Doctors', Nurses' Opinions Differ About End-of-Life Care

Veronica Hackethal, MD

September 08, 2014

Physicians have more positive perceptions about end-of-life care than nurses, according to a survey conducted among healthcare professionals at hospitals and cancer clinics in Germany and published online September 8 in Cancer.

"We found that 72% of physicians believe it is usually possible for patients to die a dignified death on their ward, but only 52% of nurses shared this opinion," commented lead author Karin Jors, MA, from the University Medical Center Freiburg, Germany.

"This difference in perception suggests that physicians and nurses may need to communicate more effectively with each other about the needs of dying patients," she told Medscape Medical News.

The researchers surveyed 1131 physicians and nurses in 16 hospitals and 10 cancer centers in Baden-Wuerttemberg, Germany, between January 2012 and May 2013. The respondents were 75% female and 25% male; notably, 26% were physicians and 67% were nurses.

"Nurses may be more aware of the discrepancy between physicians' good intentions and the actual care received by patients," Jors explained. "Physicians may have the desire to spend more time with patients and inform them comprehensively about potential treatments, but in reality, this may not always be possible."

The authors speculated that nurses' opinions might be affected by lower levels of job satisfaction in general and more frequent contact with patients.

On the other hand, physicians' sense of responsibility for providing the best care may also play a role in their survey answers and opinions, said Jors.

The new study is "unique," according to Arif Kamal, MD, who was not involved in the study and is director of quality and outcomes at the Duke Cancer Institute, Durham, North Carolina.

Little evidence compares nurses and physicians regarding their perceptions about the quality of end of life care, Dr. Kamal told Medscape Medical News. However, there is a "sense" within the profession that physicians may tend to be overly optimistic about the quality, he said.

Dr. Kamal also said it was "quite sobering" that only about half (57%) of all providers in this study agreed that a "dignified death" in a hospital was usually or always possible.

Dr. Kamal liked the efficiency of the "dignified death" assessment in the study.

"The use of the construct of a 'dignified death' is an excellent high-level way to assess the overall quality of end-of-life care," Dr. Kamal explained. "It truly captures the snapshot of what the care, conditions, and environment were like for those that die while in the hospital."

The study results are applicable to the United States and other industrialized countries, Dr. Kamal suggested.

"Compared to the US, palliative care has a longer and more robust history in Europe overall, including Germany. The German infrastructure for palliative care is considered one of the best networked, coordinated, and developed in the world," Dr. Kamal pointed out. "These findings…are probably optimistic compared to what we may find in other westernized countries."

The survey revealed that healthcare staff also need better resources, such as appropriate patient rooms, adequate training, and enough time for bedside care, according to Jors.

More than half (55%) of all respondents thought rooms for dying patients were "unsatisfactory," and only 20% felt they were "well-prepared to care for the dying." In addition, 50% felt they "rarely had enough time to care for dying patients." Almost 90% of respondents indicated a "considerable" need for improved training in end-of-life care.

End-of-life care in the United States, especially as delivered by oncologists, suffers from the same problems found in this study, according to Dr. Kamal. The percentage of patients who die of cancer while in the hospital in the United States is also similar to that in Germany, Dr. Kamal added, although the trend over the last decade has been toward home-based and long-term care.

The survey participants included palliative care staff, who seemed to have more positive viewpoints than non–palliative care staff.

About 92% of palliative care staff thought sufficient pain medication was used at the end-of-life, while 82% of non–palliative care physicians and 65% of nurses thought so. Only 4% of palliative care staff thought life-prolonging measures were used too often, compared with 12% of physicians and 33% of nurses who were not palliative care staff.

End-of-life care has improved over the last several decades in Germany, but there is still room for improvement, summarized Jors.

"Over the last 25 years, considerable improvements in the care of patients dying in the hospital setting have taken place," she said. "Our results demonstrate the positive influence of palliative care on the end-of-life situation. We therefore encourage the integration of palliative care into standard oncology care, beginning as early as diagnosis. We also advocate that palliative care becomes a required subject in medical and nursing education."

Recent medical advances have enabled physicians to extend life, with death often perceived as a "failure" on the part of physicians, the authors pointed out. But life-sustaining measures that continue until death can negatively affect quality of care in the end of life, they also say.

Limitations of the new study include a possible sampling bias: Not all cancer centers agreed to participate, and those with better conditions may have been more willing. So these results may be "more optimistic" than reality, the authors noted.

The authors and Dr. Kamal have disclosed no relevant financial relationships.

Cancer. Published online September 8, 2014. Abstract

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