Lack of documentation of evidence-based prognostication in cancer patients by inpatient palliative care consultants

J Palliat Med. 2015 Apr;18(4):382-5. doi: 10.1089/jpm.2014.0331. Epub 2015 Jan 21.

Abstract

Background: Prognostication plays a key role in palliative care (PC). It is critical for advance care planning, determining hospice eligibility, and communication. In contrast to subjective clinical prognostication, evidence-based prognostication (EBP) uses existing validated data to quantify prognosis; however, the extent to which PC providers use EBP is limited.

Objective: The objective was to analyze documentation of EBP by PC providers in the absence of an inpatient consultation note template at a single academic medical center.

Methods: We retrospectively evaluated prognostic documentation of inpatient PC consultations on oncology patients at a single academic hospital. Ratings of Eastern Cooperative Oncology Group (ECOG) Scale, Karnofsky Performance Scale (KPS), Palliative Performance Scale, and/or activities of daily living (ADLs) were considered documentation of functional status. PC-specific documentation of EBP included the Palliative Prognostic Index and/or Palliative Prognostic Score.

Results: There were 412 inpatient PC consultations for oncology patients (2012-2013). Reasons for consultation included goals of care (n=108), symptom management (n=181), or both (n=123). In the absence of a note template, functional status was documented in 6% (n=24) of consultation notes, while no consultation notes contained EBP documentation of the Palliative Prognostic Index and Palliative Prognostic Score.

Conclusion: This retrospective analysis conducted at a single academic medical center suggests poor documentation by PC providers of EBP in the absence of a consultation note template. Research and educational opportunities exist to evaluate barriers to EBP utilization and documentation by PC providers.

MeSH terms

  • Academic Medical Centers
  • Advance Care Planning / standards*
  • California
  • Documentation / standards*
  • Eligibility Determination / standards
  • Evidence-Based Practice / standards*
  • Evidence-Based Practice / statistics & numerical data
  • Female
  • Hospice Care / standards*
  • Humans
  • Male
  • Middle Aged
  • Neoplasms / diagnosis
  • Neoplasms / pathology*
  • Palliative Care / standards*
  • Prognosis
  • Referral and Consultation / standards
  • Retrospective Studies
  • Severity of Illness Index