Being Saved When You Don’t Want to Be : Many doctors ignore the wishes of the dying, study finds
Overwhelmingly, Americans say that if they had a terminal illness they would refuse any extraordinary medical intervention that meant they would spend their final months in pain in a dying body. Yet despite some patients’ express desire to be allowed to die rather than spend their last days on a respirator, many doctors press ahead with costly and aggressive treatments, a study published in the Journal of the American Medical Assn. indicates. In the process, it seems, physicians are just staving off death rather than providing care and pain management at life’s end.
An earlier study found that doctors often were unaware that patients had signed living wills dictating that life not be prolonged beyond reason. In those cases, obviously, doctors couldn’t be expected to know what their patients wanted. But why does it appear, as the JAMA study indicates, that even when doctors do know the patients’ wishes some fail to take those wishes into account?
The driving factor, according to Alexander Capron, co-director of USC’s Pacific Center for Health Policy and Ethics, appears to be a lack of clear communication between physician and patient. And, he says, the problem is compounded by an American medical culture in which doctors are trained to do everything possible to save a life.
Indeed, the new study, which tracked more than 9,000 seriously ill patients at five U.S. hospitals, including UCLA Medical Center, revealed that heroic medicine is being applied in situations when it clearly is not wanted or warranted. It showed, for example, that half of all dying patients spend at least eight days in intensive care in a coma or on life support. Especially distressing were findings that half the patients experienced “moderate or severe” pain during their last three days.
The report also demonstrated the depth of a communication problem that has occurred despite the proliferation of power-of-attorney documents and living wills restricting medical care and despite laws like the 1991 Federal Patient Self-Determination Act, which requires health care providers to give patients information on life-sustaining treatments. In half of the cases studied, physicians were not aware of or failed to take into account a patient’s order not to resuscitate. This happened sometimes even when nurses were assigned to facilitate patient-doctor dialogue.
It’s a complicated issue that more and more Americans will have to face. As Dr. Sherwin B. Nuland writes in his book, “How We Die,” “ .J.J. it is always so hard to let go. . . . The difficulty of deciding is compounded by the difficulty of living with what has been decided.”
Medical schools, as well as local, state and national medical societies, should educate doctors in the need to discuss treatments before crises lead to hospitalization. Of course clear communication of this kind requires time. Doctors can’t take the lead in meeting the wishes of dying patients if they feel constant pressure to practice a fast, revolving-door style of medicine. As patients demand that doctors listen carefully to their precious last requests, Americans must ensure that there is a medical system in place that gives physicians the time to listen.
