Why are doctors so reluctant to discuss end of life care?

A recent study suggests that doctors may put off holding end of life care discussions that involve subjects like advance directives, hospice or site of death.

Recommendations suggest that physicians hold these conversations when patients have about a year to live, but the data shows  those guidelines aren’t being followed.

Why?

According to the study’s authors, they suggest that doctors “may not be comfortable discussing it,” and, “these conversations are time-consuming and difficult. Some doctors may feel patients will lose hope. It’s easier to say, ‘Let’s try another round of chemotherapy,’ instead of having a heart-to-heart discussion.”

They also point out that medical schools spend little time giving students formal training in holding an end of life care discussion.

That’s all true, but I’ll add one more reason. Time.

Time is simply not valued within our fee for service-based health system. These complicated issues require input, not only from the patient of course, but the family as well. The fact that doctors practice in a system that discourages lengthy office visits, it’s no wonder that more are shying away from this imperative issue.

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  • http://www.MDWhistleblower.blogspot.com Michael Kirsch, M.D.

    Good points. Ideally, patients should raise this issue themselves with us, as they do with their medical complaints. If they bring ‘end of life’ to the table, then we’d have to listen and discuss. Public education should be part of the effort.

  • http://www.desouzanurse.ca Ashleigh

    I work in a Metropolitan Regional Cancer Centre in Toronto & I have seen this issue time & time again as an inpatient RN. Many of my colleagues would be afraid to discuss end of life planning with patients and their families simply b/c they felt that it would upset the attending physician. They would rationalize their actions by saying things like “the doctor didn’t talk to the patient about their DNR status (for example) so that must mean that they don’t want us to.” I think that it is important for all health professionals to take the time to have these difficult discussions as it may end up saving time, and resources in the future by understanding the wishes of the patients up front. Understanding what the patient hopes for is vital to providing basic care and we are doing them a disservice by not initiating the dialogue- regardless of how difficult or time consuming we might believe it to be.

  • http://www.drmavromatis.com drmavromatis

    The push to discuss end-of-life care with patients has always been one of my pet peeves. When admitting a patient to the hospital a check list reminds the admitting physician to address “DNR status.” This conversation, when done wrong, can go a long way to alienate a patient and his or her family, who may fear that their medical team no longer values his or her life. I believe that there are huge cultural factors that contribute to the readiness that patients have to engage in this conversation. In my experience, people, like those who are reading this blog, who are well-educated and largely american-born, are much more willing to see merit in discussing end-of-life care. I remember my Brazilian-born grandmother and her confusion over a discussion that she had with my grandfather’s MD when he had terminal lung cancer. She was left to fill out an advanced directive, which she was ill-equiped to interpret. The whole process upset her immensely. My feeling is that doctors who get to know and build trust with their patients and families over years can ease the discomfort of this discussion by collaboratively recommending, rather than asking patients to decide about end of life treatment options.

  • shirin de silva

    I don’t think it’s the doctor’s so much as the patients who don’t want to hear it. Since I work for the VA, we do discuss end of life care. I find it is relatively easy to get healthy 40 year olds to put down their wishes as opposed to, say, healthy 70 year olds. (It’s also easier to get 16 year olds to sign up as organ donors than to get older people to do so.) Similarly, the VA requires things like counselling about obesity, tobacco addiction, alcohol use, seatbelts and recreational drugs, and its amazing how reluctant people with these issues are to address them.

  • family practitioner

    Here we go again.
    It is so easy to blame us primary care doctors.
    But you know what: most seniors look at me like I am from Mars when I bring the subject up. I try, but I am not going to do a sales pitch. If they want to wind up intubated, with a trach, maybe encephalopathic, who am I to convince my patients otherwise?
    All this Sarah Palin and Republican nonsense about “death panels” only made our job more difficult.

  • http://www.senioreyecareproducts.com Jimmy Stille, Georgia

    I am a senior, 65 years old. I have never discussed end of life issues with my doctor. I thought about it when my Mom died, and when my Dad died, but never felt so strongly that I brought it up to my doctor.

    I have enough trouble trying to remember everything I need to talk to him about staying alive. I always make a list of things to ask but most of the time I don’t get to ask all of them.

    If he brought up the subject, I don’t know exactly how I would feel about it. I guess I would immediately wonder if something showed up in my blood work that made him mention it.

    I know I should have an advance directive, but procrastination seems to be holding more sway with me right now. Maybe when I get old….

  • R Watkins

    For the discussion to be meaningful, it frequently requires (based on my experience) several one-hour talks spaced out over months. So maybe the question is “Why are doctors so reluctant to do work they won’t get payed for?” Duh.

  • http://www.medicalmysteries.wordpress.com May

    I agree with the article and the people commented before me. Are there any specific guidelines to how the end-of-life-care conversation should be discussed with patients? I understand that it should be talked about when the patient has about a year left to live. But how do doctors measure their patients’ life span exactly? I think it’s a complicated situation. Plus, there should be a study that shows how patients and their families feel about the end-of-life care discussions. It will definitely be interesting to compare data.

  • IM resident

    My attendings can talk all day about CHF, diabetes, MI, etc, as well as serve as shining examples of how to manage them . However, when it comes to showing me how to talk to the patient and family about end of life issues, I’m left to my own devices. We’re given a lecture about it every year but I think what would really help is to actually show us in real life how it’s done.

  • http://www.medicalbarista.com Dr. Kona

    This is an interesting post, with many interesting comments. I want to share a personal journey with this issue. I was a hospice volunteer for about 4 years before going to medical school, where I ended up working on research in end-of-life care decision making. I continued to do hospice work in my spare time. I attended a medical school that was very much focused on primary care, which included teaching students how to have these discussions with patients. I was destined to be a geriatrician or palliative care specialist.=

    Well, I ended up in anesthesiology!! Kind of a 180 – with the focus of my day’s work being resuscitating patients.

    At any rate, it is difficult to know when to have these discussions with patients, but it is known that end-of-life care discussions happen in 3 stages – thinking about preferences, telling somebody about them (spouse, children), and writing them down. Patients that are older and patients with chronic disease are more likely to be further along this spectrum of planning. Maybe doctors would find it easier to bring up discussion with older, sicker patients, and maybe they would be willing to start the discussion earlier with these patients before a serious medical event happens.

  • DVM

    I find the comments above intriguing because I regularly discuss end-of-life issues: I’m a veterinarian. To respond, in order:

    Clients don’t necessarily raise this issue with me, but the majority are relieved when I start the conversation. In many cases I think it’s because they’re afraid to bring it up (“if the doctor doesn’t think he’s dying, I shouldn’t question her”).

    It is important to have a relationship with the people involved and approach the subject carefully. DNR doesn’t necessarily mean Do Nothing, even in veterinary medicine.

    Some people don’t want to hear about terminal illness. These can be difficult, angry conversations, sometimes resulting in a loss of client. But speaking as a doctor who cares about her patients I must say after a certain point it’s not medical “care” when there is no possibility of improving either quality of life or survival time. Sometimes I think it would be borderline malpractice for me to continue.

    As for being paid for these discussions… no, I’m not paid any more than I’m paid for the regular appointment time, during which I incorporate these discussions. Does it occasionally take more time? Yes. But it’s part of my job.

    Of course, I’ve read that veterinarians encounter death directly about 5x more often than do physicians. It may be that I’ve had a lot of practice (which doesn’t make it easier).

  • amy

    Dear DVM, I can assure you that time would be an issue if cats and dogs will be on Medicare and Medicaid.

  • http://www.nurseme.blog.com NurseMe

    Ah, yes. Thanks to Sarah Palin and the Repubs for making an already challenging discussion taboo. I’m a trauma nurse which brings the end of life discussion abruptly to the top of the list. It’s never easy, especially when we’re confirming brain death. So often families are waiting with baited breath to see if their loved one will breathe, thus failing the apnea test. I’ve been doing this for 12 years and have never seen the spontaneous return of breathing after the first brain death exam. Rather than spending the 4 hours in between exams in “wait and see” mode, the time could be better spent preparing (as best one can) for the inevitable.

  • DVM

    >>I can assure you that time would be an issue if cats and dogs will be on Medicare and Medicaid.>>

    1. I don’t treat dogs or cats.
    2. Just like any physician, I have a schedule to keep. I incorporate end-of-life discussions into the regular appointment time.

  • Wendy

    As I was reading these posts regarding end of life care, one thing above others popped out at me, and it is this: I see a lot of doctors or medical ‘professionals’ stating that they don’t want to incorporate this ‘talk’ into their appointment w/ the patient because it will take too long, and if they were to do so, either by stringing it out over many visits or at some other time when the patient isn’t sitting there in front of them, then they wouldn’t be getting PAID for it.
    As a mom, I have to tell you, I don’t get paid for anything I do, that apparently would be going above and beyond what a basic mom is to do. I am a mom , and I take that job very seriously. Imagine if I said to my child(who is grown now) or any of his friends who were in my care, as I looked down at my watch, “Sorry Charlie, you’ve gone over the allotted 5 minutes I can spend w/ you right now. My job is over with you right now. Bye.”
    That is how way too many doctors look at their job. The patient is only their patient while they are sitting there in front of them. If the medical field you have gone into is too difficult or time consuming( I’m speaking of the doctors who actually see patients face to face) for you to make sure that you are helping to take care of the whole person( patients need to be informed themselves as well), from birth to death, then maybe the operating system you are working in needs to be changed and re-worked, or maybe you should not be in the ‘people-profession’.
    Have monthly workshops that you invite patients to come to that have speakers there who are well versed in this subject(end of life).You could mail your patients info about what they could bring in as questions concerning this matter to their visits with you, or have a web page devoted to this and different subjects so that they ARE more well informed and take up less of your time in the first place.
    I have, because of health issues w/ both my son and myself, had to deal w/ a ton of healthcare workers. The best ones are the ones who DO take the the time because time IS expensive(one cannot get it back), and they put the patients at ease, which reduces stress, which reduces health issues, etc.
    I think the term medical reform needs to be re-looked at and called what it really needs to be: People Reform. Until people decide to do the right thing, the right thing will not get done. I think the medical profession’s blueprint on how things ‘should work’ is so ingrained and mis-guided. Somewhere it really got off track(I think it has to do w/ insurance). Everyone should go back to the basics( caring humans) , while utilizing all the advances we have medically to further wellness at ALL STAGES of LIFE, of which, death is one…

  • amy

    Dear Mom, I am a Mom too, I have three children that I have to feed and send to school. Time is the only commodity I have. And there are only 24 hrs in a day. It is a math problem, really. It was not like that in the first five years of practice. But after that, after 60 hrs a week for five years, it became a matter of time.
    You want the old fashioned doctor ? Fine, pay the old fashioned way.

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