Is physician awareness of impending death in hospital related to better communication and medical care?

How to talk about dying? The development of an evidence-based model for communication with patients in their last days of life and their family caregivers

Objective

To help healthcare professionals (HCP) act with more confidence when communicating about approaching death, we sought to develop a communication model for HCP to facilitate conversations with dying patients and family caregivers (FC) in nonemergency situations.

Methods

We used a four-phase integrative approach: (1) creation of a preliminary model based on a systematic literature review and expert knowledge, (2) review of the model draft by international palliative care experts, (3) review by key stakeholders, and (4) final appraisal by communication experts.

Results

After the clinical recognition of dying, the communication model provides a structure and practical communication aids for navigating the conversation based on three phases. It describes the content and relational level as core dimensions of effective conversations about approaching death and highlights the importance of HCP self-awareness and self-care when caring for the dying.

Conclusion

Based on systematic involvement of key stakeholders, the model supports clinicians navigating challenging conversations about approaching death with dying patients and their FC successfully and with more confidence.

Innovation

This study expands the theoretical basis for communication about approaching death and offers a pragmatic model for educational interventions and clinical use.

Advance Care Plans and the Potentially Conflicting Interests of Bedside Patient Agents: A Thematic Analysis

AIM

People diagnosed with a neurodegenerative disorder often contend with a threat to independence and control, leading some to complete an advance care plan. Advance care plans are commonly associated with treatment limitations; however, key patient agents (such as doctors, allied health, nurses and family) may instead make temporal, best interests or good medical practice decisions on behalf of the patient. Accordingly, there is a need to better understand ancillary decision-maker's perspectives, particularly of doctors.

PURPOSE

To explain how the potentially conflicting interests of bedside patient agents operates as a factor which influences doctors' application of advance care plans of people with a neurodegenerative disorder.

PARTICIPANTS AND METHODS

Using a constructivist grounded theory informed thematic analysis, 38 semi-structured interviews were conducted with hospital-based doctors, allied health, nurses and family of people with a neurodegenerative disorder who had an advance care plan. Data were inductively analysed using open and focused coding.

RESULTS

Analysis revealed two main themes: dynamics of discerning best interests; and avoiding conflict. Rather than applying advance care plans, doctors largely involved families to attempt best interests decision-making partnerships on patients' behalf. Bedside agents demonstrated significant intra and interpersonal challenges associated with their roles as patient agents. Doctors appeared protective of families and patients with neurodegenerative disorder.

CONCLUSION

Although bedside agents value advance care plans, doctors often favour temporal healthcare decisions in consultation with family. We suggest there are limitations to the effectiveness of advance care plans in practice, with application typically only occurring close to death. Despite the intentions of advance care planning, bedside agents may still experience considerable dissonance.

Transitioning to Comfort-Focused Care at the End of Life

Shared decision making requires the exchange of information from the patient and the surgeon (and ideally involves the expertise of the entire multidisciplinary team) to determine the medical and/or surgical treatment that best aligns with the patient's goals and values. Should the surgical patient wish to transition to end-of-life care, the transition to comfort-focused care is within the scope of practice for surgeons. Incorporating the expertise of other health care professionals is an important consideration for whole-patient care. Integrating primary palliative care into surgical practice can help mitigate unnecessary suffering and allow a smoother transition to comfort-focused care.

Narrative medicine: A comparison of terminal cancer patients' stories from a Dutch hospice with those of Anatole Broyard and Christopher Hitchens

Not all physicians readily discuss death with their terminal patients. To explore whether physicians discuss dying with their terminal patients and to pursue an in-depth understanding of patients' perceptions of death, we interviewed terminal cancer patients in a Dutch hospice and compared their stories to quotes from two autobiographies on dying from cancer, Christopher Hitchens' Mortality and Anatole Broyard's Intoxicated by my illness. This narrative medicine study could potentially teach physicians they should discuss impending death to prevent the use of an invasive medical treatment that typically extends the quantity, but not the quality, of life.

Dying in the hospital: what happens and what matters, according to bereaved relatives

CONTEXT

Most deaths in Western countries occur in hospital, but little is known about factors determining the quality of dying (QOD).

OBJECTIVES

The aim was to assess the QOD in hospital as experienced by relatives and identify factors related to QOD.

METHODS

A cross-sectional study on 18 wards of a university hospital in The Netherlands was conducted, including relatives of patients who died after an admission of more than six hours, from June 2009 to March 2011. Relatives' perceptions of QOD and quality of care and the relation between dimensions of QOD and overall QOD scores were assessed.

RESULTS

Two hundred forty-nine relatives participated (51%) and rated overall QOD at 6.3 (SD 2.7; range 0-10). According to relatives, patients suffered from 7.0 (SD 5.8) of 22 symptoms and were at peace with imminent death in 37%. Patients had been aware of imminent death in 26%, and relatives were aware in 49%. Furthermore, 39% of patients and 50% of relatives had said good-bye, and 77% of patients died in the presence of a relative. Symptom alleviation was sufficient in 53%, and in 75%, sufficient efforts had been made to relieve symptoms. Characteristics of QOD and quality of care could be summarized in nine domains, explaining 34% of the variation of QOD scores. Medical, personalized, and supportive care were most strongly related to QOD.

CONCLUSION

Relatives rated QOD as sufficient. A majority of patients and relatives were not sufficiently prepared for imminent death, and relatives experienced many problems. QOD appears to be a multidimensional construct, strongly affected by medical care and staff attentiveness.