Clinical Decision Making for Physical Therapists in Patient-Centered End-of-Life Care

Ethical dilemmas in end-of-life care, such as the request for assisted suicide, must be understood in the context of the relationship that exists between patients and the clinicians treating them. This context includes the way health professionals respond to the tasks in caring for a dying patient. This article reviews the literature exploring the factors the influence clinical decision making at the end of life. The interplay of ethics, countertransference and transference are explained in detail.

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Acute Care Decision-Making for Patients with Advanced Dementia: An Exploratory Study Using Cognitive Task Analysis

10.21926/obm.geriatr.2101159 ◽

2021 ◽

Vol 5 (1) ◽

Author(s):

Meira Erel ◽

◽

Esther-Lee Marcus ◽

Freda DeKeyser Ganz

Keyword(s):

Decision Making ◽

End Of Life ◽

End Of Life Care ◽

Task Analysis ◽

Clinical Decision Making ◽

Cognitive Task ◽

Clinical Decision ◽

Cognitive Task Analysis ◽

Thought Processes ◽

Advanced Dementia

Decision-making by medical and health care staff forms the core of professional practice. Thought processes, including non-clinical considerations, significantly impact how clinical decisions are made. Such considerations become more relevant when addressing end-of-life care decisions for patients with advanced dementia (PAD). Though palliative care is recommended for this population, its implementation tends to vary. Given the medical staff’s significant influence in guiding clinical decisions, we examined thought processes that accompany staff decisions. We used Cognitive Task Analysis (CTA) to analyze interviews conducted with 15 physicians and 11 nurses working in acute care wards in Central Israel. Participants were interviewed regarding their clinical decision-making in a hypothetical scenario of a PAD who presents with an acute, potentially life-threatening medical problem. Moral judgment orientation was the primary factor affecting clinical decision-making for advanced dementia, with a pronounced dichotomous split between deontological and utilitarian approaches. This polarization was highly associated with the medical specialty. Practitioners in surgical wards tended to focus on the patient’s current medical condition, as an isolated or disease-centered illness perspective, supported by deontological moral lines of thinking. This perspective was contrary to that of staff in medical wards who mostly treated the patient from a holistic perspective with a patient-focus approach, supported by utilitarian moral lines of thinking. Although all respondents presented the patient or family as primary decision partners, the practitioners were motivated to make decisions based on unit hierarchies or positions of authority figures. Therefore, clinical end-of-life decisions are influenced by different thinking processes of the health staff and several non-clinical factors. The moral thinking paradigm was found to be associated with a professional orientation. Understanding the subjective, non-clinical aspects of decision-making for PAD might improve end-of-life care in this population.

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