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Medscape Medical News > Oncology Doctors Nix Heroic End-of-Life Measures for Themselves by Fran Lowry

Medscape Medical News > Oncology
Doctors Nix Heroic End-of-Life Measures for Themselves

Fran Lowry  June 05, 2014

End-of-Life Care Guidelines Updated
End-of-Life Wishes: Lack of Communication Persists
Earlier End-of-Life Talk, Less Aggressive Care at the End

"Palliative Care"

Add Other Topics

Palliative Care in the Acute Care Setting
Palliative Care of the Patient With Advanced Gynecologic Cancer

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."

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 sub-specialty 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."