Interprofessional Clinician Perspectives on Goals-of-Care Communication During Chronic Critical Illness

Background: Patients with chronic critical illness (CCI) experience prolonged mechanical ventilation, severe symptoms, poor quality of life, and low survival. Guidelines recommend that clinicians discuss goals of care (GOC) with seriously ill patients and their surrogate decision-makers, but this process is understudied during CCI, when treatment burdens are high and long-term outcomes are poor. Research Question: How do clinicians from varied professions perceive barriers to discussions about GOC during CCI? Study Design and Methods: We conducted a cross-sectional survey of CCI clinicians at 2 academic ventilator facilities, assessing perceptions of barriers to GOC communication. We used Likert scale and multiple-choice responses, with statistical analysis by signed-rank, proportion, and marginal homogeneity tests. Results: Clinicians (N = 274) from 11 professions (including nursing, medicine, respiratory therapy, rehabilitation therapy, and social work) completed the survey (response rate, 78.5%). The most commonly selected reasons for delaying GOC discussions included challenges with patient or surrogate processing of prognosis (55% of respondents), explicit requests not to discuss GOC (47%), clinician prognostic uncertainty (42%), and prior clarity of GOC (40%). Clinicians contrasted their own low expectations for patient recovery (median response, unlikely) with perceived high expectations of patients (median response, likely; P < .001). In contrast to shared responsibility across professions for symptom management (ie, nursing, medicine, rehabilitation therapy, social work, and chaplaincy), perceived responsibility for initiating GOC discussions was limited primarily to physicians and nurse practitioners (P < .001 by test of proportions). Interpretation: In this 2-site cross-sectional survey, clinicians identified distinct challenges to GOC communication during CCI, including challenges processing information, discordant expectations, and differential clinician responsibilities for initiating these discussions. These provide unique and targeted opportunities to improve communication and care during CCI.