Managing Bias in Palliative Care: Professional Hazards in Goals of Care Discussions at the End of Life

Am J Hosp Palliat Care. 2018 Feb;35(2):355-363. doi: 10.1177/1049909117707486. Epub 2017 May 10.


Background: In the setting of end-of-life care, biases can interfere with patient articulation of goals and hinder provision of patient-centered care. No studies have addressed clinician bias or bias management specific to goals of care discussions at the end of life.

Objectives: To identify and determine the prevalence of palliative care clinician biases and bias management strategies in end-of-life goals of care discussions.

Design: A semistructured interview guide with relevant domains was developed to facilitate data collection. Participants were asked directly to identify biases and bias management strategies applicable to this setting. Two researchers developed a codebook to identify themes using a 25% transcript sample through an iterative process based on grounded theory. Inter-rater reliability was evaluated using Cohen κ. It was 0.83, indicating near perfect agreement between coders. The data approach saturation.

Setting/participants: A purposive sampling of 20 palliative care clinicians in Middle Tennessee participated in interviews.

Results: The 20 clinicians interviewed identified 16 biases and 11 bias management strategies. The most frequently mentioned bias was a bias against aggressive treatment (n = 9), described as a clinician's assumption that most interventions at the end of life are not beneficial. The most frequently mentioned bias management strategy was self-recognition of bias (n = 17), described as acknowledging that bias is present.

Conclusion: This is the first study identifying palliative care clinicians' biases and bias management strategies in end-of-life goals of care discussions.

Keywords: communication; goals; health-care providers; palliative care; prejudice; thematic analysis.

MeSH terms

  • Adult
  • Attitude of Health Personnel*
  • Female
  • Humans
  • Interviews as Topic
  • Male
  • Middle Aged
  • Palliative Care
  • Patient-Centered Care / organization & administration*
  • Patient-Centered Care / standards
  • Prejudice / psychology*
  • Reproducibility of Results
  • Tennessee
  • Terminal Care / organization & administration*
  • Terminal Care / standards