Strategies for effective goals of care discussions and decision-making: perspectives from a multi-centre survey of Canadian hospital-based healthcare providers

Abstract

BackgroundCommunication gaps impact the quality of patient care. Previous research has focused on communication barriers rather than seeking solutions. Our aim was to identify strategies for effective communication and decision-making about goals of care for medical interventions in serious illness, from the perspectives of hospital-based healthcare providers.MethodsA cross-sectional survey composed of closed- and open-ended questions about goals of care communication and decision-making was administered to healthcare providers in 13 centres in six Canadian provinces. We analyzed a portion of the open-ended survey questions, specifically (1) suggestions for overcoming barriers encountered in discussing goals of care, and (2) currently effective practices. Thematic content analysis was used to analyze responses to the open-ended questions.ResultsOf the 1,256 respondents to the larger survey, 468 responded to the open-ended questions (37 %), including 272 of 512 nurses (53 %), 153 of 484 internal medicine trainees (32 %), and 43 of 260 attending physicians (17 %). Responses to each of the two questions were similar, generating a common set of themes and subthemes. Effective strategies and ideas for improving communication and decision-making about goals of care clustered under five themes: patient and family factors, communication between healthcare providers and patients, interprofessional collaboration, education, and resources. Subthemes highlighted core elements of shared decision-making.ConclusionsTranslating our findings into multifaceted interventions that consider patient and family factors, address knowledge gaps, optimize resource utilization, and facilitate communication and collaboration between patients, families and healthcare providers may improve communication and decision-making about goals of care.Electronic supplementary materialThe online version of this article (doi:10.1186/s12904-015-0035-x) contains supplementary material, which is available to authorized users.

Advance Care Planning: Understanding Clinical Routines and Experiences of Interprofessional Team Members in Diverse Health Care Settings

“…We and others have described how ACP can be a care team responsibility, where interprofessional team members contribute to different aspects of ACP. 1,3,7,20 Similar to how management of hypertension involves several disciplines to assess, diagnose, treat, and monitor blood pressure, our findings suggest opportunities to review ACP clinical workflows and identify appropriate responsibilities for each team member to optimize patient engagement in ACP.…”

“…6 A recent study of Canadian inpatient physicians and nurses identified potential targets for improving clinical workflows related to communication and decision-making about goals of care, including patient/family factors, communication between health care providers and patients, interprofessional collaboration, education, and resources. 7 Taken together, these studies allude to widespread need for systematic clinical routines to facilitate ACP in clinical settings and that physicians may not be the most appropriate interprofessional team member to be responsible for all ACP-related activities given time constraints and workforce shortages.…”

“…The term interprofessional refers to providers from different disciplines who make up the greater care team, and interprofessional teams are common in the delivery of palliative care. Previous research surveys on ACP have focused on a single setting (eg, inpatient hospital or primary care), 6,7 a single group of health care providers (eg, only physicians or only palliative care providers), 5,8 specific diseases such as cancer or heart failure, 9 or were conducted outside the United States. 7,10 …”

Promoting Patient Preferences Through Nurse-prompted Elicitation of Daily Goals

“…The study described the patient and family perspective of confusion and disruption that can take place during goals of care discussions and highlighted the need for health care teams to communicate effectively with patients. Ordons et al (2015) conducted a thematic analysis of a survey composed of open and closed-ended questions administered to healthcare professionals in thirteen centers in Canada, to explore factors that impacted goals of care discussions. Major themes identified were 1) patient and family factors-advanced illness was a trigger to initiate goals of care (GOC) and identify decision makers 2) communication between health care provider and patient-identified timing, content, process and continuity of communication as mechanism to improve GOC discussions 3)…”

“…11,12,13 Investigations focused on interventions to improve goal elicitation and patient satisfaction regarding whiteboard usage and nurse-led initiatives provided the inspiration for this project. 18,19,20 Recording daily goals on a whiteboard facilitates a consistent plan of care, goal directed care, and provides health care providers with a daily list of patient goals to review.…”