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/busyness. 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.
Lo B: Improving care near the end of life. Why is it so hard?JAMA. 1995; 274(20): 1634-1636.
3.
Weggell JM: Barriers to the physician decision to offer hospice as an option for terminal care. WMJ. 1999; 98(3): 49-53.
4.
Quill TE: Initiating end-of-life discussions with seriously ill patients: Addressing the “elephant in the room.”JAMA. 2000; 284(19): 2502-2507.
5.
Allard P, Maunsell E, Labbe J, et al.: Educational interventions to improve cancer pain control: A systematic review. J Palliat Med. 2001; 4(2): 191-203.
6.
McSkimming SA, Super A, Driever MJ, et al.: Living and Healing During Life-Threatening Illness. Portland, OR: Supportive Care of the Dying: A Coalition for Compassionate Care, 1997.
7.
Rousseau P: Spirituality and the dying patient. J Clin Oncol. 2000; 18(9): 2000-2002.
8.
Block SD: Psychological considerations, growth, and transcendence at the end of life: The art of the possible. JAMA. 2001; 285(22): 2898-2905.
9.
MacLeod RD: On reflection: Doctors learning to care for people who are dying. Soc Sci Med. 2001; 52(11): 1719-1727.
10.
Prigerson HG, Jacobs SC: Perspectives on care at the close of life. Caring for bereaved patients: “All the doctors just suddenly go.”JAMA. 2001; 286(11): 1369-1376.
11.
Sollner W, DeVries A, Steixner E, et al.: How successful are oncologists in identifying patient distress, perceived social support, and need for psychosocial counselling?Br J Cancer. 2001; 84(2): 179-185.
12.
Butow PN, Brown RF, Cogar S, et al.: Oncologists’ reactions to cancer patients’ verbal cues. Psychooncology. 2002; 11(1): 47-58.
13.
von Gunten CF, Ferris FD, Emanuel LL: The patient-physician relationship. Ensuring competency in end-of-life care: Communication and relational skills. JAMA. 2000; 284(23): 3051-3057.
14.
Wenrich MD, Curtis JR, Shannon SE, et al.: Communicating with dying patients within the spectrum of medical care from terminal diagnosis to death. Arch Intern Med. 2001; 161(6): 868-874.
15.
Astin JA, Astin AW: An integral approach to medicine. Altern Ther Health Med. 2002; 8(2): 70-75.
16.
Chochinov HM: Dignity-conserving care—a new model for palliative care. JAMA. 2002; 287(17): 2253-2260.
17.
Lo B, Ruston D, Kates LW, et al.: Discussing religious and spiritual issues at the end of life. A practical guide for physicians. JAMA. 2002; 287(6): 749-754.
18.
Lynn J, Nolan K, Kabcenell A, et al.: Reforming care for persons near the end of life: The promise of quality improvement. Ann Intern Med. 2002; 137(2): 117-122.
19.
Morgan DL: Focus Groups as Qualitative Research. Beverly Hills, CA: Sage Publications, 1988.
20.
Sofaer S: Qualitative methods: What are they and why use them?Health Serv Res. 1999; 34(5 Pt 2): 1101-1118.
21.
Murphy B, Murphy M: Focus groups in health research. Health Promotion J Aust. 1992; 2: 37-40.
22.
Chibnall JT, Videen SD, Duckro PN, et al.: Psychosocial-spiritual correlates of death distress in patients with life-threatening medical conditions. Palliat Med. 2002; 16(4): 331-338.
23.
Pope C, Mays N: Reaching the parts other methods cannot reach: An introduction to qualitative methods in health and health services research. BMJ. 1995; 311(6996): 42-45.
Kosmin BA, Mayer E, Keysar A: American Religious Identification Survey. The Graduate Center City University of New York Web site. Available at www.gc.cuny.edu/studies/aris_index.htm. Accessed April 17, 2003.
26.
Steinhauser KE, Christakis NA, Clipp EC, et al.: Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA. 2000; 284(19): 2476-2482.
27.
Meier DE, Back AL, Morrison RS: The inner life of physicians and care of the seriously ill. JAMA. 2001; 286(23): 3007-3014.
28.
Federation of State Medical Boards of the United States, Inc. (FSMB) and National Board of Medical Examiners (NBME). USMLE Clinical Skills Examination (CSE) Web site. Available at www.usmle.org/news/Step2CSNews/newsrelease2503.htm. Accessed April 17, 2003.
29.
Miller DK, Duckro PN, Videen SD, et al.: Life Threatening Illness Supportive-Affective Group Experience: The LTI-SAGE Program. Supportive Care of the Dying Web site. Available at www.CareOfDying.org/default.asp?goto=ToolsForChange.html. Accessed April 17, 2003.
30.
Brady DW, Corbie-Smith G, Branch WT Jr: “What’s important to you?” The use of narratives to promote self-reflection and to understand the experiences of medical residents. Ann Intern Med. 2002; 137(3): 220-223.
31.
Novack DH, Suchman AL, Clark W, et al.: Calibrating the physician. Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient. JAMA. 1997; 278(6): 502-509.
32.
Steinberg C: Support groups for doctors are gaining members. Physicians Financial News. 2002; 20(2): 1,12.
33.
Clarke D, Coleman J: Balint groups. Examining the doctor-patient relationship. Aust Fam Physician. 2002; 31(1): 41-44.
