Did a goals-of-care discussion happen? Differences in the occurrence of goals-of-care discussions as reported by patients, clinicians, and in the electronic health record

Context: Goals-of-care discussions are associated with improved end-of-life care for patients and therefore may be used as a process measure in quality improvement, research, and reimbursement programs. Objectives: To examine three methods to assess occurrence of a goals-of-care discussion – patient report, clinician report, and documentation in the electronic health record (EHR) – at a clinic visit for seriously ill patients and determine whether each method is associated with patient-reported receipt of goal-concordant care. Methods: Secondary analysis of a multi-center cluster-randomized trial, with 494 patients and 124 clinicians caring for them. Self-reported surveys collected from patients and clinicians two weeks after a clinic visit assessed occurrence of a goals-of-care discussion. Documentation of a goals-of-care discussion was abstracted from the EHR. Patient-reported receipt of goal-concordant care was assessed by survey two weeks after the visit. Results: 52% of patients reported occurrence of a goals-of-care discussion at the clinic visit; clinicians reported occurrence of a discussion at 66% of visits. EHR documentation occurred in 42% of visits (p<0.001 for each compared with other two). Patients who reported occurrence of a goals-of-care discussion at the visit were more likely to report receipt of goal-concordant care than patients who reported no discussion (β 0.441, 95% CI 0.190-0.692; p=0.001). Neither occurrence of a discussion by clinician report nor by EHR documentation was associated with goal-concordant care. Conclusion: Different approaches to assess goals-of-care discussions give differing results and yet each may have advantages. Patient report is most likely to correlate with patient-reported receipt of goal-concordant care.