Table 2 Currently effective practices and ideas to improve communication and decision-making about goals of care*

Patient and family involvement factors

Advanced illness as a trigger for EOL discussions

Evidence of advanced illness (Resident)

Patient decisional capacity, substitute decision-making, family spokesperson

Knowing who substitute decision makers are when applicable (Nurse)

Clearly identify who is the substitute decision maker on the first day (Resident)

Care provided at EOL – family involvement in care provision, remaining in community location

Re-establishing the importance of care provided in nursing homes therefore no admit/return [to hospital] (Nurse)

Involve the family in patient care… they’re part of the team (Nurse)

Patient-family-healthcare provider (HCP) communication

Timing of communication – pre-hospital, early initiation, prior to deterioration, in stages, allowing time, expectations, reassessment, checkpoint prior to discharge

End of life care discussions need to take place sooner… too often these discussions take place at onset or during an episode or code blue (Nurse)

… in a non-rushed manner so goals/decisions can be discussed and explored adequately (Resident)

Build a GOC discussion into the daily work flow of the medical teaching unit, for example, expected by day three (Physician)

Continuity of communication between patients, families and healthcare providers, continuity of care provided by physicians (community, hospital), nursing, social workers, occupational therapists, physiotherapists

Having one physician designated for communication with a family member representative (Nurse)

Patient’s general practitioner and primary care Respirologist to come see as in-patient (Resident)

Process of communication – meetings, all stakeholders, initiator, willingness, set time, enough time, clear language, agenda, normalized, rapport, empathy, honesty, respectful, realistic, tailored, frequent updates, reassessment, consistent message, check understanding, agreement

Family meetings I find really help discussions and plans… multidisciplinary opinions, gives the family a bigger picture (Nurse)

Content of communication – medical facts, diagnosis, prognosis, options, perspectives, experiences, quality of life, functional capacity, beliefs, goals, values, preferences, expectations, emotions, recommendation, contact information

An open and honest approach with two-way dialogue (Physician)

Developing a rapport/relationship with family in order to gauge how much they understand about prognosis and then understanding what they think the medical care can provide (Resident)

Improved functional history on admission to assist with prognostic assessment & realistic risk/benefit assessment of interventions (Resident)

Interprofessional collaboration

Approach to interprofessional communication – respect, support, dialogue, meetings, bullet rounds, pre-briefing in advance of family meetings, whiteboard, common goals, primary care team involvement

Rounds among the staff have also been helpful in communicating the plan of care among physicians, nurses, and allied staff (Nurse)

Multidisciplinary meetings to establish a common understanding of prognosis and direction of patient care (Resident)

The teamcare model helps to ensure all team members are on the same page and can support each other through these conversations (Nurse)

Role clarity – clarify healthcare provider responsible for GOC discussions, expand nursing role, coordinate health care service delivery

Clear information as to whose responsibility it is to discuss GOC (Nurse)

Expanding the scope of nurses in hospital to discuss life sustaining therapies (Nurse)

Documenting GOC, substitute decision maker, family, name and designation of MD who discussed – clear documentation, standardized forms, in standardized location, include GOC designation on daily patient list

Clearly written [GOC] documentation (standardized) to avoid misinterpretation. (Nurse)

Clear documentation in the chart about the plan, what the patient has been informed of with respect to their plan of care and current status (Nurse)

Education

Societal/public awareness of advance care planning, GOC, life-sustaining therapy, financial cost of healthcare – national dialogue, education, patient stories

Information sessions for the general public to help change the discourse surrounding death and dying (Physician)

A national dialogue needs to be started with public at large to get people talking about advance directives and sharing that info with loved ones so families are not left feeling they have all the guilt & responsibility… (Nurse)

Patient-family education about initiating GOC discussions

Distribute a booklet of information to patients/families to educate them prior to a GOC discussion (Physician)

GOC, life-sustaining therapy, financial cost, ICU outcomes – pamphlets, videos, online resources

I think that education for patients and families regarding the realities of life sustaining therapies is required (Resident)

Healthcare provider education about GOC, palliative care, EOL care, conflict, culture, prognostication – physician leadership, interprofessional learning, resident teaching and role modeling through undergraduate and postgraduate medical education and continuing medical education courses

Resident education and PGY-1 [teaching sessions] on communication have been very helpful (Resident)

Training for physicians or other healthcare providers to help counsel patients and families better (Physician)

Resources

Healthcare personnel – increase healthcare provider to patient ratios, physician availability, increase attending physician involvement, unit champions, nurse liaisons

Physician availability to speak with family members (Nurse)

Have unit champions who are versed in end of life care and can act as a resource for their team (Nurse)

Consultant involvement – Palliative care, Oncology, Geriatrics, Psychology, Social Work, Spiritual Care, Occupational Therapy, Physiotherapy, Nurse Practitioners, Ethics, cultural expert

Ensure appropriate support staff consulted as early as possible (e.g.: palliative care, social work) (Nurse)

The social workers can be quite helpful in facilitating family meetings to talk about goals of care (Resident)

Physical space – quiet locations with privacy

Having 'family rooms' on units where discussions can be held (Resident)

Need to have private rooms to discuss goals of care with patients and families (Resident)

Access to documents – advance directives, specialist clinic notes, patient to carry documentation

Lack of information about prognosis would be improved by having proper access to specialists’ notes (Resident)

Written advance directive travel with patient to hospital (Resident)

Translators – availability, training in GOC discussions, available 24 h, mobile phones

Utilizing translation services (rather than family members) (Nurse)

Interpreters who are well versed and familiar with these conversations need to be available at all times (Resident)

Organizational support – patient-centred philosophy, organizational policies for GOC discussions, policy to address GOC discussions at admission, institutional culture of GOC discussions, advance care planning/GOC guideline development, remuneration, help with conflict resolution

A patient-centred facility give[s] patients and their families encouragement to be more active in their own care, which helps health care providers speak more regarding goals (Nurse)

It is part of the culture to address this with nearly every admitted patient (Resident)