Physician factors associated with discussions about end-of-life care

Abstract

Background: Guidelines recommend advanced care planning for terminally ill patients with <1 year to live. Few data are available regarding when physicians and their terminally ill patients typically discuss end-of-life issues.

Methods: A national survey was conducted of physicians caring for cancer patients about timing of discussions regarding prognosis, do not resuscitate (DNR) status, hospice, and preferred site of death with their terminally ill patients. Logistic regression was used to identify physician and practice characteristics associated with earlier discussions.

Results: Among 4074 respondents, 65% would discuss prognosis "now" (defined as patient has 4 months to 6 months to live, asymptomatic). Fewer would discuss DNR status (44%), hospice (26%), or preferred site of death (21%) immediately, with most physicians waiting for patient symptoms or until there are no more treatments to offer. In multivariate analyses, younger physicians more often discussed prognosis, DNR status, hospice, and site of death "now" (all P < .05). Surgeons and oncologists were more likely than noncancer specialists to discuss prognosis "now" (P = .008), but noncancer specialists were more likely than cancer specialists to discuss DNR status, hospice, and preferred site of death "now" (all P < .001).

Conclusions: Most physicians report they would not discuss end-of-life options with terminally ill patients who are feeling well, instead waiting for symptoms or until there are no more treatments to offer. More research is needed to understand physicians' reasons for timing of discussions and how their propensity to aggressively treat metastatic disease influences timing, as well as how the timing of discussions influences patient and family experiences at the end of life.

Figure. Timing of discussions about prognosis, DNR status, hospice enrollment, and preferred site of death with terminally ill patients, by physician specialty

The panels present physicians’ reports of when they would discuss prognosis, DNR status, hospice enrollment, and preferred site of death with a patient who is newly diagnosed with metastatic cancer whom they believe has 4–6 months to live. Dark blue reflects the proportion responding “now”, purple reflects “when the patient first develops symptoms”, red reflects “when there are no more non-palliative treatment options”, yellow reflects “only if the patient is hospitalized”, and light blue reflects “only if the patient and/or family brings it up.”