Clinicians' Comfort Levels Low With Life Expectancy Discussions

Marcia Frellick

April 24, 2019

Fewer than half of physicians, nurses, and advanced practice registered nurses (APRNs) report always or frequently having end-of-life discussions with older patients with chronic illnesses, according to a recent Medscape poll.

The providers also say many patients put off the discussions as well.

Among physicians, 42% said they always or frequently had the discussions, and 48% of nurses and APRNs answered that way.

Answers differed with the age of the provider. Among physicians younger than 55 years, 39% said they always or frequently had the discussions, but the practice was much more common among physicians aged 55 years or older. In that group, 63% said they always or frequently had the talks.

Among nurses/APRNs younger than 55 years, 44% said they frequently or always had the discussions, but the increase was less pronounced (54%) than among physicians for those aged 55 or older.

Responses totaled 348 in the poll first posted on February 6 and included 180 physicians and 168 nurses/APRNs.

The poll was taken in light of two recent articles about how and when patients wanted to talk about their life expectancy and how to approach such conversations with patients.

In the first article, published in the Annals of Family Medicine , more than 1000 older adults with chronic illnesses were asked about their preferences on life expectancy discussions. Researchers found that 59% of respondents did not want to have the discussions if the doctor expected they would live at least 10 years.

However, if expected remaining years were 2 or fewer, 55.8% wanted their physician to talk to them about that. Conversely, almost 17% of respondents didn't want to talk about life expectancy even when it dropped to 1 month, according to the article.

The second article, published in JAMA Internal Medicine , suggested that physicians start such conversations with personal hope paired with concern — for example, "I am hoping that you will have a long time to live with your heart disease, but I am also worried that the time may be short, as short as a few years."

Comments on Medscape's reporting of the two studies included divergent views among providers.

A pathologist commented: "There is really never a reason to have to have this discussion. When a patient tells me they have been given X time, I tell them diseases can't read statistics. I give them a reason to want to go on, not to go on antidepressants, which is exactly what that talk leads to."

A registered nurse took a different view: "Presenting reality and being honest may allow the patient/family to choose to [forgo] unnecessary and potentially harmful treatments and/or diagnostic studies when they are futile. This idea that we should never talk to people with multiple comorbid conditions whose disease progression and trajectory indicates they are beginning to enter the final stages is absurd."

Men More Comfortable With the Conversations

The Medscape poll shows that, while male and female physicians have life expectancy conversations with similar frequency, female physicians are often less comfortable having them.

About two fifths of female and male physicians reported that they always or frequently had the conversations. When they had the discussions, female physicians more often said they were uncomfortable or very uncomfortable (42%), while 27% of the male physicians answered that way.

Older providers reported more comfort with the discussions. Among physicians younger than 55 years, 34% said they were comfortable or very comfortable with the discussions compared with 59% of those aged 55 years or older. Among nurses/APRNs, 48% were comfortable or very comfortable vs 58% of those aged at least 55 years.

A pulmonary/critical care physician working full time as an intensivist commented on the poll that she has these discussions every day.

"[Twenty-five years] and it never gets any easier," she said. "I find the great majority of patients are receptive and appreciate honesty and full disclosure if delivered in a caring manner. Often it is family members who can have more difficulties, sometimes in opposition to the patient's wishes."

A commenter who listed his affiliation as "other healthcare provider" said he usually leaves the decision to talk about the subject to the patient.

"Outside of special circumstances, I generally wait for the patient to broach the subject," he wrote. "If I decide there is compelling need for the patient to consider this, then I will let them know that they need to take it into consideration, and I am available any time to discuss it."

However, poll respondents said many patients put off end-of-life conversations.

More than a third of physicians (36%) said older patients always or frequently put them off and 31% said patients rarely or never put them off. Nearly half of nurses/APRNs (49%) said patients always or often put off such discussions and 13% said they rarely or never do.

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