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Open Access Highly Accessed Research article

Finding common ground to achieve a “good death”: family physicians working with substitute decision-makers of dying patients. A qualitative grounded theory study

Amy Tan1* and Donna Manca2

Author Affiliations

1 Department of Family Medicine, 205 College Plaza, University of Alberta, 8215-112 Street, Edmonton, Alberta, T6G 2C8, Canada

2 Department of Family Medicine, 901 College Plaza, University of Alberta, 8215-112 Street, Edmonton, Alberta, T6G 2C8, Canada

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BMC Family Practice 2013, 14:14  doi:10.1186/1471-2296-14-14

Published: 22 January 2013

Abstract

Background

Substitute decision-makers are integral to the care of dying patients and make many healthcare decisions for patients. Unfortunately, conflict between physicians and surrogate decision-makers is not uncommon in end-of-life care and this could contribute to a “bad death” experience for the patient and family. We aim to describe Canadian family physicians’ experiences of conflict with substitute decision-makers of dying patients to identify factors that may facilitate or hinder the end-of-life decision-making process. This insight will help determine how to best manage these complex situations, ultimately improving the overall care of dying patients.

Methods

Grounded Theory methodology was used with semi-structured interviews of family physicians in Edmonton, Canada, who experienced conflict with substitute decision-makers of dying patients. Purposeful sampling included maximum variation and theoretical sampling strategies. Interviews were audio-taped, and transcribed verbatim. Transcripts, field notes and memos were coded using the constant-comparative method to identify key concepts until saturation was achieved and a theoretical framework emerged.

Results

Eleven family physicians with a range of 3 to 40 years in clinical practice participated.

The family physicians expressed a desire to achieve a “good death” and described their role in positively influencing the experience of death.

Finding Common Ground to Achieve a “Good Death” for the Patient emerged as an important process which includes 1) Building Mutual Trust and Rapport through identifying key players and delivering manageable amounts of information, 2) Understanding One Another through active listening and ultimately, and 3) Making Informed, Shared Decisions. Facilitators and barriers to achieving Common Ground were identified. Barriers were linked to conflict. The inability to resolve an overt conflict may lead to an impasse at any point. A process for Resolving an Impasse is described.

Conclusions

A novel framework for developing Common Ground to manage conflicts during end-of-life decision-making discussions may assist in achieving a “good death”. These results could aid in educating physicians, learners, and the public on how to achieve productive collaborative relationships during end-of-life decision-making for dying patients, and ultimately improve their deaths.

Keywords:
Family medicine; Advance care planning; Conflict; Substitute decision-makers; Good death