Classification of Documented Goals of Care Among Hospitalized Patients with High Mortality Risk: a Mixed-Methods Feasibility Study

Catherine L Auriemma; Anne Song; Lake Walsh; Jason J Han; Sophia R Yapalater; Alexander Bain; Lindsay Haines; Stefania Scott; Casey Whitman; Stephanie P Taylor; Scott D Halpern; Katherine R Courtright

doi:10.1007/s11606-024-08773-z

Classification of Documented Goals of Care Among Hospitalized Patients with High Mortality Risk: a Mixed-Methods Feasibility Study

J Gen Intern Med. 2024 May 6. doi: 10.1007/s11606-024-08773-z. Online ahead of print.

Authors

Catherine L Auriemma^{1

2

3}, Anne Song^{4

5}, Lake Walsh⁶, Jason J Han⁷, Sophia R Yapalater⁵, Alexander Bain⁸, Lindsay Haines⁵, Stefania Scott⁴, Casey Whitman⁴, Stephanie P Taylor⁹, Scott D Halpern^{4

5

10}, Katherine R Courtright^{4

5

10}

Affiliations

¹ Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA. Catherine.auriemma@pennmedicine.upenn.edu.
² Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Catherine.auriemma@pennmedicine.upenn.edu.
³ Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Catherine.auriemma@pennmedicine.upenn.edu.
⁴ Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA.
⁵ Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
⁶ Division of Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.
⁷ Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.
⁸ Division of Pulmonary and Critical Care, New York University-Langone, New York, NY, USA.
⁹ Division of Hospital Medicine, University of Michigan, Ann Arbor, MI, USA.
¹⁰ Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.

PMID: 38710861
DOI: 10.1007/s11606-024-08773-z

Abstract

Background: The ability to classify patients' goals of care (GOC) from clinical documentation would facilitate serious illness communication quality improvement efforts and pragmatic measurement of goal-concordant care. Feasibility of this approach remains unknown.

Objective: To evaluate the feasibility of classifying patients' GOC from clinical documentation in the electronic health record (EHR), describe the frequency and patterns of changes in patients' goals over time, and identify barriers to reliable goal classification.

Design: Retrospective, mixed-methods chart review study.

Participants: Adults with high (50-74%) and very high (≥ 75%) 6-month mortality risk admitted to three urban hospitals.

Main measures: Two physician coders independently reviewed EHR notes from 6 months before through 6 months after admission to identify documented GOC discussions and classify GOC. GOC were classified into one of four prespecified categories: (1) comfort-focused, (2) maintain or improve function, (3) life extension, or (4) unclear. Coder interrater reliability was assessed using kappa statistics. Barriers to classifying GOC were assessed using qualitative content analysis.

Key results: Among 85 of 109 (78%) patients, 338 GOC discussions were documented. Inter-rater reliability was substantial (75% interrater agreement; Cohen's kappa = 0.67; 95% CI, 0.60-0.73). Patients' initial documented goal was most frequently "life extension" (N = 37, 44%), followed by "maintain or improve function" (N = 28, 33%), "unclear" (N = 17, 20%), and "comfort-focused" (N = 3, 4%). Among the 66 patients whose goals' classification changed over time, most changed to "comfort-focused" goals (N = 49, 74%). Primary reasons for unclear goals were the observation of concurrently held or conditional goals, patient and family uncertainty, and limited documentation.

Conclusions: Clinical notes in the EHR can be used to reliably classify patients' GOC into discrete, clinically germane categories. This work motivates future research to use natural language models to promote scalability of the approach in clinical care and serious illness research.

Abstract

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