title: Improving End-of-Life Communication and Decision Making: The Development of a Conceptual Framework and Quality Indicators.
abstract: BACKGROUND
  The goal of end-of-life (EOL) communication and decision making is to create a shared understanding about a person's values and treatment preferences that will lead to a plan of care that is consistent with these values and preferences. Improvements in communication and decision making at the EOL have been identified as a high priority from a patient and family point of view.
  
  
  OBJECTIVE
  The purpose of this study was to develop quality indicators related to EOL communication and decision making.
  
  
  METHODS
  We convened a multidisciplinary panel of experts to develop definitions, a conceptual framework of EOL communication and decision making, and quality indicators using a modified Delphi method. We generated a list of potential items based on literature review and input from panel members. Panel members rated the items using a seven-point Likert scale (1 = very little importance to 7 = extremely important) over four rounds of review until consensus was achieved.
  
  
  RESULTS
  About 24 of the 28 panel members participated in all four rounds of the Delphi process. The final list of quality indicators comprised 34 items, divided into the four categories of our conceptual framework: Advance care planning (eight items), Goals of care discussions (13 items), Documentation (five items), and Organization/System aspects (eight items). Eleven items were rated "extremely important" (median score). All items had a median score of five (moderately important) or greater.
  
  
  CONCLUSIONS
  We have developed definitions, a conceptual framework, and quality indicators that researchers and health care decision makers can use to evaluate and improve the quality of EOL communication and decision making.
authors.affiliation: Department of Critical Care Medicine and Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Tasnim
authors.initials: T
authors.lastname: Sinuff
authors.affiliation: Center for Health Evaluation and Outcome Sciences and Division of Critical Care Medicine, St. Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Peter
authors.initials: P
authors.lastname: Dodek
authors.affiliation: Departments of Medicine, and Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada.
authors.forename: John J
authors.initials: JJ
authors.lastname: You
authors.affiliation: BC Center for Palliative Care, Division of Palliative Care, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Doris
authors.initials: D
authors.lastname: Barwich
authors.affiliation: Fraser Health Authority, Surrey, British Columbia, Canada.
authors.forename: Carolyn
authors.initials: C
authors.lastname: Tayler
authors.affiliation: Divisions of Critical Care and Palliative Care, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: James
authors.initials: J
authors.lastname: Downar
authors.affiliation: Divisions of Critical Care and Palliative Medicine, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: Michael
authors.initials: M
authors.lastname: Hartwick
authors.affiliation: Division of Geriatric Medicine, Department of Medicine, Queen's University, Kingston, Ontario, Canada.
authors.forename: Christopher
authors.initials: C
authors.lastname: Frank
authors.affiliation: Department of Critical Care Medicine, Institute for Public Health, University of Calgary, Calgary, and Alberta Health Services-Calgary Zone, Calgary, Alberta, Canada.
authors.forename: Henry T
authors.initials: HT
authors.lastname: Stelfox
authors.affiliation: Department of Medicine, Queen's University, Kingston, Ontario, Canada. Electronic address: dkh2@queensu.ca.
authors.forename: Daren K
authors.initials: DK
authors.lastname: Heyland
mesh_terms: D000328:Adult; D032722:Advance Care Planning; D000368:Aged; D002170:Canada; D003142:Communication; D003657:Decision Making; D005260:Female; D006282:Health Personnel / Q000523:psychology; D006801:Humans; D008297:Male; D008875:Middle Aged; D010166:Palliative Care / Q000379:methods / Q000523:psychology; D011785:Quality Assurance, Health Care; D011787:Quality of Health Care; D013727:Terminal Care / Q000379:methods* / Q000523:psychology*
keywords: Advance care planning; communication; decision making; end-of-life care; modified Delphi study; palliative care; quality indicators