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

Background Communication 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. Methods A 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. Results Of 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. Conclusions Translating 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 material The online version of this article (doi:10.1186/s12904-015-0035-x) contains supplementary material, which is available to authorized users.


Goals of Care
We define communication and decision-making about goals of care as a conversation in which, ideally, a patient or family member and the healthcare team establish the goals of treatment (e.g., cure, prolongation of life, comfort) and agree upon the types of life sustaining technology that will (or will not) be used to achieve those goals (e.g., CPR, mechanical ventilation, dialysis, intensive care unit admission, feeding tubes, or intravenous hydration).
In this questionnaire, we are interested in your perspective about: (1) The importance of various barriers to communication and decision-making about goals of care with seriously ill hospitalized patients and their families (2) Your suggestions to improve communication and decision-making about goals of care with these patients and their families (3) Your perceived role and the role that others may play in communication and decisionmaking about goals of care with these patients and their families  This questionnaire will take approximately 15 minutes to complete.
 Please select the single best response to each question unless otherwise requested.
 All responses will remain confidential. Barriers Related to the Patient/Family 1. Reflecting on your most recent month on an acute medical ward, for patients such as the one described in the above scenario, please rate the importance of the following barriers in preventing you from talking to them and/or their family members about the patient's goals of care. As you rate the importance of each barrier, consider both the magnitude of the barrier and its frequency and circle the best response from 1 = Extremely Unimportant Barrier to 7 = Extremely Important Barrier. b) Patient has an advance directive but it lacks sufficient detail Barriers Related to the Role of Physicians 2. Reflecting on your most recent month on an acute medical ward, for patients such as the one described in the above scenario, please rate the importance of the following barriers in preventing you from talking to them and/or their family members about the patient's goals of care. As you rate the importance of each barrier, consider both the magnitude of the barrier and its frequency. Barriers Related to the System or External factors 3. Reflecting on your most recent month on an acute medical ward, for patients such as the one described in the above scenario, please rate the importance of the following barriers in preventing you from talking to them and/or their family members about the patient's goals of care. As you rate the importance of each barrier, consider both the magnitude of the barrier and its frequency. c) Uncertainty about who is the substitute decision maker Other Barriers 4. Reflecting on your most recent month on an acute medical ward, for patients such as the one described in the above scenario, please describe any other barriers in preventing you from talking to them and/or their family members about the patient's goals of care and rate their importance. As you rate the importance of each barrier, consider both the magnitude of the barrier and its frequency.

Section 3 Health Care Providers' Role in Communication and Decision-Making about Goals of Care
Please consider the same scenario as in Section 1: A 70 year old patient who has severe COPD (on home oxygen), is housebound, and requires assistance for most activities of daily living, is admitted to the medical ward under your care with an exacerbation of their COPD. The patient's acute symptoms have resolved. You are uncertain about the patient's goals of care and preferences regarding the use (or non-use) of life sustaining technology.
Consider that the process of communication and decision making can be broken down into the following steps: initiating the conversation, exchanging information, coaching, and deciding. 2. Rate your willingness to exchange information (e.g., disclose diagnosis, prognosis and elicit values) with patients such as these, and their families, who are trying to reach a decision about goals of care. 3. Rate your willingness to be a decision coach (clarifying values, assisting with weighing options for care, etc.) for patients such as these, and their families, who are trying to reach a decision about goals of care.