Perceived barriers to goals of care discussions in the emergency department: a multi-center analysis of hospitalist physicians

Background: Patients who present to hospital require clarification and confirmation of their goals of care in the emergency department. The potential barriers to having these discussions in this setting are not well described. The objective of this study was to identify the most substantial barriers to conducting goals of care discussions in the emergency department as reported by hospitalist physicians. Design: Physicians modified an existing self-reported survey that explored three domains of potential barriers to goals of care discussions: patient-related factors, environmental and resource-related factors, and factors related to physician responsibility and training. Hospitalist physicians from 20 hospitals in Ontario, Canada were invited to respond on a likert-scale to 17 questions that explored potential barriers to goals of care discussions between January 2018 and April 2019. Responses were rank-ordered by the magnitude of the differences between those that agreed with a statement and those that disagreed. Key Results: A total of 181 physicians from 17 institutions were included in the study (110 staff physicians, 71 resident physicians, response rate 36%). Ninety-five percent of physicians reported engaging in goals of care discussions at least several times per month. The most substantial barriers to goals of care discussions were: difficulty communicating with outpatient healthcare providers, the emergency department environment, and the lack of prognostic tools for patients with terminal noncancer illness. Conclusions: Several modifiable barriers to conducting goals of care discussions in the emergency department exist, which were primarily related to difficulty with communication, prognosis and a challenging care environment.