For their own end of life care, more than 88 percent of doctors say that they would choose less medicine than their patients and do-not-resuscitate orders for themselves. However, studies do not support that what they say is what they actually do for themselves or others.
In research published early this year in the Journal of the American Medical Association, physicians were slightly less likely to die in hospitals than the general population. However, a different study published five months later in the Journal of the American Geriatrics Society found no statistically significant difference between how physicians die versus the rest of the population. In fact, physicians spent slightly more time in intensive care units in their last six months of life than the average patient.
Each of these studies provided surprising results, especially after a powerful essay, How Doctors Die, went viral in 2011. In the essay, retired USC family medicine physician Ken Murray suggests that doctors go gently by avoiding mistakes of intensive, last ditch and ultimately futile procedures. “Of course, they want to live,” Murray writes. “But they know enough about modern medicine to know its limits.”
However, physicians are neither trained nor rewarded for talking. They are trained and rewarded for acting.
However, the two studies do not support Murray’s conclusion. Doctors fall victim to the same temptations of non-medical patients by clinging to the hopes that trigger more treatment. Even though more than 80 percent of people say they want to avoid hospitalization and aggressive care at the end of life, the Centers for Disease Control reports that more than 75 percent die in some facility.
The medical system’s continued focus on aggressive treatment at the end of life conflicts with the majority of Americans’ wishes. The same physicians who say they would opt for less medicine tend to pursue aggressive, life-prolonging treatment for patients facing the same prognosis.
VJ Periyakoil, director of the Stanford Palliative Care Education and Training Program, says that a physician’s default is “doing.”
She explains: “in any serious illness there comes a tipping point where the 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 the other interdisciplinary team members, and it becomes much easier.”
However, physicians are neither trained nor rewarded for talking. They are trained and rewarded for acting. Periyakoil says that these incentives must be changed for end of life care to improve.
Periyakoil led a study that may shed light on this issue. It involved two sets of physician subjects; one set included physicians from a 1989 study published in the Journal of the American Medical Association who completed an advance directive attitude survey. The second set included more than a thousand physicians practicing currently in California; they completed the same survey and an advance directive form.
Surprisingly, results showed that doctors’ attitudes toward advance directives have changed very little in a quarter century. Only one in ten doctors reported having conversations with patients about death.
“The needle has not moved very much,” Periyakoil said.
Think about this. If physicians had more conversations about end of life planning with their patients, maybe they would ultimately become their own best counsel. Both patients and physicians would benefit from the discussion, one reinforcing the other. Once you profess it, you possess it.
– Image courtesy Pexels