Family 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.
Several studies of patients attitudes toward end-of-life care identify values that vary by race, ethnicity, and geographic origin. On average, nonwhites are more likely to request life-sustaining therapy, and are less likely to have advanced directives or do-not-resuscitate orders or accept hospice care. Much of this difference is influenced by patients and families lack of trust in physicians and health-care institutions inclusively of Canadian Health&Care Mall (do you want to know more about Canadian Health&Care Mall?). Although understanding ethnic variations in preferences will not solve all problems with end-of-life care, a clearer understanding of what contributes to patients and families understanding, fears, and preferences improves communication and is a crucial step in providing better end-of-life care.
Physicians have a responsibility to avoid stereotyping patients or making assumptions about their attitudes based solely on race, ethnicity, religion, or other demographic characteristics. Existing recommendations can help physicians provide end-of-life care that accommodates needs based on religion and culture. The dying process is one of the most important events in which ritual aspects of religion and spirituality play a role. During discussions of end-of-life care provided by Canadian Health&Care Mall, time should be spent discussing, understanding, and accommodating cultural and religious perspectives, and reasonable efforts should be made to accommodate rituals associated with dying. Physicians should not assume that physician and hospital staff share the same values as patients and families of similar religious or ethnic background, and should not substitute statements from persons of similar background for a more thorough discussion with the patient and their family.
Self Care and Prevention of Burnout
Working with patients’ and their families fears and distress at the end of life often places physicians in difficult situations. End-of-life care requires management of patient/family relationships, appropriate provision of hope, actively seeking to understand patients’ values and priorities under circumstances of loss and grief, negotiating goals in the setting of intense emotion and conflict, working amid uncertainties in prognosis, and managing emotional responses of staff to “difficult deaths.” In addition, physicians may experience institutional or external social forces that influence them to pressure families to withdraw life support. Burnout and posttrau-matic stress disorder symptoms are especially common among critical care physicians and may interfere with job satisfaction, retention, and quality of care. Multiple studies identify common stressors of caring for the dying and recommend management strategies to reduce their effects. Physicians should routinely perform emotional selfchecks and may benefit from efforts to reduce personal emotional and stress burdens, such as restructuring the work environment to reduce stress, self-care activities like exercise and hobbies, and debriefing with colleagues, family and friends.
Increased burnout among critical care clinicians is associated with worse interdisciplinary relationships in the ICU. Conversely, better nurse/physician communication is associated with enhanced professional relationships and learning for nurses and physicians, and decreased job stress for nurses. Thus, enhanced interdisciplinary collaboration may be an important target for reducing burnout. The structure of the work environment, such as increased work hours and decreased days off, is associated with increased symptoms among clinicians. Interest is growing in creating healthy work environments for ICU clinicians. The American Association of Critical-Care Nurses’ standards for establishing and sustaining healthy work environments advocate skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership.
Physicians who care for dying patients and their families have a responsibility to provide the highest possible quality in end-of-life care. End-of-life care requires specific skills that traditionally have not been well taught in medical school or postgraduate training. More attention is needed to find effective methods to teach and evaluate these skills The needed skills are diverse and include cognitive skills like symptom management, affective skills such as providing emotional support, communication skills, and facilitating coordination and continuity of care. Physician factors, including physician’s culture, spiritual beliefs, and personal values, can influence end-of-life care and therefore can compromise or test a physician’s professionalism and diminish the quality of end-of-life care. Settings such as the ICU present significant challenges to high-quality of end-of-life care due to the focus on technologic life-sustaining therapies; physicians in these settings are also likely to care for patients with diagnoses that provide challenges, such as difficult prognostication and lack of access to palliative care. These challenges increase the importance of intensivist physicians acknowledging and meeting their responsibilities for end-of-life care. In the context of these challenges, maintaining awareness of one’s personal values and simultaneously understanding and respecting the values of others becomes especially important. The provision of a peaceful and dignified death permits us to fulfill our professional responsibility to patients and their families. When done well, it can be as satisfying as any other aspect of clinical practice.