Factors Associated With Clinician Confidence in Communication During Goals of Care Discussions

Background: High-quality goals of care (GOC) discussions should be founded on shared decision-making (SDM) - eliciting patients' values and preferences while providing adequate information for patients to make decisions. One metric that can assess GOC discussion quality is the degree to which patients are adequately informed. Objective: Identify clinician GOC discussion attitudes and behaviors associated with clinician confidence that they conveyed adequate information to patients. Methods: We conducted a secondary analysis of national survey data from Veterans Affairs clinicians assessing attitudes toward and behaviors during GOC discussions about life-sustaining therapy. We used stepwise multivariable logistic regression models to identify factors associated with clinician confidence that they provided patients with adequate information to make informed decisions following discussions. Results: Among the 253 clinician respondents, there was high confidence that they provided adequate information (Mean = 4.09 on a 5-point scale, SD = 0.69, Median = 4.0). Higher confidence was associated with practicing in Geriatrics/Palliative Care in bivariate analyses, but not when controlling for clinician behaviors during GOC discussions. In the final multivariable model, two behaviors were statistically significantly associated with increased confidence: "identify proxy/surrogate" (β = 0.21, P = 0.015) and "suggest decision consistent with patients' values" (β = 0.16, P = 0.045). These behaviors also occurred significantly more often in Geriatrics/Palliative Care compared to other specialties. Conclusion: Specific clinician behaviors in GOC discussions differed across specialties and were significantly associated with clinicians' confidence that they conveyed adequate information. Our findings can inform strategies to enhance communication training across specialties and improve care processes to support clinicians in performing behaviors conducive to high-quality GOC discussions.