By Chris Cunningham
NEW YORK, Jun 19 (Reuters Health) - Asked how they wanted to be cared for
when terminally ill, about 10% of patients with advanced AIDS said they would
choose aggressive life-sustaining therapies even when physicians believe such
measures to be futile, according to two recent studies conducted at the
University of Washington in Seattle.
The results suggest that physicians and clinics should take into account the
diverse attitudes of patients concerning use of life-sustaining measures and
include these in end-of-life counseling, Dr. J. Randall Curtis and his
colleagues report.
The studies, published in the in the belief that it would not
contribute significantly or at all to the patient's quality of life.
The patients were given a hypothetical situation in which they were told
they had developed pneumonia and had less June 12th issue of the Archives of Internal
Medicine, examined attitudes about death and life-sustaining support among AIDS
patients and physicians, and why they do not discuss end-of-life care.
"This knowledge should influence how clinicians approach patients and
families when discussing end-of-life care and when taking a process-based
approach to futility determinations," Curtis and colleagues write.
In the first study, the researchers examined interview data from 57 patients
with advanced AIDS to learn how patients and physicians viewed physicians' use
of the "medical futility rationale," a term that refers to situations in which
physicians would not offer end-of-life treatment than 3 months to live. They were told
that their physician believed a life support such as mechanical ventilation
would be futile. The patients then were asked whether they believed it would be
acceptable for their physicians to make them comfortable without offering life
support.
Sixty-one percent said that it would definitely be acceptable for their
physicians to withhold life support, and 26% answered that it would probably be
acceptable. However, a significant 12% responded that it would definitely not or
probably not be acceptable for their physicians to withhold life support under
these circumstances.
The second part of the team's research sought to find out what improved or
prevented discussions about end-of-life issues for patients and their
physicians, particularly among minorities, injection drug users and women--those
who were least likely to discuss end-of-life care.
The investigators found that while physicians identified more barriers to
communication than patients did, the barriers identified among both groups
indicated that education about end-of-life care; counseling to help address
end-of-life concerns; and healthcare system changes would all enhance
communication.
"The structure of the system needs to be changed" and clinics need to find
ways to give the physician more time for patients, Curtis told Reuters Health in
an interview. Now physicians typically have 11 to 13 minutes to spend with each
patient, an unrealistic timeframe for discussing such complex and emotional
issues, he commented.
Another barrier was the perception that the patient was not ready to talk
about end-of-life issues yet, which may well be an incorrect assumption, Curtis
said. Medical schools need to offer more death education training, he continued,
but it is not just a matter of discussing end-of-life issues with patients. "We
need better research on how to do this," he said. "If (the physician) just
barges in on the patient, there might be harm involved."
It has become increasingly clear that advanced care planning--including
discussions between the physician and patient as to what quality means to the
patient; what preferences they have for care at the end of their lives; and
under what circumstances they would want life-sustaining support--can contribute
greatly to end-of-life quality, Curtis explained.
He concedes that it is very common for patients and physicians to feel
uncomfortable talking about end-of-life issues, and that discomfort can be used
as an excuse to avoid discussions altogether. Talking about death is difficult,
he said, and the onus is really on the physician to bring up the subject in such
a way that a productive discussion can take place.
"It will never be easy," he said. "Our goal is to help them to do it
better."
