Tuesday, July 12, 2016

Maybe doctors don't die so differently

I was wrong. Maybe you were too.

After reading Dr Ken Murray's now famous essay, "How Doctors Die," I believed the narrative: of course doctors die differently. We die better.

It makes sense: doctors own inside knowledge; we know death is normal, and we know the limits and dangers of medical care delivered at the end of life. Doctors are informed and empowered patients, and therefore, when it comes to end-of-life care, we would not be bullied by the healthcare system. We would shun futility and value quality over quantity.

New research tells a different story. A group of researchers led by Dr Dan Matlock (University of Colorado) set out to test the hypothesis that US doctors use less healthcare in their last months of life.

What they found is both surprising and informative. Matlock and colleagues used an AMA database to match nearly 10,000 physician decedents to a random sample of more than 190,000 nonphysician decedents. All of these Medicare beneficiaries died between 2008 and 2010. The outcome measures were inpatient care and hospice claims in the last 6 months of life. For inpatient services, they included general hospital admissions and ICU use. The research team adjusted for multiple covariates, including sociodemographic data, comorbidities, and regional variations in healthcare.

The results are easy to summarize: after adjustment, similar proportions of physicians (67%) and nonphysicians (70%) were admitted to the hospital in the last 6 months of life. The mean number of days spent in the hospital in the last 6 months and 1 month of life were nearly identical for physician and nonphysicians. ICU stays in the last 6 months or 1 month of life were not significantly different. Slightly more physicians (46%) than nonphysicians (43%) used hospice services (P < .001).

I had thought the anecdotes were typical: doctors diagnosed with terminal disease simply close the office and go live their remaining days in peace. We get off the metaphorical train of end-of-life care. We get hospice; we die well. Because we know the deal.

That admittedly biased view stems from more than just a belief in anecdotes: prior surveys of physician attitudes toward end-of-life care supported the notion that physicians would choose less intense care . The key word being would, as in the future. The future is easy. Being terminally ill in the present is not easy.

When ill patients ask me, "What would you do if you were me?" I almost always resist the urge. How can I presume to know what it's like to be in their body or to have their disease? Hubris scares me, and therefore I rarely interject my healthy person's point of view. Surely this brand of caution applies to terminal illness.

But that's a healthy person's view. The ugly path to death, which far too many patients take, is clear in hindsight, but hazy in the future. The train of end-of-life care can accelerate slowly: the chemotherapy that had a small chance of benefit blunts the immune system. Things are okay for a while. Then pneumonia develops, and a Foley catheter leads to a urinary infection. Bed rest and a DVT. Maybe bleeding. A transfusion reaction. Months later, frailty leads to a fall and more surgery.

One could argue physicians should, by virtue of our training, be better able to predict the future. But perhaps it is our experience as healers that nudges us toward optimism rather than realism. How else could we routinely embrace therapies with absolute risk reductions of 1% as if they were, well, necessary?

By email, Dr Diane Meier (Mount Sinai School of Medicine), a professor of geriatrics and palliative medicine, confirmed this view. She wrote, "Doctors are human and share at least as great a fear of death as the general public. We can be control freaks, and I'd argue our fear is greater, as well as our fantasy that we can beat it."…

Matlock and coauthors write that the "most troubling" explanation for their findings might be that the culture and the fee-for-service system are driving aggressive care in the last 6 months of life. To their credit, they call for future qualitative research into the reasons doctors get aggressive care at the end of life.

Think about what these results say about both our culture and system. If doctors can't stop the train or jump to the tracks, how could a regular person?


See:  http://childnervoussystem.blogspot.com/2015/06/how-doctors-die.html

1 comment:

  1. Matlock DD, Yamashita TE, Min SJ, Smith AK, Kelley AS, M Fischer S. How U.S. Doctors Die: A Cohort Study of Healthcare Use at the End of Life. J Am Geriatr Soc. 2016 May;64(5):1061-7.

    To compare healthcare use in the last months of life between physicians and nonphysicians in the United States.
    A retrospective observational cohort study.
    United States.
    Fee-for-service Medicare beneficiaries: decedent physicians (n = 9,947) and a random sample of Medicare decedents (n = 192,006).
    Medicare Part A claims data from 2008 to 2010 were used to measure days in the hospital and proportion using hospice in the last 6 months of life as primary outcome measures adjusted for sociodemographic characteristics and regional variations in health care.
    Inpatient hospital use in the last 6 months of life was no different between physicians and nonphysicians, although more physicians used hospice and for longer (using the hospital: odds ratio (OR) = 0.98, 95% confidence interval (CI) = 0.93-1.04; hospital days: mean difference 0.26, P = .14); dying in the hospital: OR = 0.99, 95% CI = 0.95-1.04; intensive care unit (ICU) or critical care unit (CCU) days: mean difference 0.35 more days for physicians, P < .001); using hospice: OR = 1.23, 95% CI = 1.18-1.29; number of days in hospice: mean difference 2.06, P < .001).
    This retrospective, observational study is subject to unmeasured confounders and variation in coding practices, but it provides preliminary evidence of actual use. U.S. physicians were more likely to use hospice and ICU- or CCU-level care. Hospitalization rates were similar.