Assessing the Quality and Impact of Goals of Care Documentation Before Intensive Care Unit Transfer.

Abstract

High-quality goals of care (GOC) conversations are essential to providing patient-centered care during clinical deterioration in hospitalized patients. However, the presence and quality of GOC documentation before deterioration events such as intensive care unit (ICU) transfer is unknown. To evaluate the quality of GOC documentation in hospitalized adults before ICU transfer and assess the association between high-quality documentation and code status change after transfer. We reviewed records of 373 adult medicine patients transferred unplanned to the ICU at a university hospital over 24 months. We collected demographic data, pre-ICU hospitalization characteristics, and code status changes within 24 hours of transfer. The primary outcome was high-quality GOC documentation, defined as the presence of ≥2 of following components: prognosis, values/goals, surrogate decision maker, and intervention preferences. We analyzed data to assess factors associated with high-quality documentation and performed logistic regression to evaluate the relationship between documentation quality and code status changes after ICU transfer. Few patients (N = 80, 21.4%) had high-quality GOC documentation. The least frequent components documented were values/goals (16.1%) and prognosis (16.9%). Older age, frailty, specific comorbidities, palliative care consultation, longer pre-ICU hospitalization, and DNAR (do-not-attempt resuscitation) or multiple code statuses were associated with high-quality documentation (P < 0.05). High-quality GOC documentation was independently associated with odds of code status change after ICU transfer (OR, 3.41; 95% confidence interval [95% CI], 1.70-6.81). High-quality GOC documentation was present in only one in five patients before ICU transfer and was associated with code status change within 24 hours of transfer.