28 Jun “Do Everything Possible” Leads To Aggressive Care At End of Life
MedicalResearch.com Interview with:
Dr Magnolia Cardona-Morrell, MPH, PhD
Senior Research Fellow
The Simpson Centre for Health Services Research
South Western Sydney Clinical School
MedicalResearch.com: What is the background for this study? What are the main findings?
Response: We name the non beneficial treatments – those intensive procedures, medications or tests administered to elderly patients who are naturally dying and which will not make a difference to their survival, will probably impair their remaining quality of life or potentially or cause them pain or suffering – that are still occurring in hospitals. Think of these as unnecessary or excessive for the expected benefit.
Our review of 38 studies, including 1.2 million patients, doctors, nurses and relatives in 10 countries, showed that on average 33% of elderly patients in the last six months of life and up to the last seven days of life received some of these treatments.
• attempting CPR on elderly patients with advanced disease or who have a “not-for-resuscitation” order (11-25%)
• admission to intensive care in patients with advanced chronic disease (average 10% and up to 33%)
• initiation or continuation of chemotherapy at the end of life (24-41%)
• hemodialysis, transfusions, oral or intravenous medications to patients in terminal admissions (7-77%)
These treatments continue happen after two decades due to a combination of factors:
• patients’ lack of communication with families about end-of-life care wishes
• unrealistic social expectation of survival due to technological advances
• family pressure for doctors to “try everything possible”
• medico-legal concerns
• doctors’ uncertainty about the time until death and
• the default position of intervening because doctors are trained to cure disease and save lives.
MedicalResearch.com: What should readers take away from your report?
Response: We need to remember that old age and chronic disease are the most significant predictors of death.
Older people and patients with chronic disease can prevent some of these non-beneficial treatments by speaking with their doctor and family about their preferences for end-of-life care before a time of crisis.
Non-beneficial treatments at the end of life cause suffering to patients, prolong dying rather than survival, give false hope to families, and lead to unsustainable costs of care and job dissatisfaction for clinicians.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
• Hospital administrators or researchers can monitor the extent and time trends of non-beneficial treatment in hospitals to identify and address the specific reasons for it at the local level
• Investigate the impact of training doctors to use prognostic tools that better identify patients near the end of life
• Assess the impact that timely end-of-life conversation has on patient choices for aggressive or palliative care
MedicalResearch.com: Is there anything else you would like to add?
The medicalisation of death through some aggressive procedures is not in the interest of dying patients.
General practitioners can initiate the discussion on end-of-life preferences with their older patients in the course of routine care and encourage them to formalise an advance care plan or an advance care directive. This will empower patients to participate in their final care, facilitate decisions by doctors, and prevent regret among family members if they have to make decisions in a health emergency.
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Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.
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