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Development and evaluation of essential information elements for palliative care consultation: A documentation
Ching-Ming Chiu1, Ling-Ying Wei2, Jen-Hsuan Liu3
1Department of Internal Medicine, National Taiwan University Cancer Center, Taipei, Taiwan; Department of Family Medicine, National Taiwan University College of Medicine, Taipei, Taiwan; Graduate Institute of Medical Education and Bioethics, College of Medicine, National Taiwan University, Taipei, Taiwan.
Effective palliative care communication requires clear documentation of key information. Improving details on decision-makers, death preferences, insight, symptoms, and goals enhances consultation effectiveness.
Area of Science:
- Palliative Care Medicine
- Health Communication
- Medical Documentation
Background:
- Palliative care consultations are a primary delivery model.
- Essential elements for effective interprofessional communication in palliative care are not well-defined.
Purpose of the Study:
- To identify crucial information components for effective palliative care consultations.
- To assess the clarity and effectiveness of current palliative care consultation documentation.
Main Methods:
- Literature review and expert consensus established key information (INFORMATION) items.
- Retrospective analysis of 189 palliative care consultation documents from National Taiwan University Hospital.
- Documentation effectiveness and INFORMATION clarity were rated; correlation analyzed via multivariate logistic regression.
Main Results:
- Most INFORMATION items lacked clarity; diagnosis and advance decision documentation were relatively high.
- Key information like place of death preferences, prognosis, and decision-maker was omitted in over 50% of documents.
- Five INFORMATION items significantly predicted document effectiveness: decision-maker, place of death preferences, disease insight, symptoms, and consultation objectives.
Conclusions:
- Current palliative care consultation documentation often lacks clarity.
- Enhancing documentation of specific elements, including decision-maker, place of death preferences, disease insight, symptoms, and consultation objectives, can improve communication effectiveness.
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