Physician Behavior toward Death Pronouncement in Palliative Care Units

Abstract

Background:

There are few studies on bereaved caregivers' perceptions of physician behavior toward death pronouncement. Although previous research indicates that most caregivers are satisfied with physician behavior toward death pronouncement at home hospices, bereaved caregivers' perceptions of death pronouncement in palliative care units (PCUs) have not been investigated.

Objective:

The aim was to examine bereaved caregivers' perceptions of physician behavior toward death pronouncement in PCUs.

Design and Methods:

This was a cross-sectional questionnaire survey of bereaved caregivers who had lost a family member in a PCU. Measures were based on a previous study to assess bereaved caregivers' evaluations of physician behavior toward death pronouncement.

Results:

Of 861 questionnaires sent to bereaved caregivers, 480 responses were analyzed. Overall, 86% of bereaved caregivers were satisfied with physician behavior toward death pronouncement. Logistic regression analysis revealed three predictors of caregiver satisfaction: “Polite behavior” (odds ratio [OR]: 0.12; 95% confidence intervals [CI]: 0.03–0.46; p < 0.01), “Physician introduced himself/herself to family” (OR: 0.3; 95% CI: 0.1–0.8; p = 0.02), and “Physician confirmed death automatically or routinely” (OR: 11.6; 95% CI: 4.7–28.4; p < 0.01). Caregivers whose family member's death was confirmed by the primarily responsible physician were significantly more satisfied than those whose family member's death was confirmed by an unfamiliar physician.

Conclusions:

Most caregivers who lost family members in PCUs were satisfied by the physicians' behavior toward death pronouncement. Politeness was one of the most important factors associated with caregiver satisfaction.

Introduction

The impact of bereavement on families varies and can be influenced by the circumstances of the bereavement. Death pronouncement is one of the most important moments in the bereavement process. The physician's behavior toward death pronouncement may affect the bereavement process of caregivers. Appropriate behavior toward death pronouncement is an essential skill that physicians must learn¹ and various guidelines are available.^2–6 However, there is some evidence that the guidelines are not always followed or used appropriately in clinical practice.⁷ In addition, there are no data on whether the effects of education about death pronouncement are retained over many years.

Kusakabe et al. investigated bereaved caregivers' evaluations of physician behavior toward death pronouncement in home hospice settings.^8,9 The results showed that most bereaved caregivers were satisfied by physician behavior toward death pronouncement. However, the authors did not include bereaved caregivers who had lost a loved one in other settings, such as palliative care units (PCUs) or acute care hospitals. There has been increasing attention on PCUs as peaceful locations in which people can spend their final days and the number of PCUs has been increasing.¹⁰ It is therefore important to examine how physicians approach death pronouncement in PCUs. We aimed to examine bereaved caregivers' perceptions of physician behavior toward death pronouncement in PCUs.

Methods

Procedure

This was a nationwide, cross-sectional, anonymous, self-report questionnaire survey of bereaved family caregivers of patients who had died of cancer in PCUs. The study was part of the Japan Hospice and Palliative Care Evaluation study. Details of the procedure have been published previously.¹¹ Seventy-one PCUs/hospices participated in this study. Each site identified consecutive bereaved family caregivers of patients with cancer who had died before January 2016. The questionnaire was sent to bereaved family caregivers. Inclusion criteria were (1) patients had died of cancer in a PCU; (2) patients' age of death was 20 years or older; (3) the bereaved family caregivers were aged 20 years or older; and (4) the patients had spent at least their last three days in the PCU. Exclusion criteria were (1) missing contact information for the family caregivers and (2) if the primarily responsible physicians judged that the caregivers were suffering from severe distress and/or would be incapable of completing the questionnaire. Based on information from the site lists, the questionnaire was sent to bereaved family caregivers between May 2016 and July 2016. All ratings were provided by the bereaved family caregivers. The review board of each participating site approved this study.

Measurements

We developed original questionnaires that asked caregivers to report the physician's behavior toward death pronouncement and the sociodemographic background of caregivers and deceased patients. Questions were created based on literature reviews and expert consensus.^8,9 Caregivers rated their overall satisfaction with the behavior toward death pronouncement using a six-point Likert scale. If a physician who was not the primarily responsible physician and was unfamiliar to caregivers carried out the death pronouncement, caregivers were asked to answer additional questions.

Statistical analyses

Sociodemographic data from deceased patients and bereaved caregivers were summarized using descriptive statistics. We compared the proportion of responses between caregivers who were satisfied and those who were dissatisfied. A chi-square test was used to analyze the categorical data and Fisher's exact test was used when the expected values in any of the contingency table cells were below 5. A pairwise deletion method was used to manage missing data. For the logistic regression analysis, a forward selection method was used to determine the predictors of caregivers' satisfaction. All statistical analyses were conducted using SPSS version 19.0 (IBM Corp., Armonk, NY).

Results

A total of 861 questionnaires were sent to bereaved caregivers. Of these, 618 were returned (response rate: 72%). After excluding caregivers who declined study participation (n = 82), who were not present at the death pronouncement (n = 47), and whose responses were not valid for other reasons (n = 9), 480 responses were statistically analyzed. Table 1 shows the sociodemographic data for deceased patients and bereaved caregivers. Overall, 86% of bereaved caregivers were satisfied with the physician's behavior toward death pronouncement (data not shown in tables).

Table 1.

Sociodemographic Data for Patients and Caregivers (N = 480)

	Mean	SD	Range
Bereaved caregivers
Age	62.1	12.2	24–93
Length of time since death	285.7	133	86–976

	n	%
Sex
Male	154	32.1
Female	316	65.8
Missing	10	2.1
Relationship
Spouse	215	44.8
Child	184	38.3
Son-/daughter-in-law	21	4.4
Parent	11	2.3
Sibling	27	5.6
Other	14	2.9
Missing	8	1.7
Education
Elementary school to high school	258	53.7
Vocational school, junior college	94	19.6
Undergraduate	97	20.2
Graduate	7	1.5
Other	2	0.4
Missing	22	4.6
Religion
None	140	29.2
Buddhism	281	58.5
Christianity	16	3.3
Shinto	12	2.5
Others	12	2.5
Missing	19	4

	Mean	SD	Range
Deceased patients
Age	75.3	11.4	30–97

	n	%
Sex
Male	270	56.3
Female	209	43.5
Missing	1	0.21
Primary cancer site
Lung	106	22.1
Liver, bile duct, pancreas	98	20.4
Stomach, esophagus	68	14.2
Colon, rectum	56	11.7
Prostate, kidney, bladder	36	7.5
Breast	20	4.17
Ovary, uterus	22	4.6
Head and neck	19	3.96
Lymphatic system	11	2.29
Brain	7	1.46
Soft tissue	6	1.25
Unknown origin	5	1.0
Bone marrow	4	0.83
Blood	2	0.42
Other	19	3.96
Missing	1	0.21
Marital state
Married	296	61.7
Single	24	5
Widowed	127	26.5
Divorced	19	4
Missing	14	2.9
Living with others
Yes	340	70.8
No (living alone)	129	26.9
Missing	11	2.3

SD, standard deviation.

Table 2 shows physician behavior toward death pronouncement. As reflected in the high rate of overall satisfaction, most physicians behaved properly and politely at death pronouncement.

Table 2.

Caregiver Perceptions of Physician Behavior toward Death Pronouncement (n = 480)

	Caregivers' perceptions
	“I think so”		“I don't think so”		Missing
	n	%	N	%	n	%
General behavior of the physician
He/she acted calmly, not rushed	440	91.7	17	3.5	23	4.8
Physician's appearance was unsuitable	35	7.3	401	83.5	44	9.2
Physician's behavior was polite	433	90.2	17	3.5	30	6.3
Physician confirmed death automatically or routinely	122	25.4	316	65.8	42	8.8
Practice of death pronouncement
He/she introduced himself/herself to family members	414	86.3	34	7.1	32	6.7
Checked for lung and heart sounds using a stethoscope	337	70.2	80	16.7	63	13.1
Checked pupils for response to light	430	89.6	15	3.1	35	7.3
Did not clearly verify the time of death	29	6.0	422	87.9	29	6.0
Left the patient's clothes disheveled	16	3.3	431	89.8	33	6.9
Explained the cause of death to the family members intelligibly	238	49.6	190	39.6	52	10.8
Wrote the death certificate courteously	365	76.0	66	13.8	49	10.2
Care for family members
He/she identified the relationship of persons present	298	62.1	140	29.2	42	8.8
Confirmed that all important family members were present before death pronouncement	286	59.6	147	30.6	47	9.8
Waited until family members were well prepared	305	63.5	111	23.1	64	13.3
Expressed empathy to family members	210	43.8	220	45.8	50	10.4
Touched the family members' backs or shoulders as an expression of empathy	35	7.3	390	81.3	55	11.5
Demonstrated a religious attitude (worship with folded hands, a Buddhist style)	273	56.9	121	25.2	86	17.9
Provided sufficient time for asking questions	239	49.8	170	35.4	71	14.8

Table 3 shows the associations between caregivers' perceptions about behavior toward death pronouncement and caregivers' satisfaction levels. Two subscales that contained questions about physician behaviors were associated with caregiver satisfaction levels. The logistic regression analysis revealed three predictors of caregivers' dissatisfaction with death pronouncement: “The physician's behavior was polite” (odds ratio [OR]: 0.12; confidence intervals [95% CI]: 0.03–0.46; p < 0.01), “The physician introduced himself/herself to family members” (OR: 0.3; 95% CI: 0.1–0.8; p = 0.02), and “The physician carried out death pronouncement automatically or routinely” (OR: 11.6; 95% CI: 4.7–28.4; p < 0.01).

Table 3.

Comparison of Perceptions of Physician Behavior toward Death Pronouncement in Caregivers with High Satisfaction and Caregivers with Low Satisfaction

	Caregivers with high satisfaction (n = 413)		Caregivers with low satisfaction (n = 59)
	n	% ^a	n	% ^a	p^b
General behavior of the physician
He/she acted calmly, not rushed	383	96.7	51	92.7	0.14
Physician's appearance was unsuitable	22	5.8	13	23.6	<0.01
Physician's behavior was polite	383	97.7	44	84.6	<0.01
Physician confirmed death automatically or routinely	79	20.8	41	74.5	<0.01
Practice of death pronouncement
He/she introduced himself/herself to family members	374	96.1	36	66.7	<0.01
Checked for lung and heart sounds using a stethoscope	304	83.5	31	62.0	<0.01
Checked pupils for response to light	378	97.2	48	92.3	0.09
Did not clearly verify the time of death	23	5.9	5	9.4	0.36
Left the patient's clothes disheveled	13	3.3	3	5.7	0.42
Explained the cause of death to the family members intelligibly	224	60.5	12	22.2	<0.01
Wrote the death certificate courteously	331	88.5	29	55.8	<0.01
Care for family members
He/she identified the relationship of persons present	275	72.4	21	38.9	<0.01
Confirmed that all important family members were present before death pronouncement	265	71.2	15	27.8	<0.01
Waited until family members were well prepared	283	78.2	20	39.2	<0.01
Expressed empathy to family members	201	54.0	8	14.8	<0.01
Touched the family members' backs or shoulders as an expression of empathy	34	9.3	1	1.8	0.06
Demonstrated a religious attitude (worship with folded hands, a Buddhist style)	250	72.0	20	46.5	<0.01
Provided sufficient time for asking questions	223	63.4	15	28.3	<0.01

Numbers and percentages represent total numbers of “I think so” responses.

Chi-square test was used. Fisher's exact test was used if expected values were less than 5.

Of 480 death pronouncements, 178 were performed by a physician who was not the patient's primarily responsible physician. Caregivers who were present at a death pronouncement by a physician who was unfamiliar to them were significantly less satisfied compared with those who were present at a death pronouncement by the primarily responsible physician (Supplementary Table S1; Supplementary Data are available online at www.liebertpub.com/jpm). Almost 77% percent of caregivers thought that an ideal physician should introduce himself/herself to caregivers during death pronouncement (Supplementary Table S2). However, at least 38% of physicians who were unfamiliar to caregivers did not introduce themselves (Supplementary Table S3).

Discussion

Most bereaved caregivers (86%) were satisfied with the physicians' behavior toward death pronouncement in PCUs. A previous study in Japan similarly found that bereaved caregivers were highly satisfied with the behavior toward death pronouncement in home hospice settings.⁸ We found that politeness was associated with caregiver satisfaction with death pronouncement. Traditionally, the Japanese society emphasizes the importance of showing politeness and respect to maintain a harmonious atmosphere in social situations. In this context, death pronouncement represents not only a medical diagnosis but also a ritual performance in caregivers' bereavement process. Checking for lung and heart sounds using a stethoscope, a behavior associated with caregiver satisfaction, may have an important symbolic meaning for caregivers in this social setting. The beauty and delicacy of ritual communications, such as the tea ceremony, have been cultivated traditionally in Japan for hundreds of years.¹² Physicians and family caregivers may be unconsciously affected by social norms linked with such communications. Thus, polite and respectful behavior toward death pronouncement is likely to satisfy caregivers.

Approximately 40% of caregivers felt they did not receive sufficient explanations about death, and 35% felt they did not have enough time to ask questions just after the death pronouncement (Table 2). Family members may find it difficult to understand the details of the disease trajectory and the challenges of the situation. Physicians may need to consider caregivers' capacity to understand the situation and help them accept it by providing simple explanations and inviting questions. Caregivers were more likely to be satisfied when physicians expressed their empathy_. Physicians may need to recognize caregivers' expectations in this regard and ensure that they respond empathically.

Our results showed that when patient death was confirmed by an unfamiliar physician, caregivers were significantly less satisfied than when death was confirmed by the primarily responsible physician. Although 82% of caregivers did not think it mattered whether it was the primary responsible physician who confirmed the death, the traditional view in Japan is that death pronouncement should be performed by the primarily responsible physician. This may help to explain the effect of physician identity on differences in caregiver satisfaction. We recommend that physicians who are unfamiliar to caregivers should be aware of those factors associated with caregiver satisfaction (as identified by our multiple regression analysis).

We should mention some limitations to this study. First, this was a cross-sectional study, so the possibility of recall bias must be considered. Second, the instrument used to assess physician behavior toward death pronouncement was developed based on expert opinions. The validity or reliability of this measure was not statistically examined. There may be other unmeasured factors related to ideal physician behavior toward death pronouncement. Third, participants were restricted to caregivers who had lost a family member in a PCU; therefore, our findings may not generalize to other populations. Further research will be aimed at investigating the evaluation of death pronouncement in acute care hospitals.

Conclusion

The study findings show high degrees of satisfaction with death pronouncement in bereaved caregivers with family members who died of cancer in a PCU. Politeness was one of the most important factors associated with caregiver satisfaction with physician behavior toward death pronouncement.

Footnotes

Acknowledgments

This study was part of the Japan Hospice and Palliative Care Evaluation 2016 (J-HOPE2016) study and was funded by Hospice Palliative Care Japan. We thank Diane Williams, PhD, from Edanz Group () for editing a draft of this article.

Author Disclosure Statement

No competing financial interests exist.

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