Managing End-of-Life Care
Health care delivered in the last year of a person’s life accounts for a large percent of overall health spending. Much of this spending is obviously fruitless, certainly in terms of prolonging life and probably in regard to quality of life in most cases. In addition to the absolute level of spending, there is significant geographic and other variation in end-of-life care and spending, again with little apparent difference in health outcomes. Much research has been conducted with the aim of understanding the reasons for the level of spending and especially the variation in spending. One aspect of that research has been examining the extent to which the care is driven by patient or physician preferences. A new study published in the journal Cancer looks at the possible role of when and why physicians have discussions with patients about end-of-life care. (Cancer Article)
The study surveyed a number of physicians about a scenario in which they had a patient with 4-6 months to live. The physicians were asked when they would discuss prognosis, DNR status, hospice care or preferred site of death with the patient. A number of physician characteristics were examined to search for possible correlations with different answers to the scenario. There were over 4000 respondents, all of whom care for cancer patients and have dealt with terminally ill patients. While 65% would discuss the prognosis when they learned of the likely remaining time of life, most would not discuss the other matters. Among other things, this is contrary to national guidelines recommending advance planning for patients with less than a year to live. Younger and male physicians were more likely to have the discussions, as were those with higher previous numbers of terminally ill patients.
Since earlier research has shown that physicians often prefer more intensive care than patients’ wish to receive, there is a cost control opportunity here. But most disturbing is the disrespect for the autonomy and maturity of these patients. They are entitled to an honest assessment of their prognosis, even if it may be disheartening, so that they are not later surprised, and they should have ample time before their condition worsens to discuss and think through the kind of care they want for the rest of their lives and the circumstances in which they wish to die, if that is what will happen. None of us would like to be in the position of the physicians, but this is part of the duty of their profession and they should be required to undertake the discussions of prognosis and care options promptly and fully.