BACKGROUND: Goals of care discussions (GOCDs) are critical for patients with serious illnesses but are hindered by clinician-level barriers. Nudges-low-burden, behaviourally informed strategies that influence clinician behaviour without restricting choice-may provide a scalable approach to increase GOCDs. We systematically reviewed and meta-analysed the effect of clinician-directed nudges on GOCD documentation. Secondary outcomes were quality of communication and healthcare utilisation.
METHODS: We searched three databases (2004-2024). Nudges were classified using the MINDSPACE framework. Random-effects meta-analysis estimated pooled odds ratios (ORs) with 95% confidence intervals (CIs) for GOCD documentation. Subgroup analyses examined nudge type, study design and co-interventions. Secondary outcomes were narratively synthesised.
RESULTS: Fifty-one studies were included (16 randomised trials, 7 non-randomised controlled studies and 28 pre-post studies). Salience-based nudges, which make key information more noticeable, were most common (86% of interventions). Most interventions (87%) were multicomponent. Nudges increased GOCD documentation (OR 3.30, 95% CI 2.40-4.53). Multicomponent interventions with a nudge component had larger effects than nudges alone (OR 4.03 vs. 1.89; P = .03). No differences were observed by nudge types or study designs. Heterogeneity was high (I2 = 96.7%) but leave-one-out sensitivity analyses supported robustness. Nudges improved quality of communication (2/2 studies) and reduced readmissions (2/2), with inconsistent effects on palliative care referrals (5/19) and no impact on hospital length of stay (0/5).
CONCLUSION: Clinician-directed nudges improve GOCD documentation and represent a scalable, low-cost strategy for quality improvement. Future research should examine a broader range of nudges, multilevel interventions and effects on the quality and timing of GOCDs across settings.
| Discipline Area | Score |
|---|---|
| Physician |  |
Physician rater
No studies on the effect of patient outcomes.
, McMaster University