title: Communication and decision making about life-sustaining treatment: examining the experiences of resident physicians and seriously-ill hospitalized patients.
abstract: BACKGROUND
  Despite evidence-based recommendations for communication and decision making about life-sustaining treatment, resident physicians' actual practice may vary. Few prior studies have examined these conversations qualitatively to uncover why ineffective communication styles may persist.
  
  
  OBJECTIVE
  To explore how discussions about life-sustaining treatment occur and examine the factors that influence physicians' communicative practices in hopes of providing novel insight into how these processes can be improved. PARTICIPANTS AND APPROACH: We conducted and recorded 56 qualitative semi-structured interviews with participants from 28 matched dyads of a resident physician and a hospitalized patient or their surrogate decision maker with whom cardiopulmonary resuscitation was discussed. Transcripts were analyzed and coded using the constant comparative method to develop themes.
  
  
  RESULTS
  Resident physicians introduced decisions about resuscitation in a scripted, depersonalized and procedure-focused manner. Decision makers exhibited a poor understanding of the decision they were being asked to make and resident physicians often disagreed with the decision. Residents did not advocate for a particular course of action; however, the discussions of resuscitation were framed in ways that may have implicitly influenced decision making.
  
  
  CONCLUSIONS
  Residents' communication practices may stem from their attempt to balance an informed choice model of decision making with their interest in providing appropriate care for the patient. Physicians' beliefs about mandatory autonomy may be an impediment to improving communication about patients' choices for life-sustaining treatment. Redefining the role of the physician will be necessary if a shared decision making model is to be adopted.
authors.affiliation: Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY 40536, USA. Klshef0@email.uky.edu
authors.forename: Kristy S
authors.initials: KS
authors.lastname: Deep
authors.forename: Charles H
authors.initials: CH
authors.lastname: Griffith
authors.forename: John F
authors.initials: JF
authors.lastname: Wilson
mesh_terms: D032722:Advance Care Planning; D000368:Aged; D016887:Cardiopulmonary Resuscitation / Q000523:psychology*; D003657:Decision Making; D005190:Family; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007396:Internship and Residency; D007407:Interviews as Topic; D008020:Life Support Care / Q000523:psychology; D008297:Male; D008875:Middle Aged; D010817:Physician-Patient Relations
references.citation: JAMA. 2000 Sep 27;284(12):1573-8
references.pmid: 11000655
references.citation: Patient Educ Couns. 2008 Jul;72(1):20-5
references.pmid: 18337051
references.citation: Crit Care Med. 2001 Jan;29(1):197-201
references.pmid: 11176185
references.citation: J Gen Intern Med. 2001 May;16(5):283-9
references.pmid: 11359545
references.citation: J Crit Care. 2003 Mar;18(1):3-10
references.pmid: 12640606
references.citation: Med Decis Making. 2003 Jul-Aug;23(4):275-80
references.pmid: 12926577
references.citation: JAMA. 2003 Sep 3;290(9):1157-65
references.pmid: 12952997
references.citation: Am J Med. 2004 Mar 15;116(6):402-7
references.pmid: 15006589
references.citation: JAMA. 2004 May 19;291(19):2359-66
references.pmid: 15150208
references.citation: Fam Pract. 2004 Aug;21(4):347-54
references.pmid: 15249521
references.citation: J Clin Epidemiol. 1990;43 Suppl:1S-123S
references.pmid: 2254785
references.citation: JAMA. 1992 Apr 22-29;267(16):2221-6
references.pmid: 1556799
references.citation: Med Decis Making. 1995 Jul-Sep;15(3):209-16
references.pmid: 7564934
references.citation: J Gen Intern Med. 1995 Aug;10(8):436-42
references.pmid: 7472700
references.citation: Ann Intern Med. 1996 Nov 1;125(9):763-9
references.pmid: 8929011
references.citation: J Gen Intern Med. 1998 Jul;13(7):447-54
references.pmid: 9686710
references.citation: Am J Med. 1998 Sep;105(3):222-9
references.pmid: 9753025
references.citation: Soc Sci Med. 1999 Jun;48(12):1779-89
references.pmid: 10405016
references.citation: Soc Sci Med. 1999 Sep;49(5):651-61
references.pmid: 10452420
references.citation: J Gerontol B Psychol Sci Soc Sci. 2005 Jul;60(4):P215-8
references.pmid: 15980289
references.citation: Soc Sci Med. 2006 Jan;62(1):116-24
references.pmid: 15992980
references.citation: J Am Geriatr Soc. 2006 Jan;54(1):150-7
references.pmid: 16420213
references.citation: J Palliat Med. 2005;8 Suppl 1:S95-102
references.pmid: 16499474
references.citation: J Palliat Med. 2006 Apr;9(2):451-63
references.pmid: 16629574
references.citation: Arch Intern Med. 2006 Aug 14-28;166(15):1597-602
references.pmid: 16908792
references.citation: Patient Educ Couns. 2006 Nov;63(3):268-78
references.pmid: 16875797
references.citation: Acad Med. 2006 Nov;81(11):1008-12
references.pmid: 17065871
references.citation: Health Expect. 2006 Dec;9(4):321-32
references.pmid: 17083559
references.citation: Arch Intern Med. 2007 Mar 12;167(5):461-7
references.pmid: 17353493
references.citation: J Gen Intern Med. 2000 Sep;15(9):620-5
references.pmid: 11029675