Physician and Patient Characteristics Associated With More Intensive End-of-Life Care

Paul R Duberstein; Richard L Kravitz; Joshua J Fenton; Guibo Xing; Daniel J Tancredi; Michael Hoerger; Supriya G Mohile; Sally A Norton; Holly G Prigerson; Ronald M Epstein

doi:10.1016/j.jpainsymman.2019.04.014

Physician and Patient Characteristics Associated With More Intensive End-of-Life Care

J Pain Symptom Manage. 2019 Aug;58(2):208-215.e1. doi: 10.1016/j.jpainsymman.2019.04.014. Epub 2019 Apr 18.

Authors

Affiliations

¹ Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Health Behavior, Society, and Policy, Rutgers University School of Public Heath, Piscataway, New Jersey, USA. Electronic address: [email protected].
² Department of Internal Medicine, University of California, Davis, Sacramento, California, USA; Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California, USA; UC Davis Comprehensive Cancer Center, University of California, Davis, Sacramento, California, USA.
³ Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California, USA; UC Davis Comprehensive Cancer Center, University of California, Davis, Sacramento, California, USA; Department of Family and Community Medicine, University of California, Davis, Sacramento, California, USA.
⁴ Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California, USA.
⁵ Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California, USA; Department of Pediatrics, University of California, Davis, Sacramento, California, USA.
⁶ Tulane Cancer Center, Tulane University, New Orleans, Louisiana, USA; Departments of Psychology, Psychiatry, and Medicine, Tulane University, New Orleans, Louisiana, USA.
⁷ James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.
⁸ Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; School of Nursing, University of Rochester, Rochester, New York, USA.
⁹ Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York, USA; Cornell Center for Research on End-of-Life Care, New York, New York, USA.
¹⁰ Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.

Abstract

Context: Although patient and physician characteristics are thought to be predictive of discretionary interventions at the end of life (EoL), few studies have data on both parties.

Objective: To test the hypothesis that patient preferences and physician attitudes are both independently associated with discretionary interventions at the EoL.

Methods: We report secondary analyses of data collected prospectively from physicians (n = 38) and patients with advanced cancer (n = 265) in the Values and Options in Cancer Care study. Predictor variables were patient attitudes toward EoL care and physician-reported comfort with medical paternalism, assessed indirectly using a modified version of the Control Preference Scale. We explored whether the magnitude of the physician variable was influenced by the inclusion of particular patient treatment-preference variables (i.e., effect modification). Outcomes were a chemotherapy use score (≤14 days before death [scored 2], 15-31 days before death [scored 1], and >31 days [scored 0]) and an emergency department visit/inpatient admission score (two or more admissions in the last 31 days [scored 2], one admission [1], and 0 admissions [0]) in the last month of life.

Results: Chemotherapy scores were nearly 0.25 points higher if patients expressed a preference for experimental treatments with unknown benefit at study entry (0.238 points, 95% CI = 0.047-0.429) or reported an unfavorable attitude toward palliative care (0.247 points, 95% CI = 0.047-0.450). A two-standard deviation difference in physician comfort with medical paternalism corresponded to standardized effects of 0.35 (95% CI = 0.03-0.66) for chemotherapy and 0.33 (95% CI = 0.04-0.61) for emergency department visits/inpatient admissions. There was no evidence of effect modification.

Conclusion: Patient treatment preferences and physician attitudes are independently associated with higher levels of treatment intensity before death. Greater research, clinical, and policy attention to patient treatment preferences and physician comfort with medical paternalism might lead to improvements in care of patients with advanced disease.

Keywords: Advanced cancer; biomedical ethics; chemotherapy; emergency department; end of life; health care utilization; hospitalization; palliative care; patient treatment preferences; physician attitudes.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Aged
Attitude of Health Personnel*
Female
Health Knowledge, Attitudes, Practice*
Hospice Care*
Humans
Male
Middle Aged
Paternalism
Patient Preference*
Prospective Studies
Terminal Care*

Abstract

Publication types

MeSH terms

Grants and funding