Most doctors would not want high-intensity treatment near the end of life, according to a new study from Stanford University School of Medicine.
In 2013, researchers surveyed nearly 1,100 young doctors who were finishing their training in a variety of medical specialties. Nearly nine in 10 said they would choose a do-not-resuscitate status near the end of life. “We see too much in our practice and training when high-intensity treatments actually hurt patients,” says Vyjeyanthi Periyakoil, a geriatrician who led the study.
She says she isn’t surprised most physicians opt to die gently, as they recognise “tipping points” when treatments become ineffective. “We know when terminally ill, treatments only help prolong the dying process, and there is no return on your investment,” she told reporters.
Still, she and her co-authors say, what doctors want for themselves and what they provide for patients is often at odds.
“More than 80 percent of patients say that they wish to avoid hospitalisations and high intensity care at the end-of-life, but their wishes are often overridden,” the researchers write in the open-access journal PLoS One.
The gap “is not likely due to patient and family choice”, the authors contend. Instead, they say, it’s largely due to things like hospital size and doctors’ practice style.
When the researchers compared their 2013 survey findings to a survey done more than 20 years earlier, they found that overall, doctors’ opinions hadn’t changed much over time.
The earlier survey was given to 790 community doctors in Arkansas in 1989, one year before Congress passed the Patient Self-Determination Act to require that health institutions ask patients if they have advance directives.
The 1989 and 2013 groups had different opinions in only three out of 14 areas. First, the modern doctors were more likely to say they have greater confidence in their treatment decisions if they’re guided by a patient’s advance directive. They were also less worried about legal consequences of limiting treatment when following an advance directive.
Finally, the modern group was less likely to believe that widespread acceptance of advance directives would result in less aggressive treatment even for people who didn’t prepare such a directive.
The researchers had hoped that the Patient Self-Determination Act “would have resulted in a very positive attitude change in doctors towards advance directives.” Instead, they say, the lack of a significant change in 11 of the 14 areas they analysed suggests “that much work needs to be done to positively change doctors’ attitudes towards advance directives”.
Periyakoil thinks the Patient Self-Determination Act fell short.
“It did not mandate the system record what the patient wants, archive it carefully, use it carefully and incorporate it into the care plan,” she said.
Congressman Sandy Levin (D-Michigan) authored the Patient Self- Determination Act. “It was an educational effort to empower people to make sure they had the information to exercise their rights in very difficult moments,” Levin told reporters. “I think it was an important step for patients in terms of having control over their lives and the care they receive.”
Pew Research shows that only one third of adults have advance directives.
“I think as health care becomes more a part of American life, the issue of advance directives will be less amenable to controversy,” Levin said.
Levin proposed a 2008 initiative to amend Medicare so that a patient’s first visit to a doctor for a physical exam would include a discussion about advance directives. A measure to reimburse doctors for facilitating discussions with Medicare patients about end of life issues was dropped from early versions of the Affordable Care Act after accusations among political opponents it would establish “death panels.” End of life counselling is currently a voluntary physician service.
“What is billable, for example, and what doctors get paid for is very different from what we would like them to do,” Periyakoil said.
“We train doctors to do high-intensity procedures, and we reward them for doing high-intensity procedures,” she added. “But we do not train or reward them for talking to patients to (ask about) what matters most.
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