Jumpstarting Goals of Care Convos: Erin Kross, Bob Lee, and Ruth Engelberg

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, who do we have with us today?

Alex: We have some wonderful guests from the Pacific Northwest. We’re delighted to welcome Erin Kross, who is a pulmonary critical care, palliative care physician researcher at the University of Washington and Cambia Palliative Care Center of Excellence. Erin, welcome to the GeriPal podcast.

Erin: Thanks so much for having us.

Alex: We’re also delight to welcome Bob Lee, who’s a pulmonary critical care physician and researcher also at the University of Washington and the Cambia Palliative Care Center of Excellence. Welcome, Bob.

Bob: Thank you.

Alex: And Ruth Engelberg, who is an esteemed palliative care and palliative care researcher also at the University of Washington and can be a palliative care center of excellence. Welcome, Ruth to GeriPal podcast.

Ruth: Thank you very much.

Eric: So on today’s podcast, we’re going to be talking about Jumpstart, which is a priming intervention for goals of care. Well, I’m going to let them describe what it is just got published in JAMA about a month ago. But before we jump into Jumpstart, what it is, does somebody have a song request for Alex? I think it’s you, Bob.

Bob: Yeah. So I was wondering if you could do Jump for My Love, with the Pointer Sisters. [laughter]

Eric: I heard this was not your first request, Bob. [laughter]

Alex: I can answer that. No, I can’t. [laughter]

Bob: Oh, man.

Alex: Do you have any other songs with the word Jump in them?

Bob: Maybe Jump Around by House of Pain?

Alex: Yeah, good one. Yeah. No, I can’t do that one either. All right, keep trying.

Bob: How about Jump, by Van Halen?

Alex: I love that song. I could do the guitar part, but I couldn’t sing it. Anything else?

Bob: Bumming me out, man. Shoot. What do we have? What do we have?

Alex: How about Jumpin’ Jack Flash by the Rolling Stones?

Bob: I like that one.

Alex: All right, good. It’s got the word jump. All right, here’s a little bit.

(singing)

Eric: That was wonderful. Sorry, Bob, that Alex did not choose your first, second, or third song of choice there. [laughter]

Bob: That’s what happens when junior faculty get invited on the podcast [laughter]

Eric: So we’re going to be talking about the article that just came out in JAMA on a priming intervention for goals of care conversations in hospitalized patients with serious illness. We’ll have a link to the article on our notes. But I also want to acknowledge that the senior author of this article was Randy Curtis.

We actually had Randy Curtis on several times in our podcast, and I think one was three years ago, but one was not too long ago just on him living with a serious illness, which was ALS, and what that was like for him. We’ll have links to that in our show notes. I’m wondering maybe even before we start, because Randy died not too long ago, for those who didn’t know. But maybe you can could share just what was that like writing this article with him and also any reflections that you have because I know Randy has touched a lot of us in the palliative care world.

Erin: Yeah, I can go first. Well, I’m sure Ruth and Bob have lots to say about this too. It’s really special to be here and to be talking about this paper, which was really important to Randy. As you mentioned, this is Randy’s. It will be his last first authored publication. He had written and submitted this to JAMA back in January before he died and was really hopeful. I think one thing that we as a group often talk about was Randy’s pathologic optimism, which sometimes was pretty irritating, but most of the time was a great boost to all of our moods and egos. But I just know he would be delighted that this ended up being published in JAMA. And Bob and Ruth and I and the whole team feel really privileged to be able to have gone through the revise and resubmission process and work with JAMA to bring this paper to publication.

Bob: You know what’s crazy is I feel like all through my training and all through my fellowship, I would meet these people who are these gods of the field. And a lot of them are amazing. And then some of them you’re like, “You’re really good at writing, but I’m not so sure you’re actually that good at doing the things that you said you would do.” And I saw Randy run family meetings before I knew he was famous, before I knew he was this legendary researcher. And the guy was just so good. He really practiced what he preached. And I think that his research was informed by his clinical practice, his clinical practice was informed by his research. He was one of our first responders to COVID. He did a lot of shifts in the COVID ICU at the beginning of all this. And he was just such a great doctor and such a great advocate for families. And I think that just added a lot of legitimacy to his work, to his academic work.

Ruth: And I guess too, I would say about this particular paper, Randy really worked on it days before he died. And it was such a mission for him that it enabled him to go through, which was a rough time near the end where his abilities were decreasing and it was just a lot more work to just type in and work on it. And it really had such, it spoke for I think his whole life in terms of research and trying to solve questions and trying to improve quality of life and quality of care for patients that this was just a mission he had and he was going to get it done. And he just plowed on through and we would connect each day to see how it was going and where the problems were. But he just never flagged. It was going to get done, and it did. So we’re all really grateful. So that’s cool.

Alex: Two quick reflections from me. One is picking up on Erin mentioned Randy’s optimism. And his song choices reflected that, Supermarket Flowers then, but most recently in his podcast on living with and studying serious illness, The Good Life. It’s been a good life. It’s been a good life.

Eric: By One Direction. That was a One Direction song.

Alex: And then the other reflection I had is also on that podcast when we talked about our favorite Randy Curtis studies. Invariably, every time we mentioned it, he would say, “The first author on that was this. I worked with so and so.” Which just goes to show how generative he was, how supportive he was of his mentees and how he wanted to grow, nurture, make this field of palliative care research into a blockbuster field. And he was a key part of that strong effort over the last several decades. So we’ll certainly miss Randy for many things and for those things as well. Eric?

Eric: Yeah. I wonder if we can just start off just going back a little bit because we had Randy on back in 2018 talking about Jumpstart, priming patients to do goals of care conversations. And if I remember that study correctly, it was priming both patients and providers in the outpatient setting to do goals of care conversations. Am I summarizing that right?

Erin: Mm-hmm.

Eric: Yeah. So what’s changed since 2018 with Jumpstart?

Ruth: I’m glad to take the first crack at it. So the growth that Jumpstart has undergone, a couple things. That was done in the outpatient setting. So that’s one change. And there was a recognition, we’re still very much interested in the outpatient. We have a newly funded study that goes back to the outpatient. But we were very curious as to what is the impact of talking to people in the hospital setting, how does that look different? Is that an appropriate place? All those kinds of questions. So that’s one change.

The other change was the issue of resource intensity and how much effort do we have to put into a priming intervention to make it work? Because the priming intervention that ended in 2018, that it was funded by PCORI, was highly resource intensive. It required a fairly large research staff. It was had both surveys and EHR data points. So that was very different. And we had to also had to consent patients for participation, and that was also different.

Eric: And just for our listeners who may have not listened to that 2018 podcast, what the heck is a priming intervention?

Alex: I think about a lawnmower.

Eric: Last time Randy was on, I’m all like, “Amazon Prime?” [laughter]

Alex: And to prime the pump.

Erin: Right. Priming the pump. Exactly. I think that the intention, Jumpstart, as Ruth said, has gone through and is still going through iterations and formatting and how we populate the form, things that we can talk about more. At its heart, it’s always been a brief, hopefully one page document that can be delivered to clinicians and or patients to get them thinking about topics related to goals of care discussions. For clinicians, we give some information that is specific to the patient at hand and then some communication topics, some words to try some conversation starters to prime the pump, as you said, Alex, to just get people thinking about this topic and hopefully give them a tool, an easy to use tool that can get the conversation going.

Bob: And I really think of this as Randy often talked about the difference between primary palliative care, palliative care that’s delivered by clinicians who are already there at the bedside and specialty palliative care, people whose badges say palliative care on them. And I think that this was always a passion of his was how do we enable and empower and promote high quality, serious illness communication amongst people for whom it’s not necessarily their specialty, but it’s still a core part of what they should do. And so I always like to think of this as, can we intervene in the room where it happens and can we intervene in the room where it is already happening? And every time I write that, I try to cite Lin-Manuel Miranda. And every time I write that, some editor says, “You can’t do that, that’s not a scholarly publication.” And they take my citation out and it really upsets me.

Eric: Well, that would be great. Another song for Alex, by the way. So there’s a shift in this most recent publication where it’s priming no longer the patient, which was what we talked with Randy about last time, with some priming of the physicians to priming of the physicians here. Can you describe a little bit about what you actually did in this study and why you chose to go down that path and not really prime patients?

Erin: I can go, Ruth. I’m looking at Ruth here, who is involved from the get-go, obviously. But I think that as Ruth was saying, while the prior Jumpstart was quite effective at both increasing frequency of and quality of both care conversations in the outpatient space, it was just too labor-intensive to think about implementing widely across a healthcare system. So that was really the driving factor behind this redesign, is could we come up with a lower resource, lower touch intervention that would also be effective?

And so Ruth highlighted one of the features of this pragmatic trial that was different than the outpatient trial was that we didn’t need to consent patients and families for participation in this study. And we were able to work under a waiver of informed consent with making the case that we were promoting, which should be standard of care. I believe that and the IRB believed that. And so that’s how we were able to proceed with the study under this waiver of consent. But that allows us to look at all patients who meet our eligibility criteria, who are hospitalized and gives us a much broader sample of patients under study. That was one motivator for this new redesign.

Eric: And the Jumpstart one pager seems simplified too. So you want to just describe the Jumpstart one pager that you used in this study?

Ruth: Yeah. Instead, the prior Jumpstart really was very dependent on survey responses from patients. And we said we don’t want to do that. How can we depend on the EHR? What can we grab from the EHR? So we grabbed some elements. We grabbed, were there POLST, was there advanced directives in the EHR? POLST advanced directives, what am I forgetting?

Erin: Code status.

Ruth: And code status, sorry. And we had the date, if it was present in the EHR, to provide that context for the clinician. Otherwise, we pick three topic areas that using user, we used expert clinicians to help us populate it. We also based it on what we had previously done. And those three topics were understanding what do you understand about your illness? The second one was… jump in guys, if I forget.

Erin: Acceptable states.

Ruth: Acceptable states. What abilities are would you not want to live without? And the last one was?

Erin: Values.

Ruth: Values. Can you tell me what’s important to you if you were to get sicker? Those were the three topics. We gave them a sentence to say to address those or their own sentences if they could. We also provided reassurance that this is not a long conversation. This is to jumpstart a conversation. It doesn’t have to take more than five or 10 minutes to open it. And so that’s kind of what it is. So it was basically a script.

Eric: And that was the only thing in this intervention? There was no further education, role play, vital talky stuff, I want to learn more, so here are some?

Alex: Each person who received the intervention would get an email with this basically one pager that would say, “Your patient had a code status of DNR, put in the system on X date, and they had a POLST on X date. They do not have a prior advanced directive. Here are three key communication domains related to goals of care, and then some words to use to get started in those different domains. And then reassurance that this will not be a long conversation and this is meant to be a Jumpstart.” And that’s it.

Erin: Yeah. And I’ll add, there’s a prompt to document the conversation which is important to the primary outcome of the study. So that then closes by saying, “Please document a short note. It will help your teammates and colleagues.”

Eric: So all of this is automated, basically, or can be automated. This does not require anything else besides the… okay.

Alex: Bob, sounds like you want to jump in here.

Bob: I was going to say the other thing that I think is really important to point out is that this isn’t getting sent to everyone. This really is patients with serious chronic life limiting illness who are hospitalized.

Eric: How’d you define serious chronic life limiting?

Bob: We used a set of nine conditions that have been used by the Dartmouth Atlas Project to study end of life care. They’re associated with about 90% of deaths in the Medicare population. I think you had to be age over 55. We also did it if you were age greater than 80, period, because we figure there’s a certain point in age at which there’s a sort of a limit on your lifespan no matter what. And we didn’t expect every one of these patients to have or need a goals of care discussion. I think it was really just this is a selected population that we think would probably benefit from one.

Eric: So older adults who are being admitted for dementia cancers with bad prognosis, COPD, heart failure, it seems all reasonable to have a goals of care conversations for those patients. So you randomized this, there’s three different hospitals, right?

Erin: Yep. Three hospitals all within the UW medicine system. So sharing one electronic health record, but three separate hospitals within them.

Eric: And the usual care group just received usual care, no other emails.

Erin: Correct.

Eric: Okay. So I get that-

Erin: I think that’s an interesting feature too, right? The usual care here really is usual care as compared to, I heard Randy describe the prior outpatient study as the usual care was really usual care plus surveys because we were serving those clinicians and patients and they knew they were enrolled in a research study, which can change behavior just based on that knowledge. So this usual care arm, patients, clinicians, nobody really even knew we were observing them in the way that we were.

Eric: But I can also assume before we go on the results that if you’re being reminded to do goals of conversations with these patients, it may influence what you do on the usual care group. So you’re not randomizing the physicians to get this right? You’re randomizing the patients. So physicians may get this for some patients, but not for others, but maybe this will influence how often they do goals of care conversations in the usual care group.

Erin: Yes. I think that’s possible. Ruth?

Ruth: I would say that Randy always said, I think it’s true that we always, on these grants, were criticized for the potential of contamination. And our response was, if it was that easy to change physician behavior, we wouldn’t need to keep doing these grants. [laughter]

Eric: You don’t need priming if you… yeah, that’s fabulous.

Okay, so I get this is much less intensive of intervention. Did it do anything?

Alex: Yeah. And what was the “anything”?

Bob: So anything was a documented goals of care discussion in the health record. So somebody had to write something down in the medical record that talked about goals of care, and there was no template, there was no form that you filled out for this. This was just really in your usual documentation. Did you write down a goals of care discussion?

Eric: So Bob, are you searching through, there’s over 2,000 patients, every single note to figure that out?

Bob: Well, I did the math on this, and if you printed out all the notes, it would be the height of a 20-story building or something like that. And so Randy said, “Do you want to read all these?” And I said, “No.” And so on the side, we’ve been working on using natural language processing to try to find goals of care discussions, with the idea that when you search for phrases like goals of care, you find a bunch of aspirational goals of care discussions that never happen and you miss a bunch of goals of care discussions that just weren’t labeled that way.

And so we’ve been using various NLP techniques to come up with without algorithms that can find these. What we ended up doing with this study was we used NLP to screen these 44,000 notes for 2,000 patients, 2,512. Randy always got mad at me when I said 2,000. And we would screen it and then we would filter that down to sort of a select number of EHR passages that we thought were of high likelihood to have a goals of care discussion. And then we kicked that bucket of passages over to a set of human reviewers who would go through and they would say, “Yes, that’s a goals of care discussion. No, it’s not.” So on and so forth.

Eric: So you’re looking as an outcome documentation of goals of character discussions in the EHR that’s found through initially a screening of NLP. Why am I blanking on the… what’s the word for it again? Natural language processing. Sorry, brain fart there. And then you had human kind of reviewers review that.

Erin: Correct.

Alex: And can I just ask what might make it in. So if I wrote a note and it said, “Had a conversation with Mr. X about his future. He would love to be able to be home and be able to garden again. We talked about my fears that might not be possible and decided that we should focus on trying to keep him comfortable in a separate sort of facility because he had so many care needs he might never make at home.” Would that make it? Do you think that would be flagged?

Bob: That would make it, that would make it. I think that was always cool is that we adopted a pretty broad definition. We really said anything that’s looking at overarching goals of medical care. And you don’t have to come to a conclusion or anything like that. You just have to be talking about the overarching goals of medical care. And then we throw in an extra caveat that said, you have to talk about something more than just code status.

Eric: I was going to ask, what about just the code status full?

Erin: Full code, not goals of care?

Ruth: That doesn’t count.

Alex: Code status, DNR?

Bob: Nope.

Alex: No, it doesn’t count.

Bob: You got to go beyond just code status with the idea that most of these patients are not in the ICU, they’re hospitalized on acute care. They’re code status, I don’t want to say it’s not important, but it’s not really the most proximal set of decisions that they’re facing.

Eric: I love that because I have yet to meet a patient where their goals are to be full code. That’s not their goal. It’s an intervention to help achieve their goals, maybe live longer. But nobody ever says, “Yeah, my goal is to get CPR. I really, really want that.”

Alex: How about, well, we talked with Mrs X this time. We talked about who she would want to make decisions if she couldn’t make decisions for herself. And she decided she wanted to assign her daughter to help make decisions.

Bob: That would make it too.

Alex: That would make it too.

Bob: And I would say that that’s pretty rare, having gone through a lot of these manually. It’s not rare in general, but I don’t think it’s commonly done in the hospital setting. I think part of that is because Washington State law requires a DPOA to be notarized. So that just adds a complexity there. But yeah, if it was something that was really discussed during the hospitalization, meaning you’re not talking about this patient has a signed DPOA from three years ago, assigning it to Jill, it has to be really something that happened during the hospitalization after randomization.

Alex: How about reaffirm the patient’s code status and surrogate decision maker is the patient’s daughter and that the pulse as stated in the electronic record is accurate, sort of confirming what was already there?

Bob: I think you had to at least touch on it and you had to actually talk with somebody about it. So you can’t just say, “I’ve looked at all these things in the record and they’re all there.” You have to actually confirm it with somebody.

Alex: Okay. Thank you.

Eric: All right. Maybe just before we jump in, did you see any difference? Was there any debate of what should the primary outcome be? Should it be increased documentation of goals of care? Should it be decreased utilization, decreased use of CPR? Other things around, I don’t know what it would be, around goal concordant care, patient satisfaction. Just love your thoughts.

Ruth: Yeah. I would say that we felt fairly strongly when we wrote this grant that the measure of this effectiveness would be documentation, that all these other things could flow from a good conversation. And that’s why we made them secondary. But I don’t think we had any reluctance to say documentation was really important. And we didn’t want to require patients to consent. We wanted it to be pragmatic. So anything that was survey based requires that. So given the design that we thought was important, the notion of making this health system friendly, low resource requirements really made documentation the primary outcome, seeming to us the best primary outcome.

Eric: Yeah.

Erin: Yeah, I agree with that. Relying on the EHR was at the center of the outcome selection. I think the question of can you define goal concordant care from EHR as a whole other conversation. But I think, no, not yet or not right now. And so while that would be a super appealing outcome to have added to the study, we have not found a way to do that yet.

Eric: Yeah. Okay. Did it do anything? Did it have any impact in documentation of goals of care?

Erin: It did. Ruth, you want to?

Eric: It did? It did.

Erin: It did. It did.

Ruth: It did. It did. We found that the control group had a documented about 30% goals of care conversations, and the intervention group was at 34%. So I could give you the decimals, but I think the message is there.

Eric: So wait, like a 4% change?

Ruth: Yes, correct. Which seems very small. And when we presented it to the DSMC, which Alex was a member too, but we thought it was nice. It was proof of concept, great news. And our DSMC said, “No, no, no, it’s better than that.” So it was nice to hear. It was significant. We did have a large sample size, but it did feel that if you can change goals of care at that size for that percentage of people, maybe with that little bit of investment in a resource that’s accessible to a healthcare system, that is maybe a significant outcome. So within those variables. So that was an important finding for the overall group, yeah. And then there’s the race and ethnicity issue.

Eric: Well, tell us about that because you found maybe some differential effects based on-

Bob: We did. So we set out, at the design of this all, we said we’re going to look at whether this intervention effect is modified by a couple factors. We’re going to look at whether they have a history of dementia, we’re going to look at the patient’s sex, we’re going to look at the patient’s age, we’re going to look at race and ethnicity, and we’re going to look at which hospital they were randomized at.

And the positive finding that came out of that analysis was that we found that there was a much larger effect of the intervention among patients of minoritized race and ethnicity. The minoritized patients made up about, I want to say a thirdish or so of the study population, and we found that there was a much larger effect there. The effect size between, the percentage points difference in goals of care discussions between the intervention group and the control group was about 10% among patients with minoritized race and ethnicity.

And when you really sort of dive into it, what appears is that patients of minoritized race and ethnicity in the control arm, they had a much lower prevalence of goals of care discussions. So non-Hispanic white patients, 32% of people in the control arm had goals of care discussions. 26% of minoritized people had goals of care discussions. And in the intervention arm, they both shake out to be about 34, 35, 36%. And so I think this is still kind of exploratory. It is a subgroup analysis, but I do think it suggests that an intervention like this, it might be able to level the playing field a little bit. It might be able to say there’s a deficit here in this particular group of patients, and by promoting goals of care discussions, it might be able to correct some of those deficits and some of those inequities in care.

Eric: That’s fascinating. I wonder, Ruth or Erin, any other thoughts on, do you think it’s working through potentially changing some of the biases that are systemically built into these systems and potentially training of physicians and others who are having these conversations?

Erin: I think possibly. I think it’s really hard to know, right? It’s hard to know exactly how this intervention is having a differential effect in those two groups. But I think it seems plausible, as Bob was saying, that it’s a nudge intervention of sorts that levels the playing field and brings the lower group up. And I should just say, this is all clinician behavior. These are correcting the behaviors of clinicians who are creating these inequities that we see in the usual care group. Yeah.

Alex: I wonder if we could name the… oh, go ahead, Ruth. Looks like-

Ruth: Yeah, I was just going to say that I think the prompts are maybe helpful to a clinician who feels uncomfortable in the exchange, and it may be an unrecognized discomfort. But having the script with some suggested language may help overcome the feeling like, I don’t really know this person well enough. And it’s particularly noticeable because they don’t share a background with me. And again, I think this is implicit, not recognized. But I do wonder if having a tool that says, just say this, here’s some words, neutralizes some of that and allows people to take on new behaviors that they may not have been comfortable with previously.

Eric: I guess one alternative explanation, and I wonder if you looked at that, is that patients of color may have had less POLST use, may have less all of those things that you looked at and that you gave people, advanced directives, DPOAs, POLST forms, they may have had less of those to start with. So physicians, this person should definitely have it, and the white population had more of it, so it just kind of balanced that out.

Erin: That’s super intriguing. Hadn’t quite thought of it in that way, but I think it’s really possible. We’ve heard from clinicians, as we’ve been redesigning the Jumpstart for different studies that at least anecdotally they are more likely to see the top of the Jumpstart where, if it says full code, note POLST, no advanced directive, that clinician was like, “Ph, maybe this is something I should talk about.” As opposed to if you get a Jumpstart that says DNR/DNI, POLST check, advanced directive check, you could imagine a clinician might see that and say, “Somebody’s already done this,” even though we excluded people in the study who had a documented conversation within that hospitalization. You could still imagine a clinician would say, “This is good enough. I’m not going to”-

Alex: Like a low wattage jump from that. But they get the high voltage jump when they see none of these advanced care planning type forms, POLSTs have been completed.

Eric: I often think this is in our own palliative care practice, our team, we have our morning rounds on our list. It includes whether or not we have a life sustained treatment documentation note in their chart. And it serves as a reminder, I guess a primer to like, oh yeah, we have to have that conversation. And I wonder how much of this is the Jumpstart and the conversations versus just a checklist. Because we also know physicians love checklists, and it reminds us what to do, like in the ICE, including checklists, improves care. Thoughts on that?

Bob: I think a lot of times, especially in the hospital setting, you just get carried away. The patient gets admitted by a different doctor overnight at 3:00 AM. It gets handed off to another physician or another team, and they’re treating the patient and they’re putting out fires all over the hospital. The patient’s getting better. And so if the patient’s getting better, they sort of say, “Okay, we’ll keep waiting for them to convalesce. And then when they’re done convalescing, they can go home.” And you miss this opportunity to say, “Hey, this is a major event in this person’s life.” Yes, they’re getting better, but this is still a big change in health status and maybe we should sit down and talk about what that means. And I think that opportunity, it just gets lost because people are busy and because no one really gives you the time to really marinate on this issue and do it. And I think just having, I imagine a tiny Mick Jagger on your shoulder just saying, “Hey, there’s a Jumpstart form-

Alex: Jumpin’ Jack Flash.

Bob: Yeah, maybe that’s enough to push the bar a little bit.

Alex: Hey, here’s a question. We had a podcast about nudges with Jennifer Blumenthal-Barby, and Scott Halpern, and we talked about different kinds of nice nudges, choice architecture. You said this is a nudge. What kind of nudge is this? In what sense is this a nudge?

Erin: Fair question. I think of it as a nudge in terms of, it’s a reminder, it’s a prompt. It’s something that comes to your email that says like, “Hey, think about doing this,” a nudging towards a behavior.

Alex: Right. So it might not be a nudge in the choice… I wonder if it does fit into that framework in the sense that they might feel that this is more expected of all patients or something like that, when they get this email, I’m not sure. I’m not whether it fits in or not.

Eric: I also wonder healthcare providers, certainly doctors don’t like to have not done something. And seeing those nos across the board at the top may make you feel like, I want to be the rest of my peers and want to do this. So there may be several nudges just on the wording choice and how it’s used.

Bob: Yeah. I think a lot of people approach goals of care as this thing where it’s like, you do this when the patient’s dying, or you do this when you have a big decision about intubation or something like that. And I think the structure of the form, particularly the lower half of the form with the communication prompts, it really tries to get away from that. It says that’s not what’s important. What’s important is not the breathing tube decision. It’s not to say that’s not important, but what’s important is what are the patient’s values? What are the patient’s goals? What actually matters to this patient? And I think it just changes the lens through which we think about goals of care a little bit.

Eric: So there’s what matters to the patient, what matters to the clinician. There’s what matters to the healthcare systems that put this together, which includes some of your secondary outcomes like utilization, because every intervention costs some money. Did it have any effect on that?

Erin: It did not. It didn’t have any effect on any of our utilization outcomes, any of our secondary outcomes, which as you said, included things like ICU stays, emergency department visits, hospital readmissions, time alive and out of the ICU.

Eric: Were you expecting it to have? Because I can imagine hearing Bob too, this is not like the ICU patients. These are people at risk. They have those nine high risk conditions. They’re older adults. But yeah, did you imagine it?

Ruth: It was part of our conceptualization. But mostly it was aspirational more than anything else. I think the hope was maybe these conversations do drive care, but I think it was really a exploratory and that I don’t think we came to it with a lot of commitment, feeling that was the kind of outcome that this sort of conversation would really determine. It may drive care down the road in terms of making people more prepared to make good decisions. But a 30 day outcome about rehospitalization or an ED visit, it doesn’t seem to me that kind of thing. But it was aimed to. It wasn’t aim one in the grant.

Alex: I have a question about… oh, sorry. Did you want to keep going with this Eric, this vein?

Eric: You can ask a question. I had another question about, I’m going to just jump in anyways. What the heck? So I can imagine you have these people, high risk conditions, and then they’re being discharged. They may have had this goals of care conversation. You’re not requiring them to put it in anywhere. And then these conversations get lost in the shuffle. So I wonder, is there a role for putting it somewhere, do you guys have somewhere, or we just had a podcast on artificial intelligence and natural language processing. Using some of these tools, so physicians and nurse practitioners and social workers can quickly find these goals of conversations as quickly as you found them through your own algorithms.

Bob: I think that’s one of our many goals. I think right now we’re really reliant on whoever’s writing the discharge summary to be like, “Hey, this is an important piece of this hospitalization, let’s recapitulate it there.”

Eric: And then somebody’s actually going to read the whole discharge summary.

Bob: Right. And I think a lot of people actually do a good job with that, but I think a lot of stuff gets missed. And I think that given the fact that we’ve tried for a long time to get people to write all of their goals of care discussions in one place in the EHR, and it’s failed miserably. You just can’t get people to do it. And so I think one of our goals with this NLP work is to really get to a point where you can click a button and say, pull up all the goals of care discussions for me. And I think that requires a high amount of accuracy because even if a small percentage of those turn out to be garbage, people are just going to stop using that button. So it’s got to be a really, really high performing algorithm. But I think we’re getting there. I think natural language processing is getting better and better each day. And I think it’s a goal that’s within sight.

Alex: Okay. I got a question and we’re running out of time, so we got to do kind of lightning round here. You avoided using the terms advanced care planning in the manuscript, as far as I remember. Maybe you didn’t avoid, maybe that was… why did you not use the term advanced care planning? Is this advanced care planning? How do you think about that? Thoughts?

Erin: I see Ruth shaking her head.

Ruth: So I would say it is not advanced care planning and the way in which it’s colloquially defined to patients and families, the way they understand it. I think it is. And I think that’s true a little bit for physicians too, in the sense that this really is about thinking about what is important in terms of care, not exactly what the treatments ought to be.

Bob: I think it’s also capturing people during an episode of acute illness, where it’s a little bit more about in the moment decision making. And that’s not to say that people can’t do sort of pure advanced care planning in this setting, but you’re in the hospital with a acute illness, you’re not there for fun. Something’s going on with you. This is sort of the time that these decisions have to take place.

Alex: Okay, now… go ahead.

Erin: I was just going to say, but I do think it’s on the spectrum. I think how we define advanced care planning is nuanced and can be pretty broad. And even the way Ruth was talking earlier about planning a seed or preparing for future decisions, is that a form of advanced care planning? Probably. Not maybe under the same labels that patients and families think of it, but within a healthcare trajectory, maybe.

Alex: Right, right. I think that’s good. But as we thought towards 2018, we talked about this was an outpatient intervention/ in there, they’re not acutely hospitalized. And so is that advanced care planning? Question for you all though, because now we’re running short on time. My last question is what’s next? What’s next? Because you talk a lot in this about how this is one key component of what probably needs to be a bigger multi-pronged effort, and that we’ve shown we can do a little bit with this modest change with this and documentation of goals of care, and that we probably could do much better, or better. And on a population basis, it’ll probably have a big impact, particularly for minoritized older adults if we combined it with other things. Thoughts of like what’s next with Jumpstart? How do you see this fitting in? Should health systems adopt this? Where are we in the next-

Eric: In 30 seconds.

Erin: In 30 seconds. I’ll try. I think there are three things on my mind about what’s coming next for Jumpstart. One is the second trial within the same grant, which is looking at this pragmatic design Jumpstart that we just published on, but in a three arm trial, pragmatic design versus the bidirectional. More similar to what we did in the prior outpatient trial where we’re serving patients and families, creating a bidirectional Jumpstart, unusual care, to help understand how important is that bidirectional prompting and the patient surveying in this.

The second is that we have some information that we’re interested in digging into a little bit more about the implementation side of this. How do clinicians use this? What do clinicians think of it? Are there ways that we can improve the implementation beyond the email and a pager prompt in the way we did here? And then the third is that I’ll preview. We are taking Jumpstart back to the outpatient space in this more pragmatic design with some interesting things to come, we hope.

Eric: When do you think it’s going to be available to the masses?

Erin: The Jumpstart?

Eric: Yeah.

Erin: I will say it is published within JAMA. You can see exactly what our Jumpstart looked like, the exact words that we had, this form that we are talking about is figure one in the Jumpstart publication.

Eric: People could start using that?

Erin: Yep, sure could. We’re starting to work on a format of Jumpstart that can be smart text within, we use Epic here at UW. So trying to come up with some ways to get it even so it can be populated more automatically within the EHR without this email portion of the intervention.

Alex: And if there are listeners out there work in health systems that want to adapt this for their health system, who should they contact? Any of you?

Erin: Any of us. Yeah. Any of us would be fine.

Alex: Great.

Eric: All right. Bob, last question for you. Do you have any more songs with the word jump in it?

Bob: Not that came to mind, but I’m sure there are more out there. I’ll have to go through my Spice Girls albums to see if there’s-

Erin: What’s the one by Kriss Kross? Isn’t there a Jump, Jump?

Eric: There is a Kriss Kross song.

Erin: That’s like my name. We could have come up with that one. That would also probably have been challenging.

Alex: Great. Okay, we need to end this podcast now. It’s going off the rails. Here’s a little bit more of Jumpin’ Jack Flash, something I can play. Here we go.

(singing)

Eric: Well, Erin Ruth, Bob, thanks for joining us on the GeriPal podcast.

Bob: Thank you.

Ruth: Thank you.

Erin: Thanks so much.

Eric: And thanks for the amazing work you do. And thank you to all of our listeners for your continued support.