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.
Highlights
Cancer 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 surveyed oncology clinicians according to the following inclusion criteria: 1) staff oncologists providing care to cancer inpatients, 2) residents enrolled as a subspecialty trainee in the hematology, radiation, and medical oncology programs at McMaster University, and 3) nurses employed full time, or part time, on the oncology wards
Perceptions of inter-professional roles in communication and decision making about goals of care Physicians and nurses together expressed a willingness to engage in GoC discussions, including initiating discussions with patients and family, exchanging important information such as diagnosis and prognosis, acting as a decision coach, and making a final decision together with the patient (Additional file 2)
Summary
Cancer is the leading cause of death in the developed world, and yet healthcare practitioners infrequently discuss goals of care (GoC) with hospitalized cancer patients. Cancer is a leading cause of mortality in the developed world [1]. Most terminally-ill cancer patients prefer to die at home [2]. An estimated 30 % of patients offered chemotherapy are in the last months of life, and this percentage is increasing each year, as are emergency room (ER) visits, hospitalizations, and admissions to the ICU [4,5,6,7,8]. Unwanted aggressive care at the end of life (EOL) is associated with increased healthcare costs, worse quality of life, and a worse death [10]
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