Painting a Rational Picture During Highly Emotional End-of-Life Discussions: a Qualitative Study of Internal Medicine Trainees and Faculty

Abstract

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.

Physician emotional experience of communication and decision making with end-of-life patients: qualitative studies systematic review

“…One paper simply defined it as expected death within 1 year 41. Two papers asked participants for their perspective,33 36 or to define a set phrase like ‘palliative care’,31 or ‘futility’,38 or ‘end-of-life’ 37 42. Two papers asked participants to recall memorable patient deaths and reflect on those experiences 39 42.…”

“…Two papers asked participants for their perspective,33 36 or to define a set phrase like ‘palliative care’,31 or ‘futility’,38 or ‘end-of-life’ 37 42. Two papers asked participants to recall memorable patient deaths and reflect on those experiences 39 42. One paper identified the difficulty that participants had in defining death,33 adding that junior staff were more likely to go beyond organic presentations to include elements like spirituality.…”

The Effect of Fear of Failure on Confidence in, and Comfortableness With, the Delivery of End-of-life Care

“…Psychological factors remain the most likely cause of ineffective or avoided EOL care. Stress, threat, and anxiety have been shown to reduce capacity for frontal cortex activity, the means for processing emotions and building relationships, allowing for practical tasks to take priority and reducing the ability to hold more challenge, complex, and emotionally laden conversations [20,29]. Fear has been found to limit one's ability to intake information and reduce learning and revision capacity, as well as increase sensitivity to the perceived threat [30].…”

“…The de nition has been developed into a more cognitive-speci c construct by Conroy [46], as a cognitive protective response to the anticipation of a threat to one's ability or sense of worth, with the goal of avoiding any strong or di cult emotional reaction connected to the threat. Within clinical environments, FOF can lead medical professionals to develop strategies that further enable avoidance; this may include aiming to avoid certain specialisms that may induce threat or panic [20,47], even when this con icts with their core values and hampers essential skill acquisition [15,29,48] -a consistent theme across FOF research. Feelings of failure are elicited in clinicians when patients reject treatment, when negotiations fail, or when a patient's body no longer responds to treatment.…”

“…However, the most recently published systematic review investigating this construct has been unable to nd collective evidence to suggest that death anxiety is substantially responsible for limiting the application of taught skills and the implementation of guidance, and triggering avoidance of EOL conversations and care [12], indicating other factors may play a role in this phenomenon.Psychological factors remain the most likely cause of ineffective or avoided EOL care. Stress, threat, and anxiety have been shown to reduce capacity for frontal cortex activity, the means for processing emotions and building relationships, allowing for practical tasks to take priority and reducing the ability to hold more challenge, complex, and emotionally laden conversations [20,29]. Fear has been found to limit one's ability to intake information and reduce learning and revision capacity, as well as increase sensitivity to the perceived threat [30].…”