"What are you afraid of?" A mixed methods exploration of serious illness communication with oncology patients on general internal medicine wards in Canada.

BACKGROUND: While emphasized as a key aspect of patient-centered care, little is known about the delivery and documentation of serious illness conversations (SIC) for patients with cancer admitted on general internal medicine (GIM) wards. OBJECTIVES: To characterize the documentation and experiences of SIC from the perspectives of patients and clinicians on GIM wards. METHODS: This mixed methods quality improvement project gathered data from GIM wards using a: (1) retrospective review of electronic medical record data of hospitalized patients with cancer, (2) survey of physicians, residents, nurses, and allied health clinicians regarding their clinical practice, and (3) semi-structured interviews with hospitalized patients/caregivers. RESULTS: The charts of 101 patients were reviewed: 85.2% had a documented code status, while less than half (46.5%) had documentation of a conversation with a clinician addressing hopes, concerns or values. Ninety-seven clinicians completed the survey and reported variable levels of documentation of SICs. Clinician-identified barriers to serious illness conversations included language barriers, prognostic uncertainty, and lack of time. The 21 patients/caregivers who were interviewed reported a lack of focus on values in their discussions with clinicians, and a desire for their clinician to tailor these discussions to their individual needs. CONCLUSION: In patients with cancer admitted to GIM wards, code status was frequently documented, whereas values-based components of these SICs were less frequently recorded Our results represent an opportunity to improve both the delivery and documentation of more holistic, person-centered aspects of serious illness conversations as a means to drive goal-concordant care through targeted clinical and educational interventions.