Myth busted: doctors don’t choose less aggressive end-of-life care for themselves

End of life

By Mardi Chapman

30 Jul 2019

The widely-accepted idea that doctors are more likely to choose to die at home or with fewer interventions than other people at the end of their lives has been dispelled.

A Canadian study, comparing end-of-life pathways between 2,507 physicians and 7,513 non-physicians in Ontario between 2004 and 2015, found the groups were more alike than not.

The primary outcome of rates of death at home was similar in both groups (42.8% v 39.0%).

Physicians and non-physician groups also had similar rates of interventions in the last six months of life including mechanical ventilation, dialysis and CPR.

The rate of recent Emergency Department (ED) visits was was lower for physicians compared to non-physicians (73.0% v 78.4%) but the risk of hospital admission was similar (67.0% v 70.6%).

Slightly more deaths in ICU occurred amongst physicians than non-physicians (11.9% v 10.0%).

Doctors were also more likely to access palliative care (52.9% v 47.4%) and at-home care visits (54.3% v 50.1%) than other people.

In a subgroup of people with chronic illness, patterns of care were similar between physicians and non-physicians, although physicians were more likely to die at home (35.2% v 30.7%).

Similarly, in a subgroup of people with cancer, physicians were more likely to die at home than non-physicians (37.6% v 28.6%) but they also received more chemotherapy (37.9% v 29.8%).

Total costs of care in the last six months of life were similar between the two groups.

The researchers said in JAMA Network Open that the differences in patterns of care between the two groups were small and inconsistent and suggested “greater complexity in end-of-life decision-making than a dichotomous model of less vs more”.

“In a system with universal health coverage, informed health care decision makers such as physicians do not consistently opt for less-aggressive care across the board, but instead vary in their choices regarding end-of-life care, with increased use of both intensive and palliative care.”

“These findings suggest that a more nuanced approach that considers patient preferences, available supports, diagnosis, specific medical problems faced, and stage of terminal illness may be more informative to efforts to improve end-of-life care.”

Commenting on the study findings, Emeritus Professor Malcolm Parker from the University of Queensland told the limbic that the mixed results – that doctors were more likely to access both intensive care and palliative care – highlighted the complexities of decision making around end of life care.

“Those factors they list there shouldn’t be news to anyone – they are the sorts of things that should be considered whether it is a physician at the end of life or anyone else,” he said.

“Physicians have a number of insights which the general public don’t, and they also have more health literacy and familiarity with the health system.”

“But of course when you are at the end of life, the fact you have been a physician or that you are a physician [is] not unimportant or insignificant, but it’s one of a number of factors.”

Professor Parker, whose interests include medical ethics and end of life issues, said in his own experience the discussions he has with his own doctor are probably somewhat different to the discussion that a non-doctor would have.

“But basically I’m a patient. I try to be a patient. It depends on what stage of practice you are at so it’s very complicated.”

He said there was currently a lot of effort being made nationwide to increase access to palliative care, however there were limitations on how equitable and accessible such services could be, particularly in the big states like WA and Queensland.

Professor Parker added that given those difficulties, access to palliative care shouldn’t necessarily be used as an argument against voluntary assisted dying which is currently under discussion on both states.

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