Physicians are trained to treat
The real culprit for why physician conversations with patients about end-of-life care occur later rather than sooner is that physicians in medical schools primarily are trained to treat rather than talk, but that appears to be changing.
"I think, by and large, doctors are trained to treat patients, and to make patients better, to cure patients. And we've traditionally had very little training and experience in focusing on improving the quality of death," says Nancy L. Keating, MD, MPH, an author of a recently published study on physician discussions with patients on end-of-life care.1 "And I think a lot of doctors feel like they've failed, if they can't cure someone or can't continue treating someone," says Keating, a member of the Department of Health Care Policy, Harvard Medical School, Boston, and the Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, both in Boston.
20% go to ICU in last month
Keating notes that about 20% of patients in the Medicare population are admitted to the ICU in the last month of life. "I think there's lots of evidence out there that many patients get lots and lots of courses of chemotherapy at the end of life," she says. "Many patients are getting new chemotherapy within 30 days of death, and all of these things suggest that we really are possibly being too aggressive with the way that we're treating people."
An encouraging sign related to this issue is that many medical schools now have structured classes on communication covering topics such as end-of-life options. Also, the survey found that more recently trained doctors were more likely to have end-of-life discussions with their patients, Keating notes.
1. Keating NL, Landrum MB, Rogers SO Jr., et al. Physician factors associated with discussions about end-of-life care. CANCER 2010; 116:998-1,006.