Painting a Rational Picture During Highly Emotional End-of-Life Discussions: a Qualitative Study of Internal Medicine Trainees and Faculty
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BACKGROUND: High-quality communication about end-of-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-of-life 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 end-of-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.
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