Barriers to end-of-life care discussions identified

The study, published in the Journal of the American Medical Association (JAMA) Internal Medicine, found that hospital-based clinicians perceive factors related to patients and their family members as the most important obstacles to having talks about the goals of the health care being provided. Those elements include:

• Family members' or the patient's difficulty accepting a poor prognosis

• Family members' or the patient's difficulty understanding the limitations and complications of life-sustaining treatments

• Disagreement among family members about the goals of care

• Patients' incapacity to make decisions on the goals of care

The findings are from a Canadian multi-site survey of more than 1,200 hospital-based clinicians about barriers to end-of-life discussions with hospitalized patients with serious illness and their family members. The study was funded by the Canadian Institutes for Health Research.

Goals of care discussions centre on making more concrete decisions about one's care plans in hospital, including decisions about use or non-use of life-sustaining treatments during an episode of serious illness.

"The fact that clinicians perceive patient and family member factors as key barriers to end-of-life discussions probably reflects understandably high levels of anxiety or even denial about confronting death that is experienced by hospitalized patients and their families," said Dr. John You, lead author of the study and an associate professor of medicine and clinical epidemiology and biostatistics with McMaster's Michael G. DeGroote School of Medicine.

"There are two issues here: We need to normalize conversations about death and dying so that people can be more comfortable having advance care planning discussions within families before there's a crisis. And, clinicians need to be highly skilled and sensitive communicators, with better training and tools like conversation guides to enable and support these conversations."

The study's authors conclude: "Our study helps to prioritize next steps for future work aimed at improving goals of care discussions with seriously ill hospitalized patients and their families.

"Promising interventions include more and better communication skills training for clinicians, conversation guides for discussion of prognosis, decision aids to support advance care planning, and greater involvement of the interprofessional health care team in this important process of care."

You and colleagues from the Canadian Researchers at End-of-Life Network (CARENET) are now embarking on work to develop these kinds of interventions.