Abstract
The idea that physicians as patients choose less-aggressive care at the end of life for themselves is an often-cited rationale to advocate for less technology-laden end-of-life care. To assess end-of-life care received by physicians compared with nonphysicians in a system with universal health care. In this population-level decedent cohort study of data from April 1, 2004, through March 31, 2015 (fiscal years 2004-2014), in Ontario, Canada, 2507 physicians were matched approximately 1:3 to 7513 nonphysicians (ie, individuals who never were registered as a physician with the College of Physicians and Surgeons of Ontario) according to age, sex, income quintile, and location of residence. The primary outcome was location of death. Other outcomes included measures of health care use in the last 6 months of life. Differences were assessed using Poisson regression with robust error variances, adjusting for the Charlson Comorbidity Index. In total, 2516 physicians and 954 836 nonphysicians died between April 1, 2004, and March 31, 2015, in Ontario; 2247 physicians (89.3%) and 474 182 nonphysicians (49.7%) were men. The median (interquartile range) age at death was 82 (74-87) years for the physicians and 80 (68-87) years for the nonphysicians. After matching, data for 2507 physicians and 7513 nonphysicians were analyzed. For physicians, the risk of death at home was no different from that for nonphysicians (42.8% vs 39.0%; adjusted relative risk [aRR], 1.04; 95% CI, 0.99-1.09), but the risk of death in an intensive care unit was increased (11.9% vs 10.0%; aRR, 1.22; 95% CI, 1.08-1.39). In the prior 6 months, physicians had a decreased risk of an emergency department visit (73.0% vs 78.4%; aRR, 0.96; 95% CI, 0.94-0.98) but increased risks of an intensive care unit admission (20.8% vs 19.1%; aRR, 1.14; 95% CI, 1.05-1.24) and of receipt of palliative care services (52.9% vs 47.4%; aRR, 1.18; 95% CI, 1.13-1.23). Among a subgroup of 457 physicians and 1347 nonphysicians with cancer, the risk of death at home or intensive care unit was increased (37.6% vs 28.6%; aRR, 1.30; 95% CI, 1.13-1.50), as was the risk of receiving chemotherapy in the last 6 months of life. There was no difference overall for physicians compared with nonphysicians in terms of the likelihood of dying at home; physicians were more likely to die in an intensive care unit and to receive chemotherapy, but also to receive palliative care services. These findings suggest that physicians do not consistently opt for less-aggressive care but instead receive end-of-life care that includes both intensive and palliative care. These findings inform a more nuanced perspective of what physicians may perceive to be optimal care at the end of life.
Highlights
Matching end-of-life care to patients’ stated preferences by reducing technology-laden, hospitalbased treatments is a common focus of quality improvement in many developed countries.[1,2,3,4,5] Studies[6,7,8] have, focused on identifying factors that are associated with more-intensive treatment before death, such as age, socioeconomic status, race, geoethnic origin, and religion.High treatment intensity at the end of life is well documented in North America,[3,9] even among patients who may have previously stated preferences for less-aggressive care
In the prior 6 months, physicians had a decreased risk of an emergency department visit (73.0% vs 78.4%; aRR, 0.96; 95% CI, 0.94-0.98) but increased risks of an intensive care unit admission (20.8% vs 19.1%; aRR, 1.14; 95% CI, 1.05-1.24) and of receipt of palliative care services (52.9% vs 47.4%; aRR, 1.18; 95% CI, 1.13-1.23)
There was no difference overall for physicians compared with nonphysicians in terms of the likelihood of dying at home; physicians were more likely to die in an intensive care unit and to receive chemotherapy, and to receive palliative care services
Summary
Matching end-of-life care to patients’ stated preferences by reducing technology-laden, hospitalbased treatments is a common focus of quality improvement in many developed countries.[1,2,3,4,5] Studies[6,7,8] have, focused on identifying factors that are associated with more-intensive treatment before death, such as age, socioeconomic status, race, geoethnic origin, and religion.High treatment intensity at the end of life is well documented in North America,[3,9] even among patients who may have previously stated preferences for less-aggressive care. Much of the focus of end-of-life care has been on location of death, because it has been observed that many individuals in developed countries die in acute care hospitals and nursing homes, despite expressed preferences for dying at home.[3,4,5] death at home may reflect access to substantial support, such as home palliative care and hospice services.[10,11] Two studies from the United States,[12,13] focused primarily on location of death, found very slight decreases in the likelihood of a hospital-based death for physicians. The primary outcome was location of death, with the hypothesis that physicians are more likely to receive less-intensive end-of-life care
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