Understanding physicians' skills at providing end-of-life care - Perspectives of patients, families, and health care workers

BACKGROUND: A framework for understanding and evaluating physicians' skills at providing end-of-life care from the perspectives of patients, families, and health care workers will promote better quality of care at the end of life. OBJECTIVE: To develop a comprehensive understanding of the factors contribu ting to the quality of physicians' care for dying patients. DESIGN: Qualitative study using focus groups and content analysis based an grounded theory. SETTING: Seattle. Washington. PARTICIPANTS: Eleven focus groups of patients with chronic obstructive pulm onary disease, AIDS, or cancer (79 patients); 3 groups of family members wh o had a loved one die of chronic disease (20 family members); 4 groups of n urses and social workers from hospice or acute care settings (27 health car e workers); and 2 groups of physicians with expertise in end-of-life care ( 11 physicians). RESULTS: We identified 12 domains of physicians' skips at providing end-of- life care: accessibility and continuity; team coordination and communicatio n; communication with patients; patient education; inclusion and recognitio n of the family; competence: pain and symptom management; emotional support : personalization: attention to patient values; respect and humility; and s upport of patient decision making. Within these domains, we identified 55 s pecific components of physicians' skills. Domains identified most frequentl y by patients and families were emotional support and communication with pa tients. Patients from the 3 disease groups, families, and health care worke rs identified all 12 domains. Investigators used transcript analyses to con struct a conceptual model of physicians' skips at providing end-of-life car e that grouped domains Into 5 categories. CONCLUSIONS: The 12 domains encompass the major aspects of physicians' skil ls at providing high-quality end-of-life care from the perspectives of pati ents, their families, and health cart workers, and provide a new framework for understanding, evaluating, and teaching these skills. Our findings shou ld focus physicians, physician-educators, and researchers on communication, emotional support, and accessibility to improve the quality of end-of-life care.