How many doctors? Relational continuity in end of life care

Abstract

Background Continuity of care is important to patients and is a key factor in providing good end of life care. Relational continuity describes the continuity of care provided by seeing the same doctor. This can facilitate difficult conversations regarding preferences for future care. A previous study of palliative care patients examined the number of doctors encountered. Since then there have been changes to medical training, limits on working hours and increased flexible working. This presents new challenges to continuity of care. Aims To study relational continuity for patients who received end of life care in the hospice setting. To assess the number of doctors encountered in the last 6 months of life. Methods A retrospective case note review was carried out for consecutive patients who died in a hospice over a 4 month period. A standardised data collection sheet was used and the number of doctors encountered noted. Encounters were identified by review of the hospital notes and documentation of a doctor's signature or an entry confirming which doctors the patient saw. Results Sixty-five patients were identified and of these 41 case notes were available. In the last 6 months of life, the minimum number of doctors met was 2 and the maximum 57, mean 19.Of the total number of encounters one third were with a doctor they had not met before. Patients saw more foundation doctors and consultants than speciality trainees. Discussion These results are highly likely to underestimate the actual number of doctors patients saw. It does not include encounters in primary care or the continuity provided by other health professionals. Some patients encounter a large number of doctors in the months preceding death. With reduced working hours for doctors, attention has focused on handover for informational continuity and patient safety; less attention may have been given to relational continuity.