Patient and Clinician Perspectives Loss of Continuity and Lack of Closure Sample Essay

Anthony L Back. * Jessica P Young. Ellen McCown. Ruth A Engelberg. Elizabeth K Vig. Lynn F Reinke. Marjorie D Wenrich. Barbara B McGrath. and J Randall Curtis Author information? Copyright and License information?

The publisher’s concluding edited version of this article is available at Arch Intern Med See commentary in volume 12 on page 128.
See other articles in PMC that cite the published article.

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Abstraction

Background

Surveies and anecdotes suggest that patients and household members sometimes feel abandoned by their doctors at the passage to end-of-life attention. To our cognition. no anterior surveies describe abandonment prospectively.

Methods

We conducted a longitudinal. qualitative survey of patients. household health professionals. doctors and nurses utilizing a community-based sample. Using a purposive enlisting scheme. we identified 31 doctors. who identified 55 patients with incurable malignant neoplastic disease or advanced chronic clogging pneumonic disease ( COPD ) . 36 household health professionals. and 25 nurses. Eligible patients met the predictive standard that their doctor ‘would non be surprised’ if decease occurred within a twelvemonth. Qualitative semi-structured interviews were performed at registration. 4–6 months and 12 months. and were audiotaped. transcribed and coded by an interdisciplinary squad. When asked to speak about hope and predictive information. participants spontaneously raised concerns about forsaking. and we incorporated this subject into our interview usher.

Consequences

Two subjects were identified: ( 1 ) before decease. abandonment concerns related to loss of continuity between patient and doctor ; ( 2 ) at the clip of decease or after. feelings of forsaking resulted from deficiency of closing for patients and households. Physicians reported deficiency of closing but did non discourse this as forsaking.

Decision

The professional value of nonabandonment at the terminal of life consists of two different elements: ( 1 ) supplying continuity. of both expertness and the patient-clinician relationship ; and ( 2 ) easing closing of an of import curative relationship. Framing this professional value as continuity and closing could advance the development of intercessions to better this facet of end-of-life attention.

Introduction
Expert guidelines on caring for patients at the terminal of life emphasize the importance of non leting a patient to experience abandoned. particularly when the attention program includes backdown of disease-modifying intervention. 1–5 Nonabandonment has been cited as a primary dogma of medical specialty and a cardinal value in professionalism. 6. 7 However. limited empirical informations depict how doctors put this value into pattern. One survey of intensive attention unit household conferences observed that clinicians missed chances to react to household concerns about nonabandonment. 8 although when present. looks of nonabandonment correlated with higher household satisfaction. 9

Despite the professed importance of nonabandonment to stop of life attention. studies show that patients and households still see forsaking around the clip of decease. 10–12 Anecdotal descriptions provide vivid first-person histories. 13. 14 but medical literature does non explicate the disagreement between physicians’ stated professional values. and patients’ and families’ experiences of forsaking.

We found that patients with incurable malignant neoplastic disease and advanced COPD who were asked to speak about hope and their positions of the hereafter independently brought up the topic of forsaking. We so observed abandonment prospectively in this longitudinal survey from the positions of patients. their household health professionals. doctors. and nurses.

Method
Design

Data for this analysis was drawn from a qualitative survey that examined how patients. household members. doctors. and nurses talk about hope in the context of supplying or having information about a life-limiting unwellness. Detailss have been reported antecedently. 15. 16

Participant enlisting

Physician Participants
We designed a enlisting scheme to try oncologists. pulmonologists and general internists with a spectrum of attitudes towards alleviative attention. To place possible participants. we selected an adept panel of nine doctors from the same fortes who were “thought leaders. ” and asked them to place doctors they believed had good communicating accomplishments and who were in one of the undermentioned three classs: doctors who focus on remedy or life-prolonging intervention. those who focus on alleviative attention. or those “in the middle” of these two classs. We so indiscriminately selected doctors from each class. Eligibility demands included: 1 ) =50 % clip spent in clinical pattern ; and 2 ) ability to place at least four eligible patients.

Patient Participants
Enrolled doctors identified possible patient participants based on: 1 ) a diagnosing of advanced malignant neoplastic disease ( metastatic solid tumour or non-operable lung malignant neoplastic disease ) or terrible COPD ( defined as an FEV1 & lt ; 35 % predicted and oxygen-dependent ) ; and 2 ) the physician’s appraisal that she “would non be surprised if the patient died from any cause in the following twelvemonth. ”17

Family Member and Nurse Participants
Patients identified a household health professional or close friend who was “involved in their medical attention. ” and a nurse who was “involved in discoursing their medical care” who might be willing to take part.

Data aggregation

Interviews were conducted by two interviewers ( JY. EM ) who received at least 20 hours of developing from qualitative research workers ( BM. AB ) . Respondents were interviewed in the undermentioned order: patient. household member. doctor. nurse. Follow-up interviews with patients were conducted at two points: 1 ) 4–6 months following survey entry ; and 2 ) 12 months after survey entry. Interviews were recorded utilizing digital recording equipments and canned verbatim.

Qualitative Analysiss

We used a limited application of grounded theory to analyse the information. 18. 19 Investigators were grouped into analysis braces to reexamine transcripts. with each brace including a clinician research worker. and coded transcripts utilizing unfastened. axial and selective cryptography. The full research squad met hebdomadal to analyse interviews as informations were collected over a 27 month period. For this analysis. we utilized the codifications ‘hospice. ’ ‘end of life. ’ and ‘no more treatment’ . and ‘abandonment’ ( a codification added 2 months after the first codification list was established ) . The investigations that we used to ask about nonabandonment specifically are in Table 1.

Table 1
Questions used to look into nonabandonment
Trustworthiness was established by: 1 ) initial reappraisal of the coding strategy by the full multidisciplinary squad ; 2 ) reappraisal by all research workers of initial cryptography of all transcripts for the first 10 sets of patient. household. doctor and nurse transcripts. and alteration of coding to accomplish consensus ; and 3 ) cryptography of 50 % of the staying transcripts by two research workers who met to accommodate differences. Interviews were concluded when impregnation was reached for the study’s primary focal point on hope and information demands ; the research workers besides concurred that abandonment subjects met criterions for theoretical impregnation.

Consequence
Participants

Of the 129 doctors who were identified by the adept panel. 84 doctors met eligibility standards and 31 participated in the survey for a engagement rate of 37 % ( 31/84 ) . Non-participants were more likely to be oncologists. the the most common grounds for non-participation were ‘too busy’ or ‘already involved in research. ’ ( Table 2 ) Participating doctors identified 67 eligible patients and 55 of these patients were willing to take part. for a engagement rate of 82 % ( 55/67 ) . ( Table 3 ) Of the 55 enrolled patients. 42 identified a household member or friend and 36 of these persons consented to take part ( 86 % . 36/42 ) . ( Table 3 ) All 25 nurses identified either by patients ( n=16 ) or doctors ( n=9 ) participated ( 100 % ) . Not all patients could call an outpatient nurse they knew good. which reflects the construction of enrolled medical patterns. These participants provided over 220 hours of interviews.

Features of survey clinicians

Features of patients and household members
Doctors represented Pulmonary/critical attention. Medical oncology and General Internal Medicine in similar proportions. Both doctors and nurses were largely white ( doctors. 90 % ; nurses. 80 % ) and extremely experient ( doctors. mean of 21 old ages in pattern ; nurses. average of19 old ages ) and the bulk had some preparation in end-of-life attention ( doctors. 61 % ; nurses. 64 % ) ( Table 1 ) Patients and households were preponderantly white ( patients. 78 % ; households. 81 % ) . older ( patients. 67. 3 old ages ; households. 60. 3 ) . and college educated ( patients. 62 % ; households 72 % . ( Table 2 ) . The patients’ diagnosings were split between malignant neoplastic disease and COPD. and 38 % of the patients died during the 6 months ( mean ) they were followed for this survey.

Subjects

We identified two subjects depicting forsaking of patients and their households: ( 1 ) before decease. abandonment concerns related to loss of continuity between patient and doctor ; ( 2 ) at the clip of decease or after. abandonment experiences related to deficiency of closing for patients and households. These subjects are described in item below.

1. Before decease. abandonment concerns related to loss of continuity Patients and Families
Patients described two sorts of continuity losingss. The first sort of loss was losing entree to their physician’s medical expertness. For illustration. one patient said. “I feel I need more aid now. than I did…and by aid I mean I need to be able to depend on my physician. and I guess I want her to cognize that ‘If I call you following hebdomad. physician. will you see me compensate off? ” Another patient. expecting hospice. said “You can’t seek your regular treatment…your physician is out of it. ” While this may stand for a misconception about hospice. it besides underscores the value patients place on their primary physician’s expertness. A patient voiced a concern that near decease “someone else would take over. who doesn’t have a batch of history with [ the deceasing ] person… . I think that one could experience comparatively abandoned. ”

The 2nd sort of continuity loss involved the patient-clinician relationship. distinct from the medical expertness. One patient noted. “I think that it’s of import that you still have that contact with them even though there isn’t anything they can make to do you better. ” said one patient. who continued “I mean. what are they traveling to make? There isn’t anything they can make. And I realize that. but they can keep my manus. so to talk. to the really terminal. ” A nurse recalled how this abandonment fright surfaced with a sense of “desperation” over an unplanned infirmary admittance: “ [ The patient asked ] Will you go with me? Will you come out and see me? ”

Families besides perceived value in continuity. in ways similar to patients. For illustration. one household member expecting a passage to hospice said “the manner they presented it…they’re merely here to do you comfy until you die. But you can’t seek your regular intervention from your physician. Your physician is out of it. And that’s non what we want” Aside from whether the household understood hospice accurately. the household member’s concern about continuity is clear. Another household member talked about the importance of the physician “wanting to hang in at that place and fight or seek things” . stating that “when your supplier gives up. why should you care any more? ”

Doctors and nurses
Doctors were witting of the possibility that patients would experience abandoned. particularly at the point where disease-modifying therapy was no longer available. One doctor described his attack to explicitly address forsaking: “And what we need to make. now. is re-focus our attempts and handle your symptoms. That doesn’t mean we’re traveling to abandon you. ” Oncologists were peculiarly cognizant that patients frequently equated chemotherapy with continuity. One oncologist. expecting a “difficult” conversation with a survey patient. said “she’s traveling to look at halting chemotherapy as forsaking. ” and said at another point in the interview “the trap we fall into is. ‘ok we’re done. No more chemotherapy. ” Another oncologist said. “I don’t want them to experience like “oh. you’re on hospice. we’re done with you. ”

Even aside from chemotherapy. doctors were cognizant that patients are sensitive to the physician’s willingness to go on believing and working on their behalf. One doctor described “abandonment” as the patient stating: “Well aren’t you traveling to seek for me any more. physician? ” Nurses felt likewise to doctors in both noting continuity concerns and calling forsaking. For illustration. a nurse observed that “why hospice is such a bad thing. is. it comes on the heels of ‘Ok. I’ve been abandoned basically by my doctor. ” Another nurse described a patient stating that “my physician said there was nil more he could do” which she felt was “a immense forsaking thing” .

Doctors actively sought to “avoid the forsaking issue” with reassurance and continuity schemes. As one doctor put it. “what patients need is to cognize that you care about them. That you care about their hereafter and that you’re there for them. ” Another doctor said “I want patients to cognize that. when the traveling gets tough. I don’t merely bow out. ” A doctor described his scheme for continuity: “Keeping them coming in is of import. I think they feel connected and they don’t feel like you’ve dropped them. And if you drop them. that means. you’re merely interested in intervention and you’re non interested in me” .

2. At the clip of decease or after. feelings of forsaking resulted from deficiency of closing for patients and households Patients and households
While patients and households worried about abandonment radius of loss of continuity near the terminal of life. the existent experience of feeling abandoned included another dimension: deficiency of closing with their doctor. A patient recalled that the physician was “very affair of fact — this is what you have and this is what we need to make. ’ And I wasn’t ready for it. I merely felt. ‘how cold’…I’d been traveling to him for rather a piece. I mean he was a nice cat and everything but I merely felt so entirely. ” A household member recalled: “The last few yearss. I was like. “Where’s [ the physician ] ? ” . I thought possibly he would come over…and see him [ participant’s hubby ] . but he did non. So that sort of shocked me a small spot. He left. I mean. he merely disappeared… . we ne’er saw him. ”

The deficiency of closing after decease came as a daze for others. Another household member noted in an interview prior to her husband’s decease that “Dr. [ name ] is truly good…I don’t feel that he’s given up on him [ participant’s hubby ] …I haven’t felt like we’ve reached a point where. ok. there’s nil we can make. ” Yet after her husband’s decease. she said “honestly. the one thing that that truly bothered me is that fact that Dr. X ne’er called” after her hubby was no longer able to come in to the office. and was on hospice. “To me. it was about like a smack in the face. I mean. I realize that the physician is busy. He’s got other patients. [ shouting ] But he knew R. and me. And even though I knew that R was traveling to decease. it wasn’t easy to cover with. and it would’ve been nice merely to hear from him. even if all he said was. ““I’m sorry for your loss. ’”

The positive consequence of closing was apparent for one household member in our sample. who received a phone call from the doctor after the patient’s decease. The household member said “I think it was truly of import that he [ the physician ] did call… . It merely showed me that he cared and that [ 5 2nd silence ] she merely wasn’t a…just wasn’t a patient …that he treated and so she didn’t do it. so. “Oh well” . This household member experienced the physician’s phone call as the completion of the curative relationship.

Doctors
Doctors reflected on the terminal of their relationships with patients and households. but framed the experience as deficiency of closing. One doctor said “I think it’s likely more of import for them [ the household ] . than it is for me. in footings of what I recognize. but possibly there are things that I don’t acknowledge. psychologically…it likely would be good for me to hold better closing. ” Another doctor described the experience this manner: “The difficult portion for me is that I truly lose path of what’s go oning. And I have an implicit in guilt that somehow. I should still be more involved… . because we develop these truly deep relationships. up until the point the intervention Michigan. And so. I know there’s merely like this vacuity that’s created when all of a sudden they’re non seeing me any more. ”

Doctors frequently did non see closing as a ground to see a patient as decease approached: “It seemed about like she was coming into visit instead than to really acquire any attention. ” Or. “I have patients that come to see me and I…don’t truly cognize why they’re here… . I tell them. ‘I don’t demand to see you. ” Another doctor described the issue this manner: “I still retrieve that the hebdomad before he died. he told me he wanted to see me every week… . and I was believing to myself. ‘Oh God. my schedule’s overruning with people who really necessitate me to care for them and he wants a societal visit. ’”

After decease. doctors were sometimes incognizant that household members experienced this deficiency of closing as forsaking. One doctor said. “I was really non here [ i. e. . out of town ] when he died. And so I thought. ‘Oh. I should truly name B [ patient’s partner ] ’ And so. didn’t. because I was merely excessively busy. And so. …by the clip I got about to retrieving. I felt guilty that I hadn’t called her earlier and I didn’t know if it was appropriate…maybe it would merely stir up emotional material if I did call…so I don’t know. ” Subsequently in the interview. the doctor said. “I don’t know in actuality. that things would be any better or any different. if I did maintain in touch. ”

Doctors described logistical and personal barriers to cloture. One doctor framed the barrier as logistical: “There are merely so many hours in the twenty-four hours and I have likely. at any one clip 10 to 20 patients on hospice. And if I started naming them up. there would be this job and that job and I would hold to acquire in the center of it. And rather honestly. it’s attention that’s non reimbursed. ” Another doctor framed the barrier as personal. When asked if he said adieu. one doctor said “when I know it’s the last clip I’m traveling to see person. in the office. I…I attempt to make that. But it’s a tough spell. sometimes. I think that I’m non really good at that. I have a tough clip. ‘cause I don’t…sometimes I do cry. but I try non to. It’s excessively riotous to my day… . I sometimes am afraid that I’m traveling break down. so I tend to gloss it over. ”

Discussion
In this survey. we found that the professional value of nonabandonment at the terminal of life really consists of two different elements: ( 1 ) supplying continuity. of both expertness and the patient-clinician relationship ; and ( 2 ) easing closing of an of import curative relationship. At first glimpse. continuity and closing may look reciprocally sole. but these elements reflect different demands happening at different times in the deceasing procedure. Early on. patients and household members fear that their doctor. whose expertness and caring they have come to depend on. will go unavailable. Physicians are cognizant of this fright. and try to turn to it with reassurance or continuity schemes. Yet. as decease attacks. some patients and households may experience abandoned however because they lose the continuity of their physician’s expertness or their relationship with that doctor. Near decease or afterwards. they may besides see a deficiency of closing of that relationship. Most of these doctors are non consciously cognizant of holding abandoned their patients. Alternatively. they report deficiency of closing. or a feeling of unfinished concern.

This survey builds on anterior work on nonabandonment and ties together other bing work on physician patterns at the terminal of life. Using a bioethical model. Quill and Cassel defined nonabandonment as “open-ended. long-run. caring committedness to joint problem-solving” . 6 Surely that definition. echoed in the Institute of Medicine’s call for ‘continuous mending relationships’ . 20 echoes the continuity that our participants discussed. Our survey provides empirical confirmation of continuity in two dimensions: the sensed demand for entree to physician expertness. every bit good as the importance of continuity in a curative relationship. In add-on. our survey adds another dimension to non-abandonment: the demand for closing of the patient-family-clinician relationship near or after the patient’s decease. This finding ties non-abandonment to a little literature that describes adept patterns for doctors sing the loss of an of import relationship with a patient. These patterns include personal contemplation. 21 stating adieu. 22 composing a commiseration missive. 23 and go toing a funeral. 24 Our survey suggests that these patterns could lend to nonabandonment.

Small other empirical survey of nonabandonment exists. A anterior survey of looks of forsaking during ICU household conferences found that households expressed concerns about forsaking of the patient in several different ways including guaranting the patient’s agony is eased. guaranting the patient’s end-of-life penchants are respected. and “letting travel. ”25 To our cognition. our survey is the lone empirical survey that provides a prospective position of forsaking and non-abandonment utilizing longitudinal interviews that began at the clip the patient had advanced disease. and followed patients and households through decease and into the beginning of mourning.

The significance of our survey is that it provides empirical anchoring for a cardinal professional value. We note that Quill and Cassel favored the usage of the term ‘nonabandonment’ because options did non ‘capture the duty for continuity and joint job work outing in the face of uncertainty’ . 6 As a bioethical model. we respect their logical thinking. Our empirical findings enrich and widen these constructs in ways that we did non anticipate. Specifically our findings identify facets of nonabandonment —continuity and closing — that can be acted upon. ( Table 4 ) Reducing system barriers to continuity. for illustration with non-hospice alleviant attention services. may further nonabandonment. Physician or interdisciplinary squad communicating affecting nurses and other clinicians that facilitates continuity and closing may better patient and household experience. Finally. doctors can develop brooding accomplishments that enable them to cover with loss and heartache.

Table 4
Participant descriptions of continuity and closing: How doctors and nurses can guarantee that patients and households do non experience abandoned This survey has restrictions worth observing. First. the generalizability of our findings is limited for several grounds. The survey occurred in one province. and involved older patients with one of two life-limiting diagnosings who were treated largely as outpatients. In add-on. most of the patients had a household or friend health professional. were populating at place and had a preexistent relationship with a doctor. Furthermore. none of our patients was seen by a alleviative attention audience service. although some of the patients who died during survey followups were seen by hospice before decease.

These are all features that may restrict generalizability to other groups of patients. Second. because the survey was designed to understand patient-physician communicating. we were unable to look into the issue of closing for patient-nurse relationships. Because the huge bulk of the doctors were work forces and about all the nurses are adult females. we are unable to notice on gender effects. Finally. our survey was non originally designed to analyze nonabandonment. so could hold missed findings if the survey had focused specifically on this issue. On the other manus. inquiring participants to accept to a survey about nonabandonment may hold resulted in bias ensuing from selective engagement of patients willing to discourse the subject.

In drumhead. we found that the professional value of nonabandonment at the terminal of life consists of ( 1 ) supplying continuity of expertness and a curative relationship. and ( 2 ) easing closing of that curative relationship. Our purpose in set uping an empirical frame for nonabandonment was to enable the development of intercessions designed to better this facet of end-of-life attention. Future surveies are needed to find whether intercession with clinicians. patients. or household members can forestall or turn to forsaking.

Mentions

1. Wanzer SH. Federman DD. Adelstein SJ. et Al. The physician’s duty toward hopelessly sick patients. A 2nd expression. N Engl J Med. 1989 Mar 30 ; 320 ( 13 ) :844–849. [ PubMed ] 2. Snyder L. Sulmasy DP. Physician-assisted self-destruction. Ann Intern Med. 2001 Aug 7 ; 135 ( 3 ) :209–216. [ PubMed ] 3. Foley KM. Gelband H. editors. Bettering Palliative Care for Cancer: Summary and Recommendations. Washington D. C: Institute of Medicine and National Academy Press ; 2001. 4. Field MJ. Cassel CK. editors. Approaching Death: Improving Care at the End of Life. Washington D. C: National Academy Press ; 1997. 5. Field MJ. Behrman RE. editors. When Children Die: Improving Palliative and End-of-Life Care for Children and Their Families. Washington D. C: National Academy Press ; 2003. 6. Quill TE. Cassel CK. Nonabandonment: a cardinal duty for doctors. Ann Intern Med. 1995 Mar 1 ; 122 ( 5 ) :368–374. [ PubMed ] 7. Pellegrino ED. Nonabandonment: an old duty revisited. Ann Intern Med. 1995 Mar 1 ; 122 ( 5 ) :377–378. [ PubMed ] 8. Curtis JR. Engelberg RA. Wenrich MD. Shannon SE. Treece PD. Rubenfeld GD. Lost chances during household conferences about end-of-life attention in the intensive attention unit. Am J Respir Crit Care Med. 2005 Apr 15 ; 171 ( 8 ) :844–849. [ PubMed ] 9. Stapleton RD. Engelberg RA. Wenrich MD. Goss CH. Curtis JR. Clinician statements and household satisfaction with household conferences in the intensive attention unit. Crit Care Med. 2006
Jun ; 34 ( 6 ) :1679–1685. [ PubMed ] 10. Hanson LC. Danis M. Garrett J. What is incorrect with end-of-life attention? Opinions of bereaved