Perceived barriers to goals of care discussions in the emergency department: a multi-center analysis of hospitalist physicians
Bibliographic record
Abstract
Abstract Background: Patients who present to hospital require clarification and confirmation of their goals of care in the emergency department to align treatment recommendations with their stated goals. The potential barriers to having these discussions in this setting are not well described. The objective of this study was to identify the most substantial barriers to conducting goals of care discussions in the emergency department as reported by hospitalist physicians who are often the first physician that a patient encounters during their admission to hospital. Design: A team of physicians from Palliative Care, Hospitalist Medicine and Emergency Medicine modified an existing self-reported survey that explored three domains of potential barriers to goals of care discussions: patient-related factors, environmental and resource-related factors, and factors related to physician responsibility and training. Across these domains, hospitalist physicians from 20 hospitals in the Greater Toronto Area in Ontario, Canada were invited to respond on a likert-scale to 17 questions that explored potential barriers to goals of care discussions between January 2018 and April 2019. Responses were rank-ordered by the magnitude of the differences between those that agreed with a statement and those that disagreed. Key Results: A total of 181 physicians from 17 institutions were included in the study (110 staff physicians, 71 resident physicians, response rate 36%). Ninety-five percent of physicians reported engaging in goals of care discussions at least several times per month. The most substantial barriers to goals of care discussions in the emergency department reported by hospitalists were: difficulty communicating with outpatient healthcare providers, the emergency department environment, and the lack of prognostic tools for patients with terminal noncancer illness. Conclusions: Several modifiable barriers to conducting goals of care discussions in the emergency department exist, which were primarily related to difficulty with communication, prognosis and a challenging care environment.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.002 | 0.011 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.001 | 0.000 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.000 | 0.001 |
| Research integrity | 0.000 | 0.001 |
| Insufficient payload (model declined to judge) | 0.002 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".