Docs No Less Likely to Die in Hospital Than Other Patients

Nicola M. Parry, DVM

July 25, 2019

With respect to end-of-life care, physicians' likelihood of dying at home is similar to that of nonphysician patients, a Canadian study suggests.

"Overall, they did not consistently opt for less-aggressive care but instead used both intensive and palliative care more than nonphysicians," Hannah Wunsch, MD, from the University of Toronto, Canada, and colleagues write in an article published online July 24 in JAMA Network Open.

Intensive end-of-life treatment is common in North America, often going against patients' previously reported preferences. Previous studies have suggested that physicians in the United States are somewhat less likely to die in the hospital than other patients, suggesting they may be better able to match their care with their preferences.

To see if that pattern held true in a system with universal healthcare, Wunsch and colleagues compared the intensity of treatment received by physician and nonphysician patients at the end of life in Ontario, Canada.

"The primary outcome was location of death, with the hypothesis that physicians are more likely to receive less-intensive end-of-life care," the authors write.

The researchers analyzed medical and death records of 2507 physicians and 7513 nonphysicians who died between 2004 and 2015.

They found that physicians were no more likely to die at home than nonphysicians (42.8% vs 39%; adjusted relative risk [aRR], 1.04; 95% confidence interval [CI], 0.99 - 1.09). However, physicians were more likely to die in an intensive care unit (ICU) (11.9% vs 10%; aRR, 1.22; 95% CI, 1.08 - 1.39).

The data also showed that, in the 6 months before death, physicians were less likely to visit an emergency department (73% vs 78.4%; aRR, 0.96; 95% CI, 0.94 - 0.98), but more likely to be admitted to an ICU (20.8% vs 19.1%; aRR, 1.14; 95% CI, 1.05 - 1.24), and to receive palliative care (52.9% vs 47.4%; aRR, 1.18; 95% CI, 1.13 - 1.23).

However, a subgroup analysis of patients with chronic conditions showed that physicians (n = 1375) were more likely to die at home than nonphysicians (n = 4117) (35.2% vs 30.7%; aRR, 1.12; 95% CI, 1.04 - 1.22). Among those with cancer in this subgroup, physicians were also more likely to die at home (37.6% vs 28.6%; aRR, 1.30; 95% CI, 1.13 - 1.50), and to receive chemotherapy in the last 6 months of life (37.9% vs 29.8%; aRR, 1.28; 95% CI, 1.13 - 1.46).

In an interview with Medscape Medical News, study coauthor Robert A. Fowler, MDCM, MS(Epi), also from the University of Toronto, was struck by how his group's findings differed from the US studies.

"We wondered whether this might relate to differences in payment systems for healthcare services in the United States, in comparison to Canada where we have a theoretically universal healthcare system for in-hospital care, yet often have more limited options for home-based and palliative care at end of life."

Overall, Fowler expressed surprise at the findings of both the US and Canadian studies — "chiefly, that many elements of end-of-life care are, despite some differences, remarkably similar among physicians and the general population."

This was different from his group's original hypothesis that physicians would opt for much less inpatient care.

"It was interesting that we did see that physicians were both more likely to receive treatment in an ICU, known for its use of technology-laden care," he added, "and also more likely to receive palliative care at the end of life."

According to Fowler, this offers a more nuanced perspective of what physicians may perceive to be optimal care at the end of life, as opposed to a simplistic notion of 'more' or 'less' being better: "Sometimes, more aggressive care is warranted," he said, "yet, at other times, focusing more squarely on comfort is best."

This study was supported by the Canadian Institutes of Health, University of Toronto, and ICES, which receives funding from the Ontario Ministry of Health and Long-Term Care. Two authors have reported receiving grants from the Canadian Institute for Health Research, National Institute on Aging, and American Federation for Aging Research, outside the submitted work.

JAMA Netw Open. Published online July 24, 2019. Abstract

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