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Doctors vary on willingness to talk about hospice

By Andrew M. Seaman

NEW YORK (Reuters Health) - Doctors' personal preferences may influence when they discuss end-of-life care with patients, says a new study.

Researchers found doctors who said they would opt for care aimed at preventing pain and suffering at the end of their own lives were more likely to discuss that type of care with a hypothetical dying patient.

"Although most patients do ultimately talk about some end-of-life topics before they die, the vast majority of these conversations happen during acute care hospital stays and at the end of life," Dr. Nancy Keating, the study's senior author, said.

Keating is an associate professor at Harvard Medical School in Boston.

The goal of so-called palliative care is to control pain and other symptoms and to make sure patients and their families are supported emotionally. Hospice care, in particular, is palliative care for patients who are in their last months of life.

Many guidelines recommend doctors discuss hospice with patients who are expected to live for less than a year.

But Keating and her colleagues write in a research letter published in JAMA Internal Medicine that those conversations are often delayed.

For the new report, the researchers used data from 4,368 U.S. doctors who took part in a study that looked at variations in cancer care across the U.S.

Researchers asked doctors about their preferences for their own end-of-life care. They also asked them when they would discuss hospice with a hypothetical patient with cancer who was expected to live for another four to six months and currently didn't have any symptoms.

About 65 percent of doctors strongly agreed they would enroll in hospice care if they were terminally ill. Another 21 percent somewhat agreed they would enroll.

Only about 27 percent of doctors said they would discuss hospice "now" with the hypothetical dying patient, however.

The others said they would wait to discuss hospice until the patient was hospitalized, the patient had symptoms, the patient's family brought it up or until there were no more treatments to offer.

Overall, the researchers found about 30 percent of the doctors who strongly agreed that they would enroll in hospice toward the end of life would discuss palliative care with the hypothetical patient. That compared to about 20 percent of doctors who provided other answers about their own end-of-life care.

"It still is much lower than I think it should be," Keating told Reuters Health.

"There is a lot of concern among physicians that talking about end-of-life care with patients with advanced cancer, who have a short life expectancy, will have patients lose trust in them," she said. But there is little data to support those concerns.

Previous studies have found patients are more likely to get care in line with their wishes when hospice is discussed early.

"I think - in general - we should all be doing this a lot more," Keating said.

In an essay published in the same journal, Dr. Tanya Tajouri and Dr. Timothy Moynihan from the Mayo Clinic in Rochester, Minnesota, tell the story of a dying 55-year-old man who was brought to their hospital.

Instead of involving palliative care services after his diagnosis, the man was aggressively treated and had a heart defibrillator surgically implanted.

"When caring for patients with a terminal illness, physicians are challenged with difficult discussions and decisions, and many times these ignore the ‘elephant in the room' - the fact that the patient is dying," Tajouri and Moynihan write.

The man died less than a month after coming to the hospital.

Keating said patients should talk with their doctors and family about their end-of-life care plans.

"People are still reluctant to talk about death, but this is one of those things that will absolutely happen to everybody," she said.

SOURCE: http://bit.ly/MbBLb9 JAMA Internal Medicine, online December 16, 2013.

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