Background: Internal medicine residents face multiple barriers to participating in and documenting goals of care (GOC) meetings in the intensive care unit (ICU). Barriers include heavy workloads, need for urgent stabilization of critically ill patients, and inadequate communication skills training. Guidelines recommend regularly conducting and documenting GOC meetings for critically ill patients, to facilitate communication across care transitions. We implemented a focused curriculum introducing an approach to GOC meetings and promoting documentation of key findings in a location easily accessible to relevant clinicians: Family Meeting Notes (FMNs) and Transfer Notes (TNs). We examined the rate and content of GOC meeting documentation in our intensive care units (ICUs), before and after this brief educational intervention. We hypothesized that intervention participants would more frequently document GOC information in TNs and FMNs than residents who did not participate in the intervention.
Methods: Residents working in the medical and cardiac ICUs during the intervention period participated in biweekly, 30-minute, interactive teaching sessions and received pocket cards outlining an approach to GOC meetings. Major teaching points included learning about each patient’s values, priorities, circumstances, and nature of a typical day prior to the critical illness; exploring understanding and perspectives; sharing information; offering empathy and support; and documenting key topics and outcomes (GOC information) in a FMN and/or TN. We reviewed charts of sequential ICU patient-stays during the pre- and post-intervention periods. TNs were eligible for patient-stays of ≥3 days. FMNs were reviewed for patient-stays of ≥3 days, or if the patient died in the ICU. 2 investigators independently coded notes for presence or absence of domains of GOC information taught in the curriculum; coding discrepancies were discussed to reach consensus. The primary outcome was rate of inclusion of GOC information in any FMN or TN. The secondary outcome was the total number of FMNs.
Results: 186 and 192 patient-stays were eligible for analysis in the pre- and post-intervention periods, respectively. The rate of documenting GOC information in TNs and FMNs was low, and for most GOC domains examined, there was no difference between pre- and post-intervention groups. Only the rate of documentation of a patient’s typical day changed (2.7% [pre] vs. 8.3% [post], p=0.02). FMNs were present in 7.0 vs. 10.4% (p=0.24). Among FMNs, more notes in the post-intervention group included descriptions of discussions about treatment goals, options, and decisions (46.2% vs. 70.0%, p=0.03).
Conclusions: Despite guidelines advocating routine GOC meetings for critically ill patients, we found that patients’ GOC were documented infrequently in TNs and FMNs before and after a brief educational intervention targeting internal medicine residents in the ICU. Future work should elucidate and address barriers to effective GOC documentation.