Physician Factors Associated With Discussions About End-of-Life Care

Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
Cancer (Impact Factor: 4.89). 02/2010; 116(4):998-1006. DOI: 10.1002/cncr.24761
Source: PubMed


Guidelines recommend advanced care planning for terminally ill patients with <1 year to live. Few data are available regarding when physicians and their terminally ill patients typically discuss end-of-life issues.
A national survey was conducted of physicians caring for cancer patients about timing of discussions regarding prognosis, do not resuscitate (DNR) status, hospice, and preferred site of death with their terminally ill patients. Logistic regression was used to identify physician and practice characteristics associated with earlier discussions.
Among 4074 respondents, 65% would discuss prognosis "now" (defined as patient has 4 months to 6 months to live, asymptomatic). Fewer would discuss DNR status (44%), hospice (26%), or preferred site of death (21%) immediately, with most physicians waiting for patient symptoms or until there are no more treatments to offer. In multivariate analyses, younger physicians more often discussed prognosis, DNR status, hospice, and site of death "now" (all P < .05). Surgeons and oncologists were more likely than noncancer specialists to discuss prognosis "now" (P = .008), but noncancer specialists were more likely than cancer specialists to discuss DNR status, hospice, and preferred site of death "now" (all P < .001).
Most physicians report they would not discuss end-of-life options with terminally ill patients who are feeling well, instead waiting for symptoms or until there are no more treatments to offer. More research is needed to understand physicians' reasons for timing of discussions and how their propensity to aggressively treat metastatic disease influences timing, as well as how the timing of discussions influences patient and family experiences at the end of life.

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Available from: Selwyn O Rogers, Aug 27, 2014
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    • "), 의사(Keating et al., 2010) 및 노인(Lee & Kang, 2007)을 대상으로 이루어졌 고, 간호사와 의사(Lee, 2007; Westphal & McKee, 2009)의 비교연구도 제시되는 등 주로 양적 연구방법을 이용하여 DNR 의 윤리적 문제에 대한 인식과 태도로 국한된 연구임을 알 수 "
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    ABSTRACT: Purpose: This study was conducted to understand the meaning of the DNR experiences of nurses. Methods: The data were collected through in-depth interviews, observation, and field records with five nurses from November 2009 to February 2011. The data were analyzed using narrative inquiry methodology. Results: Three fundamental themes were derived from data analysis as following: 'faithfulness to care for comfort,' 'helping for peaceful farewells between the patient and the family,' 'reflecting one's lives with a collision of feeling toward the death.' Conclusion: The results indicate that nurses take a role of an advocate in caring for DNR patients and being concerned about their families' conflict and anguish. In addition, this study indicates the importance of education on living will, advanced directives and preparation for the death tailored to the public including healthcare professionals.
    Korean Journal of Adult Nursing 06/2013; 25(3). DOI:10.7475/kjan.2013.25.3.322
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    • "Physician’s attitude is a factor associated with discussions about EOL care [19]. A research by Mack et al. [20] indicated that 87 % of patients had discussions with their medical professionals about death before death occurred. "
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    ABSTRACT: Purpose Discussing end-of-life care with patients is often considered taboo, and signing a do-not-resuscitate (DNR) order is difficult for most patients, especially in Chinese culture. This study investigated distributions and details related to the signing of DNR orders, as well as the completeness of various DNR order forms. Methods Retrospective chart reviews were performed. We screened all charts from a teaching hospital in Taiwan for patients who died of cancer during the period from January 2010 to December 2011. A total of 829 patient records were included in the analysis. The details of the DNR order forms were recorded. Results The DNR order signing rate was 99.8 %. The percentage of DNR orders signed by patients themselves (DNR-P) was 22.6 %, while the percentage of orders signed by surrogates (DNR-S) was 77.2 %. The percentage of signed DNR forms that were completely filled out was 78.4 %. The percentage of DNR-S forms that were completed was 81.7 %, while the percentage of DNR-P forms that were completely filled out was only 67.6 %. Conclusion Almost all the cancer patients had a signed DNR order, but for the majority of them, the order was signed by a surrogate. Negative attitudes of discussing death from medical professionals and/or the family members of patients may account for the higher number of signed DNR-S orders than DNR-P orders. Moreover, early obtainment of signed DNR orders should be sought, as getting the orders earlier could promote the quality of end-of-life care, especially in non-oncology wards.
    Supportive Care in Cancer 05/2013; 21(9). DOI:10.1007/s00520-013-1827-2 · 2.36 Impact Factor
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    • "Physicians often misjudge patients’ treatment preferences, desire for information, needs, and level of understanding [2,12]. Despite evidence that individuals with advanced cancer and their caregivers benefit from being informed about prognosis and treatment choices [1,2,13], physicians often intentionally overestimate survival [14] and avoid discussing prognosis until the patient has symptoms or there are no other treatments to offer, leading to inflated patient expectations about survival and the benefits of cytotoxic treatment [4,15]. Patients who have not discussed prognosis and treatment choices with their physicians are 3 to 8 times more likely to receive aggressive treatments in the last week of life [3,5], reducing physical and emotional quality of life and perhaps longevity [9]. "
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    ABSTRACT: Background Communication about prognosis and treatment choices is essential for informed decision making in advanced cancer. This article describes an investigation designed to facilitate communication and decision making among oncologists, patients with advanced cancer, and their caregivers. Methods/design The Values and Options in Cancer Care (VOICE) Study is a National Cancer Institute sponsored randomized controlled trial conducted in the Rochester/Buffalo, NY and Sacramento, CA regions. A total of 40 oncologists, approximately 400 patients with advanced cancer, and their family/friend caregivers (one per patient, when available) are expected to enroll in the study. Drawing upon ecological theory, the intervention uses a two-pronged approach: oncologists complete a multifaceted tailored educational intervention involving standardized patient instructors (SPIs), and patients and caregivers complete a coaching intervention to facilitate prioritizing and discussing questions and concerns. Follow-up data will be collected approximately quarterly for up to three years. Discussion The intervention is hypothesized to enhance patient-centered communication, quality of care, and patient outcomes. Analyses will examine the effects of the intervention on key elements of physician-patient-caregiver communication (primary outcomes), the physician-patient relationship, shared understanding of prognosis, patient well-being, and health service utilization (secondary outcomes). Trial registration Clinical Trials Identifier: NCT01485627
    BMC Cancer 04/2013; 13(1):188. DOI:10.1186/1471-2407-13-188 · 3.36 Impact Factor
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