Defining and Characterizing Inappropriate Goals of Care Designation: A 10-year Retrospective Multicenter ICU Cohort...

Area of Science:

• Medical Ethics
• Critical Care Medicine
• Health Services Research

Background:

• Goals of Care Designation (GCD) guides interventions during acute clinical deterioration.
• Inappropriate GCD arises from communication failures regarding patient wishes, values, documentation, or agreement on medical effectiveness.
• The prevalence and causes of inappropriate GCD in ICUs were previously unknown.

Purpose of the Study:

• To determine the frequency and contributing factors of inappropriate Goals of Care Designation (GCD) in intensive care units (ICUs).
• To identify associated stakeholder and contextual features of patients with inappropriate GCD.
• To establish a baseline incidence for future quality improvement initiatives.

Main Methods:

• Retrospective multicenter cohort study of adult patients who died in the ICU from 2010-2019.
• Utilized an existing quality assurance database and physician reviewer flagging for goals of care concerns.
• Analyzed 4656 patient cases, with 265 meeting criteria for inappropriate GCD.

Main Results:

• 5.7% (265/4656) of ICU deaths involved inappropriate GCD.
• Suboptimal communication (44.9%), documentation (29.1%), and stakeholder agreement (43.4%) were key factors.
• More intensive resuscitation orders occurred in 21.5% of cases, often during crisis communication or pre-procedure.

Conclusions:

• A validated definition of inappropriate GCD provides a baseline incidence for quality improvement.
• Systemic improvements in communication, documentation, and decision-making processes can reduce inappropriate care.
• This study highlights opportunities to optimize patient care and align it with patient values.