Abstract
ObjectiveHigh-intensity interventions are provided to seriously-ill patients in the last months of life by medical sub-specialists. This study was undertaken to determine if doctors' age, ethnicity, medical sub-specialty and personal resuscitation and organ donation preferences influenced their attitudes toward Advance Directives (AD) and to compare a cohort of 2013 doctors to a 1989 (one year before the Patient Self Determination Act in 1990) cohort to determine any changes in attitudes towards AD in the past 23 years.DesignDoctors in two academic medical centers participated in an AD simulation and attitudes survey in 2013 and their responses were compared to a cohort of doctors in 1989.OutcomesResuscitation and organ donation preferences (2013 cohort) and attitudes toward AD (1989 and 2013 cohorts).ResultsIn 2013, 1081 (94.2%) doctors of the 1147 approached participated. Compared to 1989, 2013 cohort did not feel that widespread acceptance of AD would result in less aggressive treatment even of patients who do not have an AD (p<0.001, AUC = 0.77); had greater confidence in their treatment decisions if guided by an AD (p<.001, AUC = 0.58) and were less worried about legal consequences of limiting treatment when following an AD (p<.001, AUC = 0.57). The gender (p = 0.00172), ethnicity (χ2 14.68, DF = 3,p = .0021) and sub-specialty (χ2 28.92, p = .004, DF = 12) influenced their attitudes towards AD. 88.3% doctors chose do-not-resuscitate status and wanted to become organ donors. Those less supportive of AD were more likely to opt for “full code” even if terminally ill and were less supportive of organ donation.ConclusionsDoctors' attitudes towards AD has not changed significantly in the past 23 years. Doctors' gender, ethnicity and sub-specialty influence their attitudes towards AD. Our study raises questions about why doctors continue to provide high-intensity care for terminally ill patients but personally forego such care for themselves at the end of life.
Highlights
The silver tsunami of older adults is perhaps the largest public health challenge facing society today
Compared to 1989, 2013 cohort did not feel that widespread acceptance of Advance Directives (AD) would result in less aggressive treatment even of patients who do not have an AD (p, 0.001, AUC = 0.77); had greater confidence in their treatment decisions if guided by an AD (p,.001, AUC = 0.58) and were less worried about legal consequences of limiting treatment when following an AD (p,.001, AUC = 0.57)
Doctors’ gender, ethnicity and sub-specialty influence their attitudes towards AD
Summary
The silver tsunami of older adults is perhaps the largest public health challenge facing society today. Advances in modern biomedicine have resulted in unprecedented increases in longevity and to some extent in compression of morbidity. They have failed to significantly improve health status in the last two years just prior to death resulting in millions of Americans living with the tremendous burden of major chronic disease(s) at the end of life [1]. In 2005, 133 million Americans (almost 50% of the adult population) had at least one chronic illness [2]. Older Americans account for an estimated 32% of the total Medicare spending on costs related to repeated hospitalizations in the last two years of their life and higher spending has not been associated with better health outcomes [4]. There was a twelve percentage point increase in Medicare beneficiaries who saw more than ten different physicians in the last six months of life, especially medical subspecialists, and spent more days in intensive care units in 2010 compared to 2003-07
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