Residents May Be Reluctant to Talk End-of-Life

Larry Hand

November 06, 2014

BOSTON ― Although patients with advanced, treatment-resistant cancer rarely benefit from cardiopulmonary resuscitation (CPR), admitting resident physicians in the United States are unlikely to share with the patient that poor prognosis, according to results of a national survey presented here at the Palliative Care in Oncology Symposium.

David J. Einstein, MD, of Tufts Medical Center, Boston, and colleagues distributed the survey to all US internal medicine residency program directors. Nineteen directors enrolled in the study, and 358 residents (22%) responded to the questions. The online survey focused on a hypothetical case of a patient with treatment-resistant advanced cancer.

Almost all residents responded that CPR would not be helpful, but fewer than half (46.7%) said they would likely offer the patient a recommendation about CPR. Most (69%) of those residents said the patient should make that decision independently.

Most residents felt a sense of responsibility to discuss code status independently of attending physicians, but deference to patient autonomy prevented them from advising the patient, in light of the residents' knowledge of outcomes, the researchers reported. Only a minority of residents did say they were satisfied with end-of-life discussions.

 
These data define a major unmet need in training and practice. Dr David Einstein
 

"Given the futility associated with CPR in this setting, these data define a major unmet need in training and practice," Dr Einstein and colleagues concluded.

"Clinicians working at academic centers need to be very careful how they expect residents to convey the code status discussion," Dr Einstein told Medscape Medical News. "The average clinician in an academic center is very busy, is going through a lot of information, and I think what they need to...encourage people they work with to understand is the nature of the beast and understand what is and isn't beneficial."

Dr Einstein added, "I think the first thing is to understand that it's not an issue of whether residents want to do it or not, it's a matter of the culture they're brought up in. We need to, very specifically in the curriculum, target that culture of patient autonomy."

"I couldn’t agree more," commented Jamie H. Von Roenn, MD, an oncologist and palliative care specialist and senior director of education, science, and professional development at the American Society of Clinical Oncology, Alexandria, Virginia. "In fact, it's coming," she told Medscape Medical News. "Many medical schools have required communications skills training. It's becoming more common in residency and fellowship programs, but it's not required."

"I think it's part of good medical care to talk to patients about difficult subjects, and that's certainly what this is," she added.

"It's very clear, and there are a lot of publications now to support it, that both patients and physicians tend to overestimate survival for patients with advanced cancer," she continued.

Dr Von Roenn said doctors tend to start from a place biased toward better outcomes, "but if you look at the data about the impact of CPR on patients with advanced cancer, it's horrendous. Cancer patients' overall survival from in-hospital arrest is under 10%. If the trajectory for that overall illness over that hospitalization is downhill, the impact of CPR is zero."

Missing Opportunity to Help People

"For residents to feel they have a responsibility to talk to patients but not provide appropriate information is missing the opportunity to actually help people," she continued. "It’s great that residents feel responsible. That's what we want. But they're not meeting the responsibility if they're not providing information about pros and cons of choices that are being offered. I think it's terrifying that we've taught them to be responsible but haven't educated them about how to do it."

The researchers and Dr Von Roenn have reported no relevant financial relationships.

Palliative Care in Oncology Symposium. Abstract 83. Presented October 24, 2014.

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