Assessing Goals-of-Care Documentation during the COVID-19 Patient Surge in an Academic Safety-Net Medical Center

Abstract

Context/Objectives: It is paramount that clinicians assess and document patients' priorities to guide goal-concordant interventions, especially during a public health crisis. Design: Retrospective chart review. Setting: Academic safety-net medical center in central Massachusetts, United States. Methods: We examined electronic medical records (EMRs) to discern goals-of-care (GOC) conversations with COVID-19 patients seen at some point by palliative care during their hospitalization, and all clinicians' use of a structured note template during the peak incidence of COVID-19 from March to May 2020. Patients were grouped based on comorbidities and preadmission living situation. GOC discussions were categorized into three types: code status decisions, other treatment decisions, and no treatment decisions. Results: Nearly all (97%) patients had GOC documentation within 48 hours of admission. Forty-four percent of first GOC conversations incorporated the template. Patients with dementia living in nursing facilities had GOC documentation within hours of hospital admission, whereas healthier patients had their first GOC conversation at one week of hospitalization. Decisions about code status predominated in the first (83%) and second (49%) discussions, followed by a focus on other treatment decisions in subsequent discussions (44%-57%). Many did not require a treatment decision (19%-27%) but focused on quality-of-life definitions. Nearly all survivors were discharged to a facility and only four patients returned home. Many survivors died within three months (case fatality rate: 77%). Conclusions: GOC documentation using a structured template combined with easy EMR retrievability and clinician training holds promise for aligning patients' values with real-time medical decisions, during and after the pandemic.