Quality of palliative care: why nurses are more valued than doctors?

Quality of palliative care: why nurses are more valued than practice, do not adapt easily to palliative care. Having doctors? W.K.H. Fakhoury. (The HIV Project, St. Martins a terminal illness imposes immense psychological House, London, UK). stress on dying patients and many difficulties on all Scand J Soc Med 1998, 2 (131–132). health care providers involved in their care. Several studies have looked at the quality of care delivered to terminally ill patients (8, 9, 10). One interesting finding is that when dying patients and/or Much research has been conducted evaluating the their carers were asked about the quality of nursing quality of medical and nursing care. The aim of it is care as opposed to medical care, nurses were more to ensure that patients are receiving appropriate and likely to have been praised for their services (11, 12). acceptable levels of services, and that services are The growth of the ‘‘whole person’’ approach in the delivered efficiently and effectively. Evaluation nursing process (12), the many developments in nurse research is often used to plan new health services or training which place considerable emphasis on change the existing ones to meet the patients’ needs. psycho-social care (13), the predominance of women Patient satisfaction measures, either single or multiin the nursing workforce with their supposedly natdimensional, have been used in evaluation research ural informal caring qualities (14), and the nurses’ as outcome measures of the quality of care. Patient abilities to play a role in co-ordinating with other satisfaction is believed to be determined, at least in health professionals and integrating other services in part, by the process elements of the quality of medical ways that serve the patients’ needs (11, 15), are all care: Process elements are ‘‘those activities triggered possible reasons for the observed differences in by any patient who enters the health care system’’ patients’ and/or carers’ perceptions of the quality of (1). The components of the process of care which care delivered by doctors and that provided by nurses. heavily predispose patient satisfaction are those The special relationship which dying patients and related to doctors’ competence in providing medical their carers may have with nurses could indeed hinder care and aspects pertinent to the quality and nature the development of strong and satisfactory doctorof the doctor-patient relationship (2). patient and doctor-carer relationships. Doctors, in The doctor-patient relationship is itself affected by comparison to nurses, spend considerably less time the extent to which the doctor and patient successfully with dying patients and their carers. The short-time communicate during the medical encounter. Research contact they have with patients may not be enough has identified characteristics which contribute to a for patients and their carers to break the barriers for successful patient-doctor medical encounter: doctors a supportive relationship to develop. Doctors also have to show an understanding of patients’ concerns have less training than nurses in the provision of (3); they should provide patients with all the informasocial and emotional support to dying patients and tion they want on illness and treatment (4); they carers. Such training is essential for appropriate should be able to decipher various affective states management of terminal cases; after all, the emphasis through non-verbal cues (5); and should provide an is on caring for rather than curing dying patients. A environment in which patients feel confident and able task which is best performed by nurses. Expecting to express themselves (4). Doctors have to be perdoctors to be as supportive as nurses is somewhat ceived by patients as humane, warm and trustworthy. unrealistic because palliative nursing care is intended The relationship between them and patients should to be a specialised support-based type of care while be an equal one, and based on co-operation (6, 7). doctor’s palliative medicine is symptoms-palliation This type of relationship, coupled with the characterbased. In addition, the responsibility of doctors to ‘‘break the bad news’’ does not help the development istics which doctors should have or acquire in their