In an article recently published by Visser in Critical Care are reviewed articles published in the last 10 years on the barriers perceived by doctors who work in the ICU with regard to decision-making in situations perceived as “end of life”.
It’s an article different from those we used to analyze, it does not give answers, not tell you which is the best treatment for your patients, but invites us to reflection.
When Gabi Heras asked me to comment it on the blog, my first impulse was to say no. Currently I am involved in several projects aimed at improving the care of patients from the conventional scientific point of view.
How would I spend my time to delve into a post, an unusual format for me and on a very complex subject? But finally I decided to accept the challenge, simply because I am firmly convinced that it´s just as important as offering the best available treatment to allow patients to pass the last moments in the most dignified way possible.
The results of the study coincide largely with our everyday perception and emphasize some aspects that have already been analyzed in this blog. There is a perception by physicians that we don´t have an adequate training in communication techniques, which makes difficult the management of conflict situations in which families are not able to take the situation in that lies their loved. This lack of communication skills makes it difficult, in many cases, the understanding by the patient and the environment of the evolution of the disease and is also a major source of frustration and insecurity for the doctor, who feels unable to get information despite the efforts.
Another major obstacle is the desire of the doctor for saving the patient at all costs, which delays the onset of palliative treatment until the time when death is imminent. This seems to be especially prevalent among surgeons, who tend to have a less global perception of the patient. The perception of the death of the patient as an own failure also means a barrier frequent when implementing the limitation of life support and the initiation of palliative measures.
Paternalism, reflected as the difficulty of accepting the patient and their relatives as people who can understand the situation and make valid decisions in this regard is another found barrier. This means that it is more likely that the wishes of the patient and the environment are respected when they insist on keeping treatments deemed disproportionate from the point of view physician (for fear of the possible legal consequences), that when they requested not to do that treatments that the doctor thinks indicated, while the legislation of many countries protects the autonomy of the patient in this regard.
Another important point is the problems of communication between the physicians who form the team; if this is not fluid or there is a person in charge of the patient with an overview of your situation the home of palliative measures tends to linger.
The conclusion seems to be that our fears, limitations and uncertainties as doctors (and people who doubt and feel) and our own personal convictions tend to prevail over the wishes of the patient, which is suffering the consequences of maintaining a situation, which, deep down, everyone knows that it has no solution.
This does not mean, in my opinion, that doctors are soulless beings that we worry about our own welfare than patient´s one. Probably in situations to which we refer, our intention is to ensure the patient’s interests above anything else, offer the best therapeutic options, without being able to foresee or to assume the irreversibility of the process and the suffering it entails for the patient and their relatives.
The question is: what can we do to make it not happen?
Physician Specialist in Intensive Care Medicine