Background: The goal of the larger study was to explore physicians' emotional responses to
the death of their patients; this study analyzed a subset of physician transcripts to elucidate
the construct of questioning care, which emerged from the larger study.
Objective: To analyzes how physicians question care—expressing concern, unease, or uncertainty
about treatment decisions and practices, errors, or adverse events—as they attend
dying patients.
Design: Retrospective interview study of physicians caring for randomly selected deaths on
the medical service of a major academic teaching hospital, using qualitative and quantitative
measures.
Setting, Subjects: 188 attendings, residents, and interns on the internal medical services of
two academic medical centers were part of the larger study. A subsample of 75 physician narratives
was selected for qualitative data analysis for this study.
Measurements: Qualitative measures included open-ended questions eliciting physicians'
stories of the most recent and a most emotionally powerful patient death they have experienced.
Grounded theory was used to analyze physician narratives. Quantitative instruments
measured physician attitudes toward end-of-life care and responses to the most recent and
most emotional patient death.
Results: Physicians question care more frequently in most emotional deaths (42%) than in
most recent deaths (34%). Physicians question communication with patients and families and
within medical teams, medical judgment and technique, standards of practice, and high-risk
treatments, often assigning responsibility for medical management they perceive as inappropriate,
futile, overly aggressive, or mistakes in judgment and technique. Responsibility
ranges from the distal (the culture of medicine) to the proximal (personal). Frustration, guilt,
and anger are more frequently expressed in these narratives when care is questioned.
Conclusions: A typology of questioning care emerged from these physicians' narratives that
parallels and reflects recent and classic research on medical error and the culture of medicine.
Physicians' questions about care can contribute to designing training experiences for residents
and to improving the quality of systems that affect patients' experiences at life's end
and physicians' experiences in caring for dying patients.
