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Cited by 91Palliative Care and End-of-Life IssuesPatient-Provider Communication in HealthcarePalliative and Oncologic Care

Intervention to Promote Communication About Goals of Care for Hospitalized Patients With Serious Illness: A Randomized Clinical Trial

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Curtis, J. Randall, Lee, Robert Y., Brumback, Lyndia C., Kross, Erin K., Downey, Lois, Torrence, Janaki, LeDuc, Nicole, Mallon Andrews, Kasey +10 more·2023·JAMA
DOI 10.1001/jama.2023.8812PMC PMC10201405
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Abstract

Importance: Discussions about goals of care are important for high-quality palliative care yet are often lacking for hospitalized older patients with serious illness. Objective: To evaluate a communication-priming intervention to promote goals-of-care discussions between clinicians and hospitalized older patients with serious illness. Design, Setting, and Participants: A pragmatic, randomized clinical trial of a clinician-facing communication-priming intervention vs usual care was conducted at 3 US hospitals within 1 health care system, including a university, county, and community hospital. Eligible hospitalized patients were aged 55 years or older with any of the chronic illnesses used by the Dartmouth Atlas project to study end-of-life care or were aged 80 years or older. Patients with documented goals-of-care discussions or a palliative care consultation between hospital admission and eligibility screening were excluded. Randomization occurred between April 2020 and March 2021 and was stratified by study site and history of dementia. Intervention: Physicians and advance practice clinicians who were treating the patients randomized to the intervention received a 1-page, patient-specific intervention (Jumpstart Guide) to prompt and guide goals-of-care discussions. Main Outcomes and Measures: The primary outcome was the proportion of patients with electronic health record-documented goals-of-care discussions within 30 days. There was also an evaluation of whether the effect of the intervention varied by age, sex, history of dementia, minoritized race or ethnicity, or study site. Results: Of 3918 patients screened, 2512 were enrolled (mean age, 71.7 [SD, 10.8] years and 42% were women) and randomized (1255 to the intervention group and 1257 to the usual care group). The patients were American Indian or Alaska Native (1.8%), Asian (12%), Black (13%), Hispanic (6%), Native Hawaiian or Pacific Islander (0.5%), non-Hispanic (93%), and White (70%). The proportion of patients with electronic health record-documented goals-of-care discussions within 30 days was 34.5% (433 of 1255 patients) in the intervention group vs 30.4% (382 of 1257 patients) in the usual care group (hospital- and dementia-adjusted difference, 4.1% [95% CI, 0.4% to 7.8%]). The analyses of the treatment effect modifiers suggested that the intervention had a larger effect size among patients with minoritized race or ethnicity. Among 803 patients with minoritized race or ethnicity, the hospital- and dementia-adjusted proportion with goals-of-care discussions was 10.2% (95% CI, 4.0% to 16.5%) higher in the intervention group than in the usual care group. Among 1641 non-Hispanic White patients, the adjusted proportion with goals-of-care discussions was 1.6% (95% CI, -3.0% to 6.2%) higher in the intervention group than in the usual care group. There was no evidence of differential treatment effects of the intervention on the primary outcome by age, sex, history of dementia, or study site. Conclusions and Relevance: Among hospitalized older adults with serious illness, a pragmatic clinician-facing communication-priming intervention significantly improved documentation of goals-of-care discussions in the electronic health record, with a greater effect size in racially or ethnically minoritized patients. Trial Registration: ClinicalTrials.gov Identifier: NCT04281784.

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  • The interventions tested in all three trials did not alter existing clinician EHR documentation processes or templates for documentation of goals-of-care discussions.

    “The interventions tested in all three trials (variants of the Jumpstart Guide) did not alter existing clinician EHR documentation processes or templates for documentation of goals-of-care discussions.21,28,29”

    From Assessment of a Zero-Shot Large Language Model in Measuring Documented Goals-of-Care Discussions (2026) · cites this paper as [21]

    The Methods > Intervention passage describes the current trial’s intervention as a Jumpstart Guide sent by email, with a pager alert; it does not describe changing EHR documentation templates or processes. The Introduction describes the other two trials as using Jumpstart Guides, but our copy does not establish that documentation processes and templates remained unchanged in all three trials. No page numbers are provided in the indexed passages. (LLM, conf=0.76)

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  • To date, use of NLP to identify goals-of-care discussions has facilitated at least two clinical trials.

    “To date, the use of NLP to identify this linguistically complex outcome has facilitated at least two clinical trials;19–22 and, while current clinical EHRs rely on either search-based approaches or the use of semi-structured documentation,12,23 real-time ability for clinicians to efficiently locate goals-of-care documentation seems likely to improve delivery of goal-concordant care.24”

    From Assessment of a Zero-Shot Large Language Model in Measuring Documented Goals-of-Care Discussions (2026) · cites this paper as [21]

    The Methods (Outcomes and covariates; page not provided) show that this randomized trial used NLP-screened review to identify documented goals-of-care discussions. The Discussion says the earlier pilot trial used whole-chart manual abstraction rather than NLP, so this source supports one such trial, not the claim of at least two. (LLM, conf=0.88)

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Research works printed but not linked: 1

  1. [14]Goodman DC, Fisher ES, Wennberg JE, Skinner JS, Chasan-Taber S, Bronner KK. In: Tracking Improvement in the Care of Chronically Ill Patients: A Dartmouth Atlas Brief on Medicare Beneficiaries Near the End of Life. Lebanon (NH) 2013. 36441861

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Authors
Curtis, J. R., Lee, R. Y., Brumback, L. C., Kross, E. K., Downey, L., Torrence, J., LeDuc, N., Mallon Andrews, K., Im, J., Heywood, J., Brown, C. E., Sibley, J., Lober, W. B., Cohen, T., Weiner, B. J., Khandelwal, N., Abedini, N. C., & Engelberg, R. A.
Affiliations
  • University of Washington (US)
  • Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
Corresponding author
Engelberg, Ruth A.
ORCID
Venue
JAMA
Publisher
American Medical Association (AMA)
Published
2023-06-20
Volume
329
Issue
23
Pages
2028
ISSN
  • 0002-9955 (ISSN-L)
  • 0098-7484
DOI
10.1001/jama.2023.8812
PMC
PMC10201405
OpenAlex
W4377194724
Cited by
91
References
47
Citations by year
2026: 17 · 2025: 34 · 2024: 26 · 2023: 14
FWCI
23.30
Type
journal article
Language
en
Open access
Locations
  • JAMA (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Funders
  • National Institute on Aging (R01AG062441)
  • National Heart, Lung, and Blood Institute (K12HL137940, K23HL144830, K23HL161503)
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
  • Health Sciences › Health Professions › General Health Professions › Patient-Provider Communication in Healthcare
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative and Oncologic Care
Keywords
goals of care discussions, hospitalized older adults, serious illness, palliative care, advance care planning, electronic health record documentation, racial and ethnic disparities, dementia, end-of-life care, quality improvement, hospitalization of older adults, treatment effect modifiers, sex differences, age differences
MeSH terms
Aged, Communication, Dementia, Female, Hospitalization, Humans, Male, Patient Care Planning, Terminal Care

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