Breaking silence: a survey of barriers to goals of care discussions from the perspective of oncology practitioners

BACKGROUND: Cancer is the leading cause of death in the developed world, and yet healthcare practitioners infrequently discuss goals of care (GoC) with hospitalized cancer patients. We sought to identify barriers to GoC discussions from the perspectives of staff oncologists, oncology residents, and oncology nurses. METHODS: This was a single center survey of staff oncologists, oncology residents, and inpatient oncology nurses. Barriers to GoC discussions were assessed on a 7-point Likert scale (1 = extremely unimportant; 7 = extremely important). RESULTS: Between July 2013 and May 2014, of 185 eligible oncology clinicians, 30 staff oncologists, 10 oncology residents, and 28 oncology nurses returned surveys (response rate of 37%). The most important barriers to GoC discussions were patient and family factors. They included family members' difficulty accepting poor prognoses (mean score 5.9, 95% CI 5.7, 6.2), lack of family agreement in the goals of care (mean score 5.8, 95% CI 5.5, 6.1), difficulty understanding the limitations of life-sustaining treatments (mean score 5.8, 95% CI 5.6, 6.1), lack of patients' capacity to make goals of care decisions (mean score 5.7, 95% CI 5.5, 6.0), and language barriers (mean score 5.7, 95% CI 5.4, 5.9). Participants viewed system factors and healthcare provider factors as less important barriers. CONCLUSIONS: Oncology practitioners perceive patient and family factors as the most limiting barriers to GoC discussions. Our findings underscore the need for oncology clinicians to be equipped with strong communication skills to help patients and families navigate GoC discussions.