Knowledge and Awareness of End-of-life Care among Doctors Working in Intensive Care Units at a Tertiary Care Center: A Questionnaire-based Study

INTRODUCTION

The rapidly advancing medical science and technology discovered cures for many of the previously incurable diseases, thus, leading to a longer life expectancy. However, this prolonged life span is not without its fallacies. The end stage of life is becoming more and more fraught with incapacities and suffering; thus, sparking a rise in interest in end-of-life care (EOLC). The principal aim for provision of EOLC to critically ill patients is providing a milieu for “good death” in the terminal stage of life. ¹

Management of critically ill patient involves not only symptomatic management but also discussion and communication regarding their prognosis and the pertinent end-of-life care (EOLC) decisions. ² The physicians should, therefore, be adept in communication and should be well versed with the various end-of-life issues and their implications. ³ Clinicians worldwide are realizing the futility of unnecessary prolongation of the dying process and are adopting a more humane approach toward these patients. ^2,4–7 However, the awareness and acceptability for EOLC among critical care specialists appear to be unsatisfactory. Though the efforts made by critical care and palliative care societies have helped in making significant headway, the scenario of EOLC is still in an evolving stage in India. In India, various barriers act as hindrances to effective EOLC. Prolongation of the terminal stage of life not only heightens the suffering of the patients and their families but also imposes a considerable economic burden on the country. ^1,8,9 The critical care unit receives many critically ill patients with terminal illness, so imparting EOLC is primarily based on doctors working in these critical care units. It is thus of paramount importance that these health professionals have adequate knowledge and information related to EOLC, concerns, decisions, and management.

Though there is emerging literature regarding EOLC in India as well, extensive search of literature did not reveal any reported study to assess the knowledge and awareness of critical care professionals for EOLC. ^1,8,10,11 The primary aim of this study was to assess the awareness and knowledge of doctors who have worked in critical care units toward EOLC in critically ill patients.

MATERIALS AND METHODS

This cross-sectional volunteer-based study was performed in doctors working in critical care units of a tertiary care center after receiving the approval from the Institutional Ethics Committee. The inclusion criteria included doctors working in intensive care units (ICU), of any specialty, of either gender, having at least 3 months of completely dedicated adult ICU postings in the past 3 years, and willingness to participate in the study. Those consenting to participate were informed about the nature of the survey.

A paper-based standardized questionnaire was distributed to the participants and their responses were collected anonymously. During the questionnaire filling, the respondents were not allowed to refer to any literature from any source or discuss the questions with their colleagues. The filled questionnaire was checked for its completeness and if any part was left unanswered the respondent was requested to answer it as well.

RESULTS

A paper-based standardized questionnaire was distributed to the participants and their responses were collected anonymously over a period of 7 months (January–July 2018). We approached a total of 255 participants; of which 39 did not give consent (response rate 84.7%) and 14 submitted incompletely filled forms, thereby resulting in an analytic sample of 202 (79.2%) participants. The demographic characteristics of the respondents are shown in Table 1.

DISCUSSION

We observed from our study that majority of the respondents were aware of the concept of EOLC and good death but most had only “some knowledge” about EOLC. The awareness, however, translated to clinical application in only around one third of the respondents. Lack of adequate training and information were reported to be the most frequent hindrances. It was therefore not surprising that most of the respondents were in strong favor of including specific training about EOLC in the medical teaching programs. Overall, the respondents expressed only moderate comfort and competency in discussing and managing EOLC situations and problems, with trend toward improvement in SRs who had more experience in their specialty or in ICU. Among all specialties, residents of anesthesia and internal medicine demonstrated more comfort and competency regarding EOLC issues. Although the ability to identify the terminally ill did not vary with designation or experience, the clinical application of EOLC increased with increase in experience.

Provision of optimal EOLC is a growing concern in India and its effectiveness is considerably influenced by the attending physicians’ knowledge and awareness with regard to EOLC principles. Since the greater part of hospital deaths occur in the ICUs, it stands to reason to assess the familiarity and understanding of the ICU residents with regard to EOLC.

Our results are comparable to those of Chen et al. ¹² and Mohamed et al. ¹³ in that the respondents expressed a moderate level of comfort in discussing EOLC issues with the families of critically ill patients. In contrast to the findings of Chen et al. ¹² and Mohamed et al., ¹³ we found that anesthesia residents expressed more competency and comfort in dealing with EOLC. This may reflect a higher involvement of the anesthesia residents in critical care units in our hospital, resulting in more interaction with the critical and terminally ill patients in the ICUs. Changes in institutional protocols such as increase in ICU rotations may contribute to improving the comfort and competency of residents of other fields.

Lack of awareness among majority of the respondents regarding existence of Indian guidelines pertaining to EOLC reflects the need for better education and dissemination of information. This is supported by the fact that majority of our respondents stated lack of adequate information and training as the main barriers to EOLC application and were in favor of including specific training about EOLC in the medical curriculum. This need for further education and training for doctors as well as nurses was consistent with the findings of other studies. ^10,12–16

Vejlgaard et al. studied the attitudes of Danish doctors and nurses to palliative and terminal care and found that nurses were more likely than doctors to perceive palliative/terminal care as rewarding. ¹⁵ Similar to the findings in our study, they also reported that there was a lack of education regarding palliative care among healthcare professionals. ¹⁵ An Indian study conducted in 2017 to assess the attitudes, beliefs, and knowledge of nurses working in critical care setup observed that knowledge and attitude toward EOLC was influenced by the religious inclination and the work experience of the nurses. ¹⁴ Improvement in knowledge of doctors with experience was also found in our study. Subsequent study can be planned to evaluate the effect of religious inclinations of the doctors on their attitude toward EOLC.

Limitations of our study include disproportionate group sizes with majority of the respondents belonging to the field of anesthesia, thereby causing difficulty in making appropriate comparisons between residents of different specialties. Also, the results from a single-center study cannot be extrapolated to other institutions. A large multicenter study would better give the overview of EOLC among doctors. Since this was a self-report questionnaire, inaccuracies in self-assessment and recall bias may also have had an impact on the study results.

We conclude, based on outcome of our study, it appears that EOLC needs to be an integral part of critical care management. We suggest that the critical care curriculum of the different subspecialties of critical care should include EOLC session as well. An integral referral system may also be an option for various advance disease patients getting treatment from critical care specialist to make a combined decision for EOLC.

REFERENCES

1. Macaden SC, Salins N, Muckaden M, Kulkarni P, Joad A, Nirabhawane V, et al. End of life care policy for the dying: consensus position statement of Indian Association of Palliative Care. Indian J Palliat Care 2014;20(3):171–181. DOI: 10.4103/0973-1075.138384.

2. Truog RD, Campbell ML, Curtis JR, Haas CE, Luce JM, Rubenfeld GD, et al. Recommendations for end-of-life care in the critical care unit: a consensus statement by the American College of Critical Care Medicine. Crit Care Med 2008;36(3):953–963. DOI: 10.1097/CCM.0B013E3181659096.

3. Papadimos TJ, Maldonado Y, Tripathi RS, Kothari DS, Rosenberg AL. An overview of end-of-life issues in the critical care unit. Int J Crit Illn Inj Sci 2011;1(2):138–146. DOI: 10.4103/2229-5151.84801.

4. Prendergast TJ, Luce JM. Increasing incidence of withholding and withdrawal of life support from the critically ill. Am J Respir Crit Care Med 1997;155(1):15–20. DOI: 10.1164/ajrccm.155.1.9001282.

5. Sullivan A, Lakoma M, Block S. The status of medical education in end-of-life care. J Gen Intern Med 2003;18(9):685–695. DOI: 10.1046/j.1525-1497.2003.21215.x.

6. Sprung CL, Cohen SL, Sjokvist P, Lippert A, Phelan D. End-of-life practices in European intensive care units: the Ethicus Study. JAMA 2003;290(6):790–797. DOI: 10.1001/jama.290.6.790.

7. Carlet J, Thijs LG, Antonelli M, Cassell J, Cox P, Hill N, et al. Challenges in end-of-life care in the ICU. Statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003. Intensive Care Med 2004;30(5):770–784. DOI: 10.1007/s00134-004-2241-5.

8. Mani R, Amin P, Chawla R, Divatia J, Kapadia F, Khilnani P, et al. Guidelines for end-of-life and palliative care in Indian critical care units’ ISCCM consensus Ethical Position Statement. Indian J Crit Care Med 2012;16(3):166–181. DOI: 10.4103/0972-5229.102112.

9. Myatra S, Salins N, Iyer S, Macaden S, Divatia J, Muckaden M, et al. End-of-life care policy: an integrated care plan for the dying. Indian J Crit Care Med 2014;18(9):615–635. DOI: 10.4103/0972-5229.140155.

10. Sadhu S, Salins NS, Kamath A. Palliative care awareness among Indian undergraduate health care students: a needs-assessment study to determine incorporation of palliative care education in undergraduate medical, nursing and allied health education. Indian J Palliat Care 2010;16(3):154–159. DOI: 10.4103/0973-1075.73645.

11. Sharma H, Jagdish V, Anusha P, Bharti S. End-of-life care: Indian perspective. Indian J Psychiatry 2013;55 (Suppl 2):S293–S298. DOI: 10.4103/0019-5545.105554.

12. Chen E, McCann JJ, Lateef OB. Attitudes toward and experiences in end-of-life care education in the critical care unit: a survey of resident physicians. Am J Hosp Palliat Med 2015;32(7):738–744. DOI: 10.1177/1049909114539038.

13. Mohamed ZU, Muhammed F, Singh C, Sudhakar A. Experiences in end-of-life care in the critical care unit: a survey of resident physicians. Indian J Crit Care Med 2016;20(8):459–464. DOI: 10.4103/0972-5229.188196.

14. Tripathy S, Routray PK, Mishra JC. Intensive care nurses’ attitude on palliative and end of life care. Indian J Crit Care Med 2017;21(10):655–659. DOI: 10.4103/ijccm.IJCCM_240_16.

15. Vejlgaard T, Addington-Hall JM. Attitudes of Danish doctors and nurses to palliative and terminal care. Palliat Med 2005;19(2):119–127. DOI: 10.1191/0269216305pm988oa.

16. Kassa H, Murugan R, Zewdu F, Hailu M, Woldeyohannes D. Assessment of knowledge, attitude and practice and associated factors towards palliative care among nurses working in selected hospitals, Addis Ababa, Ethiopia. BMC Palliat Care 2014;13(1):6. DOI: 10.1186/1472-684X-13-6.