Physicians’ views on the usefulness and feasibility of identifying and disclosing patients’ last phase of life: a focus group study

Abstract

ObjectivesAccurate assessment that a patient is in the last phase of life is a prerequisite for timely initiation of palliative care in patients with a life-limiting disease, such as advanced cancer or advanced organ failure. Several palliative care quality standards recommend the surprise question (SQ) to identify those patients. Little is known about physicians’ views on identifying and disclosing the last phase of life of patients with different illness trajectories.MethodsData from two focus groups were analysed using thematic analysis with a phenomenological approach.ResultsFifteen medical specialists and general practitioners participated. Participants thought prediction of patients’ last phase of life, i.e. expected death within 1 year, is important. They seemed to find that prediction is more difficult in patients with advanced organ failure compared with cancer. The SQ was considered a useful prognostic tool; its use is facilitated by its simplicity but hampered by its subjective character. The medical specialist was considered mainly responsible for prognosticating and gradually disclosing the last phase. Participants’ reluctance to such disclosure was related to uncertainty around prognostication, concerns about depriving patients of hope, affecting the physician–patient relationship, or a lack of time or availability of palliative care services.ConclusionsPhysicians consider the assessment of patients’ last phase of life important and support use of the SQ in patients with different illness trajectories. However, barriers in disclosing expected death are prognostic uncertainty, possible deprivation of hope, physician–patient relationship, and lack of time or palliative care services. Future studies should examine patients’ preferences for those discussions.

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

“…For two papers, it was defined using medical terminology related to specific medical specialties, for example, when haematological malignancies reoccur,39 and brain stem death 40. 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.…”

Discussing prognosis and the end of life with patients with advanced cancer or COPD: A qualitative study

“…discontinuation of treatment due to disease progression), in contrast to patients with advanced COPD who were mostly informed about the prognosis at the moment of diagnosis. Generally, physicians may experience difficulties in identifying the moment of transition to of the end of life in patients with chronic organ failure, due to the unpredictable illness trajectory, which could make them more reluctant to initiate discussions about prognosis [16][17][18][19][20][21]. Furthermore, physicians have concerns of taking away patients' sense of hope by discussions about prognosis [21].…”

“…Generally, physicians may experience difficulties in identifying the moment of transition to of the end of life in patients with chronic organ failure, due to the unpredictable illness trajectory, which could make them more reluctant to initiate discussions about prognosis [16][17][18][19][20][21]. Furthermore, physicians have concerns of taking away patients' sense of hope by discussions about prognosis [21]. Although physicians prefer to initiate discussions about prognosis at clear-cut moments of deterioration, such as an acute exacerbation, our findings suggest that patients with COPD may disagree [21].…”

Quality of hospital discharge letters for patients at the end of life: A retrospective medical record review

“…Other studies also found that physicians tend to find it difficult to estimate or discuss a limited life expectancy of more than 3 months (Engel et al, 2020; White et al, 2016). Other reasons for not documenting such information could be that the hospital physician feels that the patient cannot cope with such information (Meeussen et al, 2011; Simon et al, 2015), uncertainty of prognostication and about these conversations (Bernacki et al, 2014; Flierman et al, 2020; Owusuaa et al, 2021) or that the hospital physician does not perceive this to be his or her responsibility (Flierman et al, 2020; Greysen et al, 2012; Heyland et al, 2013). Nowadays, patients in the Netherlands and other countries often have access to (part of) their electronic record themselves.…”