Recognizing the Need for Goals of Care Conversations Among Critically Ill Surgical Patients

Recognizing the need for end-of-life care is a critical aspect of health care. Delayed recognition leads to undue patient suffering and nonvaluable health-care expenditures. Care of patients with surgical diseases is often focused on curative intent despite the presence of significant comorbidities and discrepant patient and family wishes. We hypothesized that surgical patients with clear end-of-life needs may not receive goals of care (GoC) conversations, with variations in frequency by provider level and specialty.

Providers caring for critically ill patients at an urban, academic, quaternary care center reviewed five case vignettes of critically ill surgical patients. The blinded providers were asked to list at least three care priorities for the patients. Responses were analyzed using Stata/BE 17.0 for inclusion of GoC.

A total of 123 participants responded to at least one scenario (24.1% response rate). In total, 95 participants (77.2%) prioritized GoC at least once for any scenario, and GoC prioritization ranged from 9.7% (scenario 1) to 73.7% (scenario 5) for individual scenarios. Surgical providers prioritized GoC more often than nonsurgical providers (83.1% versus 67.4%, P = 0.044). Critical care specialty training was not found to increase prioritization of GoC (83.3% versus 71.4%, P = 0.12). Increasing post-graduate year (PGY) levels were correlated with increased likelihood of prioritizing GoC; 60.9% of PGY1-4's prioritized GoC as compared to 90.9% of PGY5-9's (P = 0.007).

Providers demonstrated ranging abilities to identify GoC as a priority. For housestaff, increasing PGY level correlates with prioritizing GoC. Surgical providers more often prioritized GoC as compared to nonsurgical providers, suggesting familiarity with surgical pathologies may result in increased prioritization.