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From the Department of Medicine (Heyland, Groll, Pichora) and the Department of Nursing (Tranmer), Kingston General Hospital; the Department of Community Health and Epidemiology (Heyland, Shortt, Lam, Tranmer) and the Centre for Health Services and Policy Research, Queen's University (Shortt), Kingston, Ont.; the Program in Critical Care Medicine and Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital and University of British Columbia (Dodek), Vancouver, BC; the Department of Medicine, Queen Elizabeth II Health Sciences Centre and Dalhousie University (Rocker), Halifax, NS; the Centre for Health Economics and Policy Analysis and the Department of Clinical Epidemiology, McMaster University (Gafni), Hamilton, Ont.; the Department of Medicine, University Health Network and University of Toronto (Lazar), Toronto, Ont.; the Department of Critical Care, University of Alberta (Kutsogiannis), Edmonton, Alta.
Correspondence to: Dr. Daren K. Heyland, Angada 4, Kingston General Hospital, Kingston ON K7L 2V7; fax 613 548-1351; dkh2{at}post.queensu.ca
Background: Initiatives to improve end-of-life care are hampered by our nascent understanding of what quality care means to patients and their families. The primary purpose of this study was to describe what seriously ill patients in hospital and their family members consider to be the key elements of quality end-of-life care.
Methods: After deriving a list of 28 elements related to quality end-of-life care from existing literature, focus groups with experts and interviews with patients, we administered a face-to-face questionnaire to older patients with advanced cancer and chronic end-stage medical disease and their family members in 5 hospitals across Canada to assess their perspectives on the importance. We compared differences in ratings across various subgroups of patients and family members.
Results: Of 569 eligible patients and 176 family members, 440 patients (77%) and 160 relations (91%) agreed to participate. The elements rated as "extremely important" most frequently by the patients were "To have trust and confidence in the doctors looking after you" (55.8% of respondents), "Not to be kept alive on life support when there is little hope for a meaningful recovery" (55.7%), "That information about your disease be communicated to you by your doctor in an honest manner" (44.1%) and "To complete things and prepare for life's end — life review, resolving conflicts, saying goodbye" (43.9%). Significant differences in ratings of importance between patient groups and between patients and their family members were found for many elements of care.
Interpretation: Seriously ill patients and family members have defined the importance of various elements related to quality end-of-life care. The most important elements related to trust in the treating physician, avoidance of unwanted life support, effective communication, continuity of care and life completion. Variation in the perception of what matters the most indicates the need for customized or individualized approaches to providing end-of-life care.
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