The most vexing issue with setting up a serious illness conversation program is not convincing hospital administrations and physicians of the value of these conversations. Rather, stumbling blocks more often involve the logistics of implementing a system that would regularly identify and schedule meetings with those who would most benefit from an in-depth discussion about their uncertain future.
Given the busy schedules and taxed lives of clinicians, it is crucial to carefully target patients with the greatest need, says Dr. Josh Lakin, a palliative care specialist and member of the Serious Illness Care Program at Ariadne Labs.
“Of all the aspects of the program, the toughest issue and the one that keeps me up at night is patient identification,” Lakin says. “We hope clinicians can spend their precious time on the right patients at the right time.”
To explore and highlight solutions, Lakin co-authored a paper recently published in BMJ Supportive & Palliative Care that examines strategies used by five diverse health care sites across the U.S. and England who partnered with Ariadne Labs to implement the Serious Illness Care Program and its core tool, the Serious Illness Conversation Guide.
The paper, “Earlier Identification of Seriously Ill Patients: An Implementation Case Series,” gathers and shares outcomes of multiple patient selection methodologies. These include employing disease-specific criteria, existing registries, algorithms, and physician screens such as the “surprise question,” as in: “Would you be surprised if this patient died in the next X years (or months)?”
The case series found that no one method stood out as the most successful. The authors also concluded that clinical and program staff should be involved in establishing any routine method for patient identification.
“Each system had successes and challenges and that underscores our conclusion that there is not a one-size-fits-all solution,” Lakin says. “I think that the best answer is to choose something, start, and adjust – and stay flexible. Keep thinking about how to make it better.”
Lakin hopes the paper can be a resource for other facilities instituting or considering a Serious Illness Care Program. “We wrote this to shed some light on the experience of putting a program into practice,” Lakin says.
Data for the case studies were taken from emails and templates that asked facilities to self-report patient selection methodologies, success, and challenges. For example:
- The University of Pennsylvania Health System, which implemented a Serious Illness Care Program in 2017 in all its outpatient cancer centers, found that patient selection by individual providers was preferred to weekly huddles of physicians.
- Baylor Scott & White Health (BSWH) of Texas, which began a pilot in 2016 focused on oncology, geriatrics, advanced heart failure, and palliative care, utilizes a specific code and the “surprise question” to identify patients. However, this was complicated by the fact that one in six Texans lack health insurance and, hence, access to primary care. Thus the first opportunity for a serious illness conversation frequently occurs in the hospital. In response, BSWH is training all hospitalists across its system to use the Serious Illness Conversation Guide and other tools.
- National Health Service England, which launched a pilot in 2016, used various methodologies. The cancer center used coded lists of patients distributed to all trained clinicians, who then reviewed their lists and used the surprise question to identify those most at risk of death. At primary care centers, general practitioners used a registry of patients thought to be in their last 12 months of life. While the process did successfully identify patients, clinicians found the long list of patients onerous to review. The lists were adjusted to be shorter and focused on patients scheduled to be seen in the next two weeks.
The other two hospitals included in the paper were Stanford Healthcare of California and Brigham Health of Boston.
Lakin hopes the paper will add to the ongoing effort by many practitioners to find the best predictive analytics that lead to more, better, and earlier serious illness conversations.
“I think there’s a lot of people out there looking for algorithms to help identify people who are seriously ill. I hope this paper will help them think beyond predicting death but targeting the right people,” Lakin says. “I now think of the identification process as: Let’s figure out who is suffering from serious illnesses that are really interrupting their lives or their families’ lives. That is a perfect person to sit down and talk about what’s most important to them in case things get worse.”
A serious illness conversation can empower patients and their families to feel some sense of control in an often-overwhelming situation. Lakin notes that patients at the Dana-Farber Cancer Institute saw a significant reduction in stress and anxiety after a Serious Illness Care Program was established.
“We have a lot of awesome things we can do for people in our health care system if we can get them pointed in the direction that the patient and the family wants,” he says. “We presume that what’s most important is living as long as possible. It’s not a bad presumption, but when someone has a serious illness, there are other things besides living as long as possible that are also important.”