EB004 Critical Appraisal, Evaluation/Summary, and Synthesis of Evidence

Student Name

Western Governors University

D031 Advancing Evidence-Based Innovation in Nursing Practice

Prof. Name:

Date

Full APA Formatted Citation of Selected Articles

Gieniusz, M., Nunes, R., Saha, V., Renson, A., Schubert, F. D., & Carey, J. (2018). Earlier goals of care discussions in hospitalized terminally ill patients, and the quality of end-of-life care: A retrospective study. American Journal of Hospice and Palliative Medicine®, 35(1), 21–27. https://doi.org/10.1177/1049909116682470

Mack, J. W., Cronin, A., Taback, N., Huskamp, H. A., Keating, N. L., Malin, J. L., Earle, C. C., & Weeks, J. C. (2012). End-of-life discussions among patients with advanced cancer: A cohort study. Annals of Internal Medicine, 156(3), 204. https://doi.org/10.1059/0003-4819-156-3-201202070-00008

Schneiter, M. K., Karlekar, M. B., Crispens, M. A., Prescott, L. S., & Brown, A. J. (2019). The earlier the better: The role of palliative care consultation on aggressive end-of-life care, hospice utilization, and advance care planning documentation among gynecologic oncology patients. Supportive Care in Cancer, 27(5), 1927–1934. https://pubmed.ncbi.nlm.nih.gov/30209601/

Starr, L. T., Ulrich, C. M., Corey, K. L., & Meghani, S. H. (2019). Associations among end-of-life discussions, health-care utilization, and costs in persons with advanced cancer: A systematic review. American Journal of Hospice and Palliative Medicine®, 36(10), 913–926. https://doi.org/10.1177/1049909119848148

General Notes and Comments

The following section outlines the Johns Hopkins Nursing Evidence-Based Practice: Evidence Level and Quality Guide, which supports determining the strength and reliability of research evidence. This guide helps clinicians appraise research rigor, offering a structured method to evaluate the credibility and applicability of findings.

Evidence Levels Summary Table

Evidence Level	Description
Level I	Randomized controlled trials (RCTs), experimental studies, or systematic reviews of RCTs with/without meta-analysis.
Level II	Quasi-experimental research or systematic reviews synthesizing RCTs and quasi-experimental studies.
Level III	Nonexperimental research, qualitative studies, or systematic reviews of qualitative/nonexperimental work.
Level IV	Authoritative opinions and expert consensus informed by scientific evidence.
Level V	Case reports, program evaluations, literature reviews, or expert opinion based on experiential evidence.

Note on Conceptual Frameworks

Conceptual and theoretical frameworks play an essential role in shaping the foundation of research studies. These frameworks ensure that the research aligns with established knowledge, methodological rigor, and philosophical underpinnings. They guide the selection of variables, the development of instruments, and the interpretation of findings.

While literature sometimes uses the terms interchangeably, theoretical frameworks often draw on established, formalized theories, whereas conceptual frameworks focus more on the researcher’s mapping of variables and relationships specific to the study’s context. Regardless of the distinction, both frameworks strengthen the academic rigor, assist in identifying knowledge gaps, and justify the importance of the research within the broader field.

Evidence-Based Practice: Early End-of-Life Discussions

Early end-of-life (EOL) conversations between clinicians and patients facing terminal illnesses are widely recognized as essential to optimizing patient-centered care. These discussions help align treatment decisions with patient values, reduce unnecessary interventions, and promote a dignified end-of-life experience. Although significant advancements in healthcare allow clinicians to prolong life, research consistently indicates that many patients prefer comfort-focused care rather than aggressive treatments as they near death. However, a substantial proportion of terminally ill patients still die in hospitals or receive high-intensity care that may not reflect their wishes.

Findings From Gieniusz et al. (2018)

Gieniusz and colleagues conducted a retrospective study in a large academic hospital to evaluate how the timing of goals-of-care discussions (GOCDs) influences patient outcomes. Their analysis showed that more than 90% of patients had documented GOCDs, but the timing varied greatly. About 58.4% occurred early in the hospitalization, while 33% were initiated later. Importantly, each day of delay in discussing goals of care was associated with a 5% greater likelihood of inpatient death, emphasizing that earlier conversations provide more opportunities for appropriate care planning and avoidance of unwanted interventions.

The study suggests that delayed GOCDs may inadvertently funnel patients toward aggressive treatments such as ICU transfers or prolonged hospital stays. Early engagement ensures better alignment with patient priorities and reduces the likelihood of high-intensity care that may not improve outcomes.

Findings From Starr et al. (2019)

Starr et al.’s systematic review further supports the benefits of timely EOL discussions. Analyzing twenty quantitative studies, the authors concluded that such conversations are strongly associated with reduced healthcare expenditures, particularly in the last month of life. A highlighted randomized controlled trial by Patel et al., referenced within the review, demonstrated that structured EOL communication programs significantly lowered costs and reduced the use of aggressive treatments.

Beyond cost reduction, the review found that early palliative involvement improved documentation of patient wishes, increased hospice utilization, and decreased avoidable hospitalizations. These outcomes highlight both economic and ethical advantages of quality EOL communication.

Findings From Mack et al. (2012)

Despite strong evidence supporting early conversations, Mack et al. found that fewer than 40% of patients with advanced cancer had discussed EOL preferences with their providers. This gap demonstrates ongoing barriers such as clinician discomfort, time constraints, prognostic uncertainty, and concerns about patient readiness. The findings underscore the need for structured communication training and institutional protocols to support these critical discussions.

Additional Evidence: Schneiter et al. (2019)

Schneiter et al. examined palliative care consultations among gynecologic oncology patients and identified that earlier involvement led to less aggressive EOL care, increased hospice referrals, and improved advance care planning documentation. Their study reinforces the growing evidence that early palliative engagement is not only beneficial but essential for guiding care that aligns with patient goals.

Summary

Collectively, the reviewed studies strongly indicate that early end-of-life discussions:

Improve quality of life and patient satisfaction
Reduce unnecessary or unwanted aggressive care
Support clearer documentation of patient preferences
Lower healthcare utilization and associated costs
Encourage earlier hospice enrollment
Promote ethical, dignified care consistent with patient values

Implementing evidence-based communication strategies and institutional support systems is essential to ensuring that these conversations occur early and consistently.

References

Dang, D., Dearholt, S., Bissett, K., Ascenzi, J., & Whalen, M. (2022). Johns Hopkins evidence-based practice for nurses and healthcare professionals: Model and guidelines (4th ed.). Sigma Theta Tau International.