Findings
Physicians involved in MDTs held diverse opinion on ‘eolc’. Many of the
opinions were contradictory to one another. The researcher found that
conflicts occur when physicians overwhelmingly try to impose their
opinion on others in the team. According to the physicians, although
most the conflicts were “minor” in nature that got “easily” resolved
through appeal to the institutional medical board and arbitration, few
were serious that affected interpersonal relationships (refer
Table 2: Opinion of the physicians and
nurses about interpersonal conflicts within MDT ).
The following sub-sections give a more elaborate account of different
barriers of MDTs:
Differences of opinion among the members in MDT
Differences among senior specialist physicians
Generally, the primary consultant takes the major responsibility to form
MDT and coordinate. This includes planning care goals for the concerned
patient, making decisions, and sharing treatment-related information
with other members. However, it was observed that the primary
consultants were more biased in sharing information with physicians from
the same discipline than with other participant specialist physicians.
Information sharing was rather unilateral with secondary decision-makers
having no role other than merely providing consent. In other words, the
procedure seemed superficial just to comply with the institutional norm.
Physicians, particularly the intensivists felt marginalised in the team,
as they were least consulted. This was probably because all the
hospitals covered in the study had ‘open’ type ICUs, where intensivists
had no role in decision-making. An intensivist of the hospital said,
Last week a neurologist asked me to attend to a patient that in her
opinion was not doing well. I visited the patient, diagnosed, set up a
therapeutic plan, and communicated to the neurologist… But, it
turned out she [neurologist] completely ignored my opinion!
(…) Maybe they (Neurologists) don’t consider us (intensivists)
important…
Another intensivist from the same hospital lamented, “…rather than discussing and agreeing on one solution, everyone tries to
impose his/her view, and in the end the most powerful wins.” A deeper
reflection on the situation suggests that the senior consultants’
reluctance to collaborate with the intensivists mainly stemmed from the
disciplinary boundaries that existed between them; senior consultants,
who were mostly specialists in General medicine, tended to continue
treatment for a longer duration than the intensivists. Since the major
responsibility of an intensivist is to monitor patients’ vital
functions, and ensure patient comfort, they claimed to offer holistic
care and felt that other specialists had ‘narrow-spectrum’ of
understanding of patients’ conditions. Intensivists who were trained in
anaesthesia mostly emphasised on patient comfort by managing pain,
reducing infection and so on.
On the other hand, a neurologist said,
[intensivists] are too interventionist! They erratically push and
pull tubes! (…) [This morning] a new patient arrived and the
intensivist did an ECG mindlessly just because he has to comply with the
protocol…”
The study found professional boundaries in the hospitals were too
stringent to overcome. Another neurologist from the same hospital shared
his experience of working in a MDT led by a critical care specialist,
I prefer not to strongly impose my opinion on the medical team. It is
humiliating to find that my opinion, for most of the time, is not valued
by the primary consultants and their subordinates. All I do now is to
avoid putting forth my views (…). For instance, in case of
brainstem dead patients, I only give opinion to de-escalate aggressive
treatment to the team. It is up to them (team) to decide as what to
do”.
Differences between physicians and nurses
Lack of team cohesion was not only evident amongst physicians but was
also between physicians and nurses. In general, physicians considered
nurses to be deficient in knowledge and skills for caring dying
patients. A surgeon, who was highly upset with the nursing team said:
“They mess up everything…they don’t know how to insert tubes,
how to pull them off and how to handle the life-saving
equipment…often they end up causing the patient to bleed. I’ve
complained many times to the administration…”
Another physician said:
“nurses are good in carrying out orders of the doctor, but caring for a
dying person means something more than a routine work…they lack
the aptitude to identify symptoms of imminent death for a patient. They
are unfit to be included in the [medical] decision-making team!!”
Nurses, on the other hand, felt immense difficulty in properly
communicating with consultant physicians. They said that the
instructions about treatment plans reach nurses through a hierarchic
order involving junior physicians, medical officers, and the Head nurse.
The nurses were disgusted obeying to a tiring and cumbersome
communication hierarchy. They said that the situation becomes
‘nightmarish’ when terminally ill patients suffer from co-morbid
conditions. According to an ICU nurse, when a “frail, old” patient
suffering from multiple organ failure is admitted to the ICU:
“Different consultants barge into ICU and interfere with treatment
procedures. Care goals keep changing with one consultant overriding
others’ decisions. We are obliged to follow multiple instructions and
report to all the concerned physicians…at the end we are confused
and the patients distressed. It is totally a chaos for us then…”
Conflictions among nurses of different departments
The nurses of the hospital were also divided on their attitude and
perception towards terminally ill geriatric patients. For instance,
nurses at the ICU of the Oncology Department said,
“We are very different from others because we have been trained to
tackle dying issues. We know when to forego life-saving treatments. In
other departments [wards], nurses unquestionably perform whatever
the doctors prescribe (…) Death unnerves them…they panic
if anything goes against their expectation! I couldn’t stand working
there… I like working here where I feel doing something
independently (referring to supportive care).
A nurse appointed to the High Dependency Unit said,
“No matter how much we claim to have expertise in caring for critically
ill patients, physicians consider us subordinates to them. They consider
our knowledge and skills to be inadequate
These narratives illustrate the ubiquitous presence of an “invisible
boundary” between medical fraternity. Standing on either sides of the
boundaries, the professionals vehemently tried defending their
standpoints in caring.
Marginalisation of non-clinician caregivers in MDT
Organisational hierarchy as inimical to team coordination
The hospital promoted a stringent clinical protocol, dominated by
specialist physicians, who acted as primary decision-makers during
end-of-life, whereas others including registrars, nurses and medical
officers, who lacked any sort of specialised clinical knowledge were not
allowed participating in decision-making. Ironically, as evident from
Table 3 (Distribution of physicians
according to their orientation in Palliative & ‘eolc’ ) many of these
officers had basic orientation in Palliative and End-of-life care, yet
they were not empowered to take end-of-life decisions. Social workers,
spiritual healers and psychological counsellors appeared nowhere in
end-of-life decision-making process.
Geriatrics and Palliative care are extraneous to MDT
MDTs failed to integrate geriatric care even though most of the
end-of-life cases pertained to elderly patients—an observation made
during the study. This was mainly because many primary consultants, who
lead the MDTs, lacked requisite training in geriatric care.
Unfortunately, all the three geriatricians of the hospital were
appointed as General Physician in the general OPD. According to them, an
overwhelming inclination towards disease-specific treatment (or
specialised treatment) of the patients cause them to undermine
importance of geriatricians for holistic care. Thus geriatricians have
least involvement throughout the active treatment trajectory, and also
at the end of it when end-stage patients are transferred to palliative
care. Moreover, the geriatricians too divided in their opinion about
their specific role in the treatment trajectory. While one geriatrician
emphasised on their involvement at the initiation of treatment, another
laid thrust on continuous engagement and supervision of a patient in the
hospital and even post discharge. The third respondent, however, felt a
geriatrician’s presence is essential at the end of active treatment when
complications manifest that other specialists fail to address. Such
diversified opinions of the geriatricians make their position fuzzy in
the care organisation.
Similar to geriatricians, palliative physicians too had a weak
representation in the MDTs. A senior oncologist and a member of a MDT
disapproved the need to incorporate palliative care specialist in his
team. He strongly asserted, “Palliation has no proven efficacy…
I usually don’t prescribe palliative care”. The geriatricians also drew
professional boundary between Geriatrics and Palliative care. This was
particularly evident from the statement of a geriatrician who said,
“palliative care is not my perspective…it means giving up hope”.
Thus inter-linkages between Palliative care and Geriatrics was grossly
overlooked by the physicians leaving a large number of terminally ill
geriatric patients in need of palliation to die in despair. It was also
observed that a patient-coordinator, who counselled cancer patients
throughout the hospital-stay and was immensely invaluable to patients
and families for the huge amount of compassion she had for them, was not
included in MDT just because she had no formal training either in
medicine or nursing.
Implications of conflicts and dissent on end-of-life
decisions
The findings show that hospital culture was barely conducive to
consensus decision-making. This had a serious implication on end-of-life
decisions. A survey was conducted to inquire how differences in clinical
standpoints of the physicians who worked as team members affected
end-of-life decision-making. The following sub-sections reveal the
adverse consequences:
Different clinical standpoints of specialists affect comprehensive
care at the end-of-life
A survey was conducted to understand physicians’ opinion about
appropriate interventions that could be withdrawn at the end-of-life
(refer Table 4: Physicians’ opinion on
withdrawing treatment/interventions at the terminal stage ). Of the
total 40 physicians who were asked to give their opinion, 36 returned
filled-up questionnaires.
The table shows physicians differed among themselves in deciding
interventions that are to be ‘mandatorily withdrawn’, ‘to be withdrawn
after reviewing’, ‘can be withdrawn if patient wishes’ or ‘not to be
withdrawn at all’. Most of the physicians felt that chemo- and
radiotherapy during ‘eolc’ were redundant at the end-of-life (20 out of
36 physicians were in favour of withdrawing such therapies for all
patients at the end-of-life). Similarly, many felt that ICU admissions
during end-stage could be avoided (21 out of 36). On the other hand, 50
percent of the physicians (18 out of 36) said that withdrawing Ryle’s
tube to stop nutrition for the dying patient is unethical. Similarly, 39
percent of the physicians (14 out of 36) did not support the idea of
stopping IV hydration. According to these physicians, nutrition and
hydration were ‘basic’ life-supports. A senior nephrologist said nurses
in his hospital were also opposed to the idea of discontinuing food to
dying patients. Overall, an important feature that emerges from this
survey is that physicians were somewhat reluctant to withdraw
interventions that belonged to their own specialty, thus exhibiting a
sort of biased attitude in decision-making. Thus, while nephrologists
emphasised on dialysis even at the end stage, oncologists opined against
discontinuation of chemotherapy and radiotherapy. This information
infers how MDTs fail to deliver coordinated care to dying patients.