Objectives: General dissatisfaction with the experience of dying in America has been identified as a consistent theme in the U. S. health system. Early engagement of the advance care planning (ACP) process results in conversations about values and wishes of care at end-of-life (EOL) between individuals, their families and their health care providers (HCPs). This process promotes reduction of stress and anxiety for patients at EOL and reduces depression rates by surviving relatives. HCPs can be a significant source of influence on engaging patients in ACP, yet evidence suggests that HCPs’ personal beliefs and values may obstruct the process of engaging in frank discussions about EOL care and historical provider ideologies such as “physician control” and “life is preserved at all costs” hinder dialogue and planning between HCPs and patients. The objective of this systematic review was to explore provider attitudes toward death, and how these attitudes may influence patient’s ACP.
Methods: PubMed and Scopus databases were searched for studies conducted in the U.S., published in peer-reviewed English-language journals between June 2008 and June 2018. The inclusion criteria were: 1) studies that involve the discussion, description or assessment of HCPs’ attitudes, feelings or beliefs towards death, and 2) studies describing associations, effects or influences on patient ACP.
Results: Seven studies met the inclusion criteria. Studies were diverse in design and methodology, four were quantitative, two were qualitative and one was of mixed methods design. Participant size ranged from 49 to 1,081 and represented HCPs for multiple disciplines (physicians, nurses, advance practice nurses, therapists of various disciplines, social workers and chaplains). Communication problems surrounding ACP including timing of when to have the conversation and role identification of who was going to initiate the conversation were observed as themes in four of the seven studies. Physicians struggled to have these conversations, especially when caring for patients of ethnicities that differed from their own, yet there was consensus among HCPs across disciplines (including physicians) that the physician is the most responsible in initiating the conversation with the patient and family. External barriers such as patient’s language, faith, cultural awareness, health literacy and internal barriers such as HCPs’ personal beliefs and preferences for their own EOL care influenced HCPs engagement and effectiveness of EOL care and ACP with their patients.
Conclusion: The initiation of and effective communication about the ACP process for patients may be influenced by the HCPs attitude and preferences for their own EOL care. Effective communication was hindered by HCPs timing of the conversation with patients and families or delayed related to identifying who was going to initiate the conversation. Physicians were identified as the discipline most responsible for initiating these conversations yet struggled to effectively carry them out due to external and internal barriers. Future research is needed to explore correlations between initiation and effectiveness of ACP for patients and HCPs’ personal preference for life-sustaining, high intensity care for themselves at EOL or if terminally ill.
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