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.