Timing of and Barriers to Goals of Care Conversations for Patients Admitted to an Acute Oncology Setting

Background

Timely goals of care (GOC) conversations form a crucial component of high-quality cancer care, but are often delayed or do not happen over the course of an inpatient stay. This study aimed to qualitatively explore clinicians’ opinions on the appropriate timing of and barriers to GOC conversations for inpatients admitted to an acute oncology setting.

Methods

One-on-one semi-structured interviews were conducted with a purposive sample of interprofessional interdisciplinary team members providing inpatient care at a comprehensive tertiary cancer centre in Toronto, Canada. Interviews were audio-recorded, transcribed and anonymized. Using a thematic analysis approach, interviews were independently reviewed by three researchers to generate initial codes; group coding sessions identified and refined themes and subthemes.

Results

Twenty interviews were conducted with clinicians from palliative care (n=3), hospitalist medicine (n=2), medical oncology (n=2), social work (n=4), pharmacy (n=2), physiotherapy/occupational therapy (n=2), intensive care (n=2) and members of the inpatient unit management team (n=3). All participants felt that GOC should be initiated early in the disease trajectory in the outpatient setting by the patient’s primary oncologist, and revisited regularly at transition points in care, as well as specifically prior to or upon acute admission. The increasingly complex landscape of cancer care and access to novel systemic therapy options was identified as a barrier to non-oncologists initiating GOC conversations. While siloed models of care between inpatient and outpatient settings were reported to cause ambiguity around primary responsibility for leading these conversations. Clinician communication skills, appropriate interdisciplinary engagement, and challenging patient or family expectations were additional perceived barriers, while clear and accessible documentation within the electronic medical record was considered suboptimal.

Conclusions

Comprehensive GOC conversations are impeded by clinician-, patient- and system-level barriers for patients admitted to acute oncology settings. Targeted strategies aimed at addressing these, tailored to local service models and culture, should be further explored and implemented.