Hospital Care

The Research:

In the hospital setting, serious illness conversations are often too little, too late, and not great and this can contribute to treatments that are often incongruent with patient preferences. Unwanted interventions are associated with increased distress among patients and families, reduced quality of life, and lower satisfaction with care. Clinicians often experience moral distress when providing aggressive interventions for which they perceive no benefit.

The Serious Illness Care Program (SICP) is demonstrated to be feasible, acceptable and effective in stimulating more person-centred and earlier conversations about serious illness in the outpatient setting. We adapted and implemented the SICP on general internal medicine wards at four hospitals across Canada:
• Foothill Medical Centre, Calgary, Alberta
• Hamilton General Hospital, Hamilton, Ontario
• Montreal General Hospital, Montreal, Quebec
• The Ottawa Hospital Civic Campus, Ottawa, Ontario
We used a quality improvement framework to allow for tailoring the SICP to the local context to maximize uptake and impact.

Key Findings:

Based on our multi-site work in the hospital setting, we have found that the SICP workflow is readily adaptable to an inpatient general medical ward setting. The majority of patients who participated in the SICP indicated that they found the conversation worthwhile and report a significant increase in feeling heard and understood after the conversation.

Clinicians experienced the SICP as shifting the focus of serious illness conversations from an emphasis on code status to a values-based conversation which facilitates broader care planning more aligned with patients’ priorities. Clinicians reported mostly positive influences of this shift on themselves, their patients, and clinical practice.

Recommendations:

  • Training clinicians to use the Serious Illness Conversation guide is not enough on its own to change practice: system change (the entire SICP “package) is also needed.
    Our experience with implementing the SICP indicates that education on using the Serious Illness Conversation Guide (the key component of the SICP) is an important starting point but it is not enough. Clinicians need to be taught how to implement the SICP into the workflow of their clinical practice.
  • Implement all components of the SICP and follow the SICP Implementation Roadmap.
    Although there is room for adapting the SICP to local context, it is critical to implement all components of the program and follow the steps in the SICP Implementation Roadmap in order to effect change in how serious illness conversations occur on the hospital ward.

Publications:

Howard M, Elston D, De Vries B, Kaasalainen S, Gutman G, Swinton M, Carter R, Sussman T, Barwich D, Urquhart R, Jayaraman D, Munene P, You J. (2020). Implementing Advance Care Planning Tools in Practice: A Modified World Café to Elicit Barriers and Recommendations from Potential Adopters. Accepted for publication by Healthcare Quarterly, Dec 2020.

Singh J, Simon J, Ma I, Dunne F, Dugan A, Wooller K, Munene P, Kobewka D, Jayaraman D, Swinton M, Lagrotteria A, Bernacki R, You, J. Implementation of the Serious Illness Care Program on Hospital Medical Wards: methodology for a multi-site quality improvement initiative. Accepted for publication by the Canadian Journal of General Internal Medicine, Dec 2020.

Ma C, Riehm L, Bernacki R, Paladino J, You JJ. (2020). Quality of clinicians’ conversations with patients and families before and after implementation of the Serious Illness Care Program in a hospital setting: a retrospective chart review study.

 

Principal Investigators:

Dev Jayaraman, MD, MSc, FRCPC

The Research Institute of the McGill University Health Centre

Dev Jayaraman is an Associate Professor in the Departments of Medicine and Critical Care at McGill University. He is also the Director of Quality Improvement in both departments and Director of one of the clinical teaching units in the Division of General Internal Medicine. His major research interest is in improving the quality of care provided to in-patients on the medical wards and critical care units, particularly end of life care.

 

Dan Kobewka, MD, MSc

University of Ottawaphoto of Dan Kobewka

Daniel Kobewka is an Assistant Professor in the Department of Medicine, and the School of Epidemiology and Public Health at the University of Ottawa. He is a general internist at the Ottawa Hospital. His research interests are in medical decision making during serious illness and in health systems as they relate to the care of the frail elderly.

 

Jessica Simon, MBChB, FRCPC

University of Calgary
Photo of Jessica Simon
Jessica Simon is Physician Consultant for Advance Care Planning and Goals of Care (Calgary Zone) with Alberta Health Services, and Clinical Assistant Professor and Interim Division Head with the Division of Palliative Medicine, University of Calgary. A specialist in Internal Medicine, her clinical work is as a palliative consultant at the Foothills Medical Centre in Calgary. Before training in palliative medicine she completed clinical research fellowships in dementia and stroke medicine. She is a member of the Canadian Researchers at End-of-Life Network (CARENET), and her research interests are in advance care planning and the care of people living with advanced chronic disease.

 

John You, MD, MSc, FRCPC

McMaster UniversityJohn You

John You is a hospital-based general internist who is a staff physician with Hamilton Health Sciences and an Associate Professor in the Departments of Medicine, and Health Research Methods, Evidence and Impact at McMaster University. He received his BSc from McMaster University, and his MD and an MSc in Clinical Epidemiology from the University of Toronto. He is a member of the CLARITY (Clinical Advances Through Research and Information Translation) research group at McMaster, and an executive member of CARENET (Canadian Researchers at the End-of-Life Network), an interdisciplinary network of health care professionals from across Canada who collaborate to improve palliative and end-of-life care.  His primary clinical and scholarly interests are in improving the quality of end of life communication, decision-making, and care for seriously ill elderly patients and their families.

 

Co-Investigators

Dr. James Downar, Co-Investigator, BHSc, MHSc, MDCM
Dr. Robert Fowler, Co-Investigator, MDCM
Dr. Jeff Myers, Co-Investigator, MD, MSed, CCFP
Dr. Aman Nijjar, Co-Investigator, MD
Dr. Irene Ma, Co-Investigator, PhD
Dr. Peter Dodek, Co-Investigator, MD, MHSC
Mr. Peter Allatt, Co-Investigator, MHSc
Dr. Ravi Taneja, Co-Investigator, MD, FRCPC
Dr. Jennifer Kryworuchko, Co-Investigator, PhD, RN, CNCC (C )
Dr. Amanda Roze des Ordons, Co-Investigator, MD, FRCPC

Research Staff

Ms. Seema King, Project Coordinator
Ms. Joceyln Semenchuk, Research Nurse, RN
Ms. Marilyn Swinton, Research Coordinator, MSc
Mr. James Vatistas, Project Manager, BA, DIAt

 

International Collaborators:

Dr. Susan Block, International Collaborator, MD
Dr. Rachelle Bernacki, International Collaborator, MD, MS
Dr. Rebecca Sudore, International Collaborator, MD