Friday, March 9, 2012

Addressing gaps in end-of-life planning

A recent article by family physician Ken Murray in the Wall Street Journal, titled "Why Doctors Die Differently," observed that doctors are more likely than other people to decline end-of-life interventions that have little likelihood of benefit:

It's not something that we like to talk about, but doctors die, too. What's unusual about them is not how much treatment they get compared with most Americans, but how little. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care that they could want. But they tend to go serenely and gently.

Doctors don't want to die any more than anyone else does. But they usually have talked about the limits of modern medicine with their families. They want to make sure that, when the time comes, no heroic measures are taken. During their last moments, they know, for instance, that they don't want someone breaking their ribs by performing cardiopulmonary resuscitation (which is what happens when CPR is done right).

In a published survey of older physicians cited in the article, 64 percent of physicians had created an advanced directive, which Dr. Murray argues is essential to planning for end-of-life care: "Written directives can give patients far more control over how their lives end. But while most of us accept that taxes are inescapable, death is a much harder pill to swallow, which keeps the vast majority of Americans from making proper arrangements."

In the March 1st issue of AFP, Drs. G. David Spoelhof and Barbara Elliott review strategies for implementing advance directives in office practice. The authors recommend that family physicians have interactive discussions with patients regarding their end-of-life care preferences over multiple office visits, and they provide guidance for overcoming common patient- and physician-related barriers to completion of advance directives. A suggested approach for physicians is to bring up the topic of advance directives at routine visits for patients age 50 years or older and intensify discussions upon the diagnosis of a chronic and progressive illness such as cancer, heart failure, or dementia:

Following a realistic discussion of the patient's prognosis, the physician initiates a more in-depth discussion, including the proxy and family members as desired, that centers on the patient's care goals. Adding a values history to the advance directive may be helpful. After the discussion, the advance directive is updated and made as specific as possible. These issues should be readdressed periodically and as circumstances change. The last phase occurs with the onset of frailty or the need for long-term care. The discussion, centered on the patient's care goals, may result in consistent and specific physician orders regarding life-sustaining interventions.

To ensure that patients' end-of-life wishes are respected, advance directives should avoid vague language (e.g., "no heroics"), be shared with proxy decision-makers, and be made accessible in the medical record so that they are easily transferable to multiple levels of care.