remain Full Code for now, but acknowledges she might consider DNR as she nears the end of life\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eICU or other life support (n=79, 38%): Here, the clinician\u0026rsquo;s note shares information about future life support treatment possibilities, \u0026ldquo;\u003cem\u003eWe discussed my concerns that if her hypoxia worsened as a result of her cancer, intubating her and maintaining her on life support would be challenging as there would no one intervention to reverse her hypoxia and allow her to return to normal living.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eSurrogate decision making was explicitly discussed in 5% (n=10) of goals-of-care documentation, excluding a simple list of the surrogate decision maker name, relationship, and contact information. These conversations often took the form of establishing the decision maker,\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eShe is able to clearly answer questions when asked and has capacity to make decisions, but withdraws from the conversation when addressing goals of care. She would like her family to help make the decisions for her and trusts that they will have her best interest in mind.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCategory 3, Uncertainty:\u003c/u\u003e Clinicians infrequently documented discussion of uncertainty (n=8, 4%). When uncertainty was discussed, it took the form of assessing the nature of specific elements of the disease or complications, for example,\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWe discussed that it will be important to determine the etiology of his acute renal failure. If no intervention, could potentially progress from a renal failure perspective, which could be life limiting on a shorter time-frame than his prostate cancer.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCategory 4, Make recommendations:\u003c/u\u003e Including notes that indicated treatment was no longer an option, clinicians documented discussion of recommendations in 82 (n=40%) cases. Recommendations were varied, from hospice,\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIn-patient hospice recommended due to high symptom burden (mucous plugs and desaturations requiring deep suctioning, pain management) and frequent interventions (tube feeds, medications),\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eto code status and specific treatments,\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI gave him my opinion that ventilator support and cardiac resuscitation as medical interventions were unlikely to make him live longer, and might impose significant suffering, although I certainly think it is reasonable to provide interventions short of this to cover all reversible causes.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eGoals-of-care documentation infrequently addressed spiritual and emotional needs (n=31, 15%). Information of this nature tended to demonstrate information sharing with future clinicians, for example, \u0026ldquo;\u003cem\u003eShe states she is Muslim and declines chaplain services at this time. She reports continued communication with her therapist during her stay, which has been very helpful,\u003c/em\u003e\u0026rdquo; and, \u0026ldquo;\u003cem\u003eCounseling and support with patient. Discussion of diagnosis, feelings of anger, fear and anxiety. Acknowledgement of loss of ability to drive, fish and to do the things he enjoys.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDomain 3: Documentation of Decision Making Outcomes\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDecisions were documented in three ways. Categories were not mutually exclusive within each case, or with respect to different decisions.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCategory 1:\u003c/u\u003e Documentation included a clear decision or plan in 170 cases (82%). These notes included clear next-steps, such as, \u0026ldquo;\u003cem\u003eWe will continue the aggressive measures we have already embarked on but will not intubate or resuscitate if she continues to decline.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCategory 2:\u003c/u\u003e Documentation included note of ongoing decision-making processes in 46 cases (22%), including the patient or family\u0026rsquo;s desire to continue the discussion with each other of the clinician at a later time,\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBest supportive care would be a very reasonable treatment decision, and indeed would probably be what I would recommend if the patient were my family member. His family understands this discussion, particularly since he has experienced significant toxicity with more benign medications that he has been on for long periods of time like his antiepileptics and antihypertensives. They would like to discuss over the holiday and follow up after molecular testing returns.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCategory 3:\u003c/u\u003e Clinicians documented that they provided information about options with unclear next steps, or provided no documentation of shared decision making (n=8, 4%). For example, \u0026ldquo;\u003cem\u003eShe articulates a desire to explore the option of a large complicated operation vs hospice. [\u0026hellip;] She is frequently tearful on exam.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssociations between Goals-of-Care Documentation and ACP Note Template\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong patients with goals-of-care documentation (n=206), that documentation was in an ACP Note in 127 (41%). On average, documentation of goals-of-care discussions in ACP Notes included 8.7 (SD 1.98) categories, whereas documentation outside ACP Notes included 8.0 (SD 1.97) categories (p=0.01).\u003c/p\u003e\n\u003cp\u003eCompared to documentation outside of ACP Notes, goals-of-care discussions that were documented in ACP Notes more frequently included exploration of goals and values (78% vs. 90%, p=0.02), particularly about broad goals of care (including longevity, function, comfort, and quality of life; 61% vs. 80%, p\u0026lt;0.01). Relatedly, discussion of code status was more often documented in ACP Notes than not (76% vs. 34%; p\u0026lt;0.01). Emotional and spiritual needs were more frequently included in notes documented outside ACP Notes (22% vs. 7%; p\u0026lt;0.01). There were no other significant differences in the content of goals-of-care documentation whether in ACP Notes or otherwise (Table 2).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe have developed and applied an operational definition of clinical documentation of goals-of-care discussions, grounded in published conceptual frameworks of high-quality communication.\u003csup\u003e5,6,15\u003c/sup\u003e Fewer than half of patients with Stage IV cancer and acute hospitalization had a documented goals-of-care discussion. Among documented goals-of-care discussions, almost all explored patient treatment preferences and many explicitly addressed patient goals and values.\u0026nbsp; Documentation of prognostic communication and attention to patient spiritual and emotional needs was less common.\u003c/p\u003e\n\u003cp\u003eDocumentation of goals-of-care discussions is an important component of high quality goals-of-care communication skills. High-quality documentation is necessary (though likely not sufficient, alone) to ensure that other clinicians can understand patient values, preferences and honor current treatment decisions, thus supporting clinical aspects of goal-concordant care.\u003csup\u003e16\u003c/sup\u003e However, we found very little guidance for frameworks and recommendations for goals-of-care documentation practices, instead we relied on best-practices for communication, an imperfect proxy.\u003csup\u003e6,15\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eOne potential strategy to improve goals-of-care documentation is use of an ACP Note template. We found that use of this tool promoted more complete and detailed documentation. Templated EHR notes may also improve clinician-clinician communication in other ways, because: (1) the notes can then be systematically searched and reviewed for real-time decision making, and (2) templates include structure to prompt inclusion of important content, thus increasing the likelihood of including all information essential to decision making.\u003csup\u003e17\u003c/sup\u003e For example, because clinicians\u0026rsquo; understanding of emotional and spiritual concerns is important to decision making, including explicit space for such information could enhance documentation.\u003c/p\u003e\n\u003cp\u003eThe purpose of documentation is to tell other clinicians the current preference-driven treatment plan, transmit an understanding of the patients\u0026rsquo; goals and preferences, indicate current uncertainty or need for future decision-making, and other essential points to good communication with a specific patient (e.g., noting complex family dynamics or application of religious or spiritual beliefs to medical decision making).\u003csup\u003e18\u003c/sup\u003e These nuances can have large consequences on future communication and care transitions. If the next clinician cannot determine next steps, the current state of the decision-making process, or even find the note, it will likely negatively affect patient care, particularly when a patient\u0026rsquo;s decisions on not consistent with clinical defaults (generally for life prolongation). This is manifested in evidence that documentation of decisions for patients with cancer and other serious illness occurs infrequently, and often very near the end of life, potentially limiting access to treatments consistent with patient goals, including hospice.\u003csup\u003e19\u0026ndash;21\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted among patients with Stage IV solid-tumor cancer, limiting its generalizability to decision-making in patients with earlier-stage disease. This study was also conducted at a single public hospital affiliated with an NCI Comprehensive Cancer Center; therefore the patient population is quite broad, though findings may not generalize to smaller or non-academic centers. Although ACP Note templates vary, our conclusions may still be applicable to different settings in terms of similar tools.\u003c/p\u003e\n\u003cp\u003eWe set a relatively high standard for inclusion of goals-of-care documentation in this analysis, and focused on goals-of-care rather than all advance care planning, unlike, for example, National Quality Forum (NQF) metrics for documentation of treatment preferences, that are generally more inclusive.\u003csup\u003e22\u003c/sup\u003e Considering low rates of some arguably important pieces of information, documentation corresponding to goals-of-care conversations can be more robust.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eJust as there have been expert-defined and empirically-informed best practice guidelines for in-person communication with patients and their families, additional guidelines should define best-practices for documentation to maximize clinician-clinician communication without inducing undue documentation burden.\u003csup\u003e8\u003c/sup\u003e Additional empiric work can link documentation practices and patterns to whether patients receive goal-concordant care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eelectronic health record (EHR)\u003c/p\u003e\n\u003cp\u003eAdvance Care Planning (ACP)\u003c/p\u003e\n\u003cp\u003eUniversity of North Carolina (UNC)\u003c/p\u003e\n\u003cp\u003eNational Quality Forum (NQF)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate: \u003c/strong\u003eThe University of North Carolina Institutional Review Board approved all study procedures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication: \u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials: \u003c/strong\u003eThe datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests: \u003c/strong\u003eDr. Wood discloses consulting with Best Doctors, equity with Koneksa Health and Elektra Labs, and honorarium from ASH Research Collaborative. He receives research funding from Pfizer and Genentech. There are no other conflicts of interest to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding: \u003c/strong\u003eThis work was supported by a grant from the University of North Carolina Lineberger Comprehensive Cancer Center.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions: \u003c/strong\u003eNCE and KLW analyzed the data. NCE, KLW, and LCH interpreted the data. NCE and LCH were major contributors in writing the manuscript. All authors were major contributors to study design, and read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eNatalie C. Ernecoff, PhD, MPH\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eKathryn L. Wessell, MPH\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eWilliam A. Wood, MD, MPH\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eGary S. Winzelberg, MD, MPH\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eFrances A. Collichio, MD\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eLaura C. Hanson, MD, MPH\u003csup\u003e2,4\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements: \u003c/strong\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNational Consensus Project for Quality Palliative Care. \u003cem\u003eClinical Practice Guidelines for Quality Palliative Care\u003c/em\u003e. 4th ed. National Coalition for Hospice and Palliative Care; 2018.\u003c/li\u003e\n\u003cli\u003eGilligan T, Coyle N, Frankel RM, et al. Patient-Clinician Communication: American Society of Clinical Oncology Consensus Guideline. \u003cem\u003eJ Clin Oncol\u003c/em\u003e. 2017:Jco2017752311. doi:10.1200/jco.2017.75.2311\u003c/li\u003e\n\u003cli\u003eParker SM, Clayton JM, Hancock K, et al. A Systematic Review of Prognostic/End-of-Life Communication with Adults in the Advanced Stages of a Life-Limiting Illness: Patient/Caregiver Preferences for the Content, Style, and Timing of Information. \u003cem\u003eJ Pain Symptom Manage\u003c/em\u003e. 2007;34(1):81-93. doi:10.1016/j.jpainsymman.2006.09.035\u003c/li\u003e\n\u003cli\u003eBack AL, Fromme EK, Meier DE. Training Clinicians with Communication Skills Needed to Match Medical Treatments to Patient Values. \u003cem\u003eJ Am Geriatr Soc\u003c/em\u003e. 2019;67(S2):S435-S441. doi:10.1111/jgs.15709\u003c/li\u003e\n\u003cli\u003eBernacki RE, Block SD. Communication About Serious Illness Care Goals. \u003cem\u003eJAMA Intern Med\u003c/em\u003e. 2014;174(12):1994. doi:10.1001/jamainternmed.2014.5271\u003c/li\u003e\n\u003cli\u003eBraddock III CH, Edwards KA, Hasenberg NM, Laidley TL, Levinson W. Informed Decision Making in Outpatient Practice. \u003cem\u003eJAMA\u003c/em\u003e. 1999;282(24):2313. doi:10.1001/jama.282.24.2313\u003c/li\u003e\n\u003cli\u003eChilders JW, Back AL, Tulsky JA, Arnold RM. REMAP: A Framework for Goals of Care Conversations. \u003cem\u003eJ Oncol Pract\u003c/em\u003e. 2017. doi:10.1200/jop.2016.018796\u003c/li\u003e\n\u003cli\u003eSanders JJ, Curtis JR, Tulsky JA. Achieving Goal-Concordant Care: A Conceptual Model and Approach to Measuring Serious Illness Communication and Its Impact. doi:10.1089/jpm.2017.0459\u003c/li\u003e\n\u003cli\u003eSudore RL, Lum HD, You JJ, et al. Defining Advance Care Planning for Adults: A Consensus Definition From a Multidisciplinary Delphi Panel. \u003cem\u003eJ Pain Symptom Manage\u003c/em\u003e. 2017. doi:10.1016/j.jpainsymman.2016.12.331\u003c/li\u003e\n\u003cli\u003eGeerse OP, Lamas DJ, Sanders JJ, et al. A Qualitative Study of Serious Illness Conversations in Patients with Advanced Cancer. \u003cem\u003eJ Palliat Med\u003c/em\u003e. 2019;22(7):773-781. doi:10.1089/jpm.2018.0487\u003c/li\u003e\n\u003cli\u003eBuck K, Detering KM, Pollard A, et al. Concordance Between Self-Reported Completion of Advance Care Planning Documentation and Availability of Documentation in Australian Health and Residential Aged Care Services. \u003cem\u003eJ Pain Symptom Manage\u003c/em\u003e. 2019;58(2):264-274. doi:10.1016/j.jpainsymman.2019.04.026\u003c/li\u003e\n\u003cli\u003eWilson E, Bernacki R, Lakin JR, Alexander C, Jackson V, Jacobsen J. Rapid Adoption of a Serious Illness Conversation Electronic Medical Record Template: Lessons Learned and Future Directions. \u003cem\u003eJ Palliat Med\u003c/em\u003e. 2020;23(2):159-161. doi:10.1089/jpm.2019.0420\u003c/li\u003e\n\u003cli\u003eGeerse OP, Lamas DJ, Bernacki RE, et al. 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Utilizing the Electronic Health Record to Improve Advance Care Planning: A Systematic Review. \u003cem\u003eAm J Hosp Palliat Med\u003c/em\u003e. 2018;35(3):532-541. doi:10.1177/1049909117715217\u003c/li\u003e\n\u003cli\u003eLamas D, Panariello N, Henrich N, et al. Advance Care Planning Documentation in Electronic Health Records: Current Challenges and Recommendations for Change. \u003cem\u003eJ Palliat Med\u003c/em\u003e. 2018;21(4):522-528. doi:10.1089/jpm.2017.0451\u003c/li\u003e\n\u003cli\u003eTemel JS, Greer JA, Admane S, et al. Code status documentation in the outpatient electronic medical records of patients with metastatic cancer. \u003cem\u003eJ Gen Intern Med\u003c/em\u003e. 2010;25(2):150-153. doi:10.1007/s11606-009-1161-z\u003c/li\u003e\n\u003cli\u003eErnecoff NC, Wessell KL, Hanson LC, et al. Elements of Palliative Care in the Last 6 Months of Life: Frequency, Predictors, and Timing. \u003cem\u003eJ Gen Intern Med\u003c/em\u003e. 2019. doi:10.1007/s11606-019-05349-0\u003c/li\u003e\n\u003cli\u003eErnecoff NC, Wessell KL, Hanson LC, et al. Does Receipt of Recommended Elements of Palliative Care Precede In-Hospital Death or Hospice Referral? \u003cem\u003eJ Pain Symptom Manage\u003c/em\u003e. 2020;0(0). doi:10.1016/j.jpainsymman.2019.11.011\u003c/li\u003e\n\u003cli\u003eNational Quality Forum (NQF). Hospice and Palliative Care \u0026ndash; Treatment Preferences (#1641). www.qualityforum.org. Published 2018. Accessed September 13, 2019.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Characteristics of patients with Stage IV cancer and acute illness hospitalization, dichotomized by presence of EHR-documented goals-of-care discussion.\u003c/p\u003e\n\u003ctable border=\"1\" width=\"100%\"\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003en(%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003en = 492\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e\u003cstrong\u003eDocumented Goals-of-Care Discussion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003en =\u0026nbsp; 206\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e\u003cstrong\u003eNo Documented Goals-of-Care Discussion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003en =\u0026nbsp; 286\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u003cstrong\u003eAge, \u003c/strong\u003emean (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e60.2 (21-93)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e60.7 (21-90)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e59.9 (22-93)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e0.482\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u003cstrong\u003eFemale gender\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e252 (51)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e103 (50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e149 (52)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e0.646\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u003cstrong\u003eRace/Ethnicity\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; Caucasian\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e303 (62)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e122 (60)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e181 (64)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e0.512\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; African American\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e143 (29)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e59 (29)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e84 (30)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; Latino/Hispanic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e23 (5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e13 (6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e10 (4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; Asian\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e9 (2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e5 (2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e4 (1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; Other\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e8 (2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e4 (2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e4 (1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u003cstrong\u003ePrimary cancer diagnosis\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; Gastrointestinal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e112 (23)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e61 (30)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e51 (18)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e0.009\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; Genitourinary\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e91 (19)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e40 (19)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e51 (18)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; Breast\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e87 (18)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e25 (12)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e62 (22)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; Lung\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e80 (16)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e38 (18)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e42 (15)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; Head and Neck\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e53 (11)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e17 (8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e36 (13)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; Melanoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e33 (7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e10 (5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e23 (8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; Neuro\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e13 (3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e5 (2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e8 (3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; Other\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e23 (5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e10 (5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e13 (5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u003cstrong\u003ePrimary reason for hospitalization\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003eAcute medical illness\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e267 (54)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e105 (51)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e162 (57)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e0.525\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003eUncontrolled symptoms\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e168 (34)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e73 (35)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e95 (33)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003eFailure to thrive\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e35 (7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e18 (9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e17 (6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003eAcute confusion/ delirium\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e21 (4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e10 (5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e11 (4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003eOther\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e1 (0.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e0 (0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e1 (0.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u003cstrong\u003eComorbidity (CCI)**, \u003c/strong\u003emean (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e6.9 (2-15)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e6.9 (2-13)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e6.8 (2-15)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e0.318\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u003cstrong\u003eNutritional insufficiency diagnosed within 3 days of hospitalization\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e226 (46)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e115 (56)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e111 (39)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; Malnutrition\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e171 (35)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e91 (44)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e80 (28)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; Unplanned weight loss\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e155 (32)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e78 (38)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e77 (27)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e0.010\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; Failure to thrive\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e60 (12)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e36 (17)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e24 (8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e0.002\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; Cachexia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e40 (8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e31 (15)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e9 (3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u003cstrong\u003eSerum albumin level within 3 days of hospitalization*\u003c/strong\u003e, mean g/dL\u0026nbsp; (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e3.2 (1.2-5.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e3.1 (1.2-4.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e3.3 (1.7-5.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u003cstrong\u003eLength of stay, days \u003c/strong\u003emean (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e5.2 (0-57)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e6.2 (0-48)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e4.5 (0-57)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e0.002\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u003cstrong\u003eDeaths\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e156 (32)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e110 (53)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e46 (16)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"47%\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u0026nbsp; \u003c/strong\u003eSurvival, days median (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e28 (3-60)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e27 (3-57)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e33 (3-60)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"8%\"\u003e\n\u003cp\u003e0.152\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e*missing for 14% of patients\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e**CCI= Charleson Comorbidity Index; range 0-37; higher scores indicate higher disease burden\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. \u003c/strong\u003eQualitative coding framework, themes, and quantitative results.\u003c/p\u003e\n\u003ctable border=\"1\" width=\"686\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003e\u003cstrong\u003eTHEME\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003en(%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN=206\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e\u003cstrong\u003eDocumented in ACP Note\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN=84\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e\u003cstrong\u003eNot Documented in ACP Note\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN=122\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003e\u003cstrong\u003eSection 1: Documentation of Prognosis \u0026amp; Disease Stage Understanding\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003eAssess illness understanding\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e183 (89)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e76 (90)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e107 (88)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.54\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003eLife expectancy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e46 (22)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e19 (23)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e27 (22)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.93\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003eWhat will happen in the future\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e21 (10)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e7 (8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e14 (11)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.47\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003e\u003cstrong\u003eSection 2: Documentation of Decision Alternatives, including Broad Goals of Care \u0026amp; Treatment Options\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003eExplore goals and values\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e171 (83)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e76 (90)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e95 (78)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.02*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003eBroad goals of care (includes longevity, function, comfort) \u0026amp; QoL\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e141 (68)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e67 (80)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e74 (61)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026lt;0.01*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003ePersonal Goals (e.g., family, location/home, events)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e87 (42)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e36 (43)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e51 (42)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.88\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003eTradeoffs (including risks/benefits)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e58 (28)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e20 (24)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e38 (31)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.25\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003eExplore patient treatment preferences\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e201 (98)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e81 (96)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e120 (98)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.38\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003eHospice\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e128 (62)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e52 (62)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e76 (62)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.96\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003eCancer treatment\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e127 (62)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e48 (57)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e79 (65)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.27\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003eCode status\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e105 (51)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e64 (76)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e41 (34)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026lt;0.01*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003eICU/life support/machines\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e79 (38)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e37 (44)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e42 (34)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.16\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003eSurrogate decision making\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e10 (5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e7 (8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e3 (2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.05\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003eDiscuss uncertainty (medical)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e8 (4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e3 (4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e5 (4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.85\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003eMake recommendations/treatment no longer an option\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e82 (40)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e34 (40)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e4 (39)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.87\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003eAddress emotional/spiritual needs\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e31 (15)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e6 (7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e27 (22)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026lt;0.01*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003e\u003cstrong\u003eSection 3: Documentation of Decision Making\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003eDocument a clear decision/plan\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e170 (83)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e70 (83)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e100 (82)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.80\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003eDocument ongoing decision making process\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e46 (22)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e24 (29)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e22 (18)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.07\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003eProvide information about options with unclear next steps; no documentation of shared decision making\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"89\"\u003e\n\u003cp\u003e8 (4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e2 (2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e6 (5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.36\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Metastatic, Decision making, Palliative care, Electronic health record","lastPublishedDoi":"10.21203/rs.3.rs-68860/v2","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-68860/v2","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Written clinical communication regarding patients’ disease understanding and values may facilitate goal-concordant care, yet little is known about electronic health record (EHR) goals-of-care documentation. We sought to (1) describe frequency of communication best practices in EHR-documented goals-of-care discussions, and (2) assess whether templated notes improve quality of documentation.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eWe abstracted all EHR-documented goals-of-care discussions for hospitalized patients with Stage IV cancer from admission to 60-days follow-up. Goals-of-care documentation was operationalized to include discussion \u0026nbsp;of: (a) prognosis and/or illness understanding; and (b) goals and/or treatment options. Investigators qualitatively coded text based on conceptual frameworks for communication best practices, including decision making documentation, and noted if a health system template was used. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Among 206 of 492 (42%) patients with documented goals-of-care discussions, clinicians frequently communicated cancer progression or incurability (89%), but rarely addressed prognosis for life expectancy (22%).\u0026nbsp;Goals and values were documented for 83%, and a treatment decision for 82% of patients. Treatment preferences were assessed for 98% of patients; options discussed included cancer treatment (62%), hospice (62%), resuscitation (51%), or intensive care (38%). Clinicians made a treatment recommendation for 40% of patients. Attention to emotional and spiritual concerns was uncommon (15%). Use of a template increased documentation of patient goals and values (80% vs. 61%, p\u0026lt;0.01), but did not enhance other communication best practices.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eInsights from the study can be used to guide future training and research to study and improve the quality of written communication about goal of care, and its impact on goal-concordant care.\u003c/p\u003e","manuscriptTitle":"How Well Do Documented Goals-of-Care Discussions for Patients with Stage IV Cancer Reflect Communication Best Practices?","msid":"","msnumber":"","nonDraftVersions":[{"code":2,"date":"2021-01-19 11:06:28","doi":"10.21203/rs.3.rs-68860/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2021-02-12T00:00:00+00:00","index":1,"fulltext":"Recommendation: Reviewer's comments unavailable pending editorial decision\n"},{"type":"reviewerAgreed","content":"","date":"2021-02-11T00:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-02-10T00:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2021-01-10T00:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-01-09T23:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-01-09T23:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2020-09-08 20:25:27","doi":"10.21203/rs.3.rs-68860/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-12-08T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-11-05T00:00:00+00:00","index":2,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nthis is a well written paper looking at EHR documentation of goals of care discussions. A minority of patients (42%) had documented goals-of-care discussions. Almost all patients (89%)had documentation of cancer progression (89%), but clinicians infrequently documented the prognosis communicated (22%), and emotional or spiritual concerns. Clinicians often documented both goals and values and treatment decision (roughly 80% for each). Further, clinicians document treatment options (62%), hospice (62%), resuscitation (51%), or intensive care (38%). A recommendation was communicated for 40% of patients. The template provided increased documentation of patient goals , but no other changes.\n\nI would list goals and treatments separately (ie in abstract and throughout). Also, in the abstract, methods add (3) decision outcomes\npage 3, bottom, reference 10-11 should also include these references:\nWilson E, Bernacki R, Lakin JR, Alexander C, Jackson V, Jacobsen J. Rapid Adoption of a Serious Illness Conversation Electronic Medical Record Template: Lessons Learned and Future Directions. J Palliat Med. 2020 02; 23(2):159-\n161. PMID: 32023189.\nGeerse OP, Lamas, D, Bernacki, R, Sanders, J, Paladino J, Berendsen, AJ, Hilterman, TJN, Fromme EK,Block, S. Adherence and Concordance between Serious Illness Care Planning Conversations and Oncology Clinician Documentation among Patients with Advanced Cancer. J Palliat Med. 2020 Jun 22. PMID: 32580676.\npage 5, top please indicate with initials who abstracted the data\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2020-10-14T12:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-09-24T12:00:00+00:00","index":1,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nThis study used a retrospective survey to determine the frequency with which Goals of Care discussions are documented in the electronic medical record in patients with advanced cancer, and further qualitatively examined the content of these discussions.\n\nGeneral:\nAlthough the study is from a single hospital in the United States, I felt that it provides important insights into how much and what kind of Goals of Care discussion takes place and how these were documented in the medical record. I would like to comment on a few points I have noticed.\n\n1) Method section: I thought it would be good to add how many of the 492 study patients had decision-making capacity. I felt that the authors should exclude patients with poor decision-making capacity from the population because you could not have goals of care discussion with them in the first place. I felt that if there were many patients with inadequate decision-making capacity, you might be underestimating the frequency of goals of care discussion.\n2) p5, line39-55: Regarding the ACP note, how did you decide on this content? Please specify references, if any, and tell us how you determined their content.\nAlso, regarding the ACP note, I felt that their content was biased towards surrogate decision-makers, understanding of the disease condition, and treatment options.\nIf you put so much emphasis on patient values and preferences, please tell me why you didn't include items such as what the patient values and what makes them feel supported.\nFurthermore, I believe that goal-concordant care is a concept that encompasses the patient's desired life, care environment, and relationships, not simply what the patient wants to be treated, and I would appreciate it if you could explain why you did not investigate such details.\nFrom the results of this study, I felt that I could not say that the ACP notes were useful as they contained a lot of useful information outside of the ACP notes. At the very least, it felt to me like the content needed improvement.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **No**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2020-09-23T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-09-18T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-09-03T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-09-02T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-09-02T12:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2020-08-28T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3523ccb8-795a-4c6e-9261-d0bb23c90623","owner":[],"postedDate":"January 19th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":464811,"name":"Cancer Biology"},{"id":464812,"name":"Oncology"}],"tags":[],"updatedAt":"2021-03-14T15:00:37+00:00","versionOfRecord":{"articleIdentity":"rs-68860","link":"https://doi.org/10.1186/s12904-021-00733-2","journal":{"identity":"bmc-palliative-care","isVorOnly":false,"title":"BMC Palliative Care"},"publishedOn":"2021-03-10 15:00:28","publishedOnDateReadable":"March 10th, 2021"},"versionCreatedAt":"2021-01-19 11:06:28","video":"","vorDoi":"10.1186/s12904-021-00733-2","vorDoiUrl":"https://doi.org/10.1186/s12904-021-00733-2","workflowStages":[]},"version":"v2","identity":"rs-68860","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-68860","identity":"rs-68860","version":["v2"]},"buildId":"J0_U0BvcaRcwD8yVFaRlm","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}