Physician experience impacts end of life care

annelisa end of life scitech
Photo by Annelisa Leinbach.

Physicians’ level of training may influence how willing they are to comply with patients’ end of life requests, according to the findings of a new Yale study.

After compiling the results of several hundred surveys mailed to Connecticut-area physicians, researchers found that attending physicians were more likely than residents to honor patients’ requests in certain cases. The most commonly cited reason for attendings’ willingness to comply was their experience with similar situations in their own careers. For co-author John Thomas MED ’12, the study suggests possible benefits to implementing specific end-of-life training for medical students.

“We were encouraged by the results of the study,” Thomas said. “There are changes that seem to be occurring during residency, probably because of clinical experiences that physicians are having in their training.”

The survey asked physicians about their willingness to honor a patient’s request in five scenarios: when the patient requests withholding of life-saving treatment; when the patient requests extubation, or the removal of a treatment that is keeping him or her alive; when the patient requests dangerously high levels of narcotics; the prescription of enough sleeping pills for a patient to kill him or herself; and lethal injection. The first three scenarios are legal in Connecticut, while the last two are not.

While the majority of both attending physicians and residents reported that they would comply in the first three scenarios, a larger percentage of attendings was willing to comply than residents, Thomas said. This disparity raises concerns about the readiness of residents to treat patients nearing the end of their lives, he added.

“Those scenarios, such as willingness to extubate, are ones that have achieved great consensus among physicians as being acceptable in end of life care,” Thomas said. “It’s not considered controversial. So for that specific scenario, I would have to really question a physician who is unwilling to comply with that.”

For the remaining two scenarios, attendings and residents did not differ significantly. Thomas said this finding may reflect the illegal nature of the requests.

Matthew Ellman, director of medical student palliative and end-of-life care education at the Yale School of Medicine, was not surprised that physicians’ own clinical experiences were important in shaping their comfort levels. Ellman, who was not involved in the study, added that his program at the medical school works to teach students self-reflection so that they can identify and manage their emotional reactions to palliative care.

“I think as physicians have more experience caring for patients with terminal illnesses, that experience may provide them with the recognition that what’s most important is trying to meet that patient on their own terms, as best you can,” Ellman said.

The willingness of attendings to perform certain treatments may reflect evolving norms of what is acceptable in the medical world, said Terri Fried, study author and professor of geriatrics at the Yale School of Medicine. She compared the findings of this study with a similar study she had conducted 20 years ago in Rhode Island, and found that physicians’ willingness to honor certain requests had changed.

In particular, the previous generation of attendings displayed decreased willingness to withhold treatment and increased willingness to prescribe lethal doses of sleeping pills.

“This supports the idea that attending physicians have grown more comfortable with withdrawing treatment and treating pain at the end of life, but less comfortable with physician-assisted suicide, at least in the northeast, where it is not legal,” Fried said in an email.

Yale’s Palliative and End-of-Life Care Education program was founded in 2004.

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