Discussion
The multispecialty hospital considered for the study largely represents
the situation of acute care set-ups across India. An overwhelming
interest to form medical teams under leadership of consultant physicians
affects interdisciplinary collaboration, a prerequisite for ‘eolc’. The
above discussion outlines how achieving consensus over end-of-life
decisions is a challenge due to reluctance of the physicians to overcome
their domain-specific knowledge boundaries. Thus, co-located specialist
physicians, does not necessarily guarantee collaborative and
comprehensive ‘eolc’ unless they stop working as independent care
providers21. However, overcoming
inter-professional boundaries is difficult because they are deeply
rooted to the biomedical culture that contains divergent approach to
‘eolc’. These differences of opinion are detrimental to consensus
end-of-life decision-making, as evident from table no.4, where
physicians fell out in their decisions to withdraw life-sustaining
treatment. The finding gets support from global ‘eolc’ literature that
show variations in treatment-limiting decisions owe to physicians’
specialisation and level of training22-27.
Consequently, care goals became ambiguous, unattainable and sometimes
violative of rights of patients and families. This is evident from the
cases reports of few patients and families, who experienced chaos and
humiliation during treatment.
Divergent opinions result in conflict when primary consultants fiercely
impose their decisions on others in the team, overriding alternative
standpoints. Some researchers also feel that due to an overwhelming urge
to uphold the professional superiority, specialist physicians
intentionally show little or no respect for other’s view. According to
Everett C. Hughes, in a medical pluralistic environment, such a
phenomenon is common28. A similar assertion is also
made by Lancaster et al.29 according to whom
physicians tend to overlook the importance of joint responsibility and
are engrossed in asserting their superiority over nurses and other
non-clinical professionals. Vazirani, Hays, Shapiro and
Cowan30 also hold a similar opinion.
Finally, marginalisation of nurses and other non-clinical care providers
is a near-universal barrier to physician-led MDT31.
The present study is also a testimony to this fact. By
over-medicalising ‘eolc’ protocols, hospitals have made services of
nurses, psychological counsellors, spiritual healers, less important.
The study also shows how geriatricians and patient coordinators were
excluded from MDTs. Unfortunately, elderly ‘eolc’ patients died without
receiving age-appropriate care. Considering these barriers, it seems
that MDTs are mere assemblage of professionals from different
disciplines without necessarily guaranteeing integrated patient
care32-38. In other words, ‘invisible boundaries’
within MDTs and disease-specific clinical models make cross-disciplinary
communication, relationship-building and comprehensive care
unattainable.
From the writing of Choi and Pak39 it seems that the
very term MDT is problematic because multidisciplinarity has a narrow
approach. It is mainly ‘additive’ in nature, meaning, that it draws
knowledge from all fields but is restricted within boundaries of few
disciplines only. Thus, the key to provide concerted service to dying
patients in hospitals is to transform MDTs into interdisciplinary teams
or, even better, to a transdisciplinary team. They go on explaining that
while interdisciplinary approach synthesises knowledge acquired from
different disciplines, transdisciplinarity refers to integration of
health sciences with social and natural sciences in a humanistic
context; it transcends traditional disciplinary boundaries. In the
context of palliative care, Piotrowski40 briefly
outlines evolution of team approach from Traditional Multidisciplinary
Practice (a typical physician-led palliative care model where different
specialist physicians provide “ad hoc” consultations) to
Interdisciplinary Team (also physician-led team but members from
different disciplines subsumes to a common organizational framework.
However, in reality membership is restricted to physicians and nurses)
and finally to Transdisciplinary Team (shared team vision; integrated
responsibilities, training, leadership, and decision-making). In fact,
the transdisciplinary approach has proven to be effective in improving
delivery of palliative and ‘eolc’. Daly and Matzel41could successfully recast palliative care in a US-based acute care
set-up by forming a transdisciplinary palliative care team composed of
physicians, nurses, end-of-life counsellors and chaplains. Multiple
strategies were adopted to educate the staff on transdisciplinary
palliative care and communication. The authors report that adopting
transdisciplinary approach resulted in better integration of patient
services, early identification of palliative care following
hospitalisation, regular assessment of patient’s condition, and
providing spiritual and social care support to patients and families.
Moreover, the caregivers felt lesser workload and burnout.
Transdisciplinary team approach to palliative care in the Indian
hospitals can also be adopted. However, given the fact that the
physicians and other caregivers lack adequate training in palliative and
‘eolc’, they first need to undergo a rigorous orientation on the
discipline, understanding principles of palliative care. During
training, specialist physicians need to be motivated for shifting their
attention from disease-specific treatment to person-centric care for
end-of-life patients. This is followed by facilitating specialist
physicians to network with nurses, non-clinical professionals like
psychological and spiritual counsellors, and family members. Sufficient
handholding support to the team is necessary to impart skills for
leadership, shared decision-making, and conflict resolution. Hopefully,
prioritising patient’s preference over clinicians’ agencies in making
medical decisions, including treatment withdrawal, would mitigate
difference of opinion between physicians. Finally, to sustain
transdisciplinary teams in the hospital it is important that the
approach is widely promoted even among healthcare staff working outside
the hospital so that the transdisciplinary team approach extends beyond
institutional setting and the continuum of care is ensured. Unless these
measures are undertaken, adoption of an integrated approach to care for
dying patients in hospitals will remain a distant dream.