Culture and end-of-life care: an epidemiological evaluation of physicians

Nephrologists' perspectives and experiences with hospice among older adults with end-stage kidney disease

BACKGROUND

Hospice care leads to improved patient and family outcomes. Hospice use among older adults with end-stage kidney disease (ESKD) is markedly lower than among older adults with other serious illnesses, and the majority of those with ESKD who use hospice enroll in the last days of life. Here, our aim was to explore barriers to timely receipt of high-quality hospice care for older adults with ESKD.

METHODS

Utilizing a qualitative study design, we conducted a secondary analysis focused on hospice, a theme that we identified in our larger overarching study that involved semi-structured interviews with 20 nephrologists in the United States focused on treatment decision-making in older adults with advanced chronic kidney disease. We analyzed the interview transcripts using emergent thematic analysis to develop an understanding of barriers to high-quality hospice.

RESULTS

With a couple notable exceptions, nephrologists voiced general support for the concept of hospice, but few recalled patients of theirs who had received hospice. Nephrologists' interviews revealed two interrelated contributors to the lack of timely access to high-quality hospice care for seriously ill older adults with ESKD: (1) nephrologists view dialysis and hospice as mutually exclusive models of care; (2) nephrologists feel unsure who should manage hospice care for patients with ESKD. The first contributor was rooted in nephrologists' narrow vision of when to consider hospice (informed, in part, by policy barriers) and, in a couple of cases, strong discomfort with hospice. The second stemmed from nephrologists' belief that neither they nor hospice are adequately prepared to provide hospice care for ESKD.

CONCLUSIONS

Our findings suggest that, in addition to Medicare policy change, nephrologists need to receive more training in primary palliative care skills including in indications for hospice, initiating conversations about hospice with patients, and collaborating with hospice clinicians to care for these vulnerable patients.

Physicians' perspectives on estimating and communicating prognosis in palliative care: a cross-sectional survey

Background

Advance care planning (ACP) can help to enhance the care of patients with limited life expectancy. Despite physicians’ key role in ACP, the ways in which physicians estimate and communicate prognosis can be improved.

Aim

To determine how physicians in different care settings self-assess their performance in estimating and communicating prognosis to patients in palliative care, and how they perceive their communication with other physicians about patients’ poor prognosis.

Design & setting

A survey study was performed among a random sample of GPs, hospital physicians (HPs), and nursing home physicians (NHPs) in the southwest of the Netherlands (n = 2212).

Method

A questionnaire was developed that had three versions for GPs, HPs, and NHPs. Each specialism filled in an appropriate version.

Results

A total of 547 physicians participated: 259 GPs, 205 HPs, and 83 NHPs. In the study, 61.1% of physicians indicated being able to adequately estimate whether a patient will die within 1 year, which was associated with use of the Surprise Question (odds ratio [OR] = 1.65, P = 0.042). In the case of a prognosis of <1 year, 75.0% of physicians indicated that they communicate with patients about preferences regarding treatment and care, which was associated with physicians being trained in palliative care (OR = 2.02, P=0.007). In cases where patients with poor prognosis are discharged after hospital admission, 83.4% of HPs indicated that they inform GPs about these patients’ preferences compared with 29.0% of GPs, and 21.7% of NHPs, who indicated that they are usually adequately informed about the preferences.

Conclusion

The majority of physicians indicated that they believe they can adequately estimate patients’ limited life expectancy and that they discuss patients’ preferences for care. However, more physicians should be trained in communicating about patients’ poor prognosis and care preferences.

How do healthcare practitioners talk about end-of-life conversations? A poetic inquiry

Despite agreement that end-of-life conversations should happen early on in the illness trajectory, it is widely acknowledged that healthcare practitioners often engage in these conversations when death is imminent or avoid the conversation altogether. Healthcare practitioners’ feelings of distress influence how end-of-life conversations are approached, yet thorough exploration of this emotional experience and its impact are largely missing from the literature. The aims of this preliminary scoping literature review using poetic inquiry were to examine physicians’ and nurses’ emotional distress in their accounts of how they approach end-of-life conversations, and to map key concepts relevant to exploring barriers to these conversations. The poetic findings highlight the differing nature of distress for physicians and nurses. Physicians’ distress appears to stem from adhering to their role of ‘curer’ when communicating with terminally ill adult patients at the end of life, whereas the sources of nurses’ distress appear to be interprofessional hierarchies and conflicts. Future research and training that uses methods to decentre and disrupt hierarchies and ingrained practices will be important to nursing practice and in improving end-of-life conversations. Arts-based approaches are one such method that could be pursued.

A knowledge synthesis of culturally- and spiritually-sensitive end-of-life care: findings from a scoping review

Background

Multiple factors influence the end-of-life (EoL) care and experience of poor quality services by culturally- and spiritually-diverse groups. Access to EoL services e.g. health and social supports at home or in hospices is difficult for ethnic minorities compared to white European groups. A tool is required to empower patients and families to access culturally-safe care. This review was undertaken by the Canadian Virtual Hospice as a foundation for this tool.

Methods

To explore attitudes, behaviours and patterns to utilization of EoL care by culturally and spiritually diverse groups and identify gaps in EoL care practice and delivery methods, a scoping review and thematic analysis of article content was conducted. Fourteen electronic databases and websites were searched between June–August 2014 to identify English-language peer-reviewed publications and grey literature (including reports and other online resources) published between 2004–2014.

Results

The search identified barriers and enablers at the systems, community and personal/family levels. Primary barriers include: cultural differences between healthcare providers; persons approaching EoL and family members; under-utilization of culturally-sensitive models designed to improve EoL care; language barriers; lack of awareness of cultural and religious diversity issues; exclusion of families in the decision-making process; personal racial and religious discrimination; and lack of culturally-tailored EoL information to facilitate decision-making.

Conclusions

This review highlights that most research has focused on decision-making. There were fewer studies exploring different cultural and spiritual experiences at the EoL and interventions to improve EoL care. Interventions evaluated were largely educational in nature rather than service oriented.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-016-0282-6) contains supplementary material, which is available to authorized users.

Communicating under medical patriarchy: gendered doctor-patient communication between female patients with overactive bladder and male urologists in Hong Kong

BACKGROUND

Gender differences between patients and doctors markedly influence the quality of communication in treatment processes. Previous studies have shown that communication between patients and doctors of the same gender is usually more satisfactory, particularly for female patients. However, in Hong Kong, where urology is a male-dominated specialty, female patients typically require medical care from male doctors for diseases such as overactive bladder (OAB). The literature about gender-related doctor-patient communication predominantly involves people in non-Chinese communities, with few studies conducted with Chinese populations. However, the differences between Western and Chinese cultures are expected to result in different treatment and communication experiences. Furthermore, OAB has received little attention in many Chinese communities; few studies in the literature address the communication quality between OAB patients and their urologists in Chinese communities, particularly regarding female OAB patients' experiences when seeking treatment from male urologists. This study, therefore, investigated the doctor-patient communication between female OAB patients and male urologists in Hong Kong.

METHODS

This study adopted a qualitative research approach by conducting semistructured interviews with 30 female OAB patients on an individual basis from April 2012 to July 2012. The participants were purposively sampled from a patient self-help group for OAB patients in Hong Kong.

RESULTS

The participants' communication experiences with male urologists were unpleasant. Embarrassment, feelings of not being treated seriously, not being understood, and not being given the autonomy to choose treatment approaches prevailed among the participants. Furthermore, the perceived lack of empathy from their urologists made the participants' communication experiences unpleasant.

CONCLUSIONS

The gender and power differential between the participants and their urologists, which was contributed by the social and cultural values of patriarchy and doctors' dominance in Hong Kong, made the participants' communication with the urologists unpleasant and difficult. Poor doctor-patient communication can endanger patients' treatment compliance and thus the treatment outcome. Although altering such social and cultural values would be difficult, providing complementary chronic care services, such as nurse-led clinics as well as support and sharing from patient self-help groups, might be a possible solution.

Hospice Attitudes of Physicians and Nurses

The purpose of this study was to gauge the attitudes of internal medicine (IM) physicians and hospice nurses on the hospice programs in a Southeastern US county. A postal survey sought views on the following issues: (1) the level of control that hospice affords dying patients; (2) health care professionals’ education and communication involving the dying process; (3) the hospice referral process; (4) characteristics of a “good death”; and (5) gender versus professional role regarding hospice attitudes. The data revealed that occupational role in hospice care has a more significant function in the development of cognitive attitudes than of gender regarding hospice programs and that professional education needs more emphasis on the study of end-of-life issues, as well as open communication between health care professionals and patients during the dying process. Physicians were less likely than nurses to agree that patient control was important. Additionally, what constitutes a good death was similar to previous studies.