Most physicians would choose a do-not-resuscitate or "no code" status for themselves when they are terminally ill, yet they tend to pursue aggressive, life-prolonging treatment for patients facing the same prognosis.
Hypocritical? No, Hippocratic.
Is that a good thing? You betcha.
V.J. Periyakoil, MD, clinical associate professor of medicine at
Stanford University Medical Center
and lead author of the paper, says it is a disconnect, but to the public it isn't. Making a personal choice is one thing, making a social authoritarian decision for a patient is quite another.
For the paper, Periyakoil and colleagues set out to determine how physicians' attitudes have changed toward advance directives since passage of the Self-Determination Act in 1990, a law designed to give patients more control over determining end-of-life-care decisions. Advance directives are documents that patients can use to indicate end-of-life care preferences.
They used two sets of subjects: One comprised 1,081 physicians who in 2013 completed a web-based advanced directive form and a 14-item advance directive attitude survey at Stanford Hospital&Clinics and the Veterans Affairs Palo Alto Health Care System; the other comprised 790 physicians from Arkansas who were asked the same 14 survey questions — but did not complete an advance directive form — in a 1989 study published in the Journal of the American Medical Association.
The result: Doctors' attitudes toward advance directives have changed little in 25 years.
The lack of change in physicians' attitudes toward advance directives mirrors what the paper describes as the medical system's continued focus on aggressive treatment at the end of life, despite the fact that most Americans now say they would prefer to die at home without life-prolonging interventions.
Luckily, the Affordable Care Act means the government will look for lots of ways to cut costs. And aggressive treatment at the end of life will be the first to go.
"A big disparity exists between what Americans say they want at the end of life and the care they actually receive," the study said. "More than 80 percent of patients say that they wish to avoid hospitalizations and high-intensity care at the end of life, but their wishes are often overridden."
This highlights the problem with studies. Many people intellectually check off one box and then when the situation is reality change their minds. "There are no atheists in foxholes", goes an old military saying, and people tend to want to fight to live on. Yet the authors suggest patients have no input and that the health care system or doctor beliefs matter most. What doctor would agree they kept someone alive who wanted to die? It's a conspiracy fairy tale we know does not exist in an era of defensive medicine, malpractice lawsuits and a 'teach to the protocol' culture mandated by government regulators.
Yet Periyakoil says, "Patients' voices are often too feeble and drowned out by the speed and intensity of a fragmented health-care system," though the results show just the opposite.
Physicians' attitudes toward end-of-life care differed depending on thnicity and gender. Emergency physicians, pediatricians, obstetrician-gynecologists and those in physical medicine and rehabilitation had more favorable attitudes toward advance directives. Radiologists, surgeons, orthopaedists and radiation oncologists were less favorable. Caucasian and African American doctors were the most favorable; Latino physicians were the least favorable.
An overwhelming percentage of the 2013 doctors surveyed — 88.3 percent — said they would choose "no-code" or do-not-resuscitate orders for themselves.
"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. "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.
"But we don't train doctors to talk or reward them for talking. We train them to do and reward them for doing. The system needs to be changed."