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Perceived barriers and facilitators to goals of care discussions in the emergency department: A descriptive analysis of the views of emergency medicine physicians and residents

  • Niran Argintaru (a1), Kieran L. Quinn (a2), Lucas B. Chartier (a3), Jacques Lee (a4), Paul Hannam (a5), Erin O’Connor (a3), Leah Steinberg (a6), Howard Ovens (a7), Melissa McGowan (a8) and Samuel Vaillancourt (a8)...

Abstract

Objective

Few studies have examined the challenges faced by emergency medicine (EM) physicians in conducting goals of care discussions. This study is the first to describe the perceived barriers and facilitators to these discussions as reported by Canadian EM physicians and residents.

Methods

A team of EM, palliative care, and internal medicine physicians developed a survey comprising multiple choice, Likert-scale and open-ended questions to explore four domains of goals-of-care discussions: training; communication; environment; and patient beliefs.

Results

Surveys were sent to 273 EM staff and residents in six sites, and 130 (48%) responded. Staff physicians conducted goals-of-care discussions several times per month or more, 74.1% (80/108) of the time versus 35% (8/23) of residents. Most agreed that goals-of-care discussions are within their scope of practice (92%), they felt comfortable having these discussions (96%), and they are adequately trained (73%). However, 66% reported difficulty initiating goals-of-care discussions, and 54% believed that admitting services should conduct them. Main barriers were time (46%), lack of a relationship with the patient (25%), patient expectations (23%), no prior discussions (21%), and the inability to reach substitute decision-makers (17%). Fifty-four percent of respondents indicated that the availability of 24-hour palliative care consults would facilitate discussions in the emergency department (ED).

Conclusions

Important barriers to discussing goals of care in the ED were identified by respondents, including acuity and lack of prior relationship, highlighting the need for system and environmental interventions, including improved availability of palliative care services in the ED.

Objectif

Peu d’études portent sur les difficultés que rencontrent les urgentologues dans les discussions sur les objectifs de soins. Il sera donc question dans le présent article, et ce pour la première fois, de facteurs favorables et défavorables à la tenue de ces discussions, tels qu’ils sont perçus par les médecins et les résidents en médecine d’urgence (MU) au Canada.

Méthode

Une équipe composée d’urgentologues, de médecins en soins palliatifs et d’internistes a élaboré un questionnaire d’enquête comprenant différents types de questions : à choix multiple, à échelle de Likert ou encore à réponse libre, et portant sur quatre champs relatifs aux discussions sur les objectifs de soins : la formation, les communications, l’environnement et les croyances des patients.

Résultats

Le questionnaire a été envoyé à 273 membres du personnel et résidents en MU dans 6 services et, sur ce nombre, 130 (48 %) ont participé à l’enquête. Les membres du personnel médical ont indiqué tenir des discussions sur les objectifs de soins plusieurs fois par mois ou plus de 74,1 % (80/108) du temps contre 35 % (8/23) des résidents. La plupart des répondants étaient d’accord sur le fait que les discussions sur les objectifs de soins relevaient de leur champ de pratique (92 %), qu’ils se sentaient à l’aise avec ces discussions (96 %) et qu’ils étaient bien formés à cet effet (73 %). Toutefois, 66 % d’entre eux ont indiqué avoir de la difficulté à amorcer les discussions sur les objectifs de soins et 54 % étaient d’avis que celles-ci devraient se tenir dans les services d’admission. Les principaux facteurs défavorables à la tenue de ces discussions étaient le manque de temps (46 %), le manque de relations avec les patients (25 %), les désirs des patients (23 %), l’absence de discussions antérieures (21 %) et la difficulté de joindre les mandataires (17 %). Enfin, 54 % des répondants ont indiqué que la tenue possible de consultations en soins palliatifs, 24 h sur 24, faciliterait les discussions au service des urgences (SU).

Conclusions

D’après les répondants, il existe des facteurs défavorables importants à la tenue de discussions sur les objectifs de soins au SU, notamment le degré de gravité des maladies et l’absence de relations antérieures, d’où la nécessité d’élaborer des interventions touchant au système et à l’environnement, dont une disponibilité accrue des services de soins palliatifs au SU.

Copyright

Corresponding author

Correspondence to: Samuel Vaillancourt, St. Michael’s Hospital, 30 Bond St., Toronto, ON M5B 1W8; Email: sam.vaillancourt@utoronto.ca

References

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1.Lamba, S, Mosenthal, AC. Hospice and palliative medicine: a novel subspecialty of emergency medicine. J Emerg Med 2012;43(5):849-853.10.1016/j.jemermed.2010.04.010
2.Lamba, S. Early goal-directed palliative therapy in the emergency department: a step to move palliative care upstream. J Palliat Med 2009;12(9):767.10.1089/jpm.2009.0111
3.Smith, AK, McCarthy, E, Weber, E, et al. Half of older Americans seen in emergency department in last month of life; most admitted to hospital, and many die there. Health Aff (Millwood) 2012;31(6):1277-1285.10.1377/hlthaff.2011.0922
4.Kraus, CK, Greenberg, MR, Ray, DE, Dy, SM. Palliative care education in emergency medicine residency training: a survey of program directors, associate program directors, and assistant program directors. J Pain Symptom Manage 2016;51(5):898-906.10.1016/j.jpainsymman.2015.12.334
5.Grudzen, CR, Richardson, LD, Johnson, PN, et al. Emergency department-initiated palliative care in advanced cancer: a randomized clinical trial. JAMA Oncol 2016;2(5):591-598.10.1001/jamaoncol.2015.5252
6.Ouchi, K, Wu, M, Medairos, R, et al. Initiating palliative care consults for advanced dementia patients in the emergency department. J Palliat Med 2014;17(3):346-350.10.1089/jpm.2013.0285
7.Grudzen, CR, Stone, SC, Morrison, RS. The palliative care model for emergency department patients with advanced illness. J Palliat Med 2011;14(8):945-950.10.1089/jpm.2011.0011
8.Quest, T, Herr, S, Lamba, S, Weissman, D. IPAL-EM Advisory Board. Demonstrations of clinical initiatives to improve palliative care in the emergency department: a report from the IPAL-EM Initiative. Ann Emerg Med 2013;61(6):661-667.10.1016/j.annemergmed.2013.01.019
9.Sinuff, T, Dodek, P, You, JJ, et al. Improving end-of-life communication and decision making: the development of a conceptual framework and quality indicators. J Pain Symptom Manage 2015;49(6):1070-1080.10.1016/j.jpainsymman.2014.12.007
10.Fowler, R, Hammer, M. End-of-life care in Canada. Clin Invest Med 2013;36(3):E127-E132.10.25011/cim.v36i3.19723
11.You, JJ, Downar, J, Fowler, RA, et al. Barriers to goals of care discussions with seriously ill hospitalized patients and their families: a multicenter survey of clinicians. JAMA Intern Med 2015;175(4):549-556.10.1001/jamainternmed.2014.7732
12.You, JJ, Fowler, RA, Heyland, DK. Canadian Researchers at the End of Life Network (CARENET). Just ask: discussing goals of care with patients in hospital with serious illness. CMAJ 2014;186(6):425-432.10.1503/cmaj.121274
13.You, JJ, Dodek, P, Lamontagne, F, et al. What really matters in end-of-life discussions? Perspectives of patients in hospital with serious illness and their families. CMAJ 2014;186(18):E679-E687.10.1503/cmaj.140673
14.Heyland, DK, Ilan, R, Jiang, X, et al. The prevalence of medical error related to end-of-life communication in Canadian hospitals: results of a multicentre observational study. BMJ Qual Saf 2016;25(9):671-679.10.1136/bmjqs-2015-004567
15.Chiarchiaro, J, Arnold, RM, White, DB. Reengineering advance care planning to create scalable, patient- and family-centered interventions. JAMA 2015;313(11):1103-1104.10.1001/jama.2015.0569
16.Sudore, RL, Fried, TR. Redefining the “planning” in advance care planning: preparing for end-of-life decision making. Ann Intern Med 2010;153(4):256-261.10.7326/0003-4819-153-4-201008170-00008
17.You, JJ, Aleksova, N, Ducharme, A, et al. Barriers to goals of care discussions with patients who have advanced heart failure: results of a multi-centre survey of hospital-based cardiology clinicians. J Card Fail 2017;23(11):786-793.10.1016/j.cardfail.2017.06.003
18.Martin, RS, Hayes, B, Gregorevic, K, Lim, WK. The effects of advance care planning interventions on nursing home residents: a systematic review. J Am Med Dir Assoc 2016;17(4):284-293.10.1016/j.jamda.2015.12.017
19.Sutradhar, R, Barbera, L, Seow, H-Y. Palliative homecare is associated with reduced high- and low-acuity emergency department visits at the end of life: a population-based cohort study of cancer decedents. Palliat Med 2016;31(5):448-455.10.1177/0269216316663508
20.Seow, H, Barbera, L, Pataky, R, et al. Does increasing home care nursing reduce emergency department visits at the end of life? A population-based cohort study of cancer decedents. J Pain Symptom Manage 2016;51(2):204-212.10.1016/j.jpainsymman.2015.10.008
21.Lamba, S, Nagurka, R, Zielinski, A, Scott, SR. Palliative care provision in the emergency department: barriers reported by emergency physicians. J Palliat Med 2013;16(2):143-147.10.1089/jpm.2012.0402
22.Platts-Mills, TF, Richmond, NL, LeFebvre, EM, et al. Availability of advance care planning documentation for older emergency department patients: a cross-sectional study. J Palliat Med 2017;20(1):74-78.10.1089/jpm.2016.0243
23.Lakin, JR, Isaacs, E, Sullivan, E, et al. Emergency physicians’ experience with advance care planning documentation in the electronic medical record: useful, needed, and elusive. J Palliat Med 2016;19(6):632-638.10.1089/jpm.2015.0486
24.Fassier, T, Valour, E, Colin, C, Danet, F. Who am i to decide whether this person is to die today? Physicians’ life-or-death decisions for elderly critically ill patients at the emergency department-ICU interface: a qualitative study. Ann Emerg Med 2016;68(1):28-39.e3.10.1016/j.annemergmed.2015.09.030
25.Burns, KEA, Duffett, M, Kho, ME, et al. A guide for the design and conduct of self-administered surveys of clinicians. CMAJ 2008;179(3):245-252.10.1503/cmaj.080372
26.O’Cathain, A, Thomas, KJ. Any other comments?” Open questions on questionnaires – a bane or a bonus to research? BMC Med Res Methodol 2004;4(1):1-7.
27.Platts-Mills, TF, Richmond, NL, LeFebvre, EM, et al. Availability of advance care planning documentation for older emergency department patients: a cross-sectional study. J Palliat Med 2017;20(1):74-78.10.1089/jpm.2016.0243
28.Rolnick, JA, Asch, DA, Halpern, SD. Delegalizing advance directives – facilitating advance care planning. N Engl J Med 2017;376(22):2105-2107.10.1056/NEJMp1700502
29.Smith, AK, Fisher, J, Schonberg, MA, et al. Am I doing the right thing? Provider perspectives on improving palliative care in the emergency department. Ann Emerg Med 2009;54(1):86-93-93.e1.
30.Stone, SC, Mohanty, S, Grudzen, CR, et al. Emergency medicine physicians’ perspectives of providing palliative care in an emergency department. J Palliat Med 2011;14(12):1333-1338.10.1089/jpm.2011.0106
31.Quinn, KL, Detsky, AS, Smith, AK, et al. Stop that train! I want to get off: emergency care for patients with advanced dementia. Can J Gen Intern Med 2017;12(1):14-16.

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