Dying patients may not want to discuss treatment
The latest data from SUPPORT (Study to Understand Programs and Preferences for Outcomes and Risks of Treatment) indicate that half of dying patients have no desire to discuss end-of-life treatment preferences such as CPR or extended ventilator care with their physicians.
Results published in Annals of Internal Medicine1 from 1,832 patients hospitalized for a life-threatening illness and enrolled in Phase II of SUPPORT between 1992 and 1994 indicate that less than one-fourth of these patients had discussed their preferences for CPR with their physicians. Among the remainder, 58% were not interested in doing so.
A significant proportion of those who did not want to discuss their treatment preferences told researchers that they did not want to receive life-extending treatments even though hospitals might be expected to provide such treatments unless the patient or a surrogate says no. The patients unwilling to talk about treatment options were also more likely to have overly optimistic perceptions of their prognosis.
Hospice providers should not be surprised to discover that many patients would prefer to avoid these painful discussions altogether. However, the results underscore the challenges that still remain in overcoming powerful social and cultural taboos standing in the way of realistic and informed treatment decision making at the end of life. Study co-author Russell S. Phillips, MD, a general internist at Beth Israel Hospital in Boston, observes that the results confirm poor end-of-life communication between patients and physicians and that such communication "really is a two-way street. It is difficult for both doctors and patients to talk about people’s real prognoses. Patients have a hard time hearing bad news and, in the absence of hearing any news, will hope for the best, which is natural."
While the study did not explicitly address hospice, "If we had asked these patients, Do you want to talk to your doctor about hospice care?’ they might have said no," Phillips tells Hospice Management Advisor. "Patients shouldn’t make presumptions about their care preferences just because they may not want to talk about it. We need to find better ways to broach the subject. Hospice, like resuscitation, is a difficult issue, and if people can avoid it, they will," he explains.
Joanne Lynn, MD, another co-author and director of the Center to Improve Care of the Dying at George Washington University in Washington, DC, adds, "What this study shows us is that policy-makers and leaders in the health care field need to direct the same amount of energy to getting patients to talk about these issues as they do to getting doctors to talk about them. This may require a significant change for all of us in how we think, teach, and talk about end-of-life issues."
Reference
1. Hofman, JC, et al. Patient preferences for communication with physicians about end-of-life decisions. Annals of Internal Medicine 1997; 127:1-12.
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