title: Barriers to goals of care discussions with seriously ill hospitalized patients and their families: a multicenter survey of clinicians.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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
  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.
authors: Department of Medicine, McMaster University, Hamilton, Ontario, Canada2Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
authors: John J
authors: JJ
authors: You
authors: Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada4Division of Palliative Care, University of Toronto, Toronto, Ontario, Canada.
authors: James
authors: J
authors: Downar
authors: 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.
authors: Robert A
authors: RA
authors: Fowler
authors: Centre de Recherche Clinique Hôpital Universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, Québec, Canada.
authors: François
authors: F
authors: Lamontagne
authors: Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
authors: Irene W Y
authors: IW
authors: Ma
authors: Department of Internal Medicine, McGill University, Montreal, Québec, Canada.
authors: Dev
authors: D
authors: Jayaraman
authors: College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
authors: Jennifer
authors: J
authors: Kryworuchko
authors: School of Nursing, McMaster University, Hamilton, Ontario, Canada.
authors: Patricia H
authors: PH
authors: Strachan
authors: Department of Medicine, Queen's University, Kingston, Ontario, Canada13Critical Care Program, Queen's University, Kingston, Ontario, Canada.
authors: Roy
authors: R
authors: Ilan
authors: Division of General Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
authors: Aman P
authors: AP
authors: Nijjar
authors: Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
authors: John
authors: J
authors: Neary
authors: Faculty of Medicine, Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada.
authors: John
authors: J
authors: Shik
authors: School of Nursing and Midwifery, Queen's University Belfast, Belfast, Northern Ireland, United Kingdom.
authors: Kevin
authors: K
authors: Brazil
authors: Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
authors: Amen
authors: A
authors: Patel
authors: Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
authors: Kim
authors: K
authors: Wiebe
authors: Centre de Recherche de l'Hôpital du Sacré-Coeur de Montréal, Département de Médecine, Université de Montréal, Montréal, Québec, Canada.
authors: Martin
authors: M
authors: Albert
authors: Division of General Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
authors: Anita
authors: A
authors: Palepu
authors: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
authors: Elysée
authors: E
authors: Nouvet
authors: Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada.
authors: Amanda Roze
authors: AR
authors: des Ordons
authors: Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
authors: Nishan
authors: N
authors: Sharma
authors: Division of Palliative Medicine, University of Calgary, Calgary, Alberta, Canada.
authors: Amane
authors: A
authors: Abdul-Razzak
authors: Clinical Evaluation Research Unit, Department of Medicine, Kingston General Hospital, Kingston, Ontario, Canada.
authors: Xuran
authors: X
authors: Jiang
authors: Clinical Evaluation Research Unit, Department of Medicine, Kingston General Hospital, Kingston, Ontario, Canada.
authors: Andrew
authors: A
authors: Day
authors: Clinical Evaluation Research Unit, Department of Medicine, Kingston General Hospital, Kingston, Ontario, Canada22Department of Community Health and Epidemiology, Queen's University, Kingston, Ontario, Canada.
authors: Daren K
authors: DK
authors: Heyland
mesh_terms: D000328:Adult; D000368:Aged; D002170:Canada; D003144:Communication Barriers; D032882:Comprehension; D003657:Decision Making; D005190:Family / Q000523:psychology; D005260:Female; D006801:Humans; D033183:Interdisciplinary Communication; D007388:Internal Medicine / Q000193:education; D007396:Internship and Residency / Q000706:statistics & numerical data; D008297:Male; D008505:Medical Staff, Hospital / Q000706:statistics & numerical data; D016743:Mental Competency; D008875:Middle Aged; D009726:Nurses / Q000706:statistics & numerical data; D010166:Palliative Care; D010347:Patient Care Planning / Q000592:standards / Q000639:trends; D057566:Self Report; D013727:Terminal Care / Q000379:methods / Q000592:standards / Q000639:trends