Clinical Surveillance Tool to Screen for Unmet Palliative Needs Among Patients in the Final Year of Life

Condition(s) studied

Investigational drug(s) / intervention(s)

modified Hospital One-year Mortality Risk (mHOMR): Every inpatient will automatically be given the intervention (an mHOMR/HOMR Now! score) upon admission to hospital and considered for secondary interventions based on their score. Baseline threshold will be set as \>0.21 (59% sensitivity and 90% specificity for 12-month mortality with mHOMR). At minimum each individual identified by the tool will receive two assessments to screen for severe symptoms and desire to engage in advance care planning (ACP): 1. Edmonton Symptom Assessment System Revised: scores \>6 will be flagged as severe. Clinical teams will address the symptoms as appropriate for the patient. 2. 4-item Advanced Care Planning Engagement Survey: Scores of 3-4 indicate readiness to discuss ACP. Clinical teams may choose to discuss ACP and goals of care themselves, activate a local ACP intervention, or distribute ACP documentation. Both of these assessments will be done by a member of the treating team within 72 hours of the patient's hospital admission.

Study summary

One of the most important obstacles to improving end-of-life care is the inability of clinicians to reliably identify those who are approaching the end-of-life. Every aspect of a palliative approach to care - screening for unmet needs, treating symptoms, discussing goals of care, and developing a palliative management plan - depends on the reliable and accurate identification of patients with palliative needs. The investigators developed an accurate and reliable mortality prediction tool that automatically identifies patients in hospital at elevated risk of death in the coming year. In previous studies it has been shown that these patients also frequently have unmet palliative care needs at the time they are identified by the tool. This tool has been demonstrated feasible, acceptable to patients and providers, and effective for changing physician behaviour in an inpatient clinical context.

In this project, this tool is implemented as part of an integrated knowledge translation project to facilitate reliable and timely identification of unmet palliative needs across multiple hospitals with different clinical settings and contexts. The investigators have partnered with 12 hospitals to improve the quality of palliative and end-of-life care provided to patients and families. With each partner site the investigators will develop a comprehensive implementation plan, including stakeholder engagement, education, and feedback. Process measures will be collected at each site to determine whether the tool was effective for promoting the identification and documentation of unmet palliative needs. Patients who were identified by the tool will also be followed over time to collect outcome and impact measures to see if their end-of-life care was affected by the intervention compared to control groups.

Eligibility

Primary outcome measure(s)

• Identification and documentation of unmet palliative needs — Through study completion, up to 9 months
  Proportion of admissions at each site identified by the application
• Identification and documentation of unmet palliative needs — Through study completion, up to 9 months
  Proportion of admissions with a HOMR (modified or Now!) score \>0.21 with ESAS symptom score \>6 and/or documented desire to engage in ACP via the 4-item ACP Engagement Survey

Trial sites (13)

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