A doctor moves with precision in the ER, attempting to keep death at bay with heroic measures for a struggling patient. On another hospital floor a patient in the palliative ward quietly sighs his last breath, his family at his side.
Death. What our doctors decide for themselves often differs from the care patients receive. In fact, far more would choose the palliative ward over heroic measures. Should we follow their lead?
Our Sermo Physician Poll conducted this month asked, “if faced with terminal illness, what treatment options would you choose?” A small number, only seven percent, said they would choose extraordinary measures. An even stronger vote for less invasive care, 39 percent of doctors said they would sign DNR orders (do not resuscitate).
A separate study, published in PLOS ONE recently, concurs. About 88 percent of the doctors said they would want a DNR for themselves.
A CDC study, published in JAMA, tracking the death of Medicare patients, shows a different set of numbers. As of 2009:
- 53.8 percent of patients died in either acute care hospital or an intensive care unit
- 42.2 percent died in hospice care
However, 28.4 percent of patients were in hospice care for three days or less. This might reflect both cost-saving measures by hospitals and requests from patients and their families.
Palliative Care vs. Hospice Care
Palliative care happens at any stage of illness and focuses on relieving symptoms that are related to chronic illness such as cancer, cardiac disease or AIDS. Hospice care is similar to palliative care except that it focuses on end of life comfort and control of symptoms. Hospice care can only be given in most circumstances after a doctor verifies the patient is terminal with a life expectancy of less than six months.
What We Can Learn From Physicians
We discussed how doctors die last fall and showed that palliative care at the end of life not only eases suffering, but seems to prolong life more than aggressive medical care.
Not only can palliative care extend life beyond expectations, researchers also found the family suffered less, with shorter time periods for grieving and less depression after a loved one died with palliative or hospice care.
“Once we’ve done this for a while and seen outcomes, we become comfortable with what is possible … and what is not,” wrote one physician inside the Sermo community.
A rural family practitioner wrote, “At first I thought it was mostly from patients simply not hearing what they didn’t want to hear, but then I started seeing too many sensible ones I had known for years who did not realize they or their family members were terminally ill until I told them … patients and their families need and deserve an honest appraisal of their situation. Some can deal with it better than others, but all should be afforded the chance to know what we would do were we or our family the one in their situation.”
Jessica McCannon, MD, a pulmonologist as Massachusetts General Hospital, who often works with end of life patients, suggests working the conversation in gradually with patients if time allows. She recommends using the Conversation Project Kit a group of documents for patients to consider and discuss with family members before making final choices.
If only seven percent of physicians would pursue heroic measures should we try to improve communication between a patient and their caregivers? As a physician, how do you approach end of life conversations with your patients? We will be discussing this and more inside the Sermo community if you’re an M.D. or D.O. please join us.