Physicians just need to be better trained to provide the best care at the end-of-life

Abstract

Over the last decades, caring for terminally ill patients, either in the latter phases of progressive chronic diseases or in the setting of refractory organ failures in the course of acute critical illnesses, has become very frequent in intensive care units (ICUs) and such demand is expected to increase substantially in the next decades [1]. Although the end-of-life (EOL) decision-making process and the consequent strategy vary largely depending on several factors such as cultural aspects, religious beliefs, legal burdens, ethical and moral values, medical knowledge regarding terminally ill diseases and palliative care, up to three-quarters of all ICU deaths are preceded by limitations of treatment [2,3]. However, the care provided to patients at the EOL and their families needs to be urgently improved. Current information indicates that EOL care in ICUs is frequently inappropriate as a consequence of several factors including poor communication [4], inadequate symptom control [5] and divergence among the ICU team, families and the patients themselves regarding their expectations and values [6]. It is well known that conflicts in the context of EOL are perceived as much more severe and dangerous when compared to other conflicts [6].Several relevant barriers to improving EOL care at the levels of the patient/family (e.g. inability to participate in EOL discussions, lack of advance directives, unrealistic expectations), the clinician (e.g. both insufficient training in communication and expertise in symptom management, and competing demands on intensivists' time) and the hospital/institution (e.g. inadequacy or absence of local family conferences and lack of palliative care service) were raised by nurse and physician ICU directors in a survey involving 468 ICUs in the United States [7]. In this sense, many interventions have been tested to improve the quality of EOL care with different results. Ethics and palliative care consultations, intensive communication strategies, formal family conferences combined with the bereavement brochure have been demonstrated to improve the quality of EOL care by reducing the length of stay and the use inappropriate ICU resources, preventing conflicts and reducing psychological burden on family members [8][9][10][11]. Unfortunately, such interventions are still not widely adopted in ICUs [7]. On the other hand, the benefit of multifaceted quality improvement strategies remains unclear [12,13].In the current issue of Intensive Care Medicine, Forte et al. [14] present the results of a questionnaire submitted to 105 Brazilian ICU physicians selected from 11 ICUs in Intensive Care Med (2012) 38:342-344 DOI 10.1007/s00134-011-2432 EDITORIAL a university=affiliated hospital evaluating EOL decisions involving a hypothetical severely brain-damaged patient with no family members or advance directives The study has two major findings: (1) physicians who would not apply do-not-resuscitate (DNR) orders less frequently attended EOL classes; and (2) almost half of respondents would not proceed a...

Cognitive challenges to minimising low value care

“…Such aggressive care may simply diminish quality of life and even shorten an already limited lifespan. Clinicians are trained to cure, rescue and save lives and to do ‘something’ to prolong life and reverse illness, rather than confront patients and relatives with reality and focus on symptom relief and supportive care . Difficult and emotionally laden decisions around appropriate end of life care should not be deferred by offers of multiple treatment options, and providing false hope should not substitute for frank discussions about prognosis and likely clinical trajectory …”

“…Clinicians are trained to cure, rescue and save lives and to do 'something' to prolong life and reverse illness, rather than confront patients and relatives with reality and focus on symptom relief and supportive care. 23 Difficult and emotionally laden decisions around appropriate end of life care should not be deferred by offers of multiple treatment options, and providing false hope should not substitute for frank discussions about prognosis and likely clinical trajectory. 24 Remediating system of care factors that interfere with optimal decisionmaking Many environmental factors relating to the financing and organisation of the healthcare system and the social and political contexts in which we work 25 synergise with cognitive biases to create a 'perfect storm of overutilisation' 26 of care.…”