Differences in goals of care discussion outcomes among healthcare professionals: an observational cross-sectional study

摘要

Background: Goals of care discussions ensure patients receive the care that they want. Recent studies have recognized the opportunity for allied health professionals, such as nurses, in facilitating goals of care discussions. However, the outcomes of such interventions are not well studied. Aim: To compare the outcomes of goals of care discussions led by physicians and nurses. Design: This is a retrospective cohort study of patients admitted to an Internal Medicine unit from January 2018 to August 2019. A comprehensive chart review was performed on a random sample of patients. Patient's decision to accept or refuse cardiopulmonary resuscitation was recorded and analyzed. Analysis was stratified by patients' comorbidity burden and illness severity. Setting/Participants: The study took place at a tertiary care center and included 200 patients. Patients aged > 18 were included. Patients who have had pre-existing goals of care documentation were excluded. Results: About 52 of the goals of care discussions were completed by nurses and 48 by physicians. Patients were more likely to accept cardiopulmonary resuscitation in nurse-led discussions compared to physician-led ones (80.8 vs 61.4, p = 0.003). Multiple regression showed that patients with higher comorbidity burden (OR 0.71, 95 CI: 0.62-0.82), more severe illness (OR 0.89, 95 CI 0.88-0.99), and physician-led goals of care discussions (OR 0.30, 95 CI: 0.15-0.62) were less likely to accept cardiopulmonary resuscitation. Conclusions: There was a significant difference between the outcomes of goals of care discussions led by nurses and physicians. Patients were more likely to accept aggressive resuscitative measures in nurse-led goals of care discussions. Further research efforts are needed to identify the factors contributing to this discrepancy, and to devise ways of improving goals of care discussion delivery.