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.

Download full-text


Available from: Selwyn O Rogers, Aug 27, 2014
  • Source
    • "When patients experience moderate to severe distress, national guidelines strongly recommend and require accredited cancer programs to identify psychological, behavioral, and social concerns that may interfere with patients' ability to successfully cope with and fully participate in healthcare decision making (American College of Surgeons Commission on Cancer, 2011). However, not all cancer treatment facilities evaluate psychosocial distress before a patient exhibits extreme distressing symptoms (Keating et al., 2010). Sociodemographic and economic factors contribute to the gaps in psychosocial distress management for cancer patients, making patients vulnerable and susceptible to undesired health outcomes since these patients may not receive the needed services. "
    [Show abstract] [Hide abstract]
    ABSTRACT: This in-depth single-case-study explored the emergent trauma of psychosocial distress of an older male African-American veteran after being diagnosed with end-stage colon cancer. Using a qualitative case study methodology, three in-depth interviews were conducted which identified the following five themes: (1) the emotional impact of being diagnosed with cancer, (2) experiencing inescapable loss of control and independence, (3) adjusting to nursing home placement, (4) lacking social support, and (5) navigating complicated services. The findings expand our understanding of the need for identifying and managing psychosocial distress. Implications for behavioral health practitioners are discussed. © 2015: Frances R. Nedjat-Haiem, Iraida V. Carrion, Terri Wingate Lewison, and Nova Southeastern University.
    Full-text · Article · Jul 2015 · Qualitative Report
  • Source
    • "), 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 "
    [Show abstract] [Hide abstract]
    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.
    Preview · Article · Jun 2013 · Korean Journal of Adult Nursing
  • Source
    • "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. "
    [Show abstract] [Hide abstract]
    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.
    Preview · Article · May 2013 · Supportive Care in Cancer
Show more