Digest Commentator: Teja Voruganti, MD-PhD student, University of Toronto

Edited by: Mary Ann O’Brien, Department of Family and Community Medicine, University of Toronto and Jennifer Brunet, School of Human Kinetics, University of Ottawa

With a patient population that is aging and increasingly diverse, it is crucial that doctors be aware of and incorporate patient values and preferences into end-of-life (EOL) discussions, However, these conversations can be challenging to initiate for a number of reasons, though there is a dearth of research as to what these are. Periyakoil et al. 2015 have conducted a study to identify and explore doctor-reported barriers to having EOL discussions with patients.

Using a cross-sectional design, 1040 of 1234 (84%) senior medical residents at two academic hospitals were recruited to complete a survey. Participants were sampled from a variety of medical subspecialties and were advanced enough in their training to have experienced caring for seriously ill patients at the end of life. The survey consisted of three questions, one of which asked for a rating on a 5-point scale of whether EOL discussions with patients of diverse backgrounds was challenging and another was an open-ended question of barriers faced in conducting EOL conversations. A mixed methods approach to analysis was done. The quantified responses were analyzed with respect to medical specialty, identifying barriers more important to specific specialties. A qualitative approach was used to analyze open-ended responses from all participants.

The majority of participants were Caucasian or Asian (82.3%). Most trainees (85.7%) reported that having EOL conversations was challenging, with participants of Asian and African American ethnicities indicating that they struggled most. Of six barriers identified, “language and medical interpretation” in interactions with patients and families was reported to be most problematic by all participating residents. Other barriers included perceptions of patients’ religious beliefs and expectations about EOL, physicians’ ignorance about cultural practices at EOL, patients’ cultural differences in decision making and truth handling, limited patient health literacy, and patient mistrust of the medical system. Specialty-based differences in rating the relative importance of each barrier were observed. Emergency medicine specialists rated limited patient health literacy as higher relative to other specialties; neurologists reported that doctors’ ignorance of cultural beliefs/practices was a major barrier; and psychiatrists rated patients’ cultural differences in decision making/truth handling as more challenging to EOL discussions.

Why I liked this article: This study has identified six major barriers to the effective conduct of EOL discussions. An important implication of this study is that it demonstrates a clear need to better train doctors in ways to facilitate EOL discussions that are culturally-sensitive and meaningful to a patient’s own situation. As the population lives longer and becomes more ethnically diverse, an awareness of these barriers may serve as a framework for developing appropriate knowledge and attitudes in the care management of patients especially in fields such as oncology.

Article. Periyakoli, VS, Neri, E, Kraemer, H (2015). No easy talk: a mixed methods study of doctor reported barriers to conducting effective end-of-life conversations with diverse patients. PLoS ONE 10(4): e0122321. doi:10.1371/journal.pone.0122321

Journal website: http://journals.plos.org/plosone/

Author website: https://med.stanford.edu/profiles/vj-periyakoil

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