Half of dying patients refuse to talk about it
Wishes for treatment are unsatisfied
In a population of patients who were severely ill, and who had every likely reason to discuss end-of-life treatment choices, most did not want to talk about it. These latest findings in the SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment) study were published in early July.1 "Many people presume that problems in doctor-patient communication are caused by the unwillingness of doctors to discuss patient preferences," says Russell S. Phillips, MD, senior author of the study and an internist at Beth Israel Deaconess Medical Center in Boston. "What is even more surprising is that among the patients who did not want to discuss preferences, one-quarter did not want life-sustaining treatments,"he says.
One especially troubling result was that among patients who had not discussed treatment wishes with their physicians, a majority of blacks (63%) and Hispanics (62%) said they would have wanted to have these discussions.
"This certainly points to a need for physicians to be more sensitive to cultural and racial differences that may make it difficult for the patient to talk to their physician," says Phillips. "We must recognize this as a problem and be as reassuring as we can be to the patient."
In regard to younger patients, Phillips comments that the association between youth and unmet needs for end-of-life discussions may indicate that physicians are more open to discussion and more likely to bring this topic up with older patients who have chronic progressive illness than with their younger counterparts.
The SUPPORT data continue to surprise even the researchers who conducted the studies. "We were quite surprised that such a large number of patients did not want to talk, particularly since we do not see the same pattern in our own practices," Phillips says.
He suggests that primary care physicians begin discussing end-of-life issues with their patients early, while patients are still healthy. That preparation makes talking about death easier if patients do become seriously ill.
It would be easy to say, based on SUPPORT data alone, that neither doctors nor patients want to talk about difficult decisions, that neither should be blamed for a lack of communication, and that not much can be done to improve the situation. But that would certainly be a cop-out, says Phillips.
"The physician must accept the challenge of finding ways to communicate whether the patient wants to or not," he says.
Reference
1. Hofmann JC, Wenger NS, Phillips RS, et al. Patient preferences for communication with physicians about end-of-life decisions. Ann Intern Med 1997; 127:1-12.
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