Goals of Care Assessment during Hospitalization for Sepsis.

Abstract

Rationale: Sepsis is a common cause of hospital mortality, as well as new morbidity among survivors. Clinical practice guidelines recommend assessing goals of care (GoCs) during sepsis hospitalization to ensure goal-concordant care is provided. Objectives: To determine how often GoCs are assessed during sepsis hospitalization in routine practice. Methods: We conducted a cohort study of adult patients hospitalized with community-onset sepsis at 66 hospitals (2020-2023) participating in the Michigan Hospital Medicine Safety Consortium's sepsis initiative. The primary outcomes were GoC discussion documented in the health record and GoC assessment inferred to have occurred on the basis of 1) documented GoC discussion, 2) treatment limitations on admission, 3) treatment limitations initiated during hospitalization, 4) palliative care consultation, or 5) discharge to hospice. We examined the incidence of GoC discussion and GoC assessment among all sepsis hospitalizations, as well as in three subgroups defined by advanced age or health impairment; admission to intensive care; and presentation with shock or respiratory failure. We also evaluated factors associated with GoC discussion/assessment and quantified variation across hospitals using multilevel logistic regression. Results: Among 18,711 patients in the Michigan Hospital Medicine Safety Consortium sepsis initiative registry, 54.0% had advanced age or health impairment, 22.5% were admitted to intensive care, and 10.2% presented with shock or respiratory failure. GoC discussion and assessment occurred in 35.7% and 45.3% of patients, respectively, in the overall cohort. GoC discussion occurred within 3 days of presentation in 23.8%. Age, race, chronic conditions, preexisting cognitive impairment, preexisting functional limitation, admission to intensive care, and receipt of life support were each associated with GoC assessment. Median odds ratios for GoC discussion and assessment were 2.30 and 2.09, respectively, indicating substantial cross-hospital variation after accounting for patient characteristics. GoC discussion and assessment were more common among patients with advanced age or health impairment, admission to intensive care, or presentation with shock or respiratory failure, but cross-hospital variation was similar. Conclusions: GoC assessment did not occur consistently during sepsis hospitalization in this multihospital cohort, even among higher-risk patients, and there was marked variation in practice across hospitals. Future work is needed to better understand what drives high performance in assessing GoC.