Diagnosing and discussing imminent death in the hospital: a secondary analysis of physician interviews.

BACKGROUND: Many reports suggest clinicians are often inadequately prepared to "diagnose dying'' or discuss the likelihood of imminent death with patients and families. OBJECTIVE: To describe whether and when physicians report recognizing and communicating the imminence of death and identify potential barriers and facilitators to recognition and communication about dying in the hospital. METHODS: Secondary exploratory analysis of interviews with 196 physicians on the medical teams caring for 70 patients who died in the hospital. RESULTS: Although 38% of physicians were unsure on admission the patient would die during this hospitalization, over the course of hospitalization 86% reported knowing death was imminent. Most reported feeling certain days (57%) or hours (18%) before the patient died. Fewer than half of patients, however, were told of the possibility they might die. Communication was most likely to occur for patients who had at least one member of the medical team who was certain that death was imminent, patients who were lucid during their last days, and younger patients. Only 11% of physicians reported personally speaking with patients about the possibility of dying. Physicians who recognized imminent death early and who spoke with patients about the possibility of dying were more likely to report higher satisfaction with end-of-life care provided to patients. CONCLUSIONS: Because more than two thirds of patients were unconscious or in and out of lucidity in the last few days of life, waiting for certainty about prognosis may leave little opportunity to help patients and their families prepare for death. Our results identify opportunities for improvement in communication in the face of uncertainty about the imminence of death. In addition to potential benefits to patients and families, these findings suggest that enhancing communication practices may also benefit physicians through increased satisfaction with care and closer connection with those for whom they provide care.