Opportunities and challenges to improving end-of-life care for seriously ill elderly patients: A qualitative study of generalist physicians

Background: End-of-life care quality deficiencies have in part been linked to inadequate physician skill in the technical and communication domains of palliative care. Yet few studies have examined physicians' perspectives regarding their experiences caring for patients approaching the end of life. Objective: To understand generalist physicians' perspectives regarding their care of seriously ill elderly patients in order to identify challenges to improving end-of-life communication and decision-making. Design: Qualitative study using in-depth ethnographic interviews. Setting: Puget Sound region of Washington State. Participants: Thirteen community-based generalist physicians who routinely care for elderly patients and represent a range of practice styles and experiences. Results: The physicians described a "revolving door syndrome" in which elderly patients are repeatedly hospitalized with chronic illness exacerbations. Three themes influenced physicians' interactions with "revolving door" patients: (1) physicians' use of decision-making heuristics, characterized as "internal gauges," to promote care consistent with their own values; (2) families' "unreasonable expectations" that patients would return to their previous health after treatment of an acute illness; and (3) families' reluctance to accept end of life decision-making responsibility. Conclusions: Our findings suggest that physician values and physician-family interactions impact decision-making for chronically ill elderly patients. The influence of physicians' internal gauges on end-of-life care can facilitate or hinder use of palliative care as well as decision-making consistent with patients' preferences. Disparate physician and family expectations regarding their division of decision-making responsibility and patients' care outcomes may also affect decision-making. The use of communication strategies that promote alignment of these expectations may improve decision-making quality for incapacitated elderly patients.