“Postponing it Any Later Would not be so Great”: A Cognitive Interview Study of How Physicians Decide to Initiate Goals of Care Discussions in the Hospital

Background: There are missed opportunities to discuss goals and preferences for care with seriously ill patients in the acute care setting. It is unknown which factors most influence clinician decision-making about communication at the point of care. Objective: This study utilized a cognitive-interviewing technique to better understand what leads clinicians to decide to have a goals of care (GOC) discussion in the acute care setting. Methods: A convenience sample of 15 oncologists, intensivists and hospitalists were recruited from a single academic medical center in a large urban area. Participants completed a cognitive interview describing their thought process when deciding whether to engage in GOC discussions in clinical vignettes. Results: 6 interconnected factors emerged as important in determining how likely the physician was to consider engaging in GOC at that time; (1) the participants’ mental model of GOC, (2) timing of GOC related to stability, acuity and reversibility of the patient’s condition, (3) clinical factors such as uncertainty, prognosis and recency of diagnosis, (4) patient factors including age and emotional state, (5) participants’ role on the care team, and (6) clinician factors such as emotion and communication skill level. Conclusion: Participants were hesitant to commit to the present moment as the right time for GOC discussions based on variations in clinical presentation. Clinical decision support systems that include more targeted information about risk of clinical deterioration and likelihood of reversal of the acute condition may prompt physicians to discuss GOC, but more support for managing discomfort with uncertainty is also needed.