Integrating Narrative Goals of Care in the Medical Intensive Care Unit Impact on Educational and Clinical Outcomes

Background: High-quality goals of care (GOC) communication is fundamental to providing excellent critical care. Objective: Educate medical intensive care unit (MICU) clinicians, design and implement workflows relating to GOC communication, and measure the impact on communication proficiency and rate of GOC documentation. Methods: Guided by Lean Six Sigma principles, an interprofessional team from palliative and critical care tailored a multicomponent intervention—the 3-Act Model communication training and workflow modification—to equip and empower the pulmonary and critical care medicine (PCCM) fellow as the clinical lead for GOC discussions. Fellows’ education included in-person narrative reflection, asynchronous online didactic and demonstration videos of the 3-Act Model, online roleplays, and direct observation leading GOC discussions in the ICU. PCCM fellows were objectively evaluated for proficiency using the Goals of Care Assessment Tool. To evaluate the impact of our intervention on documented GOC conversations, we performed a retrospective chart review over two 3-month periods (before and after intervention) when the MICU cared exclusively for critically ill patients with coronavirus disease (COVID-19). Results: All PCCM fellows demonstrated proficiency in GOC communication via online simulated roleplays, as well as in observed bedside GOC communication. Per chart review of patients with a minimum of 7 consecutive days in the MICU, documented GOC conversations were found for 5.55% (2/36) of patients during the preintervention period and for 28.89% (13/45) of patients in the postintervention period. Palliative care consults increased in the pre- versus postintervention period: for all patients, 4.85% versus 14.52% (P, 0.05); for patients age >80 years, 3.54% versus 29.41% (P, 0.05); and for patients with MICU length of stay >7 days, 2.78% versus 24.44% (P, 0.05). Conclusion: Combining 3-Act Model education for PCCM fellows with Lean Six Sigma quality improvement resulted in effective GOC communication training and improved palliative care integration in the ICU.