Table 1 Barriers to routine advance CPR decision-making in hospitals with recommended interventions

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)

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)

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)