Doctors who were asked about causes of inappropriate care at the end of life didn’t have to look far to place blame. They blamed themselves.
Australian researchers interviewed 96 physicians from 10 medical specialties and asked them to describe situations when patients received end of life care that the doctors felt was inappropriate.
Futile medical treatment at the end of life has been shown to harm patients, cause moral distress to clinicians and waste scarce resources, as the researchers note in the Journal of Medical Ethics.
But 96 percent of physicians pointed to themselves – or “doctor-related factors” – as the main drivers of futile treatment. Poor communication, emotional attachment to patients and aversion to death were also among the causes they cited.
Patient-related factors were important, too. Ninety-one percent of the doctors cited reasons such as family or patient requests for treatment, prognostic uncertainty and not knowing the patient’s wishes as contributors to inappropriate care.
“The take-home message for patients and families is to have the conversation about what they want and don’t want at the end of life,” said study leader Lindy Willmott, of the Australian Center for Health Law Research.
“Doctors’ natural tendency is to treat in this way, and to take another path requires one or more conversations with the patient and family,” Willmott told Reuters Health. “Such conversations are difficult, and doctors are time-poor.”
Close to 70 percent of the surveyed doctors also cited hospital-related causes, such as specializations, medical hierarchy and time pressure, as factors in futile care.
It isn’t a matter of one doctor stepping back and considering the overall health of the patient, explained co-author Benjamin White, a law professor at the Queensland University of Technology.
“There are many specialists involved, each focused on a particular organ,” he told Reuters Health. The narrow focus of the individual specialists can make it difficult to coordinate a patient’s care, he and his colleagues noted in their report.
Roughly one quarter of physicians said aggressive treatments are “hard to stop once started.”
The difficulty of withdrawing treatment is a challenge that’s all too common, agreed Dr. Eytan Szmuilowicz, a palliative care physician at Northwestern University’s Feinberg School of Medicine in Chicago.
Szmuilowicz, who was not associated with the study, added that doctors’ natural aversion to conflict complicates the issue further.
“We don’t know how to manage or negotiate it,” he told Reuters Health. “It is easier behind the scenes to complain that a treatment may be inappropriate, but we haven’t taken a step back to think if we are providing care that furthers a patient’s goals.”
Szmuilowicz said he and many other physicians prefer to assess treatment in terms of “benefit” rather than “futility.”
“It comes down to what the patient values, and it’s very hard to discuss what we think the patient values if we haven’t talked about it,” he said.
Kayhan Parsi of Loyola University-Chicago’s Neiswanger Institute for Bioethics sees young physicians struggle with such discussions. Parsi, who was not involved in the study, was not surprised that 44 percent of doctors cited “inexperience with death and dying.”
As a member of his hospital’s ethics committee, Parsi meets monthly with medical trainees. “They feel pressure on them to comply with inappropriate treatment, and they don’t know how to address it in an appropriate way,” he said.
Thirty percent of the Australian doctors said they or their colleagues had provided futile treatment due to worries about legal consequences. That factor looms even larger in the U.S., according to Thaddeus Pope, director of the health law institute at Mitchell Hamline School of Law in St. Paul, Minnesota.
“Researchers don’t frame the issue in terms of patient safety, but that is a big implication of this study,” said Pope, who tracks the issue on his Medical Futility Blog.
Pope urges doctors to present medical options in even-handed ways.
“If physicians are too aggressive, families are going to fall in line,” he told Reuters Health. “It’s emotionally hard for (families) to pass up what doctors say is a reasonable option. If they knew the real risks, benefits and alternatives, they may not pick the treatment they are receiving.”