Likely not — and it still looks like where we live, rather than what we want, most strongly shapes how we die.
By Elena Gooray
(Photo: Christopher Furlong/Getty Images)
We’ve heard the same verdict on death in the United States for a while: Americans are not expiring well. We’ve been told repeatedly that most doctors, with their intimate knowledge of the medical system, would choose to die with less aggressive end-of-life care, which can often worsen patients’ quality of life in their last days. But recent research has found that, whatever their preferences, doctors end up meeting their ends pretty much like the rest of us.
A study published last week found that doctors spend as much time in the hospital toward the end of their lives as everyone else. The researchers, who looked at thousands of Medicare patients, and demographically matched physicians over the age of 65, found that doctors used hospice care at slightly higher rates, and spent less than half a day longer in the intensive care unit during the last six months of life.
These differences are moderate, says Stacy Fischer, senior researcher on the study and an associate professor at the University of Colorado School of Medicine. But her team’s results suggest that, insofar as doctors do differ in their end-of-life experiences, it’s by being a bit more likely across the board to use available services, whether that’s hospice care focused on comfort and support, or intensive unit care focused on using all possible medical interventions to combat someone’s underlying illness.
One motivation for the study, the authors write, is that Americans across the board are increasingly concerned about end-of-life health care use. For the past few years, we’ve channeled that concern into a nationalconversation on death led largely by medical professionals. People may expect doctors to be guideposts on matters of death because they have constant contact with it, Fischer says.
Americans across the board are increasingly concerned about end-of-life health care use.
Physicians have, in fact, reported strong support for non-aggressive, comfort-based treatment when confronted with debilitating illness, and they have been more likely than non-physicians to set advance directives spelling out their wishes. These habits suggest doctors are less likely to get pulled into intensive hospital care in their last months. But Fischer’s team’s results cast doubt on that popular narrative.
Two reports published this January in the Journal of the American Medical Association did support the physicians-die-more-naturally story, finding that doctors and other health professionals die slightly less often in a hospital. These differences were also moderate and might stem from not fully controlling for people’s geographic region, which, Fischer says, may most strongly predict end-of-life care by having the biggest impact on available resources and treatment culture.
“As a palliative care physician, [I find it] disturbing to think that individual preferences might have less to do with what your last days look like than the medical culture of your environment,” Fischer says.
Someone living in Orlando, Florida, for example, is more than twice as likely to receive aggressive end-of-life treatment than someone in Grand Junction, Colorado, according to the Dartmouth Atlas of Health Care.
But death practices are shifting nationwide. Medicare hospice use almost doubled between 2002 and 2012, and hospice spending outside the last year of life increased from $0.9 billion to $3.4 billion in that same time, according to a report submitted to the Medicare Payment Advisory Commission. As a result, Fischer says, doctors’ end-of-life choices may look different in the coming decades.
“The physicians [in this study] trained before hospice was really around in the United States, and certainly before the palliative care movement started in earnest,” she says. “This will be a really interesting study to repeat down the road, to see whether where you live might still be more important than who you are.”
Futurestudies will also represent a less white and male physician population, as medicine achieves greater racial and gender diversity. For now, if we’re expecting doctors to model how to die, we may need to separate what they say from what they’re actually able to do.