Abstract
Context: Hospitalized patients with advanced cancer often face complex, preference-sensitive decisions. How clinicians and patients engage in shared decision-making during goals-of-care discussions is not well understood. Objective: The objective of this study was to explore decision-making by patients and clinicians during inpatient goals-of-care discussions. Methods: This is a qualitative study of audio-recorded goals-of-care discussions between hospitalized patients with advanced cancer and their clinicians. Grounded theory was used to analyze transcripts. Results: Sixty-two patients participated in goals-of-care discussions with 51 unique clinicians. Nearly half of patients (n = 30) were female and their mean age was 60.1 years (SD = 12.7). A palliative care attending or fellow was present in 58 of the 62 discussions. Decisions centered on three topics: 1) disease-modifying treatments; 2) hospice; and 3) code status. Clinicians' approach to decision-making included the following stages: “information exchange,” “deliberation,” “making a patient-centered recommendation,” and “wrap-up: decisional status.” Successful completion of each stage varied by the type of decision. When discussing code status, clinicians missed opportunities to engage patients in information exchange and to wrap up decisional status. By contrast, clinicians discussing disease-modifying treatments and hospice failed to integrate patient preferences. Clinicians also missed opportunities to make patient-centered recommendations when discussing treatment decisions. Conclusion: Clinicians missed opportunities to facilitate shared decision-making regarding goals of care, and these missed opportunities differed by type of decision being discussed. Opportunities for clinician communication training include engagement in collaborative deliberation with patients and making patient-centered recommendations in situations of high medical uncertainty.
Original language | English (US) |
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Pages (from-to) | 216-223 |
Number of pages | 8 |
Journal | Journal of Pain and Symptom Management |
Volume | 58 |
Issue number | 2 |
DOIs | |
State | Published - Aug 2019 |
Funding
This project was supported by the Robert H. Lurie Comprehensive Cancer Center of Northwestern University Director's Fund and the Eunice Kennedy Shriver National Institute of Child Health & Human Development K12 HD055884 . Dr. Sharma was also supported by an American Cancer Society Mentored Research Scholar grant (MRSG 14-058-01-PCSM). The authors thank Dr. Melanie Smith for her assistance in coding discussions. The authors would also like to thank all the patients and clinicians who participated in this study. This project was supported by the Robert H. Lurie Comprehensive Cancer Center of Northwestern University Director's Fund and the Eunice Kennedy Shriver National Institute of Child Health & Human Development K12 HD055884. Dr. Sharma was also supported by an American Cancer Society Mentored Research Scholar grant (MRSG 14-058-01-PCSM). The authors thank Dr. Melanie Smith for her assistance in coding discussions. The authors would also like to thank all the patients and clinicians who participated in this study.
Keywords
- Decision-making
- cancer
- communication
- palliative care
ASJC Scopus subject areas
- General Nursing
- Clinical Neurology
- Anesthesiology and Pain Medicine