Doctors Nix Heroic End-of-Life Measures for Themselves

Fran Lowry

June 05, 2014

Physicians continue to provide high-intensity care for terminally ill patients even though they do not want the same aggressive treatment for themselves at the end of life.

This conclusion comes from a study presented at the recent meeting of the American Geriatrics Society, which was widely reported in the lay press. The study was published online May 28 in PLoS One.

The findings on physician attitudes about end-of-life care are particularly important because of the "silver tsunami" of older adults who will be needing end-of-life care in the United States and around the world, said lead author Vyjeyanthi S. Periyakoil, MD, director of palliative care education and training at Stanford University School of Medicine in California.

"We have seen large advances in modern biomedicine that have increased longevity but have failed to improve, significantly, a person's health or quality of life in the 2 years prior to death," she told Medscape Medical News.

"This results in millions of Americans living with a tremendous burden of major chronic diseases at the end of life," she explained.

There is also a big disparity between what Americans say they want at the end of life and the care they actually receive, Dr. Periyakoil noted.

"The overwhelming majority of patients, at least 80%, wish to avoid extreme measures to prolong their lives, but their wishes are often overridden," she said.

"Most patients want to die a peaceful death at home without being a burden to their families, emotionally or financially. But what they want and what they get depends not so much on their preferences or advanced directives, but on their local healthcare system and individual doctors' practice styles," she added.

Why the Disconnect?

Dr. Periyakoil and her colleagues sought to determine what factors influence whether physicians choose to pursue aggressive end-of-life treatment for their patients when they would not want it for themselves.

They also looked at how physicians' attitudes about advance directives have changed since 1990, when the Self-Determination Act was passed, giving patients more control over their end-of-life care.

The study involved 2 cohorts. The first comprised 1081 physicians who completed a Web-based advanced directive form and a 14-item advance directive attitude survey at Stanford Hospital & Clinics and the Veterans Affairs Palo Alto Health Care System in 2013.

The second comprised 790 internal medicine and family medicine physicians from Arkansas who were asked the same 14 survey questions in 1989 but who did not complete an advance directive form (JAMA. 1989;262:2415-2419).

Responses from the 2 cohorts were compared.

"We hypothesized that because advance directives are routine and an accepted healthcare practice, current-day doctors' attitudes would be much more positive toward them than those in the 1989 group," Dr. Periyakoil said.

Surprisingly, attitudes changed very little over time.

Because the 1989 and 2013 cohorts were different, "you might argue that we were comparing apples and oranges," she explained.

There were more women in the 2103 cohort than the 1989 cohort (51.4% vs 7.5%). In the 2013 cohort, 48.9% of respondents reported being an ethnic minority; ethnic diversity for the 1989 cohort was not reported.

In 2103, attitudes about advance directives varied significantly by ethnic group. White and black doctors had similar positive attitudes about advance directives; Hispanic/Latino doctors had the least positive attitudes about advanced directives.

Attitudes also differed by subspecialty in 2013. Physicians from emergency medicine, physical medicine and rehabilitation, pediatrics, and obstetrics and gynecology were more positively disposed to advance directives than physicians from radiology and nuclear medicine, surgery, orthopedics, and radiation oncology.

Differences between the emergency medicine and radiation oncology specialties were notable (success rate difference [SRD], 0.305), as were differences between pediatrics and radiation oncology (SRD, 0.304), emergency medicine and orthopedics (SRD, 0.283), and obstetrics and gynecology and radiation oncology (SRD, 0.280).

Differences in attitudes about advance directives between the 2 cohorts were significant for only 3 of the 14 items.

More 2013 respondents than 1989 respondents were unlikely to believe that advance directives would lead to less aggressive treatments (P < .001).

The 2013 respondents also had greater confidence in treatment decisions guided by an advance directive (P < .001), and were less worried about legal consequences when limiting treatment in accordance with an advance directive (P < .001).

In the 2013 cohort, 88.3% of respondents reported that they would opt for a do-not-resuscitate or no-code status.

Notably, those who were less supportive of advance directives were more likely to opt for full-code status for themselves and less likely to choose to donate their organs.

"The needle has not moved at all between 1989 and 2013, which leads us to the conclusion that much more needs to be done to make doctors better understand how they can effectively use advance directives in their practice and how to support patients in their decisions about advance directives," Dr. Periyakoil said.

Most doctors do not want high-intensity treatment for themselves at the end of life.

With regard to physicians' attitudes about end-of-life care, she said: "Their attitudes are very congruent about the way I feel about my own death. And it's very congruent with what I hear my friends and colleagues and fellow physicians say, which is, 'I want to fade away. When it's my time to go, I want to gently sail away into the sunset. I don't want to be in an intensive care unit when I die.' We had always known this anecdotally, but we wanted to prove or measure it. And we were right. Most doctors do not want high-intensity treatment for themselves at the end of life."

Dr. Periyakoil, who is also a geriatrics specialist, said she understands the disconnect between the type of care doctors want for themselves at the end of life and what they actually do for their patients.

At the core of the problem is a biomedical system that rewards doctors for taking action, not for talking with their patients.

"It's not because doctors are trying to make more money or because they are intentionally insensitive to their patients' desires. At the core of the problem is a biomedical system that rewards doctors for taking action, not for talking with their patients. Our current default is 'doing', but in any serious illness, there comes a tipping point where high-intensity treatment becomes more of a burden than the disease itself. It's tricky, but physicians don't have to figure it out by themselves. They can talk to the patients and their families and to other interdisciplinary team members, and it becomes much easier. But we don't train doctors to talk or reward them for talking. We train them to do and reward them for doing. The system needs to be changed."

The study was supported by the National Institutes of Health and the Department of Veterans Affairs. Dr. Periyakoil has disclosed no relevant financial relationships.

PLoS ONE. Published May 28, 2014. Abstract


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