Table 1.
Barriers to routine advance CPR decision-making in hospitals with recommended interventions
| Themes with barrier (category) | Description | Recommended Intervention |
|---|---|---|
| (i) Knowing what to say | ||
| Lack of knowledge (cognitive) | Uncertain how to optimally perform the medical assessment (JFG)
Falsely high expectation that a useful predictive tool exists (JFG) Range of experiences of CPR outcomes (JFG) Poor understanding of differences between active and palliative management [22] (L, JFG, CFG) |
Staff education using video resource - Outline of medical assessment process including statistics, uncertainty and how this relates to overall treatment plan. - Promote palliative care as an active treatment option. - Demonstrate frailty and different health trajectories which can trigger the use of the ‘surprise question’aand SPICT tool [35] in the assessment process. - Propose use of a consistent approach using ethical framework [11]. - Provide statistics for outcome in different settings and use of statistics in applying the Goals of Patient Care decision-making framework. |
| Lack of skill/expert clinical reasoning (cognitive) | Difficulty predicting patient trajectory and outcomes (L, JFG, CFG)
Juniors evaluate prognosis intuitively [19] (L, JFG) Difficulty in coming to a decision [19] (L, CFG) Wide variation in approach modeled by consultants (JFG, CFG) |
|
| Lack of evidence utility (guideline) | Guidelines only address technical aspects of CPR [20] (L)
Difficult to relate CPR outcome data to individual patients (CFG) Potential for worse care with NFR decision [21] (L, CFG) |
|
| (ii) Knowing how to say it | ||
| Lack of self-efficacy (attitudinal) | Range of views about role the family and patient play in coming to a decision (JFG, CFG) | Staff education using video resource - Recommend routine engagement with scripted questions - Promote conversations are rewarding and desired by consumers. - Acknowledge the challenge of emotional distress but that communication skills can be learnt and specific strategies to deal with emotions. - Promote the benefit of discussing patient preferences with patient and family members. Goals of Patient Care Process - Supports routine use of two scripted questions by junior doctors to attain surrogate decision-makers and advance care planning - Normalise conversations as routine care, with decisions viewed as part of overall treatment plan. - Promote consultants to refine skills, lead and mentor communication skills. - Promotes the doctor as a medical expert using a shared decision-making approach |
| Lack of confidence in ability (emotive) | Juniors experience discomfort or embarrassment [19, 28] (L, JFG, CFG)
Concerns regarding potentially offending patients and may upset them (L, JFG, CFG) A desire not to cause anxiety or distress [28] (L) |
|
| Lack of knowledge about patient (cognitive) | Difficult discussing resuscitation with patients whom they did not know [28].(L, JFG, CFG) | |
| Lack of knowledge (cognitive) | Juniors feeling unskilled to undertake task [33] (L,JFG) | |
| Lack of peer guidance and role models (physician) | Poor training for decision making and communication [32, 33] (L, JFG, CFG)
Lack of modeling and mentoring by consultants (JFG) |
|
| Conflicting culture (patient) | Patients have falsely high expectations of CPR outcome (L, JFG, CFG)
Discrepancy between patient and family desire for CPR (JFG, CFG) |
|
| (iii) Wanting to say it | ||
| Awareness (cognitive) | Under-estimate patients wanting discussion [26, 28] (L)
Families can be unaware of the terminal status of patient [27] (L, JFG) |
Staff education using video resource - Acknowledge that doctors are the main barriers with patients willing to engage. - Appreciate that the area is new and consultant also required to improve skills. - Acknowledge that all doctors have a role to engage in discussions and collaborate with collegues. Goals of Patient Care Process - Outline clear roles for junior and senior staff. - Audit rates of decisions, decision-making process and communication levels. - Provide organizational endorsement. - Allow clinicians to undertake discussions in practical manner and build capacity, without imposing mandated targets. - System changes to routinely seek patient preferences - View limitations to escalation plans as still receiving active care by describing as a goal of care. - Update policy in line with improved clinical care. - Emphasis the benefits by the process extending beyond current admission. |
| Lack of accurate self-assessment (attitudinal) | Perceive problems with other practitioners, not themselves [23] (L, JFG, CFG)
Juniors over emphasise abilities [28] (L, JFG, CFG) Poor insight into substandard communication [23] (L, JFG, CFG) |
|
| Lack of sense of authority (emotive) | Juniors feel don’t have decision-making authority, they feel disempowered and frustrated (JFG) | |
| Lack of motivation (physician) | Consultants express frustration at inaction of others (CFG)
Consultant inertia, poor ownership and avoidance (CFG) |
|
| Legal concerns (physician) | Fear of complaint [31] (L, JFG, CFG) | |
| Time and support (resource) | Time pressures to complete rounds (JFG, CFG)
Inadequate time to establish rapport with patient (JFG, CFG) Difficult to set aside time and co-ordinate meetings (JFG, CFG) |
|
| Workload/overload (system) | Competing demands with CPR decisions dropping in priority (CFG) | |
| Organizational (process) | Variable triggers to have a discussion with range of views on when to have conversation [34] (L, JFG, CFG) | |
| Lack of harmony (system) | Policies out of date with contemporary practice (CFG) | |
JFG Junior focus group; CFG Consultant focus group; L Literature
aSurprise question: Would you be surprised if this patient died within the next 12 months?