A Multicenter Study to Identify Clinician Barriers to Participating in Goals of Care Discussions in Long-Term Care.

Long-term care (LTC) is an important setting for goals of care (GoC) discussions. Understanding clinician barriers to GoC discussions could identify opportunities for LTC-specific interventions to improve quantity and quality of GoC discussions in the context of serious illness. A multicenter, cross-sectional survey study. 1184 LTC clinicians from 34 Ontario LTC homes were invited to participate. The questionnaire assessed (1) clinician barriers related to the LTC resident power of attorney (POA), the health care provider, and the health care system; (2) willingness to engage in GoC discussions; and (3) suggestions to address identified barriers. Responses were rated on a 7-point scale (1 = extremely unimportant/unwilling, 7 = extremely important/willing). A linear mixed-effects model determined significance between mean importance ratings for each barrier and the willingness to engage in GoC discussion between physicians and nurses. A simple content analysis was performed on written suggestions to address GoC discussion barriers. The overall response rate was 49% (581/1184). The top 3 rated barriers were (1) POA's difficulty accepting their loved one's poor prognosis, (2) POA's difficulty understanding the limitations and complications of life-sustaining therapies, and (3) lack of adequate documentation of prior discussions with LTC resident or POA. Barriers related to the health care provider, and the health care system, were deemed statistically more important by nurses. LTC physicians were more willing to exchange information, be a decision coach, and participate in the final decision than nurses. Suggestions to improve GoC discussions include a dedicated team to have these conversations in LTC, and updating policies to mandate and standardize these conversations at all family meetings. This study has identified key LTC clinician-identified barriers to GoC discussions. Developing targeted interventions to these barriers could be the foundation for developing new interventions that support high-quality GoC discussions.

Siu HYH ，Elston D ，Arora N ，Vahrmeyer A ，Kaasalainen S ，Chidwick P ，Howard M ，Heyland DK ... -  《-》

Perceived Barriers to Goals of Care Discussions With Patients With Advanced Cancer and Their Families in the Ambulatory Setting: A Multicenter Survey of Oncologists.

Ethier JL ，Paramsothy T ，You JJ ，Fowler R ，Gandhi S ... -  《-》

Barriers to goals of care discussions with seriously ill hospitalized patients and their families: a multicenter survey of clinicians.

You JJ ，Downar J ，Fowler RA ，Lamontagne F ，Ma IW ，Jayaraman D ，Kryworuchko J ，Strachan PH ，Ilan R ，Nijjar AP ，Neary J ，Shik J ，Brazil K ，Patel A ，Wiebe K ，Albert M ，Palepu A ，Nouvet E ，des Ordons AR ，Sharma N ，Abdul-Razzak A ，Jiang X ，Day A ，Heyland DK ，Canadian Researchers at the End of Life Network ... -  《-》

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

Piggott KL ，Patel A ，Wong A ，Martin L ，Patel A ，Patel M ，Liu Y ，Dhesy-Thind S ，You JJ ... -  《BMC CANCER》

Goals of care discussions among hospitalized long-term care residents: Predictors and associated outcomes of care.

There are limited data on the occurrence, predictors, and impact of goals of care (GOC) discussions during hospitalization for seriously ill elderly patients, particularly for long-term care (LTC) residents. The study was a retrospective chart review of 200 randomly sampled LTC residents hospitalized via the emergency department and admitted to the general internal medicine service of 2 Canadian academic hospitals, from January 2012 through December 2012. We applied logistic regression models to identify factors associated with, and outcomes of, these discussions. Overall, 9.4% (665 of 7084) of hospitalizations were patients from LTC. In the sample of 200 patients, 37.5% had a documented discussion. No baseline patient characteristic was associated with GOC discussions. Low Glasgow Coma Scale, high respiratory rate, and low oxygen saturation were associated with discussions. Patients with discussions had higher rates of orders for no resuscitation (80% vs 55%) and orders for comfort measures only (7% vs 0%). In adjusted analyses, patients with discussions had higher odds of in-hospital death (52.0, 95% confidence interval [CI]: 6.2-440.4) and 1-year mortality (4.1, 95% CI: 1.7-9.6). Nearly 75% of patients with a change in their GOC did not have this documented in the discharge summary. In hospitalized LTC patients, GOC discussions occurred infrequently and appeared to be triggered by illness severity. Orders for advance directives, in-hospital death, and 1-year mortality were associated with discussions. Rates of GOC documentation in the discharge summary were poor. This study provides direction for developing education and practice standards to improve GOC discussion rates and their communication back to LTC. Journal of Hospital Medicine 2015;11:824-831. © 2015 Society of Hospital Medicine.

Wong HJ ，Wang J ，Grinman M ，Wu RC ... -  《-》