Physician and Patient Characteristics Associated With More Intensive End-of-Life Care

Paul R. Duberstein, Richard L Kravitz, Joshua J Fenton, Guibo Xing, Daniel J Tancredi, Michael Hoerger, Supriya G. Mohile, Sally A. Norton, Holly G. Prigerson, Ronald M. Epstein

Research output: Contribution to journalArticle

Abstract

Context: Although patient and physician characteristics are thought to be predictive of discretionary interventions at the end of life (EoL), few studies have data on both parties. Objective: To test the hypothesis that patient preferences and physician attitudes are both independently associated with discretionary interventions at the EoL. Methods: We report secondary analyses of data collected prospectively from physicians (n = 38)and patients with advanced cancer (n = 265)in the Values and Options in Cancer Care study. Predictor variables were patient attitudes toward EoL care and physician-reported comfort with medical paternalism, assessed indirectly using a modified version of the Control Preference Scale. We explored whether the magnitude of the physician variable was influenced by the inclusion of particular patient treatment-preference variables (i.e., effect modification). Outcomes were a chemotherapy use score (≤14 days before death [scored 2], 15–31 days before death [scored 1], and >31 days [scored 0])and an emergency department visit/inpatient admission score (two or more admissions in the last 31 days [scored 2], one admission [1], and 0 admissions [0])in the last month of life. Results: Chemotherapy scores were nearly 0.25 points higher if patients expressed a preference for experimental treatments with unknown benefit at study entry (0.238 points, 95% CI = 0.047–0.429)or reported an unfavorable attitude toward palliative care (0.247 points, 95% CI = 0.047–0.450). A two–standard deviation difference in physician comfort with medical paternalism corresponded to standardized effects of 0.35 (95% CI = 0.03–0.66)for chemotherapy and 0.33 (95% CI = 0.04–0.61)for emergency department visits/inpatient admissions. There was no evidence of effect modification. Conclusion: Patient treatment preferences and physician attitudes are independently associated with higher levels of treatment intensity before death. Greater research, clinical, and policy attention to patient treatment preferences and physician comfort with medical paternalism might lead to improvements in care of patients with advanced disease.

Original languageEnglish (US)
JournalJournal of Pain and Symptom Management
DOIs
StatePublished - Jan 1 2019

Fingerprint

Terminal Care
Physicians
Patient Preference
Paternalism
Drug Therapy
Hospital Emergency Service
Inpatients
Therapeutics
Palliative Care
Neoplasms
Patient Care
Research

Keywords

  • Advanced cancer
  • biomedical ethics
  • chemotherapy
  • emergency department
  • end of life
  • health care utilization
  • hospitalization
  • palliative care
  • patient treatment preferences
  • physician attitudes

ASJC Scopus subject areas

  • Nursing(all)
  • Clinical Neurology
  • Anesthesiology and Pain Medicine

Cite this

Physician and Patient Characteristics Associated With More Intensive End-of-Life Care. / Duberstein, Paul R.; Kravitz, Richard L; Fenton, Joshua J; Xing, Guibo; Tancredi, Daniel J; Hoerger, Michael; Mohile, Supriya G.; Norton, Sally A.; Prigerson, Holly G.; Epstein, Ronald M.

In: Journal of Pain and Symptom Management, 01.01.2019.

Research output: Contribution to journalArticle

Duberstein, Paul R. ; Kravitz, Richard L ; Fenton, Joshua J ; Xing, Guibo ; Tancredi, Daniel J ; Hoerger, Michael ; Mohile, Supriya G. ; Norton, Sally A. ; Prigerson, Holly G. ; Epstein, Ronald M. / Physician and Patient Characteristics Associated With More Intensive End-of-Life Care. In: Journal of Pain and Symptom Management. 2019.
@article{b5d3bc8e004e4ec08fc6f0c0dc0889f2,
title = "Physician and Patient Characteristics Associated With More Intensive End-of-Life Care",
abstract = "Context: Although patient and physician characteristics are thought to be predictive of discretionary interventions at the end of life (EoL), few studies have data on both parties. Objective: To test the hypothesis that patient preferences and physician attitudes are both independently associated with discretionary interventions at the EoL. Methods: We report secondary analyses of data collected prospectively from physicians (n = 38)and patients with advanced cancer (n = 265)in the Values and Options in Cancer Care study. Predictor variables were patient attitudes toward EoL care and physician-reported comfort with medical paternalism, assessed indirectly using a modified version of the Control Preference Scale. We explored whether the magnitude of the physician variable was influenced by the inclusion of particular patient treatment-preference variables (i.e., effect modification). Outcomes were a chemotherapy use score (≤14 days before death [scored 2], 15–31 days before death [scored 1], and >31 days [scored 0])and an emergency department visit/inpatient admission score (two or more admissions in the last 31 days [scored 2], one admission [1], and 0 admissions [0])in the last month of life. Results: Chemotherapy scores were nearly 0.25 points higher if patients expressed a preference for experimental treatments with unknown benefit at study entry (0.238 points, 95{\%} CI = 0.047–0.429)or reported an unfavorable attitude toward palliative care (0.247 points, 95{\%} CI = 0.047–0.450). A two–standard deviation difference in physician comfort with medical paternalism corresponded to standardized effects of 0.35 (95{\%} CI = 0.03–0.66)for chemotherapy and 0.33 (95{\%} CI = 0.04–0.61)for emergency department visits/inpatient admissions. There was no evidence of effect modification. Conclusion: Patient treatment preferences and physician attitudes are independently associated with higher levels of treatment intensity before death. Greater research, clinical, and policy attention to patient treatment preferences and physician comfort with medical paternalism might lead to improvements in care of patients with advanced disease.",
keywords = "Advanced cancer, biomedical ethics, chemotherapy, emergency department, end of life, health care utilization, hospitalization, palliative care, patient treatment preferences, physician attitudes",
author = "Duberstein, {Paul R.} and Kravitz, {Richard L} and Fenton, {Joshua J} and Guibo Xing and Tancredi, {Daniel J} and Michael Hoerger and Mohile, {Supriya G.} and Norton, {Sally A.} and Prigerson, {Holly G.} and Epstein, {Ronald M.}",
year = "2019",
month = "1",
day = "1",
doi = "10.1016/j.jpainsymman.2019.04.014",
language = "English (US)",
journal = "Journal of Pain and Symptom Management",
issn = "0885-3924",
publisher = "Elsevier Inc.",

}

TY - JOUR

T1 - Physician and Patient Characteristics Associated With More Intensive End-of-Life Care

AU - Duberstein, Paul R.

AU - Kravitz, Richard L

AU - Fenton, Joshua J

AU - Xing, Guibo

AU - Tancredi, Daniel J

AU - Hoerger, Michael

AU - Mohile, Supriya G.

AU - Norton, Sally A.

AU - Prigerson, Holly G.

AU - Epstein, Ronald M.

PY - 2019/1/1

Y1 - 2019/1/1

N2 - Context: Although patient and physician characteristics are thought to be predictive of discretionary interventions at the end of life (EoL), few studies have data on both parties. Objective: To test the hypothesis that patient preferences and physician attitudes are both independently associated with discretionary interventions at the EoL. Methods: We report secondary analyses of data collected prospectively from physicians (n = 38)and patients with advanced cancer (n = 265)in the Values and Options in Cancer Care study. Predictor variables were patient attitudes toward EoL care and physician-reported comfort with medical paternalism, assessed indirectly using a modified version of the Control Preference Scale. We explored whether the magnitude of the physician variable was influenced by the inclusion of particular patient treatment-preference variables (i.e., effect modification). Outcomes were a chemotherapy use score (≤14 days before death [scored 2], 15–31 days before death [scored 1], and >31 days [scored 0])and an emergency department visit/inpatient admission score (two or more admissions in the last 31 days [scored 2], one admission [1], and 0 admissions [0])in the last month of life. Results: Chemotherapy scores were nearly 0.25 points higher if patients expressed a preference for experimental treatments with unknown benefit at study entry (0.238 points, 95% CI = 0.047–0.429)or reported an unfavorable attitude toward palliative care (0.247 points, 95% CI = 0.047–0.450). A two–standard deviation difference in physician comfort with medical paternalism corresponded to standardized effects of 0.35 (95% CI = 0.03–0.66)for chemotherapy and 0.33 (95% CI = 0.04–0.61)for emergency department visits/inpatient admissions. There was no evidence of effect modification. Conclusion: Patient treatment preferences and physician attitudes are independently associated with higher levels of treatment intensity before death. Greater research, clinical, and policy attention to patient treatment preferences and physician comfort with medical paternalism might lead to improvements in care of patients with advanced disease.

AB - Context: Although patient and physician characteristics are thought to be predictive of discretionary interventions at the end of life (EoL), few studies have data on both parties. Objective: To test the hypothesis that patient preferences and physician attitudes are both independently associated with discretionary interventions at the EoL. Methods: We report secondary analyses of data collected prospectively from physicians (n = 38)and patients with advanced cancer (n = 265)in the Values and Options in Cancer Care study. Predictor variables were patient attitudes toward EoL care and physician-reported comfort with medical paternalism, assessed indirectly using a modified version of the Control Preference Scale. We explored whether the magnitude of the physician variable was influenced by the inclusion of particular patient treatment-preference variables (i.e., effect modification). Outcomes were a chemotherapy use score (≤14 days before death [scored 2], 15–31 days before death [scored 1], and >31 days [scored 0])and an emergency department visit/inpatient admission score (two or more admissions in the last 31 days [scored 2], one admission [1], and 0 admissions [0])in the last month of life. Results: Chemotherapy scores were nearly 0.25 points higher if patients expressed a preference for experimental treatments with unknown benefit at study entry (0.238 points, 95% CI = 0.047–0.429)or reported an unfavorable attitude toward palliative care (0.247 points, 95% CI = 0.047–0.450). A two–standard deviation difference in physician comfort with medical paternalism corresponded to standardized effects of 0.35 (95% CI = 0.03–0.66)for chemotherapy and 0.33 (95% CI = 0.04–0.61)for emergency department visits/inpatient admissions. There was no evidence of effect modification. Conclusion: Patient treatment preferences and physician attitudes are independently associated with higher levels of treatment intensity before death. Greater research, clinical, and policy attention to patient treatment preferences and physician comfort with medical paternalism might lead to improvements in care of patients with advanced disease.

KW - Advanced cancer

KW - biomedical ethics

KW - chemotherapy

KW - emergency department

KW - end of life

KW - health care utilization

KW - hospitalization

KW - palliative care

KW - patient treatment preferences

KW - physician attitudes

UR - http://www.scopus.com/inward/record.url?scp=85065537608&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85065537608&partnerID=8YFLogxK

U2 - 10.1016/j.jpainsymman.2019.04.014

DO - 10.1016/j.jpainsymman.2019.04.014

M3 - Article

C2 - 31004774

AN - SCOPUS:85065537608

JO - Journal of Pain and Symptom Management

JF - Journal of Pain and Symptom Management

SN - 0885-3924

ER -