Advance Directives: Physician Attitudes Differ From Actions

Caroline Helwick

May 22, 2014

ORLANDO, Florida — Physicians continue to provide high-intensity care for terminally ill patients but personally choose to forego such care at the end of life, according to a survey of young physicians.

"There is a striking difference between the end-of-life care that doctors choose for themselves and the care they provide to their patients," said lead investigator Vyjeyanthi Periyakoil, MD, from Stanford University in Palo Alto, California.

"The data are sobering," she added. "It appears that patients don't get preference-sensitive care."

Her team conducted the survey to determine what influences attitudes about advance directives, and whether attitudes have changed since the passage of the Patient Self-Determination Act in 1990.

She presented the results during the plenary session here at the American Geriatrics Society 2014 Annual Scientific Meeting.

Doctors Prefer to "Die Gently"

Of the 1081 survey respondents, 60% were 30 to 39 years of age. All were medical subspecialists finishing their clinical training at 2 academic hospitals. All respondents completed a Web-based form and a 14-item attitude survey on advance directives from March to June 2013.

Attitudes about advance directives were influenced by sex (P = .00172), ethnicity (P = .002), and subspecialty (P = .004). Women were more positive about them than men, and Hispanic American doctors were least positive.

Doctors from emergency medicine, physical medicine and rehabilitation, pediatrics, and obstetrics and gynecology were most positive about advance directives, whereas specialists in radiology and nuclear medicine, surgery, orthopedics, and radiation oncology were least positive.

Overall, 88.3% of respondents reported that they would opt for a "no code" or "do not resuscitate" status if they became terminally ill. In addition, most were willing to become organ donors.

Doctors who were more likely to opt for "full code" status were less supportive of organ donation and were less supportive of advance directives.

End-of-Life Costs

Approximately one-third of all Medicare spending is related to repeat hospitalizations in the last 24 months of life; 25% of that is spent in the last 12 months, and 40% is spent in the last month. Higher spending, however, has not been associated with better health outcomes, said Dr. Periyakoil.

"Despite all our efforts, end-of-life care in the United States is increasingly fragmented because of high-intensity interventions provided by medical subspecialists to seriously ill older adults in the last 6 months of life," she explained.

Comparison of Cohorts 25 Years Apart

Survey responses were compared with responses from a historic cohort of Arkansas physicians who completed the same survey in 1989 (JAMA. 1989;262:2415-2419).

There were more women in the 2013 cohort than in the 1989 cohort (51.4% vs 7.5%). Data on the ethnic breakdown of the 1989 cohort are not available, but 48.1% of the 2013 cohort reported being an ethic minority.

In general, attitudes about advance directives have not changed since the Patient Self-Determination Act was passed. "Twenty-five years later, young doctors are remarkably the same," said Dr. Periyakoil.

There were some differences, however. Doctors in the 2013 cohort were significantly less likely than those in the 1989 cohort to believe that advance directives lead to less aggressive treatment (area under the curve [AUC], 0.77; P < .001). In addition, 2013 doctors had more confidence in treatment decisions guided by advance directives (AUC, 0.58; P < .001), and worried less about the legal consequences of limiting treatment in accordance with an advance directive (AUC, 0.57; P < .001).

Improving Quality of Care at the End of Life

Efforts should be made to better promote advance directives among physicians and patients alike, said Adrienne Mims, MD, MPH, chief medical officer and vice president of Alliant GMCF, the Medicare Quality Improvement Organization for Georgia.

"All parties need to be involved in that conversation," she told Medscape Medical News. "We have been trying to infuse knowledge within the clinical community that patients really want these conversations."

"We should be seeing better management of patients at the end of life, but we are not," she said. "Clinicians have not been trained for these conversations."

Although the survey shows that doctors are less worried about advance directives now than they used to be, resistance is coming from the legal community. "There are attorneys who feel that doctors don't have adequate protection against liability," she explained.

Dr. Mims supports the development of national legislation to provide funding for broad public education and physician/patient discussions about end-of-life care.

There has been some progress recently, said Swati Gaur, MD, a board-certified physician in geriatrics, hospice, and palliative medicine who is affiliated with the Northeast Georgia Physician's Group in Gainesville.

Georgia is the sixteenth state to implement the Physician Orders for Life Sustaining Treatment (POLST) form, which translates shared decisions into actionable medical orders, she reported.

"The document could be perceived as 'no code,' but it means more than 'do not resuscitate'," Dr. Gaur explained. "I have spoken about this in the community and the reception is very good. The community is much more ready for this than I had imagined."

Dr. Periyakoil, Dr. Mims, and Dr. Gaur have disclosed no relevant financial relationships.

American Geriatrics Society (AGS) 2014 Annual Scientific Meeting. Abstract P3. Presented May 15, 2014.

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