John J You1, James Downar2, Robert A Fowler3, François Lamontagne4, Irene W Y Ma5, Dev Jayaraman6, Jennifer Kryworuchko7, Patricia H Strachan8, Roy Ilan9, Aman P Nijjar10, John Neary11, John Shik12, Kevin Brazil13, Amen Patel11, Kim Wiebe14, Martin Albert15, Anita Palepu10, Elysée Nouvet16, Amanda Roze des Ordons17, Nishan Sharma5, Amane Abdul-Razzak18, Xuran Jiang19, Andrew Day19, Daren K Heyland20. 1. Department of Medicine, McMaster University, Hamilton, Ontario, Canada2Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada. 2. Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada4Division of Palliative Care, University of Toronto, Toronto, Ontario, Canada. 3. Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada6Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada. 4. Centre de Recherche Clinique Hôpital Universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, Québec, Canada. 5. Department of Medicine, University of Calgary, Calgary, Alberta, Canada. 6. Department of Internal Medicine, McGill University, Montreal, Québec, Canada. 7. College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada. 8. School of Nursing, McMaster University, Hamilton, Ontario, Canada. 9. Department of Medicine, Queen's University, Kingston, Ontario, Canada13Critical Care Program, Queen's University, Kingston, Ontario, Canada. 10. Division of General Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada. 11. Department of Medicine, McMaster University, Hamilton, Ontario, Canada. 12. Faculty of Medicine, Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada. 13. School of Nursing and Midwifery, Queen's University Belfast, Belfast, Northern Ireland, United Kingdom. 14. Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada. 15. Centre de Recherche de l'Hôpital du Sacré-Coeur de Montréal, Département de Médecine, Université de Montréal, Montréal, Québec, Canada. 16. Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada. 17. Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada. 18. Division of Palliative Medicine, University of Calgary, Calgary, Alberta, Canada. 19. Clinical Evaluation Research Unit, Department of Medicine, Kingston General Hospital, Kingston, Ontario, Canada. 20. Clinical Evaluation Research Unit, Department of Medicine, Kingston General Hospital, Kingston, Ontario, Canada22Department of Community Health and Epidemiology, Queen's University, Kingston, Ontario, Canada.
Abstract
IMPORTANCE: Seriously ill hospitalized patients have identified communication and decision making about goals of care as high priorities for quality improvement in end-of-life care. Interventions to improve care are more likely to succeed if tailored to existing barriers. OBJECTIVE: To determine, from the perspective of hospital-based clinicians, (1) barriers impeding communication and decision making about goals of care with seriously ill hospitalized patients and their families and (2) their own willingness and the acceptability for other clinicians to engage in this process. DESIGN, SETTING, AND PARTICIPANTS: Multicenter survey of medical teaching units of nurses, internal medicine residents, and staff physicians from participating units at 13 university-based hospitals from 5 Canadian provinces. MAIN OUTCOMES AND MEASURES: Importance of 21 barriers to goals of care discussions rated on a 7-point scale (1 = extremely unimportant; 7 = extremely important). RESULTS: Between September 2012 and March 2013, questionnaires were returned by 1256 of 1617 eligible clinicians, for an overall response rate of 77.7% (512 of 646 nurses [79.3%], 484 of 634 residents [76.3%], 260 of 337 staff physicians [77.2%]). The following family member-related and patient-related factors were consistently identified by all 3 clinician groups as the most important barriers to goals of care discussions: family members' or patients' difficulty accepting a poor prognosis (mean [SD] score, 5.8 [1.2] and 5.6 [1.3], respectively), family members' or patients' difficulty understanding the limitations and complications of life-sustaining treatments (5.8 [1.2] for both groups), disagreement among family members about goals of care (5.8 [1.2]), and patients' incapacity to make goals of care decisions (5.6 [1.2]). Clinicians perceived their own skills and system factors as less important barriers. Participants viewed it as acceptable for all clinician groups to engage in goals of care discussions-including a role for advance practice nurses, nurses, and social workers to initiate goals of care discussions and be a decision coach. CONCLUSIONS AND RELEVANCE: Hospital-based clinicians perceive family member-related and patient-related factors as the most important barriers to goals of care discussions. All health care professionals were viewed as playing important roles in addressing goals of care. These findings can inform the design of future interventions to improve communication and decision making about goals of care.
IMPORTANCE: Seriously ill hospitalized patients have identified communication and decision making about goals of care as high priorities for quality improvement in end-of-life care. Interventions to improve care are more likely to succeed if tailored to existing barriers. OBJECTIVE: To determine, from the perspective of hospital-based clinicians, (1) barriers impeding communication and decision making about goals of care with seriously ill hospitalized patients and their families and (2) their own willingness and the acceptability for other clinicians to engage in this process. DESIGN, SETTING, AND PARTICIPANTS: Multicenter survey of medical teaching units of nurses, internal medicine residents, and staff physicians from participating units at 13 university-based hospitals from 5 Canadian provinces. MAIN OUTCOMES AND MEASURES: Importance of 21 barriers to goals of care discussions rated on a 7-point scale (1 = extremely unimportant; 7 = extremely important). RESULTS: Between September 2012 and March 2013, questionnaires were returned by 1256 of 1617 eligible clinicians, for an overall response rate of 77.7% (512 of 646 nurses [79.3%], 484 of 634 residents [76.3%], 260 of 337 staff physicians [77.2%]). The following family member-related and patient-related factors were consistently identified by all 3 clinician groups as the most important barriers to goals of care discussions: family members' or patients' difficulty accepting a poor prognosis (mean [SD] score, 5.8 [1.2] and 5.6 [1.3], respectively), family members' or patients' difficulty understanding the limitations and complications of life-sustaining treatments (5.8 [1.2] for both groups), disagreement among family members about goals of care (5.8 [1.2]), and patients' incapacity to make goals of care decisions (5.6 [1.2]). Clinicians perceived their own skills and system factors as less important barriers. Participants viewed it as acceptable for all clinician groups to engage in goals of care discussions-including a role for advance practice nurses, nurses, and social workers to initiate goals of care discussions and be a decision coach. CONCLUSIONS AND RELEVANCE: Hospital-based clinicians perceive family member-related and patient-related factors as the most important barriers to goals of care discussions. All health care professionals were viewed as playing important roles in addressing goals of care. These findings can inform the design of future interventions to improve communication and decision making about goals of care.
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