"Getting everyone on the same page": Nursing home physicians' perspectives on end-of-life care

Purpose: To improve understanding of nursing home physicians' perspectives regarding end-of-life care, and to suggest directions for further research. Methods: An exploratory qualitative design based on interviews of 12 nursing home physicians, 10 of whom were medical directors. Medical students served as interviewers. Sample: A purposeful sampling strategy yielded interviews with 12 physicians. The sample was selected based on "intensity sampling," which seeks information-rich but not extreme cases. Ten of the 12 physicians were nursing home medical directors; all respondents practiced at least 4 years part-time or full-time in a nursing home setting. Respondents varied by age, gender, urban/rural location, and fellowship training (half the sample had completed a geriatrics fellowship). Seven physicians were affiliated with an academic medical center. Results: Four themes were identified in the analysis of the 12 interview transcripts: extensive familiarity with dying; consensus is integral to good end-of-life care; obstacles can interfere with consensus; and advance directives set the stage for conversations about end-of-life care. The importance of consensus, both in terms of prognosis and in developing a palliative care plan, emerged as the major finding. Conclusions: For the 12 physicians in this study consensus about the resident's status and an appropriate care plan are important features of good end-of-life care. Further research is needed to determine if other members of the health care team (i.e., residents, family members, nursing staff, social worker, etc.) also value consensus highly. It will be important to determine what barriers to consensus other team members identify. Based on the understanding generated from this study, a refinement of the general Education for Physicians on End-of-Life Care (EPEC) model describing the relationship between curative and palliative care is proposed for nursing homes. The refinement underscores the points at which the team might consider revisiting consensus about the resident's status and care plan.