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 Unrealistic Expectations May Lead To Poor Choices At End Of Life: Study

Advance care planning and communication with family members about an elderly loved one’s conditions, prognosis, and expectations are more important than ever, especially in light of a new study, which found that many elderly patients hospitalized at the end of life received invasive and potentially harmful medical treatments.
“It is not unusual for family members to refuse to accept the fact that their loved one is naturally dying of old age and its associated complications, so they pressure doctors to attempt heroic interventions,” said Magnolia Cardona-Morrell, MPH, PhD, who led the study out of the University of New South Wales’ Simpson Centre for Health Services Research.
This is partly driven, she suggested, by advances in technology and medicine that have led people to have unrealistic expectations. Additionally, she said, “Doctors also struggle with the uncertainty of the duration of the dying trajectory and are torn by the ethical dilemma of delivering what they were trained to do, save lives, versus respecting the patient’s right to die with dignity.”
Cardona-Morrell and her colleagues analyzed 38 studies over two decades, based on data from 1.2 million patients, bereaved relatives, and clinicians in 10 countries. They found the practice of doctors initiating excessive medical or surgical treatment on elderly patients in the last six months of their life continues worldwide. The study revealed that 33 percent of elderly patients with advanced, irreversible chronic conditions were given non-beneficial interventions such as admission to intensive care or chemotherapy in the last two weeks of life, while others who had not-for-resuscitation orders were still given cardio pulmonary resuscitation (CPR).
The researchers also found evidence of invasive procedures, unnecessary imaging and blood tests, intensive cardiac monitoring, and concurrent treatment of other multiple acute conditions with complex medications that made little or no difference to the outcome, but which could prevent a comfortable death for the individuals.
“Our findings indicate the persistent ambiguity or conflict about what treatment is deemed beneficial and a culture of ‘doing everything possible,’” Cardona-Morrell said. “The lack of agreed definitions in the medical community of what constitutes ‘treatment futility’ also makes a global dialogue challenge.
 “However, using data from these studies, we have defined as nonbeneficial those procedures or medical treatments administered to elderly people in terminal stages of disease which prolong suffering rather than survival, that can potentially cause harm, are sometimes given against patients’ wishes, and are unlikely to improve the person’s health or quality of remaining life.”
Cardona-Morrell’s study was published in the June issue of the International Journal for Quality in Health Care (
It isn’t surprising that patients and families think that extreme measures such as CPR will have positive results. They see resuscitations in movies and television, the vast majority of which are highly successful. In fact, the literature suggests that just 22 percent of elders may survive initial resuscitation. Only 10 to 17 percent may survive to discharge, most with impaired function. Interestingly, chronic illness more than age determines prognosis.
Several studies have found that elderly patients actually welcome conversations with their practitioners about end-of-life issues such as whether or not they want CPR. For instance, one study of elderly veterans showed that most wanted discussions with their physicians about CPR and that most had overestimated their survival chances after this intervention.
The key to enabling realistic expectations is education, the researchers said. One study showed that of 371 patients, 41 percent wanted CPR prior to learning about the probability of survival. Afterwards, only 22 percent said they would want this intervention.
Other studies have documented the value of end-of-life conversations to encourage realistic expectations and help patients identify what a “good death” means to them. For example, one recent report found that structured communication tools—instead of ad hoc end-of-life decision-making approaches—may increase the completion of advance directives and improve advance care planning.
Structured communication may be helpful, especially since end-of-life conversations aren’t just difficult for patients and families. They also can be difficult for physicians. In fact, physicians often report finding these talks stressful and emotionally draining.
Some organization use formal guidelines that encourage and equip practitioners to talk with patients about issues such as the risks and benefits associated with CPR and other treatments. These can enable patients and families to express fears, concerns, and wishes and promote conversations about expectations and goals of care. These guidelines can make an uncomfortable talk empowering and productive.
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