This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on Web of Science (3)  • Contact me when this article is cited  Related Content  • Related article  • Similar articles in this journal  Topic Collections  • Nursing Care  • End-of-life Care/ Palliative Medicine  • Alert me on articles by topic  Social Bookmarking   What's this?

Loss of Continuity and Lack of Closure

Anthony L. Back, MD; Jessica P. Young, MS; Ellen McCown, BA; Ruth A. Engelberg, PhD; Elizabeth K. Vig, MD; Lynn F. Reinke, PhD; Marjorie D. Wenrich, MPH; Barbara B. McGrath, PhD; J. Randall Curtis, MD, MPH

Arch Intern Med. 2009;169(5):474-479.

Background  Surveys and anecdotes suggest that patients and family members sometimes feel abandoned by their physicians at the transition to end-of-life care. To our knowledge, no prior studies describe abandonment prospectively.

Methods  We conducted a longitudinal, qualitative study of patients, family caregivers, physicians, and nurses using a community-based sample. Using a purposive strategy, we recruited 31 physicians who identified 55 patients with incurable cancer or advanced chronic obstructive pulmonary disease, 36 family caregivers, and 25 nurses. Eligible patients met the prognostic criterion that their physician "would not be surprised" if death occurred within a year. Qualitative, semistructured interviews were performed at enrollment, 4 to 6 months, and 12 months and were audiotaped, transcribed, and coded by an interdisciplinary team. When asked to talk about hope and prognostic information, participants spontaneously raised concerns about abandonment, and we incorporated this topic into our interview guide.

Results  Two themes were identified: before death, abandonment worries related to loss of continuity between patient and physician; at the time of death or after, feelings of abandonment resulted from lack of closure for patients and families. Physicians reported lack of closure but did not discuss this as abandonment.

Conclusions  The professional value of nonabandonment at the end of life consists of 2 different elements: (1) providing continuity, of both expertise and the patient-physician relationship; and (2) facilitating closure of an important therapeutic relationship. Framing this professional value as continuity and closure could promote the development of interventions to improve this aspect of end-of-life care.

Author Affiliations: Fred Hutchinson Cancer Research Center (Dr Back); School of Medicine, Departments of Medicine (Drs Back, Engelberg, Vig, and Curtis and Mss Young, McCown, and Wenrich) and Medical History and Ethics (Drs Back and Curtis); School of Nursing (Drs Reinke and McGrath), Departments of Biobehavioral Nursing and Health Systems (Dr Reinke) and Psychosocial and Community Health (Dr McGrath), University of Washington, Seattle.

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter     What's this?

RELATED ARTICLE

In This Issue of Archives of Internal Medicine
Arch Intern Med. 2009;169(5):428.
FULL TEXT  

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Making Difficult Discussions Easier: Using Prognosis to Facilitate Transitions to Hospice
Finlay and Casarett
CA Cancer J Clin 2009;59:250-263.
ABSTRACT | FULL TEXT  

A New Era of For-Profit Hospice Care -- The Medicare Benefit
Iglehart
NEJM 2009;360:2701-2703.
FULL TEXT