title: Barriers to conducting advance care discussions for children with life-threatening conditions.
abstract: OBJECTIVE
  Advance care discussions (ACD) occur infrequently or are initiated late in the course of illness. Although data exist regarding barriers to ACD among the care of adult patients, few pediatric data exist. The goal of this study was to identify barriers to conducting ACD for children with life-threatening conditions.
  
  
  METHODS
  Physicians and nurses from practice settings where advance care planning typically takes place were surveyed to collect data regarding their attitudes and behaviors regarding ACD.
  
  
  RESULTS
  A total of 266 providers responded to the survey: 107 physicians and 159 nurses (54% response rate). The top 3 barriers were: unrealistic parent expectations, differences between clinician and patient/parent understanding of prognosis, and lack of parent readiness to have the discussion. Nurses identified lack of importance to clinicians (P = .006) and ethical considerations (P < .001) as impediments more often than physicians. Conversely, physicians believed that not knowing the right thing to say (P = .006) was more often a barrier. There are also perceived differences among specialties. Cardiac ICU providers were more likely to report unrealistic clinician expectations (P < .001) and differences between clinician and patient/parent understanding of prognosis (P = .014) as common barriers to conducting ACD. Finally, 71% of all clinicians believed that ACD happen too late in the patient's clinical course.
  
  
  CONCLUSIONS
  Clinicians perceive parent prognostic understanding and attitudes as the most common barriers to conducting ACD. Educational interventions aimed at improving clinician knowledge, attitudes, and skills in addressing these barriers may help health care providers overcome perceived barriers.
authors.affiliation: Department of Anesthesiology, Perioperative and Pain Medicine, Children’s Hospital Boston, Boston, Massachusetts 02115, USA. amy.durall@childrens.harvard.edu
authors.forename: Amy
authors.initials: A
authors.lastname: Durall
authors.forename: David
authors.initials: D
authors.lastname: Zurakowski
authors.forename: Joanne
authors.initials: J
authors.lastname: Wolfe
mesh_terms: D000328:Adult; D032722:Advance Care Planning / Q000458:organization & administration*; D001291:Attitude of Health Personnel; D002648:Child; D003144:Communication Barriers; D016638:Critical Illness / Q000628:therapy*; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006776:Hospitals, Pediatric; D006801:Humans; D008297:Male; D008505:Medical Staff, Hospital / Q000941:ethics* / Q000523:psychology / Q000592:standards; D010166:Palliative Care / Q000592:standards*; D011795:Surveys and Questionnaires; D014481:United States