End of Life discussion in a Academic Family Health Team in Kingston, Ontario, Canada (original) (raw)
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Family Practice, 2019
Background As doctors who provide care across the life-course, general practitioners (GPs) play a key role in initiating timely end-of-life discussions. Nonetheless, these discussions are often not initiated until close to death. Given the ageing of the population, GPs will be confronted with end-of-life care more often, and this needs to become a core skill for all GPs. Objective To describe GPs’ approach to initiating end-of-life discussions. Methods Fifteen GPs or GP trainees from South-East Queensland, Australia, were purposively recruited to participate in a semi-structured interview. We analysed transcripts using a thematic analysis. Results GPs’ approach to initiating end-of-life discussions was summarized by four themes: (1) Preparing the ground; (2) finding an entry point; (3) tailoring communication and (4) involving the family. Conclusions Emphasis on the doctor–patient relationship; assessing patient readiness for end-of-life discussions; and sensitive information delive...
End-of-life discussions: Who's doing the talking?
Journal of Critical Care, 2018
To determine, in a tertiary academic medical center, the reported frequency of end-of-life discussions among nurses and the influence of demographic factors on these discussions. Methods: Survey of nurses on frequency of end-of-life discussions in two urban academic medical centers. Chisquare tests were used to separately assess the relationship between age, gender, specialty, and experience with responses to the question, "Do you regularly talk with your patients about end-of-life wishes?" Results: Overall, more than one-third of respondents reported rarely or never discussing end-of-life wishes with their patients. Only specialty expertise (p b 0.001) was statistically significantly associated with discussing endof-life issues with patients. Over half of nurses specializing in critical care responded that they have these discussion "always" or "most of the time." However, for the specialties of surgery (59%) and anesthesiology (56%), the majority of respondents reported rarely or never having end-of-life discussions with patients. Conclusions: In a survey conducted in two tertiary care institutions, more than one-third of nurses from all disciplines responded that they never or almost never discuss end-of-life issues with their patients. Specialty influenced the likelihood of discussing end-of-life issues with patients.
BMC Palliative Care, 2019
Background: End-of-life (EOL) conversations in hospital should serve to give patients the opportunity to consider future treatment options and help them clarify their values and wishes before it becomes relevant to make decisions about treatment. However, it is known that EOL conversations are not performed systematically in hospital. This may mean that patients and their relatives do not address EOL issues. There is a lack of knowledge about who is responsible for conducting these conversations, and when and under what circumstances they are conducted. The aim of this study was to explore the existing practices regarding EOL conversations in an acute care hospital setting. Methods: The design was Interpretive Description and the methods for the data collection included: 1. Participatory observational studies in a pulmonary medical and surgical ward (a total of 66 h); 2. Four focus group interviews with healthcare professionals (n = 14) from the wards. The analysis followed Spradley's ethnosemantic analysis. Results: The results revealed three cultural categories related to: 1. The physical and organizational setting; 2. The timing of EOL conversations and competencies and roles in addressing EOL issues and 3. Topics addressed in EOL conversations. The EOL conversations were part of daily clinical practice, but there was a lack of competencies, roles were unclear and the physical and organizational environment was not conducive to the conversations. The topics of the EOL conversations revolved around a "here-and-now" status of the patient's disease progression and decisions about the level of treatment. To a lesser extent, the conversations included the patient's and relatives' thoughts and wishes concerning EOL, which allowed long-term care planning. Conclusion: This study demonstrates that there are several barriers to talking about EOL in an acute care hospital setting, and future strategies must address an overall approach. In order to provide patients and their relatives with better opportunities to express their EOL wishes, there is a need for clearer roles and guidelines in an interdisciplinary approach to EOL conversations, alongside improved staff competencies and changes to the organizational and physical environment.
Family Practice, 2019
Background End-of-life discussions often are not initiated until close to death, even in the presence of life-limiting illness or frailty. Previous research shows that doctors may not explicitly verbalize approaching end-of-life in the foreseeable future, despite shifting their focus to comfort care. This may limit patients’ opportunity to receive information and plan for the future. General Practitioners (GPs) have a key role in caring for increasing numbers of patients approaching end-of-life. Objective To explore GPs’ thought processes when deciding whether to initiate end-of-life discussions. Methods A qualitative approach was used. We purposively recruited 15 GPs or GP trainees from South-East Queensland, Australia, and each participated in a semi-structured interview. Transcripts were analyzed using inductive thematic analysis. Results Australian GPs believe they have a responsibility to initiate end-of-life conversations, and identify several triggers to do so. Some also desc...
Journal of General Internal Medicine, 2020
BACKGROUND: High-quality communication about endof-life care results in greater patient and family satisfaction. End-of-life discussions should occur early during the patient's disease trajectory and yet is often addressed only when patients become severely ill. As a result, end-oflife discussions are commonly initiated during unplanned hospital admissions, which create additional challenges for physicians, patients, and families. OBJECTIVE: To better understand how internal medicine attending physicians and trainees experience end-of-life discussions with patients and families during acute hospitalizations. DESIGN: We conducted an interview-based qualitative study using an interpretivist approach. We selected participants based on purposeful maximal variation and theoretical sampling strategies. We conducted an individual, in-depth, semi-structured interview with each participant. PARTICIPANTS: We recruited 15 internal medicine physicians with variable levels of clinical training and experience who worked in one of five university-affiliated academic hospitals. APPROACH: Interview transcripts were analyzed inductively and reflectively. Data were grouped by themes and categories. Data collection and analysis occurred concurrently, led to iterative adjustments of the interview guide, and continued until theoretical sufficiency was reached. KEY RESULTS: Physicians depicted end-of-life discussions as a process directed at painting a realistic picture of a clinical situation. By focusing their efforts on reaching a shared understanding of a clinical situation with patients/families, physicians self-delineated the boundaries of their professional responsibilities regarding endof-life care (i.e., help with understanding, not with accepting or making the "right" decisions). Information sharing took precedence over emotional support in most physicians' accounts of end-of-life discussions. However, the emotional impact of end-of-life discussions on families and physicians was readily recognized by participants. CONCLUSION: End-of-life discussions are complex, dynamic social interactions that involve multiple, complementary competencies. Focusing mostly on sharing clinical information during end-of-life discussions may distract physicians from providing emotional support to families and prevent improvements of end-of-life care delivered in acute care settings.
Increasing Comfort With End-of-Life Discussions
2015
End-of-life discussions and advanced care planning are part of the healthcare process, and within the scope of practice for providers. Despite the evidence supporting the effectiveness of these conversations, the system falls short. Talking about death is never easy. At times, it is difficult for healthcare providers to approach the topic with patients who are living with serious life-limiting illness. Reports in the end-of-life literature reveal that healthcare professionals avoid discussions about preparations for end-of-life care due to feeling unprepared, and a lack of framework for such discussions. Purpose: The purpose of this doctoral project was to improve the quality of end-of-life care for patients with life-limiting illnesses by increasing provider comfort with end-of-life conversations. Method: This project was a Quazi-experimental pre and post intervention design. A preintervention baseline assessment of healthcare providers comfort with end-of-life discussions through a self-assessment survey and retrospective chart audits was conducted. An educational intervention was completed implementing an evidenced-based tool to guide end-of-life discussions. Healthcare providers were instructed to utilize the tool for sixty days to guide them in end-of-life discussions on appropriate patients. Post intervention data was collected to include a repeat of the self-assessment survey and retrospective chart audits to determine changes in comfort level. Conclusion: Providers reported increases in level of comfort and demonstrated an increase in conversations from baseline.
The Yale Journal of Biology and Medicine, 2019
The need for improved clinical education surrounding the way difficult news is delivered and how to initiate end-of-life (EOL) discussions with seriously ill patients and their families is essential. Physicians and medical students often report feeling unprepared or uncomfortable with broaching the topic of death with their patients and families [1]. Early and honest conversations with patients concerning diagnoses and advance directives help patients and their families make well-informed decisions regarding future medical care, minimize pain and fears, and allow patients to experience a “peaceful death [1].” Moreover, end-of-life conversations frequently focus on resuscitation plans (advance directives), but should be broadened to include patients’ psychosocial, physical, and economic concerns. Transparent, realistic, and sensitive end-of-life conversations can help patients maintain autonomy and dignity in the dying process and increase their quality of life as they near death. Ad...
Opportunity lost: End‐of‐life discussions in cancer patients who die in the hospital
Journal of Hospital Medicine, 2012
BACKGROUND: End-of-life discussions are associated with decreased use of life-sustaining treatments in patients dying of cancer in the outpatient setting, but little is known about discussions that take place during terminal hospitalizations. OBJECTIVES: To determine the proportion of patients assessed by the clinical team to have decisional capacity on admission, how many of these patients participated or had a surrogate participate in a discussion about end-of-life care, and whether patient participation was associated with treatments received. DESIGN: Retrospective review.