Comparing Goals-of-Care (GOC) with Not-for-Resuscitation (NFR) Orders in Medical and Oncology Patients. A quasi-experimental comparative pre-and-post study.

This is a quasi-experimental pre-and post study. The pre-component / retrospective control phase (March 1st - September 30th 2016) will be the current hospital Not-for-Resuscitation (NFR) form. The post-component / intervention phase (March 1st - September 30th 2017) will involve replacement of the NFR form with a new Goals-of-Care (GOC) on two hospital wards that predominately care for oncology and medical patients in a large Australian private hospital. The GOC form has been designed to be more explicit to delineating the care pathways for individual patients. The original NFR form is completed on an ad-hoc basis at any point in a patient's hospital admission with a binary outcome pathway of essentially full resuscitation or palliation. The intent for the new GOC form is that it will be completed for every inpatient hospital admission and offers 4 distinct care pathways (A) All life sustaining treatment i.e full active resuscitation (B) Life extending treatment - with treatment ceilings regarding ICU and MER call feasibility (C) Active ward based treatment - with symptom and comfort care i.e not for ICU (D) Optimal comfort treatment i.e essentially good palliative care. This study aims to have the new GOC form completed within 48 hours of admission. Where a patient clearly qualifies for Treatment Goal A - all life sustaining treatment, then the box is ticked and patient discussion is not necessary. Where the treating doctors are uncertain then the study requests a discussion with the treating specialist and patient as appropriate. It is hoped that the new GOC will trigger a greater consideration on the most appropriate care pathway for a patient early in their admission. Changes in the care pathway will be monitored as part of the outcomes. Prior to the introduction of the GOC form (intervention phase) on March 1st 2017 there will be a series of educational activities coordinated and run by the Department of Palliative Care. These will include:: (1) Three online short videos between 11 -18 minutes that can be watched at http://ww2.health.wa.gov.au/Articles/A_E/Advance-CPR-decision-making-in-the-hospital-setting . This activity is already available and we are encouraging for all hospital staff to review them prior to the new GOC form intervention. (2) Hospital grand round presentations - two in total - each lasting 45 minutes with time for questions and answers. These will be conducted in November 2016 and February 2017. All hospital staff will be encouraged to attend these sessions. (3) Junior medical staff teaching sessions. These will be for all RMO and registrars regardless of which wards they work on as they will rotate positions through the year and have after-hours ward cover that may involve one of the intervention wards. There will be four x 45 minute sessions to be held in January, February and March 2017 during dedicated routine JMO teaching sessions. (4) Nursing education sessions two x 45 minute sessions (4 in total) on the designated wards (oncology and general medicine wards) for the GOC intervention. There will be a separate 45 minute session for the ICU nurses who are involved in the Medical Emergency Response Team in February 2017. These will be arranged at handover times in January and February 2017 and conducted by the clinical nurse consultant in palliative care. (5) Specific senior medical training sessions. There will be 2 x 1 hour long case scenario and simulations sessions arranged for senior clinician staff in February 2017. Only senior staff involved in the studied wards will be invited. These include the specialists in the fields of oncology, haematology and internal medicine specialties. Senior staff training sessions will be strongly encouraged but voluntary. If necessary, additional training sessions will be arranged in the first three months after the introduction of the new GOC based on staff feedback and research monitoring for compliance. The education will focus on -> the reasons for the change in forms from NFR to GOC; the content of the new GOC form and how it differs from the old NFR form; how, when and on who to complete the new GOC form for; and describe the surrounding research project. During the intervention (GOC) phase, all old NFR forms will be removed and replaced with the intervention GOC form. The intervention will be applied to every patient admitted to one of three medical / oncology wards over a six-month period. It will be completed by junior medical officers (JMOs) and consultant physicians within the first 48 hours of all admissions. Each GOC form will apply for the entire admission but can be changed by the treating team at time points later in the admission if the patients' clinical situation changes. If a patient is re-admitted during the same time period a new form will need to be completed. All the interventions (GOC forms) will be personalised according to the treating teams overall management strategy for the patient at any given time. Intervention adherence will be assessed by the number of forms completed, the date and time they where completed, and the number of times they are altered during a patient's admission.