End-of-Life Care: What Doctors Want

The study, conducted by the Stanford University School of Medicine, was recently published in PLOS One. Supported by the National Institutes of Health and the Department of Veterans Affairs, the study found that of 2013 doctors surveyed, 88.3 percent said they would choose “no-code” or do-not-resuscitate orders for themselves. More than 80 percent of patients say they want to avoid hospitalizations and high-intensity care at the end of life, but their wishes are often overridden, according to the study.

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Study Looked at Two Groups of Physicians

The researchers looked at a group of 1,081 physicians who, in 2013, completed a web-based advance-directive form and a 14-item advance-directive attitude survey at Stanford Hospital & Clinics and the Veterans Affairs Palo Alto Health Care System.

The researchers also looked at a study published in 1989 in JAMA, in which 790 physicians from Arkansas, who did not complete an advance-directive form, were asked the same 14 survey questions.

Lead study author, Vyjeyanthi Periyakoil, M.D., clinical associate professor of medicine and director of the Stanford Palliative Care Education and Training Program, told Healthline, “The current healthcare system is very much biased toward overtreatment, and there is a tipping point in every disease trajectory, whether it is cancer, heart failure, or dementia. Beyond the tipping point, the treatment actually becomes more of a burden than the disease itself.”

The best way to find out what that tipping point is, said Periyakoil, is for patients and their families to talk to their doctor to “figure out what matters to you.”

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High-Tech Treatments

Periyakoil said the current healthcare system default is to use high-technology treatments for every patient until the patient says he or she doesn’t want those treatments any longer. Patients should ask what the benefits and burdens of high-tech treatments are, advised Periyakoil. “If a person has breast cancer and a doctor puts her in the ICU and hooks her up to machines, the patient should ask, 'How is this going to help me? When are you going to know if this treatment worked or not? When can we reassess?'” said Periyakoil.

She noted that while some terminal patients are better served with “a more gentle approach of care,” sometimes the patient's family wants to pursue more aggressive treatments.

“Most doctors, including myself, don’t want high technology if we are terminally ill, because we see so many patients hurt when they continue to want technology beyond the tipping point. We want to prolong life; we don’t want to prolong the dying process. The tipping point is where you determine life as it matters or worth living is not there anymore,” said Periyakoil.

Periyakoil said some studies show that providing “supportive care” enables end-of-life patients to live longer. “They live with loved ones as opposed to being in intensive care in a hospital environment. Death is a very personal process. Doctors see people dying in the hospital without their family at their bedside. We have seen so much that we never want that for ourselves or our loved ones.”

The study also showed that physicians’ attitudes toward end-of-life care differed depending on their ethnicity and gender. Emergency physicians, pediatricians, obstetrician-gynecologists, and those in physical medicine and rehabilitation had more favorable attitudes toward advance directives. Radiologists, surgeons, orthopedists, and radiation oncologists had less favorable views about advance directives. Caucasian and African-American doctors had the most favorable attitudes, while Latino physicians had the least favorable views.

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More Training for Docs Is Crucial

Commenting on the study’s findings, R. Sean Morrison, M.D., director of the Hertzberg Palliative Care Institute, Icahn School of Medicine at Mount Sinai in New York, told Healthline there is a lack of physician training in communication and how to have important goals of care discussions with patients and families. “As physicians, we have an idea of what our goals would be in the setting of a serious illness, and painfully know the benefits and burdens of various life-prolonging treatments. Most physicians are not well-trained to have those conversations with patients and families,” said Morrison.

Pointing out that communication skills can be taught, and they need to be practiced, Morrison said that when this happens there is very good data showing that outcomes are better. “Our palliative medicine fellows learn how to communicate bad news to patients and their family, how to list the goals of care preferences, and how to discuss treatment options. The only level of training where that happens is in palliative medicine fellowship training. It should be true for cancer and cardiology,” he said.

“Everyone wants to have realistic hopes and realistic expectations," he added. "If you don’t have that, you can’t plan for meaningful events. If you are spending all your time going back and forth to the hospital for chemo, and no one has talked to you about realistic outcomes, that’s a huge amount of time you didn't get to spend with your family. If you had known that, you may have made a different choice in terms of those balances. It’s all about being informed and making choices aligned with your values.”

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