Expanding Goals of Care Conversations Across a Health System: The Mapping the Future Program

Context: Clinician failure to discuss goals of care (GOC) with seriously ill patients remains prevalent. Small-scale educational interventions have demonstrated improvement in physician communication skills, but it is unknown if these results translate into practice changes.

Objectives: To implement a large-scale educational intervention that would facilitate increased GOC discussions in at-risk patients, increase clinician confidence in having GOC discussions, and prove to be sustainable.

Methods: The Mapping the Future courses were four-to-eight-hour trainings, with brief lectures and demonstrations followed by practice with simulated patient cases. Participants completed precourse and postcourse surveys, including demographic information, self-confidence in a variety of communication tasks, willingness to initiate GOC discussions, barriers to GOC discussions, and self-perceived skill at having GOC conversations. We compared the rate of documentation of GOC discussions with at-risk inpatients in three hospitals for physicians who had taken the course and those who had not.

Results: Over a two-year period, we trained 512 clinicians in 42 sessions. After the course, participants felt that they had improved in all the skills that we taught and agreed that they would be more likely to initiate GOC conversations. Trained physicians were more likely than their nontrained colleagues to document a GOC discussion with at-risk patients (30.8% vs. 27.2%; P = 0.0001).

Conclusion: A large-scale educational intervention involving simulated patient cases increased GOC documentation across a health system. Other programs might consider collaboration with quality improvement specialists to measure the impact of education and situate it within other system changes to support increased GOC discussions.