Despite most patients with cancer preferring to die at home, about a third still die in the hospital, with about 10% being in the intensive care unit (ICU), causing more pain and anxiety to the patient and increasing the risk of post-traumatic stress disorder and prolonged grief disorder for family and caregivers, according to a new study published in BMC Cancer.
Not only do many patients die in the hospital, an estimated 30% of late-stage patients will be offered chemotherapy in the last few months of life, according to the study. This number is on the rise, as is emergency room visits, admission to the ICU, and hospitalizations. In addition, study authors also noted that clinicians often lack the knowledge of their patients wishes regarding hospital resuscitation.
The study, titled, “Breaking silence: a survey of barriers to goals of care discussions from the perspective of oncology practitioners” found that less than a third of patients with advanced cancer had a goals-of-care conversation with a member of their care team.
The study was conducted by sending a survey to 185 oncology clinicians, 30 staff oncologists, 10 oncology residents, and 28 oncology nurses. The survey used a 7-point Likert scale where respondents assessed barriers to goal-of-care discussions.
Researchers found that the patients and family are the biggest barrier to goals-of-care discussions. The study states, “these included: family member's difficult accepting a poor prognosis, lack of family agreement in the goals of care, difficulty understanding the limitations of life- sustaining treatments, lack of patients capacity to make goals of care decisions, and language barriers.” System and healthcare factors were perceived as less important.
“While GoC discussions improve the dying experience for patients, this study adds to the literature demonstrating that patients and family factors are the biggest barriers to effective GoC discussions as perceived by clinicians,” the study states.
Researchers found that care teams should make time over the course of the entire illness for goals-of-care discussions. Due to the denial and anxiety many patients may have regarding their illness, the discussions should be led by physicians and nurses who have strong communication skills and who have received training. The study also found that participants think social workers can also initiate goals of care discussions.
The study faced several limitations such as low response rate, small sample size, and that most respondents were residents and relatively young. However, the findings were similar to a larger study conducted on medical wards, according to the report.
“Other studies have found that oncology practitioners often lack communication skills training and have discomfort with difficult discussions that include mortality acknowledgement and the introduction of a palliative care approach to care,” the study states.
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