Tuesday, January 12, 2010

What Paradox? Patients Nor Doctors Want To Plan For Death.

Dr. Drew Rosielle at PalliMed gives another angle to the issues I've been thinking about since coming across an article, noted below, on a new study about doctor's conversations with their patients about end of life care options.

Rosielle writes that a recent survey of patients provides paradoxical answers to questions about their knowledge of end of life care choices and tools:

Only 5 patients reported a discussion about ADs with their oncologist. When they asked patients if they would like to discuss ADs with their oncologist, only 23% said they would (this is similar to the finding in the study 10 years ago). When, however, they asked patients which, of all their doctors, they would prefer to discuss ADs, a plurality said their oncologist (48%). That is, if they have to do it, they'd prefer their oncologist. Notably the vast majority of patients (87%) thought that physicians admitting a patient to the hospital should ask about ADs (they indicated this was not only ok but an important thing to do). Thus, the title of their article, and this post - 'Paradoxes in ACP....'

(They also asked patients about knowledge of hospice care and palliative care. 21% of patients reported knowledge of 'palliative care' vs. 81% for 'hospice care,' and hardly anyone said they knew anyone who had received palliative care.)

From outside the medical world looking in, I think there are a few factors here that add up to no paradox at all: patients don't want to talk about or plan for their deaths; doctors are seen as authorities, patients expect them to guide or inform of medical choices and patients follow their cues; doctors too don't want to talk about death either.

An article in the New York Times yesterday highlighted a new survey of doctors that asks when patients should be told a fatal prognosis, asked about a DNR (Do not resuscitate order), informed of hospice and palliative care, or asked about their death-site preferences.

Time's Denise Grady reports:

Dr. Nancy L. Keating, the first author of the study and an associate professor of medicine and health care policy at Harvard, said not much was known about how, when or even if doctors were having these difficult talks with dying patients. But she said that her research team suspected that communication was falling short, because studies have shown that even though most people want to die at home, most wind up dying in the hospital.

The researchers surveyed 4,074 doctors who took care of cancer patients, instructing them to imagine one who had only four to six months left, but was still feeling well. Then the doctors were asked when they would discuss the prognosis, whether the patient wanted resuscitation or hospice care, and where he or she wanted to die.

The results came as a surprise: the doctors were even more reluctant to ask certain questions than the researchers had expected. Although 65 percent said they would talk about the prognosis “now,” far fewer would discuss the other issues at the same time: resuscitation, 44 percent; hospice, 26 percent; site of death, 21 percent. Instead, most of the doctors said they would rather wait until the patients felt worse or there were no more cancer treatments to offer.

Doctor's need to take the lead in discussing end of life options with terminal and elderly patients. Their patients are waiting for them to do so.

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