Providing potentially unnecessary or ineffective care for patients near the end of life can contribute to feelings of futility and burnout and a desire to leave the medical profession, researchers found.

The researchers broadly defined the condition, says Jason Lambden, MSPH, an MD candidate at Weill Cornell Medicine in New York City.

“We really wanted to get to the essence of the care that clinicians feel that they provide that might not be in the patient’s best interest,” he says. “The distinction in the literature is that ‘futile care’ is care that cannot possibly achieve the intended goals for a patient.” Possible inappropriate care (PIC) is care that “might not” achieve the intended goals for a patient, he adds.

“Our hope in using both of these definitions was to encapsulate all the care that clinicians provide that they think might not be in the best interest of the patient,” Lambden says.

To determine whether futile care/PIC is associated with measures of clinician well-being, researchers surveyed 1,794 healthcare workers at two NYC hospitals. The 349 respondents included attending physicians, residents, nurses working in intensive care, internal medicine, and a variety of specialties.

Overall, 91% of responding clinicians reported that they had provided or possibly provided futile care/PIC in the prior six months. The highest level of 95.3% was in physician trainees.

“These morally distressing experiences during the most formative years of training can lead to diminished professional identity and demoralization,” the authors reported.1

In applying measures of wellness to those who thought they delivered futile care, the researchers found that overall, 43.4% of clinicians experienced burnout syndrome and 35.5% were thinking of leaving the profession.

Moreover, there seemed to a be a dose-effect response, with a higher perceived level of futile care/PIC linked to increased burnout and thoughts of quitting. One approach to alleviating these perceptions is improved communication between providers, patients, and family members.

“One in five Americans will receive intensive care at or near the end of life,” the authors noted. “Although such care saves lives, it also has the potential to prolong the dying process and increase suffering of patients and families.”

Communicate to Change Perception

Hospital Employee Health asked Lambden to provide further insight into this issue in the following interview, which has been edited for length and clarity.

HEH: How does futile care\PIC contribute to burnout?

Lambden: It has been my experience as a medical student in the hospital that often when providers are providing care that they don’t feel is appropriate for the patient’s own goals and interests, it can be very distressing. Our hypothesis was that the stress that [clinicians] feel when they are providing care would be associated with measures of wellness, including burnout and having thoughts of quitting.

HEH: Was this hypothesis borne out in the study?

Lambden: Yes, in the study we measured how often clinicians feel that they have personally provided care that they believe to be either futile or potentially inappropriate. We also included screening questions for measures of wellness, including burnout and thoughts of quitting. We found a strong association between the amount of futile and inappropriate care that they feel they are providing and measures of burnout and thoughts of quitting.

There are a lot of potential confounders, including the type of job and clinicians. For example, an attending physician vs. a nurse, the department that they work in, and also the number of dying patients that they care for overall.

HEH: The overall number of those who believe they were providing this type of care was something on the order of nine out of 10 respondents. Does that speak to the high acuity of patients now?

Lambden: One of the surprises to us in the study was how many clinicians believe that they provided futile or potentially inappropriate care for their patients. We expected it to be a relatively higher number, but 91% exceeded our expectations.

I certainly do think that high-acuity patients are more likely to experience this sort of care. But regardless of whether [providers] worked in an intensive care setting or in general internal medicine, the same association between providing futile care and measures of wellness existed.

HEH: Is there something specific to futile care regarding a desire for clinicians to quit, or is that a common manifestation of burnout in general?

Lambden: I think that both are probably true. Having a desire to quit is certainly a manifestation of burnout. My own speculation on this is that clinicians want to feel good about the work they do. We take pride in the work we do. I think when we start to feel uncomfortable about the care we are providing, it takes away a lot of the satisfaction of doing the job. My suspicion is that this is the ultimate source of this desire to quit, and it is certainly associated with burnout as well.

HEH: The suggested strategies in the paper included changing the “perception” of futile care. Can you elaborate on that point?

Lambden: One of the main ways we need to change is increased communication among all providers for patients at the end of life. This includes things like having all providers present for difficult family conversations to make sure everyone is on the same page, and that there are no misunderstandings among providers.

Also, I think having a formal debriefing session after difficult conversations can be really helpful in making sure that all clinicians understand the purpose and the intention of the care they are providing.

Another way we can help clinicians is to increase the support they have for these difficult, end-of-life care issues. This can be done by creating a culture where disagreements can be respectfully discussed and having ethics consults when they are needed.

REFERENCE

  1. Lambden JP, Chamberlin P, Kozlov E. Association of Perceived Futile or Potentially Inappropriate Care with Burnout and Thoughts of Quitting Among Health-Care Providers. Am J Hosp Palliat Care. 2018 Aug 5:1049909118792517.doi:10.1177/1049909118792517. [Epub ahead of print]