The turning point: identifying end-of-life care in everyday health care practice

There is a broad consensus among international policy statements that care provided at end-of-life should be different from care provided during other periods of life which assumes a turning point which reflects the onset of the dying process and the associated care reorientation. Few studies derived from empirical data have described this turning point from a clinical perspective. With the purpose to increase the clinical understanding about the nature of such turning points this study explores this phenomenon as determined from health-care records of a representative sample of adults who accessed the public health care system, and who died in the County of Västra Götaland, Sweden, during 2001 (n=229). Record entries reflecting a turning point, that is recognition of the patients as being at the end-of-life and a message about a switch from curative, life-extending or rehabilitative care to an emphasis on palliation, were found in slightly less than 70% of the records while slightly more than 30% lacked such descriptions. The record entries were analyzed with content analysis. As a whole, the descriptions were largely relying on a biomedical discourse and typically put in terms of signs of declining processes, undefined serious condition, prognostications of fatal outcome or justifications of given up active treatments. The procedures which followed the recognition of a turning point revealed that nurses and physicians typically emphasize procedures directed to the patients' families, on re-orientation of treatments and on approaches to further care. The picture of the patients' last time of life as reflected from these record entries is that end-of-life is described in biomedical and factual-oriented terms. The end-of-life care was broadly described in vague terms with lack of concrete care plans. Holistic and good end-of-life care as revealed in this study is indistinguishable, highly embedded in a medical model of care and, hence, an abstract and unknown territory without specific content.