Breaking silence: a survey of barriers to goals of care discussions from the perspective of oncology practitioners

Abstract

BackgroundCancer is the leading cause of death in the developed world, and yet healthcare practitioners infrequently discuss goals of care (GoC) with hospitalized cancer patients. We sought to identify barriers to GoC discussions from the perspectives of staff oncologists, oncology residents, and oncology nurses.MethodsThis was a single center survey of staff oncologists, oncology residents, and inpatient oncology nurses. Barriers to GoC discussions were assessed on a 7-point Likert scale (1 = extremely unimportant; 7 = extremely important).ResultsBetween July 2013 and May 2014, of 185 eligible oncology clinicians, 30 staff oncologists, 10 oncology residents, and 28 oncology nurses returned surveys (response rate of 37%). The most important barriers to GoC discussions were patient and family factors. They included family members’ difficulty accepting poor prognoses (mean score 5.9, 95% CI [5.7, 6.2]), lack of family agreement in the goals of care (mean score 5.8, 95% CI [5.5, 6.1]), difficulty understanding the limitations of life-sustaining treatments (mean score 5.8, 95% CI [5.6, 6.1]), lack of patients’ capacity to make goals of care decisions (mean score 5.7, 95% CI [5.5, 6.0]), and language barriers (mean score 5.7, 95% CI [5.4, 5.9]). Participants viewed system factors and healthcare provider factors as less important barriers.ConclusionsOncology practitioners perceive patient and family factors as the most limiting barriers to GoC discussions. Our findings underscore the need for oncology clinicians to be equipped with strong communication skills to help patients and families navigate GoC discussions.Electronic supplementary materialThe online version of this article (10.1186/s12885-019-5333-x) contains supplementary material, which is available to authorized users.

Prognosticating for Adult Patients With Advanced Incurable Cancer: a Needed Oncologist Skill

“…There are also a number of organisational factors that could contribute to better communication of prognosis. These include allowing sufficient time to discuss prognosis, allowing patients to ask questions [96], better integration of oncology with palliative care [97], and support for clinicians through encouragement of reflective practice [98].…”

Barrieren für Gespräche über Tod und Sterben in der Medizin

“…Es fällt ihnen zudem schwer, die Bereitschaft ihrer Patienten für solche Gespräche einzuschätzen, und sie sorgen sich, ihnen mit diesen Gesprächen zu schaden und ihnen Hoffnung zu nehmen [18,21,22]. In aktuellen Befragungen sahen Ärzte die entscheidenden Hindernisse für Diskussion von Therapiezielen in Barrieren ihrer schwer kranken Patienten und deren Angehöriger, insbesondere in der fehlenden Akzeptanz einer schlechten Prognose [23,24].…”

Advance Care Planning in Healthcare Systems: A Literature Review and Call to Action

“…Instead the perceived patients and their families did not accept their own poor prognosis. [43,44] Providers also describe inherent difficult in discussing ACP and advance directives with patients pursuing curative therapies, research describes this phenomenon in patients awaiting both solid organ and bone marrow transplants. [45,46] The description of ACP barriers described by clinicians has recurring themes of poor understanding of prognosis, ignorance of the limitations of life-sustaining therapies, and lack of capacity to understand goals of care conversations on the part of patients, families, and caregivers.…”

“…[45,46] The description of ACP barriers described by clinicians has recurring themes of poor understanding of prognosis, ignorance of the limitations of life-sustaining therapies, and lack of capacity to understand goals of care conversations on the part of patients, families, and caregivers. [43,44,47] Ironically, this is not likely the result of poor understanding by patients and their families regarding the role of ACP and use of advance directives. This is the result of initiating ACP too late in course of a chronic and eventual terminal illness.…”