Physician and Nursing Perspectives on Patient Encounters in End-of-Life Care

Perhaps that [high-tech interventions in the intensive care unit] gave them a false sense of security that appropriate therapy had been given, and therefore there was a chance of survival. I did give them statistics saying that, you know, the mortality for this condition is 80%.I think patients whenever they hear that always think they’re the 20% that’s going to survive. They grasp onto the 20% rather than hone in on the adverse.

Effective Communication

Effective communication described the sharing of information in a direct and honest manner by an interdisciplinary team, as well as the exploration of goals, values, and feelings at multiple points in time. It was the primary category cited by all participants. Effective communication can be manifested as an evolutionary process of discussing treatment options at multiple points in time and sometimes over years. Time was a major component of effective communication, time to have complex discussions as well as selecting the optimal time to approach patients and families with difficult issues. One geriatrician noted the link between communication and time: “Communication is difficult and hard, especially if it is a sudden bolt out of the blue. There isn’t time for information to percolate. Families need time.”

Participants related that timing issues were influenced by provider and patient characteristics and by disease prognosis and clarity. of ten discussions were triggered by acute medical events or by ineffective therapeutic interventions. In positive encounters, frequent discussions occurred within the context of an established provider-patient relationship and without a sense of urgency. Communication in negative encounters was characterized by an atmosphere of fear and anger, a lack of trust, and a crisis orientation:

I just think there was no time to get used to the idea that we have a malignancy that is not going to be cured, and if you had the opportunity to build a professional relationship that can be a therapeutic relationship, you can work through some of those issues. But in her case there was absolutely no time to do it. She was extremely frightened at the beginning, and so there was no time to build; there was no trust.

The timing to approach end-of-life care discussions was difficult to judge, and participants had conflicting opinions about whether discussions should occur when patients were still healthy or when there was evidence of a decline. The variability and uncertainty of chronic disease trajectories despite functional status confounded the timing of discussions. An internist who serves as a hospice medical director reflected on a discussion she recently had with a patient:

The good news is you’ve been pretty functional, you feel pretty good. The bad news is you could die any-time. And you know, who is the decision maker ifyou can’t speak for yourself, what are your goals, and how aggressive should we be.

In most positive encounters the participants described spending time with patients and families, a task that was difficult and influenced by the realities of clinical practice in settings that were “overbooked in every slot,”as one participant explained.

A cohesive interdisciplinary team enhanced effective communication. Participants viewed social workers and chaplains as invaluable in assisting patients and families to assimilate information and to facilitate an acceptance of death. A common value system and knowledge base regarding treatment plans among care team members also marked positive encounters:

And some people get it right away and are very realistic. But for most people it takes several conversations over time, and it takes the whole team being on the same page basically. We all have to be saying the same thing.

In contrast, participants identified problems that occurred when interdisciplinary members functioned in independent roles, lacked a team concept and a shared understanding of treatment goals, and did not communicate among themselves.

Discussion

The purpose of our study was to explore the complex phenomena that occur between nursing and physician providers and their dying patients and to describe those factors that providers identify as important in those encounters. The results of our study have both theoretical and practical applications for providers of end-of-life care. Although our original aim was to identify factors, our results suggested that interrelationships existed among the categories. A descriptive conceptual framework was therefore built to graphically depict these relationships (Figure). A conceptual framework explains key categories either graphically or narratively and the presumed relationships among them.²² We constructed an initial framework and several iterations until consensus was reached.

The framework outlines a dynamic reorientation process of both patient and provider norms, values, and behaviors from a curative biomedical perspective to a palliative course that is centered around assisting patients in achieving a quality, comfortable death. This process has been characterized as socialization to dying.²³ In medical settings socialization is inclusive of the content and characteristics of learning social and cultural cues and adaptations, as well as the manner and process by which ideas and ideals are communicated and reinforced.²⁴