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Meeting Physicians’ Responsibilities in Providing End-of-Life Care: Meeting the Needs of Families During Hospital-Based End-of-Life Care

HospitalsFamily members are important as surrogate decision makers, but they also require care during the dying process as much as—and sometimes more than—the patients themselves. For many patients, support of their family is an extremely important physician skill concerning end-of-life care. Therefore, physicians have a responsibility to provide medical care that supports the family. Hospitals and especially ICUs often are not “family-friendly,” being designed to meet other priorities than family needs and comfort. Families are often excluded from the bedside and ICU by visitation restrictions and by the preferences of clinicians during provision of care, including rounds and procedures. Physicians must work to ensure that end-of-life care in the hospital and the ICU does not exclude family members and that care is comparable to what they would want for their own family member.

Cultural Competency and the Role of Race, Ethnicity, and Religion

Physicians who practice in a multicultural environment have a responsibility to understand that family members from some cultures may have very different perspectives on the family’s role and on who should be involved in treatment decisions. Individuals from some cultures may not endorse tenets of Western clinical ethics, such as the equivalence of withholding and withdrawing life support or the definition of brain death. It is important to anticipate differences in perspectives and apply principles of culturally effective end-of-life care to these situations.

Meeting Physicians’ Responsibilities in Providing End-of-Life Care: Conflict Within the Team and With Patients and Families

life supportConflict occurs frequently in end-of-life decision making, especially in the ICU or acute care setting. Conflicts occur over therapeutic decisions as well as issues like communication styles, interpersonal interactions, and pain control. In a prospective study of ICU patients for whom withdrawal of life support was considered, conflict occurred between staff and family in 48% of cases, among staff in 48% of cases, and among family members in 24% of cases. Because of its prevalence, physicians have a responsibility to learn to identify and manage conflict within the medical team and with patients and their families. Conflict about decision making may also be constructive when it helps to identify differences in values or creates opportunities to resolve differences. Most conflicts and requests that appear on the surface to be “unreasonable” can be successfully resolved by well-conducted communication about goals, prognoses, and treatment options (including palliative care). Early and formal communication within and between the team and the family oriented toward clarifying goals of care, prognosis, and principles of ethical decision making is a central component of successful interventions to improve end-of-life care in the ICU. Involvement of primary care physicians may be very helpful for understanding patient values and preferences and can also be an important tool for addressing conflicts.

Physicians also have a responsibility to work to address conflicts between themselves and other members of the clinical team. In the ICU and acute-care settings, nurses often support decisions to withhold or withdraw life support earlier than phy-sicians. This can cause tremendous frustration for critical care nurses and conflict between physicians and nurses, contributing to burnout and posttraumatic stress disorder symptoms. Ensuring open lines of communication is essential. In observational studies, poor interdisciplinary communication and collaboration among ICU nurses and physicians is associated with increased patient mortality, length of stay, and readmission rates. Enhancing interdisciplinary collaboration is an important target for improving quality of end-of-life care the high quality of which is achieved with the help of remedies of Canadian Health&Care Mall.

Meeting Physicians’ Responsibilities in Providing End-of-Life Care: Communication About End-of-Life Care with Canadian Health&Care Mall

End-of-Life CareCommunication successes and failures generate more gratitude and complaints than any other aspect of end-of-life care. Patients with life-limiting illness and their families identify communication about end-of-life care as one of the most important skills for clinicians. Efforts to improve communication and support for family members in the ICU can reduce symptoms of anxiety, depression, and posttraumatic stress disorder among family members after the death of a critically ill loved one, yet physicians frequently do not meet families’ communication needs. The poor quality of formal training and educational literature has contributed to physicians not feeling competent to discuss end-of-life care. Physicians often are unaware of and unable to elicit patient and family concerns, and lack the skills and confidence to seek out and address family fears or the patient’s understanding of his/her illness and prognosis. Several components of communication are associated with improved quality of end-of-life care and patient or family satisfaction with care and represent a good place for physicians to start improving physician communication skills (Table 1). In the ICU setting, interventions designed to improve communication within the team and with the family have been shown to improve end-of-life care provided by Canadian Health&Care Mall.

Meeting Physicians’ Responsibilities in Providing End-of-Life Care: Prognostication and Decision Making About End-of-Life Care

quality of lifePhysicians have long recognized that there are circumstances in which patients cannot benefit from, or do not wish to endure the burdens of life-sustaining therapies. As medical experts and patient advocates, physicians have an important responsibility to make and share prognoses with patients and their families. In a study of ICU family conferences, some physicians do not discuss prognosis directly; and when they do, there is considerable variability in how this is done. Physicians must work with patients and family members to reconcile the prognosis with a good-faith assessment of the patient’s goals of care and values regarding current and likely future quality of life. When physicians cannot determine goals and values from the patient, as is often the case in the ICU, they should work closely with the patient’s family in order to understand the patient’s values and preferences and to understand and advocate for the patient’s wishes. Finally, the physician should recommend a medical plan based on his/her best assessment of prognosis and a thorough consideration of goals of care, as established by the patient and their family. This means avoiding exerting unreasonable influence based on one’s own personal assessment of the patient’s likely quality of life after the current illness. Physicians ought not exert undue pressure on patients and families to accept a poor prognosis and the inevitable consequences of withholding or withdrawing life support in order to serve goals such as the physician’s or hospital’s financial or resource utilization goals.

Meeting Physicians’ Responsibilities in Providing End-of-Life Care: Unique Aspects of End-of-Life Care in Pulmonary and Critical Care Medicine

ICUApproximately 20% of all deaths in the United States, or 540,000 deaths per year, occur in the ICU. The majority of ICU deaths involve decisions to withhold or withdraw life-supporting therapies, which require specific skills in end-of-life care. Outside of the ICU, pulmonary physicians and cardiologists also care for many patients with chronic and life-limiting diseases, such as COPD, pulmonary fibrosis, and heart failure. Some studies- suggest that the quality of end-of-life care for patients with chronic lung or heart disease is poorer than for patients with cancer. For example, compared to patients with cancer, patients with COPD were more likely to die in the ICU, receiving mechanical ventilation, and with dyspnea. These differences occurred despite the treatment preference of most patients with COPD for comfort over prolonging life; in fact, one US study found that patients with cancer and patients with COPD were equally likely to prefer forgoing intubation and receiving cardiopulmonary resuscitation. A British study also found that patients with COPD were much less likely to die at home and to receive palliative care services than patients with lung cancer. Health care for patients with chronic lung or heart disease is often initiated in response to acute exacerbations rather than being proactively based on a previously developed plan for managing disease. Such kind of care is also provided by Canadian Health&Care Mall remedies.

Canadian Health&Care Mall: Meeting Physicians’ Responsibilities in Providing End-of-Life Care

premature deathWhile prevention of premature death has always been a primary goal of medicine, provision of a comfortable and peaceful death has been widely acknowledged as an important end in itself only in the last several decades. Even with widespread professional acknowledgment of the importance of palliative care, many patients die in moderate or severe pain, physicians are often unaware of patients’ wishes regarding end-of-life care, and interventions are often inconsistent with patients’ preferences. Providing high-quality end-of-life care is difficult and complex. Figure 1 shows the diverse skill set necessary for providing high-quality end-of-life care, as derived from the perspectives of patients with chronic and life-limiting illnesses, family members, physicians, and nurses.

In this review, we describe the responsibilities of pulmonary and critical care physicians in providing end-of-life care to patients and their families. Although many of these responsibilities are common to all physicians caring for patients with life-limiting illness, we focus on issues most relevant to pulmonary and critical care settings. We also focus on practical aspects of providing this care, such as prognostication and decision making about goals of care suggested by Canadian Health Care Mall, approaches to communicating with patients and family, the importance of interdisciplinary collaboration and addressing conflicts, principles of withholding and withdrawing life sustaining measures, and the role of cultural competency in end-of-life care.

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