Surprise Question in End of Life (SeQuEL) Care and the Effect of Prompting Palliative Care Consultation: End-Stage Liver Disease

End-Stage Liver Disease Clinical Trial

— SeQuEL  

Official title:

Pragmatic Trial Investigating Surprise Question in End of Life (SeQuEL) Care and the Effect of Prompting Palliative Care Consultation on Provider Referral Rates and Subsequent Outcomes for Hospitalized Adults With Serious Illnesses: End-Stage Liver Disease

Clinical Trial Details — Status: Not yet recruiting

Administrative data

• NCT number: NCT06400498
• Other study ID #: 240233
• Status: Not yet recruiting
• Phase: N/A
• Start date: December 1, 2024
• Est. completion date: February 29, 2028

Study information

• Verified date: May 2024
• Source: Vanderbilt University Medical Center
• Contact: Mohana Karlekar, MD
• Phone: (615) 936-2187
• Email: mohana.b.karlekar[@]vumc.org
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

This is a single center randomized platform trial determining whether prompting consideration of palliative care consultation through the electronic health record impacts the number of palliative consultations placed and hospital-free days among hospitalized adults with End-Stage Liver Disease.

Description:

Palliative care is specialized medical care focused on providing patients with relief from the symptoms, pain, and stress of serious illness, regardless of diagnosis, by anticipating, preventing, and treating suffering. The goal is to improve quality of life for both the patient and the patient's family. Palliative care is appropriate at any age and at any stage in a serious illness. It may be provided together with curative treatment, and includes intensive focus on symptom and pain management, psychosocial and spiritual support, and assistance in advance care planning.

There is potential benefit to introducing palliative care earlier in the course of illness for patients with chronic liver disease. For some patients with cirrhosis, palliative care has been shown to improve physical and emotional symptoms. In a recent observational study, it was found that for patients with End-Stage Liver Disease (ESLD) on the waiting list for liver transplant, an early palliative care intervention counteracted the progression of worsening symptoms and significantly improved pruritus, appetite, anxiety, depression, fatigue, and well-being. Moreover, the introduction of palliative care within the care course of patients with decompensated cirrhosis is endorsed by an AASLD (American Association for the Study of Liver Diseases) practice guidance document.

Despite the available evidence regarding the potential benefits of specialized palliative care across multiple serious illnesses, the incorporation of palliative care consultation into clinical practice in many settings is inconsistent and often too late in the clinical trajectory. In an effort to introduce palliative care sooner and more consistently into patients' care pathways, the study team will explore an interruptive provider nudge to prompt palliative care consideration in ESLD. This integrated approach will also help bridge the knowledge gap as to whether systematically prompting palliative care consultation can improve referral rates and outcomes for patients with ESLD.

The processes used to 1) identify hospitalized patients with ESLD, 2) query a provider about their status, and 3) prompt consideration of palliative care consultation are amenable to conduct through the electronic health record. Step 1 will employ phenotyping of clinical and admission characteristics readily extractable from the medical record. Step 2 will utilize the "Surprise Question" as a screening tool for identification of potentially unmet palliative care needs. In previous studies of serious illness, patients for whom consideration of palliative care consultation might be appropriate have used the "Surprise Question", which asks the treating clinician "would you be surprised if this patient died in the next 12 months?" Step 3 will harness the capability to prompt a provider to consider appropriately indicated, complementary, supportive care that may be otherwise underutilized while managing the patient's immediate health crisis.

Given the preliminary evidence that specialist palliative care may improve the quality and quantity of time spent alive and outside of the hospital for patients with serious illness and the incomplete implementation of specialty palliative care in current clinical practice, the study team will evaluate the effect of prompting consideration of palliative care consultation in the electronic health record on provider referral rates to the palliative care service and hospital-free days among hospitalized patients with ESLD.

Recruitment information / eligibility

• Status: Not yet recruiting
• Enrollment: 776
• Est. completion date: February 29, 2028
• Est. primary completion date: February 29, 2028
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years and older

Eligibility

Inclusion Criteria:

• Patient is an adult (age = 18 years).

• Patient is admitted to the study hospital.

• Patient meets phenotype criteria for End-Stage Liver Disease.

• Patient's treating physician, physician associate, or nurse practitioner answers "No" to a prompt in the electronic health record asking, "Would you be surprised if this patient died in the next 12 months?"

Exclusion Criteria:

• Patient is known to have received any VUMC palliative care consultation during the prior 3 months and/or the current admission.

• Patient is known to be a prisoner.

• Patient has received a liver transplant.

Related Conditions & MeSH terms

• Death
• End Stage Liver Disease
• End-Stage Liver Disease
• Liver Diseases

Intervention

Behavioral:
• Prompted Palliative Care Consult
When a patient is randomized to the Palliative Care Consultation Prompt Group, a clinical decision support tool in the electronic health record will inform the treating clinician of the patient's serious illness and the results of the Surprise Question and prompt the treating clinician to consider a palliative care consultation. If the treating clinician feels a palliative care consultation would be indicated for the patient, the clinical decision support tool will facilitate the placement of a palliative care consultation by the treating clinician. If the treating clinician feels that a palliative care consultation would not be indicated, then the clinical decision support will record a reason it is not indicated.

Locations

Country	Name	City	State
United States	Vanderbilt University Medical Center	Nashville	Tennessee

Sponsors (1)

Lead Sponsor	Collaborator
Vanderbilt University Medical Center

Country where clinical trial is conducted

United States, 

References & Publications (10)

Baumann AJ, Wheeler DS, James M, Turner R, Siegel A, Navarro VJ. Benefit of Early Palliative Care Intervention in End-Stage Liver Disease Patients Awaiting Liver Transplantation. J Pain Symptom Manage. 2015 Dec;50(6):882-6.e2. doi: 10.1016/j.jpainsymman.2015.07.014. Epub 2015 Aug 22. — View Citation

Ferrell BR, Twaddle ML, Melnick A, Meier DE. National Consensus Project Clinical Practice Guidelines for Quality Palliative Care Guidelines, 4th Edition. J Palliat Med. 2018 Dec;21(12):1684-1689. doi: 10.1089/jpm.2018.0431. Epub 2018 Sep 4. — View Citation

Holden JH, Shamseddeen H, Johnson AW, Byriel B, Subramoney K, Cheng YW, Saito A, Ghabril M, Chalasani N, Sachs GA, Orman ES. Palliative Care and Hospice Referrals in Patients with Decompensated Cirrhosis: What Factors Are Important? J Palliat Med. 2020 Aug;23(8):1066-1075. doi: 10.1089/jpm.2019.0501. Epub 2020 Feb 24. — View Citation

Moroni M, Zocchi D, Bolognesi D, Abernethy A, Rondelli R, Savorani G, Salera M, Dall'Olio FG, Galli G, Biasco G; on behalf of the SUQ-P group. The 'surprise' question in advanced cancer patients: A prospective study among general practitioners. Palliat Med. 2014 Jul;28(7):959-964. doi: 10.1177/0269216314526273. Epub 2014 Mar 24. — View Citation

Moss AH, Ganjoo J, Sharma S, Gansor J, Senft S, Weaner B, Dalton C, MacKay K, Pellegrino B, Anantharaman P, Schmidt R. Utility of the "surprise" question to identify dialysis patients with high mortality. Clin J Am Soc Nephrol. 2008 Sep;3(5):1379-84. doi: 10.2215/CJN.00940208. Epub 2008 Jul 2. — View Citation

Radbruch L, De Lima L, Knaul F, Wenk R, Ali Z, Bhatnaghar S, Blanchard C, Bruera E, Buitrago R, Burla C, Callaway M, Munyoro EC, Centeno C, Cleary J, Connor S, Davaasuren O, Downing J, Foley K, Goh C, Gomez-Garcia W, Harding R, Khan QT, Larkin P, Leng M, Luyirika E, Marston J, Moine S, Osman H, Pettus K, Puchalski C, Rajagopal MR, Spence D, Spruijt O, Venkateswaran C, Wee B, Woodruff R, Yong J, Pastrana T. Redefining Palliative Care-A New Consensus-Based Definition. J Pain Symptom Manage. 2020 Oct;60(4):754-764. doi: 10.1016/j.jpainsymman.2020.04.027. Epub 2020 May 6. — View Citation

Reframing Palliative Care | Messages Matter | On-Demand Webinar.; 2017. https://www.capc.org/events/recorded-webinars/reframing-palliative-care-messages-matter/

Rogal SS, Hansen L, Patel A, Ufere NN, Verma M, Woodrell CD, Kanwal F. AASLD Practice Guidance: Palliative care and symptom-based management in decompensated cirrhosis. Hepatology. 2022 Sep;76(3):819-853. doi: 10.1002/hep.32378. Epub 2022 Apr 22. No abstract available. — View Citation

Shinall MC Jr, Karlekar M, Martin S, Gatto CL, Misra S, Chung CY, Porayko MK, Scanga AE, Schneider NJ, Ely EW, Pulley JM, Jerome RN, Dear ML, Conway D, Buie R, Liu D, Lindsell CJ, Bernard GR. COMPASS: A Pilot Trial of an Early Palliative Care Intervention for Patients With End-Stage Liver Disease. J Pain Symptom Manage. 2019 Oct;58(4):614-622.e3. doi: 10.1016/j.jpainsymman.2019.06.023. Epub 2019 Jul 2. — View Citation

Woodrell CD, Goldstein NE, Moreno JR, Schiano TD, Schwartz ME, Garrido MM. Inpatient Specialty-Level Palliative Care Is Delivered Late in the Course of Hepatocellular Carcinoma and Associated With Lower Hazard of Hospital Readmission. J Pain Symptom Manage. 2021 May;61(5):940-947.e3. doi: 10.1016/j.jpainsymman.2020.09.040. Epub 2020 Oct 6. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Percentage of patients with palliative care consults placed within 48 hours after enrollment	Percentage of patients identified within the EHR identified with palliative care consults.	48 hours post-enrollment
Primary	Hospital-free days by day 90	The number of calendar days between enrollment and day 90 in which the patient is alive and outside of an acute-care hospital. Days spent at home, at a rehabilitation facility, at a nursing facility, and at an inpatient hospice facility will count as hospital-free.	90 days post-enrollment
Secondary	Survival to day 90	The number of calendar days in which the patient is alive between enrollment and day 90.	90 days post-enrollment