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Community Physicians Who Provide Terminal Care
Laura C. Hanson, MD, MPH;
Jo Anne Earp, PhD;
Joanne Garrett, PhD;
Manoj Menon, MPH;
Marion Danis, MD
Arch Intern Med. 1999;159:1133-1138.
Background Most dying patients are treated by physicians in community practice, yet studies of terminal care rarely include these physicians.
Objective To examine the frequency of life-sustaining treatment use and describe what factors influence physicians' treatment decisions in community-based practices.
Methods Family members and treating physicians for decedents 65 years and older who died of cancer, congestive heart failure, chronic lung disease, cirrhosis, or stroke completed interviews about end-of-life care in community settings.
Results Eighty percent of eligible family and 68.8% of eligible physicians participated (N=165). Most physicians were trained in primary care and 85.4% were primary care physicians for the decedents. Physicians typically knew the decedent a year or more (68.9%), and 93.3% treated them for at least 1 month before death. In their last month of life, 2.4% of decedents received cardiopulmonary resuscitation, 5.5% received ventilatory support, and 34.1% received hospice care. Family recalled a discussion of treatment options in 78.2% of deaths. Most discussions (72.1%) took place a month or more before death. Place of death, cancer, and having a living will were independent predictors of less aggressive treatment before death. Physicians believed that advanced planning and good relationships were the major determinants of good decision making.
Conclusions Community physicians use few life-sustaining treatments for dying patients. Treatment decisions are made in the context of long-term primary care relationships, and living wills influence treatment decisions. The choice to remain in community settings with a familiar physician may influence the dying experience.
From the Division of General Internal Medicine (Drs Hanson and Garrett) and School of Public Health (Dr Earp and Ms Menon), University of North Carolina at Chapel Hill; and Clinical Bioethics Department (Dr Danis), National Institutes of Health, Bethesda, Md.
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