Physicians Choose to Forego Aggressive, End-of-Life Care

Although physicians provide high-intensity care for terminally ill patients, they often forego such care for themselves at the end of their own lives, according to a new study in PLOS ONE.

Despite the fact that 80% of patients wish to avoid hospitalizations and high-intensity care at the end of life, their wishes are often overridden. Lead author VJ Periyakoil, MD, and colleagues discovered there was little change in doctors’ attitudes toward advance directives when comparing a 1989 cohort with one from 2013.

The data show that a majority of physicians choose to forego high-intensity treatments for themselves. According to the 2013 cohort, 88.3% of physicians opted to be no-code.

“Why do we physicians choose to pursue such aggressive treatment for our patients when we wouldn’t choose it for ourselves?” said Periyakoil, director of the Stanford Palliative Care Education and Training Program, said in a statement. “The reasons likely are multifaceted and complex.”

The researchers point out that in the last 6 months of life, terminally ill Americans receive care from many subspecialists and are subjected to ineffective, high-intensity treatments before, ultimately, dying from known chronic illnesses. Meanwhile, data show that these patients prefer to die naturally at home.

“It is to be noted that, populations receiving higher care intensity in the last 6 months of life do not have lower mortality rates compared to populations receiving lower intensity care,” the authors wrote.

Periyakoil and colleagues speculate doctors would prefer to forego high-intensity treatments at the end of life because they frequently witness the suffering of their terminally ill patients undergoing high-intensity treatments. The researchers also surmise that physicians tend to optimistically overestimate the lifespan of their patients.

Providers aren’t entirely at fault for choosing high-intensity care for their terminally ill patients. The authors point out maximal interventions is the default in the current state of healthcare; plus, hospitals and doctors are rewarded fiscally for medical procedures providing high-intensity care. Currently, 40% of Medicare’s budget for services to beneficiaries in the last year of life is spent on patients in the last 30 days of life.

“Our current default is ‘doing,’ but in any serious illness there comes a tipping point where the high-intensity treatment becomes more of a burden than the disease itself,” said Periyakoil, who trains physicians in palliative medicine. “It’s tricky, but physicians don’t have to figure it out by themselves. They can talk to the patients and their families and to the other interdisciplinary team members, and it becomes much easier.”