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.