July 31, 2019
By Will Boggs MD
NEW YORK (Reuters Health) - Compared with nonphysicians, physicians are more likely to use intensive end-of-life care but also more likely to employ palliative care, researchers report.
"I think our findings demonstrate a more nuanced perspective of what physicians may perceive to be optimal care at the end, as opposed to a simplistic notion of 'more' or 'less' being better," Dr. Robert A. Fowler from Sunnybrook Health Sciences Center and Dalla Lana School of Public Health at the University of Toronto told Reuters Health in an email interview. "Sometimes more aggressive care is warranted; yet, at other times, focusing more squarely on comfort is best."
A common perception in the health care community is that doctors opt for less aggressive end-of-life care on the basis of their own experience and knowledge of the potential downsides of technology-laden, institutional care. Whether this is actually the case has not been clear.
Dr. Fowler's team assessed the intensity of treatment received by 2,507 physicians and 7,513 similar nonphysicians who died in Ontario between 2004 and 2014.
Rates of death at home did not differ significantly between physicians (42.8%) and nonphysicians (39.0%), but significantly more physicians (11.9% vs 10.0%) died in an intensive care unit (ICU).
In the last six months of life, the risk of an emergency department visit was lower for physicians (73.0%) than for nonphysicians (78.4%), but the groups did not differ significantly in the risk of a hospital admission.
Physicians were slightly more likely than nonphysicians to be admitted to an ICU and to receive a surgical feeding tube, but the groups did not differ in their risk of receiving mechanical ventilation, dialysis, or cardiopulmonary resuscitation.
Physicians were significantly more likely than nonphysicians to receive palliative care in the last six months of life (52.9% versus 47.4%, respectively) and to receive one or more home care visits (54.3% versus 50.1%), according to the July 24th JAMA Network Open online report.
In the last six months of life, total costs of care did not differ significantly between physicians and nonphysicians, but long-term care costs were lower and home care costs were higher for physicians.
"We are trying to help better understand patients' goals of care and use this to shape advance care planning and real-time care planning," Dr. Fowler said. "However, someone's 'goals of care' is a dynamic process - goals of care change as patients move through their life journey."
"I think that what we saw with physicians might reflect this more nuanced approach to care as we age, as we get closer to death," he said. "We perceive for ourselves that it is OK to have in-hospital treatments, and even care in an intensive care unit can co-exist with palliative care, and that each can have a valuable contribution to end-of-life care at different stages in what we have considered the end of life."
Dr. Joseph A. Hyder from Mayo Clinic, Rochester, Minnesota, who has also investigated end-of-life care intensity among physicians and other occupations, told Reuters Health by email, "The most important question we can ask is whether patients are achieving their end-of-life goals, and this study cannot answer that question."
Speaking for himself (and not for the Mayo Clinic), he added, "Moving forward, we ought to ask different questions and use better tools to find answers. Are folks who regularly work with medical catastrophe and end-of-life care - typically physicians and nurses in the emergency department, intensive care, or palliative care - more successful in achieving their individual end-of-life care goals than are others? To what extent are any such differences attributable to specific medical knowledge and experience rather than social privilege that physicians and nurses commonly enjoy?"
"The clinical care of patients ought to be tailored to each patient's goals and needs in the context of their personal relationships," Dr. Hyder said. "Meeting the needs of patients and families approaching the end of life requires entering their narratives - learning their values and experiences with end of life care. These narratives are difficult or impossible to reconstruct with the kind of data used in this study (and earlier, similar studies I have conducted with others)."
"From a technical side, the paper uses some causal-sounding language when we really don't know that any of the differences are causal," he added. "It's correlation at best."
JAMA Network Open 2019.(c) Copyright Thomson Reuters 2019. Click For Restrictions - https://agency.reuters.com/en/copyright.html