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 contributing to the quality of physicians' care for dying patients. DESIGN: Qualitative study using focus groups and content analysis based on grounded theory. SETTING: Seattle, Washington. PARTICIPANTS: Eleven focus groups of patients with chronic obstructive pulmonary disease, AIDS, or cancer (79 patients); 3 groups of family members who had a loved one die of chronic disease (20 family members); 4 groups of nurses and social workers from hospice or acute care settings (27 health care workers); and 2 groups of physicians with expertise in end-of-life care (11 physicians). RESULTS: We identified 12 domains of physicians' skills at providing end-of-life care: accessibility and continuity; team coordination and communication; communication with patients; patient education; inclusion and recognition of the family; competence; pain and symptom management; emotional support; personalization; attention to patient values; respect and humility; and support of patient decision making. Within these domains, we identified 55 specific components of physicians' skills. Domains identified most frequently by patients and families were emotional support and communication with patients. Patients from the 3 disease groups, families, and health care workers identified all 12 domains. Investigators used transcript analyses to construct a conceptual model of physicians' skills at providing end-of-life care that grouped domains into 5 categories. CONCLUSIONS: The 12 domains encompass the major aspects of physicians' skills at providing high-quality end-of-life care from the perspectives of patients, their families, and health care workers, and provide a new framework for understanding, evaluating, and teaching these skills. Our findings should focus physicians, physician-educators, and researchers on communication, emotional support, and accessibility to improve the quality of end-of-life care.