Barriers to Goals of Care Discussions With Seriously Ill Hospitalized Patients and Their Families: A Multicenter Survey of Clinicians

Importance: Seriously ill hospitalized patients have identified communication and decision making about goals of care as high priorities for quality improvement in end-of-life care. Interventions to improve care are more likely to succeed if tailored to existing barriers.

Objective: To determine, from the perspective of hospital-based clinicians, (1) barriers impeding communication and decision making about goals of care with seriously ill hospitalized patients and their families and (2) their own willingness and the acceptability for other clinicians to engage in this process.

Design, Setting, and Participants: Multicenter survey of medical teaching units of nurses, internal medicine residents, and staff physicians from participating units at 13 university-based hospitals from 5 Canadian provinces.

Main Outcomes and Measures: Importance of 21 barriers to goals of care discussions rated on a 7-point scale (1 = extremely unimportant; 7 = extremely important).

Results: Between September 2012 and March 2013, questionnaires were returned by 1256 of 1617 eligible clinicians, for an overall response rate of 77.7% (512 of 646 nurses [79.3%], 484 of 634 residents [76.3%], 260 of 337 staff physicians [77.2%]). The following family member-related and patient-related factors were consistently identified by all 3 clinician groups as the most important barriers to goals of care discussions: family members' or patients' difficulty accepting a poor prognosis (mean [SD] score, 5.8 [1.2] and 5.6 [1.3], respectively), family members' or patients' difficulty understanding the limitations and complications of life-sustaining treatments (5.8 [1.2] for both groups), disagreement among family members about goals of care (5.8 [1.2]), and patients' incapacity to make goals of care decisions (5.6 [1.2]). Clinicians perceived their own skills and system factors as less important barriers. Participants viewed it as acceptable for all clinician groups to engage in goals of care discussions-including a role for advance practice nurses, nurses, and social workers to initiate goals of care discussions and be a decision coach.

Conclusions and Relevance: Hospital-based clinicians perceive family member-related and patient-related factors as the most important barriers to goals of care discussions. All health care professionals were viewed as playing important roles in addressing goals of care. These findings can inform the design of future interventions to improve communication and decision making about goals of care.

Post-Conflict Performance, Film and Visual Arts:Cities of Memory

This book examines how contemporary theatre, performance, film and the visual arts respond to the post-conflict condition. The contents of the volume focus on a range of post-conflict cities, encouraging interdisciplinary discussion on the role of the arts and its relation to issues of testimony, witnessing, forgetting, representation, healing, reconciliation, agency, and metaphor. Contributors include: Thomas Elsaesser, Jane Taylor, Marvin Carlson, Rob Stone, Laurel Borisenko, Katarzyna Puzon, Miriam Paeslack, Emma Grey, Paula Blair, Zoran Poposki, Marija Todorova, Elena Carduro, and Paul Devlin.

Fine-structure photoionization cross sections of Fe II

We present the first calculation of fine-structure photoionization cross sections for the ground state of singly ionized Fe. These large-scale ab initio calculations, limited to the near-threshold region, were performed in the close-coupling approximation using a Dirac–Coulomb R -matrix method implemented within a modified version of the DARC package. Our calculated cross sections reproduce in detail the resonance structures observed in previous experimental determinations.

Influence of testing on permeability of compacted fine soils

The British standard constant-head triaxial test for measuring the permeability of fine-grained soils takes a relatively long time. A quicker test could provide savings to the construction industry, particularly for checking the quality of landfill clay liners. An accelerated permeability test has been developed, but the method often underestimates the permeability values compared owing to structural changes in the soil sample. This paper reports on an investigation
into the accelerated test to discover if the changes can be limited by using a revised procedure. The accelerated test is assessed and compared with the standard test and a ramp-accelerated permeability test. Four different finegrained materials are compacted at various water contents to produce analogous samples for testing using the three different methods. Fabric analysis is carried out on specimens derived from post-test samples using mercury intrusion porosimetry and scanning electron microscopy to assess the effects of testing on soil structure. The results show that accelerated testing in general underestimates permeability compared with values derived from the standard test, owing to changes in soil structure caused by testing. The ramp-accelerated test is shown to provide an improvement in terms of these structural changes.