Identifying barriers to psychosocial spiritual care at the end of life: a physician group study

OBJECTIVE: The recent literature addresses the need to improve care for dying patients. The purpose of this study was to identify barriers to the psychosocial spiritual care of these patients by their physicians. Psychosocial spiritual care is defined as aspects of care concerning patient emotional state, social support and relationships, and spiritual well-being. The study was an exploratory means for generating hypotheses and identifying directions for interventions, research, and training in care for the dying. DESIGN AND PARTICIPANTS: The study used a qualitative group discussion format. Seventeen physicians at a university-based health sciences center representing 10 areas of medical specialty--including internal medicine, oncology, pediatrics, and geriatrics met in two groups for 20 75-minute discussion sessions over the course of one year. Discussions were recorded, analyzed, and categorized. RESULTS: Barriers to psychosocial spiritual care were grouped into three domains and seven themes. The cultural domain included the themes of training, selection, medical practice environment, and debt/delay. Participants believed that medical selection and training combine to marginalize psychosocial spiritual approaches to patient care, while the practice environment and debt/delay augment emotional isolation and dampen idealism. The organizational domain included the themes of dissatisfaction and time/business. Physicians indicated that the current reimbursement climate and time pressures contribute to dissatisfaction and the tendency to avoid patient psychosocial spiritual issues. The clinical domain included the theme of communication. Physicians were concerned about their ability to communicate nonmedical issues effectively and manage the patient s reactions and needs in the psychosocial spiritual arena. CONCLUSIONS: This study suggests that research and educational approaches to improving the psychosocial spiritual care of the dying by physicians should address barriers at the cultural, organizational, and clinical levels. Suggestions for interventions at various levels are offered.     

Narrative nuances on good and bad deaths: internists' tales from high-technology work places

Public and professional discourses in American society about what constitutes a "good death" have flourished in recent decades, as illustrated by the pivotal SUPPORT study and the growing palliative care movement. This paper examines a distinctive medical discourse from high-technology academic medical centers through an analysis of how physicians who are specialists in internal medicine tell stories about the deaths of patients in their care. 163 physicians from two major academic medical centers in the United States completed both qualitative open interviews and quantitative attitudinal measures on a recent death and on the most emotionally powerful death they experienced in the course of their careers. A subsample of 75 physicians is the primary source for the qualitative analysis, utilizing Atlas-ti."Good death" and "bad death" are common in popular discourse on death and dying. However, these terms are rarely used by physicians in this study when discussing specific patients and individual deaths. Rather, physicians' narratives are nuanced with professional judgments about what constitutes quality end-of-life care. Three major themes emerge from these narratives and frame the positive and negative characteristics of patient death. Time and Process: whether death was expected or unexpected, peaceful, chaotic or prolonged; Medical Care and Treatment Decisions: whether end-of-life care was rational and appropriate, facilitating a "peaceful" or "gentle" death, or futile and overly aggressive, fraught with irrational decisions or adverse events; Communication and Negotiation: whether communication with patients, family and medical teams was effective, leading to satisfying management of end-of-life care, or characterized by misunderstandings and conflict. When these physicians' narratives about patient deaths are compared with the classic sociological observations made by Glaser and Strauss in their study A Time for Dying (1968), historical continuities are evident as are striking differences associated with rapid innovation in medical technologies and a new language of medical futility. This project is part of a broader effort in American medicine to understand and improve end-of-life care.     

Overcoming the tendency to lie to dying patients

A meaningful death can be fostered for a patient and his or her family with the aid of medical treatment, specifically through the alleviation of the patient's suffering and pain. To recognize the dying process is a part of the art of medicine. Compassionate care for dying patients includes a move from a curative model of care to a palliative model of care in defining the primary goal. Hospice volunteer training and practice is sufficient palliative care training to develop these skills. The time has come for incorporating palliative care into the curriculum of medical school.     

Clinical Update: Medical Care of Transsexual Patients

Transsexual patients often have difficulty finding care because many physicians are not comfortable prescribing appropriate hormone regimens. Management of hormones for transsexual patients is not difficult, and these medications are safer than many therapies routinely prescribed by the primary care physician. The diagnosis of gender identity disorder (GID) must be established by an experienced mental health professional prior to consideration for hormonal management. Medical evaluation includes a thorough medical history, social history, family history, physical examination, and basic laboratory screening. If there are no medical contraindications, a variety of regimens for the male-to-female transsexual may be initiated, with initial close follow-up for medical and psychological well-being. There is less variation in female-to-male management with testosterone, but initial frequent follow-up is equally important. This review is intended to teach primary care providers how to initiate and maintain hormone regimens for transsexual patients and describe medical issues unique to transsexual patients.     

Defining Competencies and Performance Indicators for Physicians in Medical Management

The recent and profound changes in the American health care delivery system have created a need for physicians who are trained and willing to assume a high level of responsibility for managing evolving health care organizations. Yet most physicians receive no formal training in medical administration and management because changes in medical school and residency education have lagged behind changes in clinical practice and reimbursement. To avoid haphazard approaches and unnecessary duplication of resources, it is important for physicians involved in managerial medicine to collectively identify competencies in this area needed in the marketplace. The American College of Preventive Medicine (ACPM), with funding from the Health Resources and Services Administration (HRSA), undertook an effort to identify competencies essential for physicians who will fill leadership roles in medical management. Like ACPM’s earlier effort to develop core competencies in preventive medicine, this project drew upon the theoretical model of competency-based education. This article describes the strategy we followed in reaching consensus among a diverse group of physician executives and preventive medicine residency program directors, and includes the list of medical management competencies and performance indicators developed. Recurrent issues that can sidetrack competency development projects are also presented as well as suggestions for overcoming them. The competencies can serve as a framework for expanding current core preventive medicine training in management and administration and for developing new training programs to equip physicians with the special expertise they will need to provide management leadership within the changing landscape of health care delivery.     

Negotiating natural death in intensive care

Recent empirical evidence of barriers to palliative care in acute hospital settings shows that dying patients may receive invasive medical treatments immediately before death, in spite of evidence of their poor prognosis being available to clinicians. The difficulties of ascertaining treatment preferences, predicting the trajectory of dying in critically ill people, and assessing the degree to which further interventions are futile are well documented. Further, enduring ethical complexities attending end of life care mean that the process of withdrawing or withholding medical care is associated with significant problems for clinical staff. Specific difficulties attend the legitimation of treatment withdrawal, the perceived differences between 'killing' and 'letting die' and the cultural constraints which attend the orchestration of 'natural' death in situations where human agency is often required before death can follow dying. This paper draws on ethnographic research to examine the way in which these problems are resolved during medical work within intensive care. Building on insights from the literature, an analysis of observational case study data is presented which suggests that the negotiation of natural death in intensive care hinges upon four strategies. These, which form a framework with which to interpret social interaction between physicians during end of life decision-making in intensive care, are as follows: firstly, the establishment of a 'technical' definition of dying--informed by results of investigations and monitoring equipment--over and above 'bodily' dying informed by clinical experience. Secondly, the alignment of the trajectories of technical and bodily dying to ensure that the events of non-treatment have no perceived causative link to death. Thirdly, the balancing of medical action with non-action, allowing a diffusion of responsibility for death to the patient's body; and lastly, the incorporation of patient's companions and nursing staff into the decision-making process.     

A better approach to care of the dying. Catholic healthcare and the Catholic community can present an alternative to physician-assisted suicide

To combat physician-assisted suicide, Catholic healthcare and the Catholic community cannot solely focus on mounting campaigns and formulating policies. They must also demonstrate an alternative way to approach death and care of the dying, taking a leadership role in improving end-of-life care. To accomplish this, Catholic healthcare must foster a culture that recognizes death as the inevitable outcome of human life and makes care for the dying as important as care for those who may get well. The ministry must acknowledge the limits of human life, human abilities, human ingenuity, and medical technology; and respect decisions to forgo life-sustaining therapies. In addition, physicians must address advance directives with patients before hospitalization and must be willing to offer hospice care as an option to dying patients and their families. More effective pain management must be devised. Catholic facilities must develop palliative care policies and commit to ongoing education to provide such care. It is essential that they pay attention to the environment in which patients die; identify the physical, psychosocial, and spiritual needs of family members; and use prayer and rituals in meaningful ways. With a clear focus on improving end-of-life care, Catholic healthcare--in partnership with other denominations--can eliminate some of the factors that can make physician-assisted suicide seem appealing to suffering people.     

Use of focus groups to assess the educational needs of the primary care physician for the management of asthma

OBJECTIVES: To determine the educational needs of primary care physicians, in the management of patients with asthma. DESIGN: Focus group discussions with physicians, pharmacists, respiratory therapists and patients. SETTING: Metropolitan Edmonton, Alberta, Canada. PARTICIPANTS: Out of an original mail request to 100 potential recruits, 52 people attended the focus group sessions. These included physicians, pharmacists, respiratory therapists, adult patients and paediatric patients accompanied by their parents. MAIN OUTCOME MEASURE: Consensus of the specific group being interviewed using facilitator-mediated responses, to identify problems in the care of asthma patients and appropriate educational methods to improve the situation. RESULTS: Both diagnostic and treatment concerns were identified by the primary care physicians and others in the study. Confusion with infection was the most common diagnostic problem. Major treatment problems involved confusion about aspects of management strategy and a lack of communication between physicians, patients and other members of the health care team. Poor patient compliance and patients changing doctors frequently were also of major concern. There were inconsistencies in the treatment of asthma between physicians. While most physicians felt that they were up-to-date in management, Asthma Control Guidelines were seldom followed. CONCLUSIONS: There is an urgent need for continuing medical education, not only in management but also in communication with patients and with other members of the health care team. The data permit the development of an ongoing educational programme which is practical and designed to deal with the issues identified in this survey.     

Support in a time of need. The team approach at Mercy Medical Hospice addresses medical, emotional, and spiritual needs

Mercy Medical Hospice, Daphne, AL, uses an interdisciplinary team approach, which includes medical, nursing, social work, pastoral care, pharmacy, therapies, volunteer, and bereavement services. Mercy Medical has two home care offices and offers inpatient respite care for short periods, which is helpful for those who have an inadequate care giver system or need time to work out a better alternative to care in the home. An assessment of medical and nursing care needs, mental and emotional state, and psychological and spiritual needs is the first step after patients enter hospice. The entire team develops a care plan for the patient and family. Among the issues they address are education about the disease process, medication for pain control and symptom management, and how the patient and family cope with the patient's imminent death. Working with the dying and their families can be stressful for staff members, and they offer each other a lot of support. Working in hospice requires good stress management techniques, but staff feel that it is a calling that enriches their lives.     

Risks,chances and perspectives of restricting the free choice of doctors by patients

Population surveys regarding free access to primary care physicians and medical specialists focus on selected aspects of public opinion. They are helpful but not sufficient in answering the relevant question: 'What are appropriate and efficient ways of access to the health care system?'. More important than survey results would be options for practical decisions by the patients themselves, based on a system offering different possibilities of choice. Competent piloting by 'gatekeepers' would need a problem- oriented and patient-centred medical education for primary-care physicians, starting during medical education and training and continuing throughout the professional medical careers. It should focus on three additional issues: New, alternative and unbiased ways of access to medical care should be developed, tried and evaluated to ensure beneficial use of the full potential of our health care system.     

Importance of nutritional issues among family physicians

Physicians spend three or more years after medical school in residency training. Nutrition education in medical schools is often absent or inadequate, but residency offers an excellent opportunity for appropriate training. A mail survey of all graduates of a family medicine residency was used to ascertain their nutrition interests and practices, obtaining an 86% response rate (142 responses). Almost all of these physicians counseled patients about nutrition and made referrals for patients with nutritional problems. About 63%, primarily those in metropolitan areas, referred patients to registered dietitians in private practice. These physicians believed that most nutrition issues were important in medical practice, especially nutrition in diabetes management, weight control and cardiovascular disease. Life cycle nutrition issues as a group were ranked as being more important than chronic disease or prevention issues. Physicians who were women, younger (40 years of age), or non-white ranked nutritional issues as more important to the practice of medicine. Nutrition education of physicians during residency should be encouraged, especially as it pertains to chronic disease and prevention.     

Changing the culture of dying. A new awakening of spirituality in America heightens sensitivity to needs of dying persons

Americans increasingly believe there are material solutions to all problems. Though we once accepted death as a part of life, we now think that--with enough technology--death can be controlled and postponed. Throughout this century, we have moved the dying process from the home to institutional settings. But institutions have a tendency to push all care to its logical end, which leads to alienation, fragmentation, and diminishment. Alienation is the result of the isolation and regimentation found in acute and skilled nursing care facilities. When care givers are indifferent to patients' pain, or do not know how to control it, they further impair the ability of dying persons to interact with others. Care for the dying person, "system by system, organ by organ," as is typical in institutional settings, fragments the dying process into a series of medical events. And, finally, institutionalized care often results in a diminishment of respect by care givers, who may come to view the dying person more as an object of academic interest than as a human whose spiritual needs may transcend physical ones. Such behavior has begun to show us the human costs of denying death and is contributing to a reawakening of spirituality in this country. The devastating effects of alienation, fragmentation, and diminishment can be ameliorated by a heightened sensitivity to the dying person's spiritual needs. With the proper supports, the dying process can be relocated from institutions to the home. Specialized training can educate healthcare professionals about palliative care and human needs at the end of life. We can rehumanize dying persons by first rehumanizing their care givers, specifically addressing the issues of stress and burnout on the job. Ultimately, the way we give care at the end of life reflects broader issues in U.S. culture. Only when communitarian values replace individualistic ones will resources be reallocated in a manner that best serves the most people. Only then will physicians, nurses, and other care givers receive rewards for supporting the dying person when tests and treatment are no longer needed.     

Effectively training the hospice and palliative medicine physician workforce for improved end-of-life health care in the United States

The widening gap between the demand for palliative care services and the supply of trained palliative care professionals has resulted in considerable end-of-life distress for patients. Without formal training in palliative medicine and end-of-life symptom management, physicians in the United States are less equipped to competently address seriously ill and dying patients' medical, emotional, and spiritual needs. Recent attempts within graduate medical education training deliberately seek to prepare a critical mass of physicians as the new hospice and palliative medicine workforce in the United States. In addition, healthcare reform proposals may re-define the National Health Service Corps (NHSC) post-graduate training over the next five years and the Hospice Medicare Benefit altogether. Healthcare policy options include steady changes at multiple levels of medical training -namely, medical school curriculum mandates, requiring all graduate physician residency training to foster patient-centered communication skills and discussions about advanced directives, and instituting palliative medicine proficiency Continuing Medical Education (CME) requirements for all states' medical licensing boards. Attracting qualified physicians to serve patients at the end of life, innovative medical school loan repayment programs and scholarships will also foster excellence in the field of hospice and palliative medicine. Correcting our current paucity of formal training in palliative medicine better utilizes hospice and restores patients' dignity at the end of life.     

Physicians' attitudes toward death and dying

INTRODUCTION: In the study the physicians' knowledge and attitude was examined towards death and dying. During the study a questionnaire survey was executed, including 124 physicians (family doctors from Budapest and from the country, hospital and clinical doctors) in which there were questions edited by the authors and also used the Lester and Neirmeyer scales to assess the fear of death. AIMS: The aim was to assess how much the physicians were prepared during their education to face with dying people and death, how much they are able to get in touch with dying patients, and how much they are afraid of death. METHODS: The questionnaires evaluated by the SPSS statistical program. RESULTS: According to results most physicians in Hungary have a very little knowledge with regard to death and dying. This lack of knowledge, their own fears and refusal in connection with the transitoriness can have a negative influence on their relationship with dying people: their attitudes towards dying are generally negative, many of them try to avoid dealing with the questions worrying the dying people and if after all there is a communication situation most of them avoid the more difficult fields instead. CONCLUSIONS: To draw attention to these problems, to point out the necessity of the gradual education of issues connected to death and dying and to stress how important is to mold attitudes towards dying people. The study is finished with some particular education program-proposals.     

Training physicians in communication skills with adolescents using teenage actors as simulated patients

Role-play exercises with simulated patients may serve the purpose of training professionals to develop appropriate communication skills with adolescents. Authentic adolescent responses toward the physicians may be achieved by actors who themselves are in their teenage years. We describe our experience in continuing medical education programmes for primary care physicians aimed at improving their skills in communicating with adolescents, using simulation methodology with teenage actors. Eight 16-17-year-old actors from the drama department of a high school for the arts were trained to simulate 20 cases with characteristic adolescent medical problems, as well as confidentiality issues and home and school problems. The actors performed in front of large groups of 20-30 paediatricians, family practitioners, or gynaecologists in continuing medical education. Diagnostic issues as well as therapeutic and management approaches were discussed, while the actors provided feedback to the trainees about their understanding and their feeling regarding the issues raised during the exercises. Normally, smaller learning groups are more suitable for such training purposes; nevertheless the participants could appreciate learning the principles of careful listening, a non-judgmental approach and assuring confidentiality. A collaboration of medical schools and postgraduate programmes with high schools which have drama departments may be fruitful in the teaching of adolescent medicine with special emphasis on communication skills with teenagers.     

Trends in the physician workforce, 1980-2000

Over the past twenty-five years the nation has struggled with a series of physician workforce issues: determining the appropriate number of physicians needed and the appropriate number to produce; the role of international medical school graduates; the mix of primary care and non-primary care physicians; efforts to increase the number of underrepresented minorities in medicine and the supply of physicians in rural areas; and the impact of the growing number of female physicians. This paper documents physician workforce trends over the past twenty years, especially as they relate to these issues.     

加强防范措施减少医疗纠纷

充分阐述了处理好医疗纠纷,加强宏观管理的重要及现实意义,并提出减少医疗纠纷的措施加强法制教育,努力维护患者及医生的合法权益;加强基本功训练,提高医务人员整体的技术水平;加强医院管理,建立健全并落实医院的各项规章制度.     

Does compassion include euthanasia? Physicians' roles in caring for the terminally ill preclude the use of euthanasia

As technological advances continue to allow physicians to prolong dying patients' lives, healthcare providers face many issues surrounding physician-assisted suicide and euthanasia. When a physician performs euthanasia or assists in suicide, he or she is killing the patient. The action can in no way be interpreted as allowing an eventually inevitable death to occur earlier rather than later. The physician is culpable. Physicians play three important roles when caring for terminally ill patients: adviser, friend, and priest. The risks inherent in each of these could create an illusion that performing euthanasia and assisting in suicide are humane and logical options. Finally, physicians should not miss opportunities for grace when caring for dying patients. When physicians convey the diagnosis, when patients express the desire to control the timing of the death, and when patients are feeling sadness and anger, physicians must rise to the occasion to act as friend and minister and to introduce grace and healing to the dying.     

Care of the dying: a Catholic perspective. Part I, Cultural context: a CHA document challenges care givers to define appropriate care for the dying

In a society tempted to adopt legalized assisted suicide and euthanasia as appropriate responses to dying, the healthcare community is challenged to nurture positive attitudes toward death among all ages and to help those with terminal illnesses to live well while dying. Whereas family and friends were once the primary care givers, now members of the healthcare professions are. This shift has introduced tensions between medical professionals and patients, including their families, in defining appropriate behavior toward the dying. To enable the terminally ill to live well while dying, we need to allow them to retain as much control as possible within the limits of belonging to a community. Also, we need to secure their network of significant relationships so they can experience the affective bonds of trust and love that support personal dignity and enhance the meaning of life. Medical technology is to be used in service of the total good of the patient. This includes not only the relief or cure that therapy can bring, but also what the patient prefers, values about life, and regards as giving ultimate meaning to life. Catholic healthcare institutions are challenged to promote a sensitivity and respect for cultural diversity as they respond to the needs of the dying and those who care for them.     

Good deaths,bad deaths: Older people's assessments of the risks and benefits of morphine and terminal sedation in end-of-life care

Little is known about end-of-life preferences or how risks are assessed surrounding doctor-patient or doctor-family relationships during end-of-life decision making. Older people are often excluded from end-of-life care research although there is some evidence that most would express preferences for 'comfort care' rather than life-sustaining interventions if facing terminal illness. This paper draws on data from focus group discussions with older people to illuminate how interpersonal and bodily aspects of the dying process are associated with shifting evaluations of two core techniques of palliative care: morphine administration and terminal sedation. Participants understood an idealised death to be that in which morphine administration and terminal sedation serve to provide dying people with an easy, comfortable and quiet death. In this, bodily symptoms of distress are discreetly controlled and death occurs at an appropriate time and place. At the same time the role of medicine in procuring an idealised death is linked to profound concerns about new risks that flow from the intermarriage of medical science with the basic human obligation of providing compassionate care to those who are dying.