Why do physicians continue to provide high-intensity care for terminally ill patients but choose to forgo such care for themselves at the end of life? That's the question raised by a new Stanford study published in PLOS ONE today.
An overwhelming percentage of doctors surveyed for the study in 2013 - 88.3 percent to be exact - said they would choose “no-code” or do-not-resuscitate orders for themselves. And though other studies have shown that most other Americans would choose to die gently and naturally at home, that's not what's happening. As I describe in a release:
"A big disparity exists between what Americans say they want at the end of life and the care they actually received," the study says. "More than 80 percent of patients say that they wish to avoid hospitalizations and high-intensity care at the end of life, but their wishes are often overridden."
In fact, the type of treatments they receive depends not on the patients’ care preferences or on their advance directives, but rather on the local health-care system variables, such as institutional capacity and individual doctors’ practice style, according to the study.
The study involved two sets of subjects - 1081 physicians in 2013 and 790 physicians in 1989 - which both completed the same 14-question survey on their attitudes concerning advanced directives. Stanford researchers hypothesized that attitudes would have changed in the 24-years since the passage of the Self-Determination Act in 1990, a law designed to give patients more control over end-of-life care decisions and requires health care organizations to inform patients that they have the option to fill out such directives.
Surprisingly, despite the law, physicians attitudes have not changed, said VJ Periyakoil, MD, an expert in palliative care and lead author of the study. More from the release:
As a geriatrics and palliative care physician who sits at the bedside of sick patients herself, Periyakoil 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. 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 the high-intensity treatment becomes more of a burden than the disease itself," said Periyakoil, who trains physicians in palliative medicine. "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 the 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."
A touching first-person essay on this topic by Ken Murray, MD, a retired family practitioner has been popping up recently on various blogs and other internet sites. It describes how doctors don’t want to experience the kind of suffering that they see their patients go through. In the piece, titled "How doctors die: It’s not like the rest of us, but it should be," the author mentions that he has even seen one medical professional with a "Do not Resuscitate" tattoo.
Previously: Communicating with terminally ill patients: a physician's perspective, Asking the hardest questions: Talking with doctors while terminally ill, On a mission to transform end-of-life care, The importance of patient/doctor end-of-life discussions and A Stanford nurse shares her experience in talking to her aging mother about end-of-life decisions
Photo by Frank DiBona