Team profile by David Casarett, Simran Bansal, Preya Paltanwale, Nikhita Nanduri, Astha Ray, Lauren Howard, Julia Gambino, Daniel Lee, Avery Garmon, Elissa Gorman, Haripriya Dukkipati and Sai Rachakonda

Patients who are facing a serious illness must make complex healthcare decisions regarding treatment options, quality of life considerations and life expectancy. Too often, patients and their families must make these decisions without adequate communication about their hopes, fears, values and goals. The result is that many patients receive more treatment than they would like, or treatment that is intended to prolong survival, when their goals are really to maximize comfort and preserve quality of life.

Patients who lack access to open, accurate and empathetic communication about their goals often receive treatment that is overly aggressive and costly, creating financial burdens for them and their families. Poor consideration of a patient's perspective may lead to an overall worsened quality of life due to unwanted tests and/or treatments. 

With an aging population and increasingly complex healthcare options, there is mounting importance to ensure that all patients have access to thoughtful, open and accurate communication about their goals.

Goals of care conversations (GOCC) can promote care that is concordant with patients’ values and medical realities. The aim of this project was to identify provider-perceived barriers to implementing GOCC to develop future interventions targeted to improve the frequency and quality of these conversations. 

In collaboration with Duke Health’s Center for Palliative Care, this project team began by interviewing palliative care providers to understand what differentiates this field from hospice and end-of-life care. Then, the team conducted virtual focus group interviews of 12 providers — including nurses, social workers and doctors across different departments — to understand barriers of effective GOCC. 

The team analyzed interview transcripts and identified the following themes: 1) time constraints, 2) electronic health records (EHR), 3) social determinants of health (SDOH), 4) ineffective communication, 5) coordinating care, 6) emotional burden, and 7) lack of formal training.  GOCC benefit from longer time, as it facilitates a rapport between provider and patient, and allows patients to feel comfortable sharing their goals and values. SDOH factors can influence patient trust in the health system and access to adequate care. Documenting GOCC also can contribute to physician burnout; though documentation is a helpful resource to track a patient’s values, providers often feel burdened by the sheer amount of time it demands. 

However, accurate documentation of GOCC is also pivotal to provider communication. In complex cases, one individual patient may be receiving medical recommendations from several providers, and it is important to ensure that these conversations are aligned centrally around the patient’s goals. There are questions around how to best coordinate care across specialties and effectively communicate via documentation. Additionally, there is a need for further training so that providers can better navigate these emotionally charged situations.

Preliminary recommendations include improving advance care planning (ACP) templates, flagging patients in EPIC who might benefit most from GOCC, creating a better interdisciplinary platform for coordinating care and standardizing training materials. Furthermore, there may be opportunities to open community discourse regarding goals of care more generally to normalize these discussions when they do arise.  

Future directions include developing interventions targeted specifically towards the Duke clinical context. 

Improving Goals of Care Conversations at DUHS

Poster by David Casarett, Preya Paltanwale, Haripriya Dukkipati, Julia Gambino, Avery Garmon, Elissa Gorman, Lauren Howard, Daniel Lee, Nikhita Nanduri, Sai Rachakonda, Astha Ray and Nikki Daniels

Although there is compelling evidence that goals of care conversations (GOCC) improve patient satisfaction and outcomes, we recognized that very few Duke Health patients had documented GOCCs in the last 6 months of life. This Bass Connections team has played an integral role in the Duke Health goals of Care initiative, through participation in research projects and close work with faculty. This poster describes the work the Bass Connections team has done to understand and overcome barriers to GOCC across Duke Health.

The Role of Communication in the Physical Health of Cancer Patients

Poster by Astha Ray, Karena Leo, Katherine Ramos and Laura Porter

Receiving a cancer diagnosis comes with a complex physical and emotional burden on both the patient and their spouse/caregiver. In this study, we analyzed the role of couples’ communication on the physical health of cancer patients using an observational coding approach. We found that intimacy-building behaviors as observed by the patient were associated with greater reporting of physical health symptoms.

Affective Expressions and Mental Health Outcomes Among Couples Coping with Cancer

Poster by Lauren Howard, Daniel Lee, Karena Leo, Laura Porter and Katherine Ramos

Our study explores how emotions displayed in couples’ conversations correlate with psychological distress. Using 10 minute recorded conversations between cancer patients and their partners, we coded for expressed affect to examine the correlations with measures of distress. After analyzing the results with a a multi-level modeling system, we found that expression of positive individuating affect was associated with less psychological distress and expression of hard negative affect was associated with greater psychological distress for both patients and partners.