Clinical Trial Search

Primary: Proportion of Subjects Who Select Palliative Care Options — 31; 50; 47 percentage who select palliative care

Primary: Proportion of Participants That Select to Complete an Advance Directive — 0.35; 0.20 proportion of participants

Primary: Increased Concordance Rate in Stated Goals of Care (Life-prolonging Medical Care, Selective Medical Care, or Comfort-focused Care) — 20; 15; 5; 10 Participants

Primary: Number of Participants Who Completed an Advance Directive — 30; 5 participants

Primary: Hospital Transfers — 1.2; 1.3 number of hospital transfers — p=0.3313

Primary: Adapted Decision Making Confidence Scale — 4.8; 4.7; 3.7; 5 score on a scale

Primary: Dyad Congruence With Goals-of-Care Tool — 9; 4; 11; 24 Participants

Primary: Intent to Discuss Advance Directives (Based on the Transtheoretical Stages of Change Model) — 0; 1; 1; 3 Participants

Primary: Number of Patient's Documented Advance Care Planning Discussion- Nurse Navigator — 134; 0 Discussions

Primary: Number of Participants That Completed Patient Quality of Life Survey — 4; 3; 3; 3 Participants

Primary: New Advance Care Planning Documentation in the Medical Record at 9 Months — 35; 25 percentage of participants

Primary: Number of Patients Who Found the Intervention Acceptable and Provided Suggestions for Improvement — 48 Participants

Primary: Change in Advance Care Planning (ACP) Engagement With Clinicians at One Month — 2.84; 2.87; 3.37; 3.32 score on a scale — p=0.5835

Primary: Do-Not-Resuscitate — 144; 136 Participants

Primary: Measured ACP Content in the Presurgical Consent Visit — 6; 5; 10; 8 Recordings

Primary: Identification of a Goals of Care Conversation in the Electronic Health Record (EHR) During the Index Hospitalization — 3744; 2396 Participants

Primary: Number of Patients 65 and Older With New Documentation of Any Advance Directive in the Electronic Health Record (EHR) — 2190; 2130; 255; 409 Participants

Primary: Completion of Advance Directive — 15; 55 Participants — p=<0.05

Primary: Presence of Discussions About End of Life Care Goals/Wishes — 13; 8 participants — p=.77

Primary: Retention Rate — 38; 3 Participants

Primary: Difference in Mean Patient Health Questionaire 9 Score From Baseline — .74; 3.38 units on a scale — p=<.009

Primary: Documented Decisions to Forgo Hospitalization — 133; 119 Participants

Primary: Number of Eligible Participants Enrolled in the Study — 50 Participants

Primary: Documentation of Goals of Care — 16; 6 Participants — p=0.036

Primary: All-cause Mortality — 4.4 Percentage of subjects

Primary: Mean Feasibility of Intervention Measure — 16.4; 16.1; 19.0 score on a scale

Primary: Advance Care Planning Values/Beliefs — 24.9; 26.3 Score on a scale

Primary: Dyad Congruence — 48; 64 percentage of congruent dyads — p=<.05

Primary: Kidney Disease Quality — 75.4; 78.3; 78.4; 73.4 score on a scale

Primary: Number of Participants With Completed Goals of Care Documentation. We Will Evaluate if 75% of Patients in the Intervention Arm Have a Documented Goals of Care Titled…