" Am I Dying Doctor ? " : How End-Of-Life Care is Portrayed in Television Medical

Background: Patient-clinician communication about end-of-life care is important for patients with chronic lifelimiting diseases and their loved ones but requires engagement from patients and loved ones. Television is a powerful medium in influencing people’s behaviour. However, it is unknown which image is sketched on television about end-of-life care communication. Objective: To explore communication about end-of-life care between healthcare professionals and patients or loved ones in popular medical dramas on television. Methods: 68 episodes of television medical drama were reviewed (22 episodes of House, 22 episodes of ER, and 24 episodes of Grey’s Anatomy). Three types of events were identified: communication between healthcare professionals and patients or loved ones about end-of-life care, cardiopulmonary resuscitation (CPR), and death. Results: In total, 99 events of end-of-life care communication, 47 events of CPR, and 27 events of death were observed. Discussions about end-of-life care were mostly initiated by physicians in the presence of patients and loved ones. The most frequently addressed topics were: talking about the possibility of dying, treatment options, and life-sustaining treatments. The immediate success rate of CPR was 51.1%. Of the patients who deceased, the majority died unexpected, usually a life-prolonging treatment was performed before death, and advance directives were uncommon. Conclusion: Healthcare professionals in television medical dramas talked with patients or loved ones about endof-life. However, topics important for patients in real life were often not discussed.


Introduction
Advance Care Planning (ACP) is defined as an ongoing process whereby patients, in consultation with healthcare professionals and loved ones, make individual decisions about their future healthcare, to prepare for future medical treatment decisions, which often take place at the end-of-life [1].A systematic review and meta-analysis showed that ACP interventions increase the completion of advance directives, occurrence of discussions about ACP, and the concordance between preferences for care and delivered care [2].However, despite these benefits, discussions between physicians, patients and loved ones about end-of-life care are still uncommon [3,4].Most patients will not initiate these discussions and will wait for their physician to initiate end-of-life discussions, especially when patients were unaware about the life-threatening nature of their disease [5] or had little knowledge of ACP [6].Indeed, lack of patient knowledge and understanding of medical information are physicianreported barriers for ACP [7].In addition, patients reported that they had "never thought about it" [8] and often did not know that they can be involved in discussions about end-of-life care [7,8].
Previous research showed that the behaviour change theory is important in motivating individuals to engage in ACP [9].According to this theory, willingness to engage in ACP behaviour is determined by knowledge and beliefs about ACP and expectations about treatment outcomes [9][10][11].Increased public awareness of the importance of timely end-of-life discussions may facilitate patients' and loved ones' willingness to be engaged in end-of-life care discussions and may improve patient empowerment [12,13].Patient empowerment is defined as an educational process to help patients develop the knowledge to effectively make their own health-related decisions [14].Traditionally, doctors were the primary source of information for patients.However, patients can also empower themselves through selfeducation facilitated by for example internet or television [15].In fact, previous studies showed that television is a powerful medium in influencing people's behavior [16][17][18] and that the majority of elderly patients obtain information about cardiopulmonary resuscitation (CPR) from television [19].However, a previous study showed that in movies dealing with life-threatening illness and death the level of reality is limited [20].Furthermore, a recent study demonstrated that discussions about ACP rarely occur in television medical dramas [21].
To the present authors' knowledge, detailed data concerning communication about end-of-life care on television are currently lacking.It seems reasonable that television can play an important role in patient perceptions about end-of-life care.The aim of this study is to explore communication about end-of-life care between healthcare professionals and patients or loved ones in popular medical dramas on television.

Methods
We viewed all episodes of the last season available on DVD of the television medical dramas ER (season 15), House (season 8), and Grey's Anatomy (season 9).All three programs are American medical drama series in the hospital setting.A predesigned data sheet was used to identify and score three types of events: 1) communication between healthcare professionals and patients or loved ones (defined as persons who are close to the patient, regardless of whether they are spouse, significant others, relatives, grown-up children, or friends [22]) about end-of-life care; 2) CPR; and 3) death of a patient.For all events the patient's sex and life stage (unborn, baby, child, adolescent, or adult) were recorded.
For every occurrence of end-of-life care communication between a healthcare professional and patient or loved one the following information was recorded: who initiated communication about endof-life care (patient, physician, nurse, loved one, or other); who were present during the conversation (patient, physician, nurse, loved one, or other); which words were used when talking about the end of life (death, dying, or other), and which topics were discussed.Discussed topics recorded were based on expert suggestions and partly derived from the end-of-life subscale of the Quality of Communication (QOC) questionnaire [23], a validated instrument to measure quality of communication between patients and healthcare professionals.
In addition, for every occurrence of CPR the following information was recorded: the location where CPR was performed (Intensive Care Unit (ICU), Operating Room (OR), Emergency Room (ER), hospital department, other location in hospital, or out-of-hospital), and whether patients survived CPR.CPR was defined as each observed situation in which chest compressions and/or defibrillation was performed on a patient.
Finally, for all deaths the following information was recorded: whether death of the patient was (un)expected; who were present at time of death (physician, nurse, loved one, or not shown); location of death (ICU, OR, ER, hospital department, other, or not shown); whether the patient had an advance directive; whether life-sustaining treatments were performed and if so, whether these were discontinued before death, and whether there was distress during the dying phase.
All episodes were independently watched and events were scored by two authors (C.H. and D.J.), blinded to each other findings.In case of disagreement, the event was watched again by both authors and disagreements were solved by consensus.
Frequencies and percentages were used to present the results.The frequencies of the use of the words "death" and "dying" were compared between patients, loved ones and healthcare professionals using a Chi square test.

Results
A total of 68 episodes (in total 48 hours) of television medical dramas were reviewed.We viewed 22 episodes of ER (15 hours), 22 episodes of House (16 hours), and 24 episodes of Grey's Anatomy ( 17hours).

End-of-life communication
We observed 99 events of end-of-life communication between a healthcare professional and patient or loved one (27.3% in ER, 41.4% in Grey's Anatomy and 31.3% in House) shown in Table 1.Most patients were male adults.In 45.5% of the events a physician initiated a discussion about end-of-life care.The words "death" and "dying" were used in 16.2% and 47.5% of the events, respectively.Chi square tests revealed no significant differences in the use of the words "death" and "dying" between patients, loved ones and healthcare professionals (p>0.05).Other words used when talking about end-of-life care were for example "fatal", "the heart will stop", and "nothing we can do".The most frequently addressed topics were: talking about the possibility of dying, treatment options, and life-sustaining treatments.Patients' feelings about getting sicker were not discussed at all.In 12.1 % other topics were discussed such as talking about sedation, talking about the fact that the patient has already died, talking about the death of a loved one, talking about a death wish or preferred place of death.Data are presented as number of patients or events (%).* In one event the patients were a couple, which is scored as one event, but under the heading "gender" separated into male and female.# 8 patients were unconscious and 2 patients were unborn.† Items derived from Quality of Communication (QOC) questionnaire.

Death
During the 68 episodes, 27 patients died (59.3% in ER, 33.3% in Grey's Anatomy and 7.4% in House) (Table 3).In general, death was unexpected and patients were surrounded by a physician, loved one and/or nurse.Life-sustaining treatments were shown for 81.5% of the patients who eventually died and mechanical ventilation was discontinued in a minority before death.In only 11.1% of the situations in which patients died there was a reference to an advance directive.

Key findings
The present study shows that in television medical dramas healthcare professionals and patients or loved ones talked regularly about end-of-life care.Also CPR and death were frequently portrayed.Discussions about end-of-life care in television medical dramas were mostly initiated by physicians in the presence of patients and loved ones.The most frequently addressed topics were: talking about the possibility of dying, treatment options, and life-sustaining treatments.The immediate success rate of CPR was 51.1%.Death was often unexpected.Usually, a life-prolonging treatment was performed before death.Finally, advance directives were uncommon.

Communication
The physician was mostly the initiator of the discussion about endof-life care and the discussion was rarely initiated by a patient.Therefore, watching television medical dramas will not activate people to engage in ACP and initiate a discussion about end-of-life care by themselves.Indeed, studies performed in real life showed that patients believe it is the healthcare professional's responsibility to initiate discussions and that patients will rarely initiate these discussions [8,24].However, physicians perceive initiation of a discussion about end-of-life care by a patient as a facilitator for communication about end-of-life care [24].In addition, preferences for end-of-life care in the observed television medical dramas were mostly discussed because of an acute life-threatening trauma or injury, while in real life healthcare professionals need to have these conversations with chronically ill patients or elderly living in long term care settings [2].Therefore, television medical dramas do not contribute to the public awareness of the fact that ACP is of major importance for patients with a chronic disease.
The possibility of dying was discussed in more than half of the events, but topics as life expectancy, what dying might be like, feelings about getting sicker and things that are important in life were rarely discussed.However, research performed in real life showed that a majority of the patients want more information regarding prognosis than is provided in current care [25].Patients and caregivers also desired more detailed information about what dying might be like J Palliat Care Med ISSN:2165-7386 JPCM, an open access journal Volume 6 • Issue 1 • 1000247 [26], whereby in general caregivers require more detailed information about the dying process, allowing them to prepare for what to expect [27].Moreover, patients emphasized the importance of talking about things that are important for them during the end-of-life, such as maintaining dignity, getting support from healthcare professionals and family, and pain management [27].Finally, it is important for patients to talk about their feelings about getting sicker and probably dying, because they are often afraid of the dying process and also want to talk about the meaning of death in order to prepare for a "good death" [28].
Although treatment options were frequently discussed, there was little attention for documenting preferences for life-sustaining treatments in the form of an advance directive or appointing a surrogate decision maker.Therefore television medical dramas did not contribute to the public awareness about the possibility to document preferences for end-of-life and will not stimulate viewers to change behaviour regarding completion of an advance directive.
Further, in the television medical dramas palliative care was rarely discussed.A previous study aimed to analyse how issues of illness and death were presented in movies also showed that the term "palliative care" was not mentioned once in any films [20].This could be explained by the fact that palliative care is still not known well enough by the general public [20] and includes too little action and sensation to be shown on television [29].When physicians in television medical dramas do discuss palliative care this may raise public awareness by providing education about for example preferences regarding end-oflife care and the possibility of shared-decision making.Video-based tools are found to be effective in improving patient knowledge about ACP and palliative care [30] and were even used in large-scale national campaigns, such as Dying Matters [31] to increase public awareness about end-of-life care [32].In the television medical dramas words as "death" and "dying" were regularly used and in this respect the television medical dramas contribute to normalizing the use of these words.Previous studies have shown that using clear words as "death" and "dying" instead of vague euphemisms is important for good endof-life communication [33].After all, there are many things that could be done in the end-of-life concerning pain and symptom management or hospice referral for example [34].The use of clear words when talking about end-of-life may contribute to enhanced acceptance of the reality of impending death and it possibly can help patients prepare for death [35].

CPR
The immediate success rate of CPR in the reviewed television medical dramas was 51.1%.Comparing success rates of CPR in television medical dramas with those in the medical literature is difficult.First, television medical dramas only show the results immediately after CPR and did not portray longterm outcomes, while success rates in the medical literature are mainly focused on survival rates to discharge.In fact, in real life the survival rate of in-hospital CPR to hospital discharge in patients without a chronic disease is only 17.3% [36].Second, in the television medical dramas CPR was mainly performed in the ER or operation room (OR), while studies usually exclude patients whose cardiac arrest happened when they were in the ER or OR, because of the distinct circumstances of cardiac arrest in these settings [37].Third, cardiac arrests in the television medical dramas were often caused by acute injury, while in real life most of arrests results from underlying cardiac disease [37].Since previous research assumed that television medical dramas have an effect on the perceptions and attitudes regarding the outcome of CPR [38], the current authors recommend physicians to discuss differences between CPR in television medical dramas and real life in daily clinical practice.

Death
Nearly half of all deaths portrayed in the studied television medical dramas occurred in the ER and were associated with trauma, resulting in mainly unexpected deaths.Although trauma was a common cause of death in the 1900s, nowadays people often die from chronic diseases and cancer [39].Therefore, the image portrayed in television medical dramas does not reflect reality regarding causes of death.This can be largely explained by the fact that series were mostly set in the ER and add drama and action to make the series attractive for the general public [29].
In almost all events a physician or nurse was present at the time of death and in addition often a loved one.This is in line with what seriously ill patients and their family caregivers rated as important at the end-of-life in real life, namely "presence of family" and "not die alone" [40].
In only three of the deceased patients in the television medical dramas an explicit reference was made to an advance directive.In the meantime, life-sustaining treatment preferences were performed before death in almost all patients and were discontinued in only three patients.Research performed in real life showed that many people in the general public are unwilling to undergo life-sustaining treatments in the case of cancer, cardiac failure, dementia, or persistent vegetative state following a road traffic accident.In fact, regardless of the presented scenario, about 70% do not want CPR or mechanical ventilation in these situations [41].However, the documentation rate of preferences for end-of-life care in the general population is still low [6].Perhaps videos which have been developed for more educational purposes will affect the completion of advance directives rather than television medical dramas.Indeed, recent research has shown that video educations enhances the completion of advance directives and are therefore useful tools in helping patients and clinicians to discuss and document preferences for end-of-life care [42].

Limitations
The present study has some limitations.First, we reviewed only one season of three television medical dramas.However, since the structure of the television medical dramas seems to remain the same during the seasons it is not to be expected that reviewing more seasons would have led to different results.Second, discussions about end-of-life care were not completely shown and consequently we could only analyse the broadcasted part of the discussion.Despite this limitation, we were able to review almost hundred events of communication about end-oflife care.Third, the reviewed medical dramas were all from American origin and therefore maybe not comparable with the depiction of endof-life care in television series from other countries.Indeed, previous studies regarding depiction of CPR in medical series showed that CPR survival rates in British and Flemish medical series seem to be more realistic than in American television medical dramas [43,44].Whether this is also true for end-of-life care communication remains currently unknown.

Conclusions
The present study shows that healthcare professionals in television medical dramas talked with patients or loved ones about end-of-life.However, these discussions are often limited to discussions about the possibility of dying and treatment options.Topics such as preferences for life-sustaining treatments, advance directives, and palliative care were rarely discussed.Therefore television medical dramas don't seem to contribute in empowerment of patients and loved ones in the process of ACP and don't facilitate behaviour change resulting in increased willingness to be engaged in end-of-life communication.However they could influence patients' and loved ones' attitudes regarding ACP, CPR, and dying.Therefore, healthcare professionals need to take into account this influence when having discussions about end-of-life.

Table 1 :
End-of-life communication in television medical dramas.Anatomy and 10.7% in House) (Table2).The immediate success rate of CPR was 51.1%.

Table 3 :
Dying in television medical dramas.