Development and evaluation of essential information elements for palliative care consultation: A documentation quality analysis
Journal
Journal of the Formosan Medical Association
ISSN
0929-6646
Date Issued
2026-03
Author(s)
Abstract
Although palliative care consultation is the predominant delivery model, the essential elements for effective interprofessional communication remain poorly defined. This study aimed to identify key information components necessary for effective palliative care consultations. We established Palliative Care consultation Information (INFORMATION) items through literature review and expert consensus. Three experienced palliative care specialists retrospectively examined palliative care consultation documents from National Taiwan University Hospital (April 1-30, 2023) in two phases: documentation effectiveness and INFORMATION clarity. Document effectiveness was rated on a 5-point scale to assess how well the documents assist palliative care consultation teams. INFORMATION clarity was rated as clear, vague, or omitted. The correlation between INFORMATION clarity and document effectiveness was analyzed using multivariate logistic regression. In total, 189 palliative care consultation documents were evaluated. Description quality was suboptimal across most INFORMATION items. Diagnosis was clearly presented in 92.06% of documents and advance decision in 62.96%. Information regarding place of death preferences, prognosis, and decision-maker was omitted in >50% of documents, whereas that for symptom and disease insight was predominantly vague at 83.59% and 59.79%, respectively. Multivariate analysis identified five INFORMATION items that significantly predicted document effectiveness: decision-maker (AOR [adjusted odds ratio] = 51.5, p < 0.001), place of death preferences (AOR = 28.0, p < 0.007), disease insight (AOR = 13.1, p < 0.038), symptoms (AOR = 38.1, p < 0.049), and consultation objectives (AOR = 4.65, p < 0.048). Most INFORMATION items lacked clarity. Improving documentation of decision-maker, place of death preferences, disease insight, symptoms, and consultation objectives can enhance consultation communication effectiveness.
Publisher
Elsevier BV
Type
journal article