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\begin{document}

\title{Barriers to multidisciplinary team approach in end-of-life
decision-making: Insights from an Indian hospital}



\author[1]{Jaydeep Sengupta}%
\author[2]{Suhita Chopra Chatterjee}%
\affil[1]{Sidho-Kanho-Birsha University}%
\affil[2]{Indian Institute of Technology Kharagpur}%


\vspace{-1em}



  
  \date{June 13, 2024}


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\selectlanguage{english}
\begin{abstract}
A common perception about Multidisciplinary team (MDT) approach is that
it improves quality of care to hospitalized patients, particularly those
who are dying. However, there is paucity of information on challenges in
implementing such approach in end-of-life care (eolc). The present study
explores barriers to MDT functioning in the context of `eolc'. Data
collected through interviews of physicians, nurses and other staff, and
review of case records of deceased patients of a multispecialty hospital
in Kolkata (India) suggest that the MDT approach fails to live up to its
rhetoric. One of the major challenges is professional boundary that is
intrinsic to MDT. Due to this, specialist physicians fail to make
consensus end-of-life decisions by overcoming disciplinary boundaries.
Moreover, holistic caregiving is compromised in the physician-dominant
medical team, where nurses and other non-clinical caregivers feel
marginalized. The hospital environment is also not conducive to
multidisciplinary teamwork. Application of a disease-specific treatment
protocol in `eolc' settings aggravates team coordination. `Eolc'
referrals and care transfers becomes very difficult. Dying patients and
their families are specially affected by such discordant care. Based on
the findings, the study suggests that while team approach is imperative
to effective `eolc', there is a need to shift focus from
multidisciplinary to transdisciplinary approach to enhance care
integration and patient-centric care to terminally ill patients.%
\end{abstract}%



\sloppy


\textbf{Barriers to multidisciplinary team approach in end-of-life
decision-making: Insights from an Indian hospital}

\textbf{Introduction}

In the report,\emph{Health Professions Education: A Bridge to
Quality}\textsuperscript{1}, `cooperation', `communication', and
`coordination' are identified as essential competencies that all
healthcare professionals need to have. It implies the importance of
collaborative teamwork in providing comprehensive care. Accordingly,
Western countries have implemented this collaborative approach through
multidisciplinary teams (MDTs) at all levels of healthcare delivery,
drawing membership from professionals across different disciplines and
specialties. Besides, physicians, it MDTs also include nurses and other
non-clinical healthcare professionals like occupational therapists,
spiritual healers, psychosocial counsellors and so on to provide
comprehensive and holistic care to patients. There are multiple
evidences to support importance of MDT in hospitals. Most promisingly,
it decreases length of stay, improves health outcome, enhances
inter-personal communication, yields patient
satisfaction\textsuperscript{2,3}\textbf{,} and reduces workplace
burnout of the caregiving staff\textsuperscript{4}. A number of
palliative care literature also unanimously support multidisciplinary
collaboration as a key to holistic care by addressing physical,
emotional and spiritual distress of patients at the end-of-life; it also
helps formulating comprehensive, person-centric care
goals\textsuperscript{5.6}. However, few literature also point out
drawbacks of multidisciplinary teamwork like physicians' difficulty in
fostering long-term relationships with professionals from other
disciplines, uneven distribution of work load, unequal recognitions,
heterogeneity in orientation of the caregivers and so
on\textsuperscript{7}. Moreover, in the present time, when
disease-specific treatment has emerged as a dominant model of caregiving
in biomedicine, maintaining a multidisciplinary approach is difficult.
Professional boundaries have crept into MDTs, leading to ``Invisible
boundaries'', as Libertii and Gorli\textsuperscript{8} describes the
situation where physicians compartmentalize themselves into watertight
specialized disciplines leaving no scope for collaboration. Specialist
physicians in the capacity of being appointed as the `primary
consultant' usually follow a paternalistic model in planning care goals
for the patients, deciding treatment modalities, and unilaterally
conveying decisions to other members in the team. To utter dismay, they
pay least attention to opinions of other physicians, and also to the
preferences of the patients under their supervision. It is as if they
own patients\textsuperscript{9}. Such an approach adversely affects
patient care\textsuperscript{10-13}, and is particularly inimical to
end-of-life care. Professional boundaries seem to increase the unmet
need for palliation, as most specialist physicians feel palliative care
not to be their prerogative\textsuperscript{14}\textbf{.} Similar
results emerge from works of Gardiner et al.\textsuperscript{15} and
Powell and Davies\textsuperscript{16}.

In India, implementing inter-professional collaboration in caring for
dying patients is all the more difficult. Firstly, most hospitals follow
a consultative model of palliative care. It means the care is available
to terminally ill patients only on referral from the concerned primary;
palliative care is not an integral part of treatment protocol. Second,
specialist physicians-led MDT have very little representation of
non-clinical caregivers like spiritual carers, occupational therapists,
community nurses and so on. And finally, unlike West, where MDTs are
available at different levels of healthcare delivery
system\textsuperscript{17}\textbf{,} in India MDT formation is limited
to hospital staff, making it highly disadvantageous for the physicians
to network with stakeholders beyond institutional
boundary\textsuperscript{18}. Apart from these few insights, there is
lack of information as how `eolc' is managed in MDTs; what are the
challenges and drawbacks. This study presents a number of observations
from a multispecialty hospital to address to the information lacunae. It
lays special focus on intra/inter-professional boundaries that are
potentially disadvantageous to MDTs.

\textbf{Materials and methods}

The study took a mini-ethnographic approach to collect information on
the nature of inter-professional collaboration in a large private
hospital and the complexities therein. The sample hospital is a
750-bedded multispecialty facility centre situated in the metro-city of
Kolkata (India). It is a nationally reputed institute with branches all
over India, and accredited by the Joint Commission International for
Patient Safety and Security. Data was collected from June, 2016 to
Februray,2017. The researchers studied MDTs that were constituted for
terminally ill, geriatric patients during the study period.

Primary data was collected through in-depth interviews and focus group
discussions with physicians, nurses, representative members from
hospital administration and other staff. A total forty physicians,
twenty nurses and ten members from hospital management participated
(refer to Table 1: \textbf{General information about the respondents} ).
Research participation was restricted within professionals, who were
part of the sample MDTs. Besides first-hand data collection, thirty-five
case reports were retrospectively reviewed to understand the quality
`eolc' provided to deceased patients. Triage pattern, treatment
trajectories, team coordination during care transfers and role of
patients' families were given special emphasis. Additionally, overall
observation of the hospital procedures also provided valuable insights
about MDTs.

The study complied with basic ethical principles laid down by the Indian
Council for Medical Research\textsuperscript{19} and the Declaration of
Helinsky\textsuperscript{20} regarding obtaining informed consent from
the respondents, maintaining confidentiality of data, and presenting
cases anonymously. Respondents were adequately informed of the aims,
methods, sources of funding, any possible conflicts of interest,
institutional affiliation of the researcher, anticipated benefits and
potential risks of the study before signing the consent form.
Researchers also sought and received ethical clearance from the
concerned hospital authorities to gain access inside the premise.

\textbf{Findings}

Physicians involved in MDTs held diverse opinion on `eolc'. Many of the
opinions were contradictory to one another. The researcher found that
conflicts occur when physicians overwhelmingly try to impose their
opinion on others in the team. According to the physicians, although
most the conflicts were ``minor'' in nature that got ``easily'' resolved
through appeal to the institutional medical board and arbitration, few
were serious that affected interpersonal relationships (refer Table 2:
\textbf{Opinion of the physicians and nurses about interpersonal
conflicts within MDT} ).

The following sub-sections give a more elaborate account of different
barriers of MDTs:

\textbf{Differences of opinion among the members in MDT}

Differences among senior specialist physicians

Generally, the primary consultant takes the major responsibility to form
MDT and coordinate. This includes planning care goals for the concerned
patient, making decisions, and sharing treatment-related information
with other members. However, it was observed that the primary
consultants were more biased in sharing information with physicians from
the same discipline than with other participant specialist physicians.
Information sharing was rather unilateral with secondary decision-makers
having no role other than merely providing consent. In other words, the
procedure seemed superficial just to comply with the institutional norm.
Physicians, particularly the intensivists felt marginalised in the team,
as they were least consulted. This was probably because all the
hospitals covered in the study had `open' type ICUs, where intensivists
had no role in decision-making. An intensivist of the hospital said,

Last week a neurologist asked me to attend to a patient that in her
opinion was not doing well. I visited the patient, diagnosed, set up a
therapeutic plan, and communicated to the neurologist\ldots{} But, it
turned out she {[}neurologist{]} completely ignored my opinion!
(\ldots{}) Maybe they (Neurologists) don't consider us (intensivists)
important\ldots{} Another intensivist from the same hospital lamented,
\emph{``\ldots{}}rather than discussing and agreeing on one solution,
everyone tries to impose his/her view, and in the end the most powerful
wins.'' A deeper reflection on the situation suggests that the senior
consultants' reluctance to collaborate with the intensivists mainly
stemmed from the disciplinary boundaries that existed between them;
senior consultants, who were mostly specialists in General medicine,
tended to continue treatment for a longer duration than the
intensivists. Since the major responsibility of an intensivist is to
monitor patients' vital functions, and ensure patient comfort, they
claimed to offer holistic care and felt that other specialists had
`narrow-spectrum' of understanding of patients' conditions. Intensivists
who were trained in anaesthesia mostly emphasised on patient comfort by
managing pain, reducing infection and so on. On the other hand, a
neurologist said, {[}intensivists{]} are too interventionist! They
erratically push and pull tubes! (\ldots{}) {[}This morning{]} a new
patient arrived and the intensivist did an ECG mindlessly just because
he has to comply with the protocol\ldots{}'' The study found
professional boundaries in the hospitals were too stringent to overcome.
Another neurologist from the same hospital shared his experience of
working in a MDT led by a critical care specialist, I prefer not to
strongly impose my opinion on the medical team. It is humiliating to
find that my opinion, for most of the time, is not valued by the primary
consultants and their subordinates. All I do now is to avoid putting
forth my views (\ldots{}). For instance, in case of brainstem dead
patients, I only give opinion to de-escalate aggressive treatment to the
team. It is up to them (team) to decide as what to do''.

Differences between physicians and nurses

Lack of team cohesion was not only evident amongst physicians but was
also between physicians and nurses. In general, physicians considered
nurses to be deficient in knowledge and skills for caring dying
patients. A surgeon, who was highly upset with the nursing team said:

``They mess up everything\ldots{}they don't know how to insert tubes,
how to pull them off and how to handle the life-saving
equipment\ldots{}often they end up causing the patient to bleed. I've
complained many times to the administration\ldots{}'' Another physician
said: ``nurses are good in carrying out orders of the doctor, but caring
for a dying person means something more than a routine work\ldots{}they
lack the aptitude to identify symptoms of imminent death for a patient.
They are unfit to be included in the {[}medical{]} decision-making
team!!''

Nurses, on the other hand, felt immense difficulty in properly
communicating with consultant physicians. They said that the
instructions about treatment plans reach nurses through a hierarchic
order involving junior physicians, medical officers, and the Head nurse.
The nurses were disgusted obeying to a tiring and cumbersome
communication hierarchy. They said that the situation becomes
`nightmarish' when terminally ill patients suffer from co-morbid
conditions. According to an ICU nurse, when a ``frail, old'' patient
suffering from multiple organ failure is admitted to the ICU:

``Different consultants barge into ICU and interfere with treatment
procedures. Care goals keep changing with one consultant overriding
others' decisions. We are obliged to follow multiple instructions and
report to all the concerned physicians\ldots{}at the end we are confused
and the patients distressed. It is totally a chaos for us then\ldots{}''

Conflictions among nurses of different departments

The nurses of the hospital were also divided on their attitude and
perception towards terminally ill geriatric patients. For instance,
nurses at the ICU of the Oncology Department said,

``We are very different from others because we have been trained to
tackle dying issues. We know when to forego life-saving treatments. In
other departments {[}wards{]}, nurses unquestionably perform whatever
the doctors prescribe (\ldots{}) Death unnerves them\ldots{}they panic
if anything goes against their expectation! I couldn't stand working
there\ldots{} I like working here where I feel doing something
independently (referring to supportive care).

A nurse appointed to the High Dependency Unit said,

``No matter how much we claim to have expertise in caring for critically
ill patients, physicians consider us subordinates to them. They consider
our knowledge and skills to be inadequate

These narratives illustrate the ubiquitous presence of an ``invisible
boundary'' between medical fraternity. Standing on either sides of the
boundaries, the professionals vehemently tried defending their
standpoints in caring.

\textbf{Marginalisation of non-clinician caregivers in MDT}

Organisational hierarchy as inimical to team coordination

The hospital promoted a stringent clinical protocol, dominated by
specialist physicians, who acted as primary decision-makers during
end-of-life, whereas others including registrars, nurses and medical
officers, who lacked any sort of specialised clinical knowledge were not
allowed participating in decision-making. Ironically, as evident from
Table 3 (\textbf{Distribution of physicians according to their
orientation in Palliative \& `eolc'} ) many of these officers had basic
orientation in Palliative and End-of-life care, yet they were not
empowered to take end-of-life decisions. Social workers, spiritual
healers and psychological counsellors appeared nowhere in end-of-life
decision-making process.

Geriatrics and Palliative care are extraneous to MDT

MDTs failed to integrate geriatric care even though most of the
end-of-life cases pertained to elderly patients---an observation made
during the study. This was mainly because many primary consultants, who
lead the MDTs, lacked requisite training in geriatric care.
Unfortunately, all the three geriatricians of the hospital were
appointed as General Physician in the general OPD. According to them, an
overwhelming inclination towards disease-specific treatment (or
specialised treatment) of the patients cause them to undermine
importance of geriatricians for holistic care. Thus geriatricians have
least involvement throughout the active treatment trajectory, and also
at the end of it when end-stage patients are transferred to palliative
care. Moreover, the geriatricians too divided in their opinion about
their specific role in the treatment trajectory. While one geriatrician
emphasised on their involvement at the initiation of treatment, another
laid thrust on continuous engagement and supervision of a patient in the
hospital and even post discharge. The third respondent, however, felt a
geriatrician's presence is essential at the end of active treatment when
complications manifest that other specialists fail to address. Such
diversified opinions of the geriatricians make their position fuzzy in
the care organisation.

Similar to geriatricians, palliative physicians too had a weak
representation in the MDTs. A senior oncologist and a member of a MDT
disapproved the need to incorporate palliative care specialist in his
team. He strongly asserted, ``Palliation has no proven efficacy\ldots{}
I usually don't prescribe palliative care''. The geriatricians also drew
professional boundary between Geriatrics and Palliative care. This was
particularly evident from the statement of a geriatrician who said,
``palliative care is not my perspective\ldots{}it means giving up
hope''. Thus inter-linkages between Palliative care and Geriatrics was
grossly overlooked by the physicians leaving a large number of
terminally ill geriatric patients in need of palliation to die in
despair. It was also observed that a patient-coordinator, who counselled
cancer patients throughout the hospital-stay and was immensely
invaluable to patients and families for the huge amount of compassion
she had for them, was not included in MDT just because she had no formal
training either in medicine or nursing.

\textbf{Implications of conflicts and dissent on end-of-life decisions}

The findings show that hospital culture was barely conducive to
consensus decision-making. This had a serious implication on end-of-life
decisions. A survey was conducted to inquire how differences in clinical
standpoints of the physicians who worked as team members affected
end-of-life decision-making. The following sub-sections reveal the
adverse consequences:

Different clinical standpoints of specialists affect comprehensive care
at the end-of-life

A survey was conducted to understand physicians' opinion about
appropriate interventions that could be withdrawn at the end-of-life
(refer Table 4: \textbf{Physicians' opinion on withdrawing
treatment/interventions at the terminal stage} ). Of the total 40
physicians who were asked to give their opinion, 36 returned filled-up
questionnaires.

The table shows physicians differed among themselves in deciding
interventions that are to be `mandatorily withdrawn', `to be withdrawn
after reviewing', `can be withdrawn if patient wishes' or `not to be
withdrawn at all'. Most of the physicians felt that chemo- and
radiotherapy during `eolc' were redundant at the end-of-life (20 out of
36 physicians were in favour of withdrawing such therapies for all
patients at the end-of-life). Similarly, many felt that ICU admissions
during end-stage could be avoided (21 out of 36). On the other hand, 50
percent of the physicians (18 out of 36) said that withdrawing Ryle's
tube to stop nutrition for the dying patient is unethical. Similarly, 39
percent of the physicians (14 out of 36) did not support the idea of
stopping IV hydration. According to these physicians, nutrition and
hydration were `basic' life-supports. A senior nephrologist said nurses
in his hospital were also opposed to the idea of discontinuing food to
dying patients. Overall, an important feature that emerges from this
survey is that physicians were somewhat reluctant to withdraw
interventions that belonged to their own specialty, thus exhibiting a
sort of biased attitude in decision-making. Thus, while nephrologists
emphasised on dialysis even at the end stage, oncologists opined against
discontinuation of chemotherapy and radiotherapy. This information
infers how MDTs fail to deliver coordinated care to dying patients.

\textbf{b. Patients as recipients of discordant care}

Case records, available from the hospital are schematically presented to
highlight chaos, conflicts, and tensions that surrounded dying patients
in absence of well-coordinated MDTs.

\textbf{Fig. A: Case of Mrs Soma (70 years; Ca Lung with bone
metastasis)}

(Figure A)

The case of Mrs. Soma highlights two important issues: firstly, the
structured pattern of caregiving in the hospital did not exempt the
frail aged dying patient from undergoing aggressive cardio-pulmonary
resuscitation (CPR). Moreover, most of the physicians, who were involved
in the treatment trajectory of Mrs. Soma, were unfamiliar with her
treatment preferences and choices. Such abrupt and short-duration
involvement of the physicians with the treatment trajectory possibly
made the dying patients feel discomfort. Unfortunately, Soma's
preference was only known to the primary physicians, who did not
communicate it to the rest of the team members. Worse still, the primary
consultant of the patient could not be reached over the phone. This
compelled the on-duty physicians to make crucial medical decision of
resuscitating the gasping patient; it not only dishonoured the family's
request to not to resuscitate but violated patient's autonomy also!

\textbf{Fig. B: Case of Mr Gopal (82 years; COPD and kidney
failure)}(Figure B)

In this case, too, the patient was compulsorily subjected to aggressive
treatment at the end-of-life. As a result, the patient had to follow
strict treatment regime characterised by series of diagnostic tests, ICU
admission, and multiple CPR attempts. Unfortunately, the procedure could
not save the patient, who eventually died. In fact, Mr. Gopal died
without proper end-of-life care. Although he was treated by a team of
doctors, none seemed to consider his advanced age and multiple
morbidities as criteria to stop aggressive treatment. Moreover, like the
previous case he too was transferred from one specialist to another who
had little coordination among themselves. Unfortunately, the
nephrologist under whose supervision, Mr. Gopal was admitted, was
nowhere around during his death. Gopal's family too were not around his
deathbed. Such a situation rarely guarantees a continuum of care. It
also indicates physicians in their overwhelming enthusiasm to
resuscitate patients, ignores symptoms of the impending death.

\textbf{Fig. C: Case of Mr Kumar (72 years; Metastasis in the right
pyriform sinus)}(Figure C)

Mr. Kumar's case also ends with conflict between family members,
physicians and the hospital administration on the issue of ICU
admission. While the hospital authority and the physicians insisted for
ICU admission as per the treatment protocol, the family members strongly
opposed the decision. This soon led to chaos and scuffle around the
deathbed of the patient. The incident was soon over but took a severe
toll on the patients' physical condition who suffered a massive cardiac
arrest. None seemed to take into consideration the patient's choice. As
a result, Mr. Kumar died alone in the ICU; it was certainly not a `good
death' by any means.

\textbf{Discussion}

The multispecialty hospital considered for the study largely represents
the situation of acute care set-ups across India. An overwhelming
interest to form medical teams under leadership of consultant physicians
affects interdisciplinary collaboration, a prerequisite for `eolc'. The
above discussion outlines how achieving consensus over end-of-life
decisions is a challenge due to reluctance of the physicians to overcome
their domain-specific knowledge boundaries. Thus, co-located specialist
physicians, does not necessarily guarantee collaborative and
comprehensive `eolc' unless they stop working as independent care
providers\textsuperscript{21}\textbf{.} However, overcoming
inter-professional boundaries is difficult because they are deeply
rooted to the biomedical culture that contains divergent approach to
`eolc'. These differences of opinion are detrimental to consensus
end-of-life decision-making, as evident from table no.4, where
physicians fell out in their decisions to withdraw life-sustaining
treatment. The finding gets support from global `eolc' literature that
show variations in treatment-limiting decisions owe to physicians'
specialisation and level of training\textsuperscript{22-27}.
Consequently, care goals became ambiguous, unattainable and sometimes
violative of rights of patients and families. This is evident from the
cases reports of few patients and families, who experienced chaos and
humiliation during treatment.

Divergent opinions result in conflict when primary consultants fiercely
impose their decisions on others in the team, overriding alternative
standpoints. Some researchers also feel that due to an overwhelming urge
to uphold the professional superiority, specialist physicians
intentionally show little or no respect for other's view. According to
Everett C. Hughes, in a medical pluralistic environment, such a
phenomenon is common\textsuperscript{28}. A similar assertion is also
made by Lancaster~et al.\textsuperscript{29} according to whom
physicians tend to overlook the importance of joint responsibility and
are engrossed in asserting their superiority over nurses and other
non-clinical professionals. Vazirani, Hays, Shapiro and
Cowan\textsuperscript{30} also hold a similar opinion.

Finally, marginalisation of nurses and other non-clinical care providers
is a near-universal barrier to physician-led MDT\textsuperscript{31}.
The present study is also a testimony to this fact\textbf{.} By
over-medicalising `eolc' protocols, hospitals have made services of
nurses, psychological counsellors, spiritual healers, less important.
The study also shows how geriatricians and patient coordinators were
excluded from MDTs. Unfortunately, elderly `eolc' patients died without
receiving age-appropriate care. Considering these barriers, it seems
that MDTs are mere assemblage of professionals from different
disciplines without necessarily guaranteeing integrated patient
care\textsuperscript{32-38}. In other words, `invisible boundaries'
within MDTs and disease-specific clinical models make cross-disciplinary
communication, relationship-building and comprehensive care
unattainable.

From the writing of Choi and Pak\textsuperscript{39} it seems that the
very term MDT is problematic because multidisciplinarity has a narrow
approach. It is mainly `additive' in nature, meaning, that it draws
knowledge from all fields but is restricted within boundaries of few
disciplines only. Thus, the key to provide concerted service to dying
patients in hospitals is to transform MDTs into interdisciplinary teams
or, even better, to a transdisciplinary team. They go on explaining that
while interdisciplinary approach synthesises knowledge acquired from
different disciplines, transdisciplinarity refers to integration of
health sciences with social and natural sciences in a humanistic
context; it transcends traditional disciplinary boundaries. In the
context of palliative care, Piotrowski\textsuperscript{40} briefly
outlines evolution of team approach from Traditional Multidisciplinary
Practice (a typical physician-led palliative care model where different
specialist physicians provide ``ad hoc'' consultations) to
Interdisciplinary Team (also physician-led team but members from
different disciplines subsumes to a common organizational framework.
However, in reality membership is restricted to physicians and nurses)
and finally to Transdisciplinary Team (shared team vision; integrated
responsibilities, training, leadership, and decision-making). In fact,
the transdisciplinary approach has proven to be effective in improving
delivery of palliative and `eolc'. Daly and
Matzel\textsuperscript{41}could successfully recast palliative care in a
US-based acute care set-up by forming a transdisciplinary palliative
care team composed of physicians, nurses, end-of-life counsellors and
chaplains. Multiple strategies were adopted to educate the staff on
transdisciplinary palliative care and communication. The authors report
that adopting transdisciplinary approach resulted in better integration
of patient services, early identification of palliative care following
hospitalisation, regular assessment of patient's condition, and
providing spiritual and social care support to patients and families.
Moreover, the caregivers felt lesser workload and burnout.

Transdisciplinary team approach to palliative care in the Indian
hospitals can also be adopted. However, given the fact that the
physicians and other caregivers lack adequate training in palliative and
`eolc', they first need to undergo a rigorous orientation on the
discipline, understanding principles of palliative care. During
training, specialist physicians need to be motivated for shifting their
attention from disease-specific treatment to person-centric care for
end-of-life patients. This is followed by facilitating specialist
physicians to network with nurses, non-clinical professionals like
psychological and spiritual counsellors, and family members. Sufficient
handholding support to the team is necessary to impart skills for
leadership, shared decision-making, and conflict resolution. Hopefully,
prioritising patient's preference over clinicians' agencies in making
medical decisions, including treatment withdrawal, would mitigate
difference of opinion between physicians. Finally, to sustain
transdisciplinary teams in the hospital it is important that the
approach is widely promoted even among healthcare staff working outside
the hospital so that the transdisciplinary team approach extends beyond
institutional setting and the continuum of care is ensured. Unless these
measures are undertaken, adoption of an integrated approach to care for
dying patients in hospitals will remain a distant dream.

\textbf{References}

{[}1{]} Knebel E, Greiner AC. editors.~\emph{Health professions
education: A bridge to quality} . Washington, D.C: National Academies
Press; 2003

{[}2{]} Epstein NE. Multidisciplinary in-hospital teams improve patient
outcomes: A review. \emph{Surgical Neurology International} 2014;5(Suppl
7):S295

{[}3{]} Saghir NS, Keating NL, Carlson RW, Khoury KE, Fallowfield L.
Tumor boards: optimizing the structure and improving efficiency of
multidisciplinary management of patients with cancer
worldwide.\emph{American Society for Clinical Oncology Educational
Book}2014;34:e461--6

{[}4{]} Gorbenko K, Mendelev E, Keefer L. Can multidisciplinary team
meetings reduce burnout? \emph{Journal of Evaluation in Clinical
Practice} 2019; June: 1--3.

{[}5{]} Rosen MA, DiazGranados D, Dietz AS, Benishek LE, Thompson D,
Pronovost PJ, Weaver SJ. Teamwork in healthcare: Key discoveries
enabling safer, high-quality care.~\emph{American Psychologist}2018;~73:
433-450

{[}6{]} Vissers, KC, van den Brand MW, Jacobs J, Groot M, Veldhoven C,
Verhagen C, \ldots{} Engels, Y. Palliative medicine update: a
multidisciplinary approach.~\emph{Pain Practice} ~2013;13: 576-588

{[}7{]} Iliffe S. Myths and realities in multidisciplinary
team-working.\emph{London Journal of Primary Care} 2008; Nov
1;1(2):100-2

{[}8{]} Liberati EG, Gorli M, Scaratti G. Invisible walls within
multidisciplinary teams, disciplinary boundaries and their effects on
integrated care.~\emph{Social Science \&Medicine} 2016; 150: 31-39

{[}9{]} McKee M, Healy J.~\emph{Hospitals in a changing Europe} .
Philadelphia: Open University Press; 2002

{[}10{]} Dixon-Woods M. Why is patient safety so hard? A selective
review of ethnographic studies. \emph{Journal of Health Services
Research and Policy} 2010; 15: 11-16

{[}11{]} Nugus P, Greenfield D, Travaglia J, Westbrook J, Braithwaite J.
How and where clinicians exercise power: interprofessional relations in
health care. \emph{Social Science \& Medicine} 2010; 71: 898-909

{[}12{]} Hewett, DG,Watson BM, Gallois C,Ward M, Leggett BA. Intergroup
communication between hospital doctors: implications for quality of
patient care. \emph{Social Science \& Medicine} 2009; 69: 1732-1740

{[}13{]} Nembhard, IM, Edmondson AC. Making it safe: the effects of
leader inclusiveness and professional status on psychological safety and
improvement efforts in health care teams. \emph{Journal of
Organizational Behavior} 2006; 27:941-966

{[}14{]} Kennedy R, Abdullah N, Bhadra R, Bonsu NO, Fayezizadeh M, Ickes
H. Barriers to effective use of palliative care services in the acute
care setting with emphasis on terminal non-cancer diseases.
Indian\emph{Journal of Palliative Care} 2019;25:203-9

{[}15{]} Gardiner C, Cobb M, Gott M, Ingleton C. Barriers to providing
palliative care for older people in acute hospitals. \emph{Age and
Ageing} 2011: Mar 1;40(2):233-8

{[}16{]} Powell AE, Davies HT. The struggle to improve patient care in
the face of professional boundaries.~\emph{Social science \&
Medicine}2012;~75: 807-814

{[}17{]} Royal College of Nursing and Royal College of General
Practice.\emph{Report of the Joint Working Party on the Primary Health
Care Team}1961. London: RGCP

{[}18{]} Bowen L. The multidisciplinary team in palliative care: A case
reflection\emph{.~Indian journal of Palliative Care} 2014; 20: 142-145

{[}19{]} Indian Council of Medical Research. \emph{Ethical Guidelines
for Biomedical Research on Human} . New Delhi: ICMR 2006

{[}20{]} World Medical Association\emph{.} World Medical Association
Declaration of Helsinki-Ethical principles for medical research
involving human subjects. \emph{Nursing Ethics} 2002; 9: 105

{[}21{]} Imison C, Naylor C, Maybin J. \emph{Under one roof: will
polyclinics deliver integrated care?} London: The King's Fund; 2008

{[}22{]} McDonald R, Waring J, Harrison S. Rules, safety and the
narrativisation of identity: a hospital operating theatre case
study\emph{.~Sociology of Health \& Illness} 2006;~28: 178-202

{[}23{]} Cook DJ, Guyatt G H, Jaeschke R, Reeve J, Spanier A, King D,
\ldots{} Tweeddale M. Determinants in Canadian health care workers of
the decision to withdraw life support from the critically
ill.~\emph{Journal of American Medical Association} 1995;~273: 703-708

{[}24{]} Raffin, TA. Withdrawing life support, how is the decision
made?\emph{Journal of American Medical Association} 1995;~273: 738-739

{[}25{]} Caralis PV, Hammond, JS. Attitudes of medical students,
housestaff, and faculty physicians toward euthanasia and termination of
life-sustaining treatment.~\emph{Critical Care Medicine} 1992; 20:
683-690

{[}26{]} Lega F, DePietro C. Converging patterns in hospital
organization, beyond the professional bureaucracy. \emph{Health
Policy}2005\emph{;} 74: 261-281

{[}27{]} Vera A, Kuntz L. Process-based organization design and hospital
efficiency. \emph{Health Care Management Review} 2007; 32:55-65

{[}28{]} Zetka Jr, JR. Establishing specialty jurisdictions in medicine:
the case of American obstetrics and gynaecology.~\emph{Sociology of
Health \& Illness} 2011; 33: 837-852

{[}29{]} Lancaster, G,~Kolakowsky-Hayner, S,~Kovacich, J,
Greer-Williams. Interdisciplinary communication and collaboration among
physicians, nurses, and unlicensed assistive personnel. \emph{Journal of
Nursing Scholarship} 2015; 47:275-284

{[}30{]} Vazirani, S, Hays RD, Shapiro MF, Cowan, M. Effect of a
multidisciplinary intervention on communication and collaboration among
physicians and nurses.~\emph{American Journal of Critical Care}2005;~14:
71-77

{[}31{]} Atwal A, Caldwell K. Do multidisciplinary integrated care
pathways improve interprofessional collaboration? \emph{Scandinavian
Journal of Caring Science} 2002; 16: 360-367

{[}32{]} Oborn E, Dawson S. Knowledge and practice in multidisciplinary
teams, struggle, accommodation and privilege. \emph{Human
Relations}2010; 63:1835-1857

{[}33{]} Lewin S, Reeves S. Enacting ``team'' and ``teamwork'', using
Goffman's theory of impression management to illuminate
interprofessional practice on hospital wards. \emph{Social Science \&
Medicine} 2011; 72: 1595-1602

{[}34{]} Sanders T, Harrison S. Professional legitimacy claims in the
multidisciplinary workplace, the case of heart failure
care.\emph{Sociology of Health and Illness} 2008; 30: 289-308

{[}35{]} Waring J, Marshall F, Bishop S. Understanding the occupational
and organizational boundaries to safe hospital discharge. \emph{Journal
of Health Services Research \& Policy} 2015; 20: 35-44

{[}36{]} Mackintosh N, Sandall J. Overcoming gendered and professional
hierarchies in order to facilitate escalation of care in emergency
situations, the role of standardised communication
protocols.\emph{Social Science and Medicine} 2010\emph{;} 71: 1683-1686

{[}37{]} Ferlie E, Fitzgerald L, Wood M, Hawkins C. The nonspread of
innovations, the mediating role of professionals. \emph{Academy of
Management Journal} 2005; 48: 117-134

{[}39{]} Choi, BC, Pak AW. Multidisciplinarity, interdisciplinarity and
transdisciplinarity in health research, services, education and policy:
Definitions, objectives, and evidence of effectiveness.~\emph{Clinical
and Investigative Medicine} 2006; 29: 351

{[}40{]} Piotrowski LF. \emph{Transdisciplinary care: The next
frontier}2017. Available from
https://www.nacc.org/vision/july-august-2017/transdisciplinary-care-next-frontier/.
Accessed 25\textsuperscript{th} March,2020

{[}41{]} Daly D, Matzel SC. Building a transdisciplinary approach to
palliative care in an acute care setting. \emph{OMEGA-Journal of Death
and Dying} 2013 Aug; 67(1-2):43-51

\textbf{Acknowledgement}

The authors would like to thank the Ethics committee of Apollo
Gleneagles Hospital, Kolkata, India. We are also grateful to all the
participating departments, clinicians and nurses of the hospital.

\textbf{Conflict of interest}

This research has no conflict of interest.

\textbf{Author contribution}

Dr Jaydeep Sengupta conducted the fieldwork for this study as part of
his PhD programme. The work was supervised by Prof. Suhita Chopra
Chatterjee. A part of the main thesis is produced in this co-authored
paper, in which Prof. Chopra Chatterjee made a significant contribution,
including cross-checking the information, English language correction
and editing.

\textbf{Funding}

Dr J. Sengupta was awarded a full-time studentship to undertake this
study by the Indian Institute of Technology Kharagpur.

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\verb`Tables 1.docx`  available at \url{https://authorea.com/users/317500/articles/447578-barriers-to-multidisciplinary-team-approach-in-end-of-life-decision-making-insights-from-an-indian-hospital}

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\verb`Tables 3.docx`  available at \url{https://authorea.com/users/317500/articles/447578-barriers-to-multidisciplinary-team-approach-in-end-of-life-decision-making-insights-from-an-indian-hospital}

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\verb`Tables 4.docx`  available at \url{https://authorea.com/users/317500/articles/447578-barriers-to-multidisciplinary-team-approach-in-end-of-life-decision-making-insights-from-an-indian-hospital}

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