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End-of-Life Care

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Palliative care study challenges assumptions about physician emotional involvement and communication with patients

A new study of doctor-patient relationships and palliative care weighs the consequences of physicians' emotional involvement with patients, dependence on protocols for handling difficult communication issues, and unqualified reliance on consumer empowerment to assure that care is responsive to patients' needs. It also questions the adoption of narrowly defined boundaries between medical and social service systems in caring for patients.

Michael J. Yedidia, Ph.D., of Rutgers University, suggests that medical schools should help prepare doctors to appropriately manage their emotions in routine clinical work through personal awareness training, facilitating reflection on the effectiveness of interactions with patients through use of standardized patients and videotapes, and expanding physicians' capacity to address a broad range of patient needs through teamwork training.

Dr. Yedidia observed the care of 40 patients in the inpatient hospice unit and at home, interviewed patients and family members, and interviewed 22 doctors and 2 nurses providing end-of-life care to these patients. He examined five dimensions of doctor-patient relationships: range of needs addressed, source of authority (for example, for tests or treatments), maintenance of trust, emotional involvement, and expression of authenticity.

He concluded that addressing patients' needs to maintain their identities as their illnesses progress is central to the delivery of effective hospice care, and requires sensitivity to patients' belief systems and models of health and illness. This may entail modifying established procedures to harmonize with particular patient and family expectations. In making clinical decisions, providers rarely relied strictly on their status as experts in asserting authority.

Both physicians and patients agreed that belief in the provider's technical competence was essential to establish trust, but not sufficient to maintain it, particularly as care shifted from curative to palliative goals. Patients had to feel they would not be abandoned, regardless of the unpleasantness of the illness or the uncertainties of the therapy. Often, the physician's emotional involvement served as a mechanism for entering the patient's world.

Finally, patients' needs are often entangled with complex social problems, are too numerous to address in the course of a normal workday, and require a team approach.

The study was supported by the Agency for Healthcare Research and Quality (HS13654).

See "Transforming doctor-patient relationships to promote patient-centered care: Lessons from palliative care," by Dr. Yedidia, in the January 2007 Journal of Pain and Symptom Management 33(1), pp. 40-57.

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