B. V. Udelsman1, K. Lee2,4, L. Traeger3, K. Lillemoe1, D. Chang1, Z. Cooper2 1Massachusetts General Hospital,Surgery,Boston, MA, USA 2Brigham And Women’s Hospital,Surgery,Boston, MA, USA 3Massachusetts General Hospital,Cancer Center And The Behavioral Medicine Service,Boston, MA, USA 4University of California San Diego,Department Of Surgery,San Diego, CA, USA
Introduction: Little is known about the process by which inpatient teams document and convey goals of care (GOC) for critically ill surgical patients. We sought to explore clinician perspectives on the barriers and facilitators to clinical team communication and delivery of goal-concordant patient care.
Methods: Purposive and snowball sampling were used to recruit a multi-disciplinary sample of clinicians who had roles in a surgical intensive care unit at a single tertiary care facility. Semi-structured interviews with clinicians regarding communicating and honoring patient GOC were conducted between October and December 2017. Two study team members independently coded the interview transcripts in an iterative fashion based on a framework approach. Inter-rater agreement measured by kappa, and was acceptably high at 0.91.
Results: Thirty-three clinicians were interviewed: eight surgeons, eight nurses, seven anesthesiologists/intensivists, five mid-level providers, three residents, and two social workers. Of the surgeons, four completed fellowship in trauma/acute care, two in surgical oncology, one in vascular surgery, and one in cardiothoracic surgery. Analysis revealed that all clinicians feel responsible for honoring patient GOC. The process of GOC communication among inpatient teams occurs in three distinct phases. (1) A discussion takes place between clinicians and the patient or their surrogates; (2) clinicians document that conversation within the electronic health record; (3) inpatient teams read GOC documentation in order to inform treatment and provide goal concordant care. Within these phases of GOC communication, six themes emerged that described both facilitators and barriers to the communication of GOC among clinicians and delivery of goal concordant care (Table 1). Conflicts over patient GOC arose between clinicians who had longitudinal relationships with patients (pre-operative and post-operative) versus those who had single-phase relationships (post-operative). Barriers to clinician-to-clinician communication and delivery of goal-concordant care included inaccessible records, lack of protocols, and difficulty in documenting complex conversations. Facilitators included family members in active agreement with patient GOC and a clinician understanding of unique patient priorities.
Conclusion: Differences in the longitudinal clinician-patient relationship and difficulty accessing information about patient preferences contribute to clinician conflicts and concerns with the appropriateness of patient care. These themes exist over multiple phases of patient care and represent areas of focus for quality improvement.
