Clinicians' attention lacking in discussions of end-of-life care

Clinicians consistently fall short in discussing end-of-life care with patients with chronic obstructive pulmonary disorder (COPD), according to a study completed by researchers in Washington. The study focused on the communication skills of staff physicians, physician trainees and advanced practice nurses.

Results of the study will be presented at the ATS 2011 International Conference in Denver.

Although previous studies have shown that patients and healthcare systems benefit when engage in end-of-life conversations with patients diagnosed with life-limiting illnesses, current research suggests that clinicians often elect to focus on life-preserving treatments and avoid conversations about patients' preferences for end-of-life care, noted study author Lynn F.
Reinke, PhD, ARNP, research investigator at VA Puget Sound , Seattle.

"In this study, clinicians under-addressed all seven end-of-life topics with their patients, with four of the items being rarely discussed and the remaining three items discussed only some of the time," she said "The findings from our study confirm previous research that clinicians under-address end-of-life topics that are important to patients."

Dr. Reinke said the goal of the study was to describe patient-clinician about end-of-life care from patients' perspectives by examining responses from a specially designed questionnaire focusing on the quality of communication.

"We were interested in which end-of-life care topics were addressed and which were not, as well as patient ratings of the quality of communication about those topics," she said. "We also looked at whether clinician characteristics such as training, practice location, sex and length of clinician-patient relationship were associated with specific end-of-life communication topics being addressed or not addressed."

The researchers reviewed questionnaire responses from 376 patients diagnosed with severe, stable COPD, who were seen by a total of 92 clinicians, including 31 staff physicians, 33 physician trainees and 28 advanced practice nurses. Most of the clinicians practiced in general internal medicine clinics and pulmonary clinics.

The researchers found all seven end-of-life topics were under-addressed and of those, four were not discussed 77 percent to 94 percent of the time, including how long patients might live; what dying may be like; future treatment decisions; and patients' spiritual/religious beliefs. When these topics were addressed, patients reported high satisfaction levels for discussions of three of the four items, while discussion of the topic of what dying may be like was rated poor to fair.

There were no associations between clinicians' characteristics that were measured and whether or not they addressed end-of-life topics.

"Only one item – 'involving you in decisions about the treatments that you want if you get too sick to speak for yourself' - was addressed more often by clinicians that had a relationship with the patient of more than five years," Dr. Reinke said.

Dr. Reinke said she hopes these results will be used to help develop and test practical skills to help clinicians effectively address patients' end-of-life care concerns in an outpatient setting.

"It may be difficult for clinicians to discuss end-of-life topics, but our study and previous studies confirm that most patients with COPD want to have these conversations," Dr. Reinke said. "Developing an intervention that focuses on these specific sensitive topics and the appropriate time to address these issues with may improve patient satisfaction with clinicians' care.

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