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 Table of Contents 
ORIGINAL ARTICLE
Year : 2013  |  Volume : 2  |  Issue : 3  |  Page : 263-265  

End of life discussion in an academic family health team in Kingston, Ontario, Canada


1 Department of Family Medicine, Queen's University, Kingston, Ontario, K7L5E9, Canada
2 Department of Family Medicine; Centre of Studies in Primary Care, Queen's University, Kingston, Ontario, K7L5E9, Canada

Date of Web Publication29-Oct-2013

Correspondence Address:
Lawrence Leung
Department of Family Medicine, Centre of Studies in Primary Care, Queen's University, Kingston, Ontario, K7L5E9
Canada
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DOI: 10.4103/2249-4863.120749

PMID: 24479094

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  Abstract 

Background: End-of-life (EOL) discussions remain difficult in non-terminal patients as death is often perceived as a taboo and uncertainty. However, the call for proper EOL discussions has recently received public attention and media coverage. Evidence also reveals that non-terminal patients are more satisfied with health-care encounters when EOL has been discussed. Objectives and Methods: The objective of this study was to explore the prevalence of EOL discussions in non-terminal adult patients, the perceived barriers to such discussions and suggested methods for improvement. A study mixed-methods study was performed by a group of PGY1 family medicine residents in an academic health team in Kingston, Ontario. Results: EOL discussion was performed in a very small proportion of non-terminal patient encounters. Compared with attending physicians, residents were less likely to discuss EOL issues and reported more perceived barriers. Conclusion: Our findings reflect the need for an early and open approach in conducting EOL discussion for non-terminal healthy patients.

Keywords: End of life discussion, patient-centred care, mixed-methods study


How to cite this article:
French R, Zhang W, Parks K, Ashton S, Dumas M, Haider A, Leung L. End of life discussion in an academic family health team in Kingston, Ontario, Canada. J Fam Med Primary Care 2013;2:263-5

How to cite this URL:
French R, Zhang W, Parks K, Ashton S, Dumas M, Haider A, Leung L. End of life discussion in an academic family health team in Kingston, Ontario, Canada. J Fam Med Primary Care [serial online] 2013 [cited 2014 Sep 1];2:263-5. Available from: http://www.jfmpc.com/text.asp?2013/2/3/263/120749


  Introduction Top


End-of-life (EOL) discussion is a challenging issue in primary care as death often conjures negative connotations in both patients and clinicians. [1] Unfortunately, lack of proper EOL discussion will leave the patient with feelings of conflict, uncertainty and unpreparedness when confronted with dying. Dula and Williams also pointed out that there are contradictory views between different ethnic origins when it comes to EOL discussion, in particular, the African-Americans often prefer more aggressive care than their Caucasian cohorts. [2] Recently, concern is mounting for better EOL discussion between healthy individuals and health-care providers to ensure a smoother transition and avoid ambiguity regarding life support measures. Nevertheless, EOL discussion is rarely a regular agenda item of regular doctor-patient consultation. There is also wide variation in access to EOL care. [3] When advanced EOL directives were absent, health-care providers often felt compelled to provide futile therapy under legal pressures, especially in intensive care settings. [4] Despite 70% of US population wish to die at home, the same percentage end up dying in hospitals and nursing homes. [5] On the contrary, terminal patients who had EOL discussions reported better quality-of-life and entailed lesser care costs in their last week of life. [6]


  Objectives and Methods Top


In order to explore the prevalence of EOL discussion in non-terminal patients and clinicians' views on barriers to EOL discussion, we performed a mixed-methods study, which included a patient records review followed by an online survey to medical practitioners in an academic Family Heath Team in Kingston, Ontario. From the electronic medical records database, 350 patient records were randomly selected and were screened for incidence of EOL discussion using the key terms. We then distributed an anonymous on-line survey to all medical practitioners (attending physicians and PGY1 residents) in the health team. The survey consisted of seven structured questions exploring the respondents' willingness to initiate EOL discussions, the type of patients that warrant discussion, potential barriers to discussions and improvements that may eliminate such barriers.


  Results Top


Out of 350 medical records, 69 of them were initially flagged after electronic search using the relevant key words. Further manual analysis of paper records confirmed four patients (1%) who had a relevant and documented EOL discussion. The online survey was distributed by E-mail to 100 primary care providers (43 attending physicians, 53 PGY1 residents and four nurse practitioners) and a response rate of 37% was recorded [Figure 1]a,b. A number of perceived barriers to EOL discussion were identified [Table 1]. Finally, we recorded factors that may encourage more EOL discussions: provision of patient information pamphlet, tailored-made worksheet for patients and families, modifications in the electronic medical record for documenting EOL discussions and structured teaching sessions for care providers to facilitate EOL discussions.
Figure 1:

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Table 1: Perceived barriers to EOL discussions

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  Discussions and Conclusion Top


Existing data on the prevalence of EOL discussions in non-terminal patients is extremely sparse. Our study revealed that such discussion only happened in 1% of encounters in non-palliative family medicine setting. This contrasts the expressed wish for EOL discussions as revealed by various studies. [7],[8],[9] A recent study in Japan showed that EOL discussion in healthy elderly patients led to more acceptance of advanced directives and less preference of artificial nutrition as the life-sustaining measure. [10] The likelihood of EOL discussion also depends on factors specific to the patients (e.g., age and comorbidity) and to the care providers (e.g., training status and time constraints). One study among healthy older adults showed that patients with recent hospitalization [11] or bereavement from death of a loved one [11],[12] often facilitated EOL discussions. Ways to enhance EOL discussions would include printed information for patients, prompts in the medical record system and organized teaching for care providers. Having said, our study had limitations: possible biases due to small sample and generalizability of data to the community setting. Nevertheless, we do believe primary care providers are the best suited to conduct and maintain EOL dialog with patients and those EOL discussions should be initiated as early as possible and not to be postponed until the end is foreseeable for the patients. This paper serves to sustain the need for a more proactive discussion of EOL care among non-terminal patients.

 
  References Top

1.Karver SB, Berger J. Advanced care planning - Empowering patients for a peaceful death. Asian Pac J Cancer Prev 2010;11 Suppl 1:23-5.  Back to cited text no. 1
    
2.Dula A, Williams S. When race matters. Clin Geriatr Med 2005;21:239-53.  Back to cited text no. 2
    
3.Menec VH, Nowicki S, Kalischuk A. Transfers to acute care hospitals at the end of life: Do rural/remote regions differ from urban regions? Rural Remote Health 2010;10:1281.  Back to cited text no. 3
    
4.Palda VA, Bowman KW, McLean RF, Chapman MG. "Futile" care: Do we provide it? Why? A semistructured, Canada-wide survey of intensive care unit doctors and nurses. J Crit Care 2005;20:207-13.  Back to cited text no. 4
    
5.Goodman E. Die the way you want to: Taking charge of your last days eases everyone's burden, 2012. Available from: http://hbr.org/2012/01/tackling-social-problems/ar/pr.  Back to cited text no. 5
    
6.Zhang B, Wright AA, Huskamp HA, Nilsson ME, Maciejewski ML, Earle CC, et al. Health care costs in the last week of life: Associations with end-of-life conversations. Arch Intern Med 2009;169:480-8.  Back to cited text no. 6
    
7.Balaban RB. A physician's guide to talking about end-of-life care. J Gen Intern Med 2000;15:195-200.  Back to cited text no. 7
    
8.Tulsky JA, Fischer GS, Rose MR, Arnold RM. Opening the black box: How do physicians communicate about advance directives? Ann Intern Med 1998;129:441-9.  Back to cited text no. 8
    
9.Smucker WD, Ditto PH, Moore KA, Druley JA, Danks JH, Townsend A. Elderly outpatients respond favorably to a physician-initiated advance directive discussion. J Am Board Fam Pract 1993;6:473-82.  Back to cited text no. 9
    
10.Matsui M. Effectiveness of end-of-life education among community-dwelling older adults. Nurs Ethics 2010;17:363-72.  Back to cited text no. 10
    
11.Carr D, Khodyakov D. End-of-life health care planning among young-old adults: An assessment of psychosocial influences. J Gerontol B Psychol Sci Soc Sci 2007;62:S135-41.  Back to cited text no. 11
    
12.Carr D. "I don't want to die like that ...": The impact of significant others' death quality on advance care planning. Gerontologist 2012;52:770-81.  Back to cited text no. 12
    


    Figures

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    Tables

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Abstract
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