Most dying doctors would refuse aggressive treatment for themselves

Harold Mandel's picture
Health care

We are taught from a morale, ethical and legal position in the United States that physicians are generally expected to do all in their powers to preserve life until the bitter end. Even at times when it appears virtually impossible to save a patient's life the general understanding remains to attempt to do so anyway until the patient is pronounced legally dead. However, there are times when physicians themselves would rather simply pull the plug on even their own lives.

Medical sub-specialists provide high intensity interventions to extremely ill patients in the last months of life reported the journal PLOS One. Researchers have investigated attitudes of doctors towards advance directives at the end of life. It was found that doctors' attitudes dealing with advance directives have not changed significantly in the past 23 years. This study has raised questions about why physicians continue to provide high intensity care for terminally ill patients but personally do not want such care for themselves at the end of their life.

Most terminal physicians would choose no code status for themselves

When they are terminally ill most physicians would choose a do-not-resuscitate or no code status for themselves reports Stanford School of Medicine. Yet, according to researchers from Stanford University School of Medicine these same doctors generally pursue aggressive, life-prolonging treatment for patients who are being confronted with the same bleak prognosis.

VJ Periyakoil, MD, clinical associate professor of medicine and lead author of the study, has raised the question of why physicians choose to pursue such aggressive treatment for their patients and yet they wouldn’t choose it for themselves. Periyakoil thinks the reasons for this are likely to be multifaceted and complex. Periyakoil and her colleagues pursued a determination of how physicians’ attitudes have changed towards advance directives ever since passage of the Self-Determination Act in 1990. This law was designed to give patients more control over making determinations regarding end-of-life-care decisions.

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Most Americans would prefer to die at home without life-prolonging interventions

In spite of the medical system’s continued focus on aggressive treatment at the end of life the majority of Americans now say they would prefer to die at home without life-prolonging interventions. It was found in the study that there is a big difference between what Americans say they desire at the end of their own life and the care which they actually receive. Greater than 80 percent of patients have said that they wish to avoid hospitalizations and high intensity care at the end of life, but their desires are generally overridden.

Overall it has been found that the type of treatments which patients receive depends more on the local health-care system variables, such as institutional capacity and the practice style of individual doctors, than it depends on the patients’ care preferences or on their advance directives. Periyakoil says the desires of patients are often lost due to the speed and intensity of a health care system which is terribly fragmented.

The entire health care system should be changed

Periyakoil points out that the focus in the health care system is on doing something. And yet with any very serious illness there comes a point where the high intensity treatment actually becomes more of a burden than the disease itself actually is. Periyakoil, who trains physicians in palliative medicine, says physicians can speak to the patients and their families and to the other interdisciplinary team members, and this entire process becomes much easier. However, Periyakoil also notes doctors are not trained to talk or rewarded for talking. Doctors are trained to do and rewarded for doing. Periyakoil expresses the feeling that the system should be changed.

There is often a great deal of dissatisfaction in the health care system expressed by patients. There is a growing interest in a holistic approach to patient care wherein physicians take the time to look at the whole person, including a consideration of physical, nutritional, social, environmental, emotional, spiritual and lifestyle values. Yet, most physicians do not practice this way.

This often creates a very painful experience for patients who are told such variables as empathy have nothing to do with a real scientific approach to quality health care. This is not true with many studies suggesting there is a significant association between how a patient is dealt with from a psychological perspective and actual clinical outcomes. The bottom line is the entire health delivery system really needs to be changed. A more holistic perspective would make decisions dealing with non lethal conditions and advance directives dealing with terminal conditions easier to handle in a more humane manner.