J Pain Symptom Manage 2018 03 3;55(3):906-912. Epub 2017 Nov 3.
Duke Divinity School, Durham, North Carolina, USA; Trent Center for Bioethics, Humanities, and History of Medicine, Duke University, Durham, North Carolina, USA; Duke Palliative Care, Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina, USA.
Context: Little is known about patient and physician factors that affect decisions to pursue more or less aggressive treatment courses for patients with advanced illness.
Objectives: This study sought to determine how patient age, patient disposition, and physician religiousness affect physician recommendations in the context of advanced illness.
Methods: A survey was mailed to a stratified random sample of U.S. physicians, which included three vignettes depicting advanced illness scenarios: 1) cancer, 2) heart failure, and 3) dementia with acute infection. One vignette included experimental variables to test how patient age and patient disposition affected physician recommendations. After each vignette, physicians indicated their likelihood to recommend disease-directed medical care vs. hospice care.
Results: Among eligible physicians (n = 1878), 62% (n = 1156) responded. Patient age and stated patient disposition toward treatment did not significantly affect physician recommendations. Compared with religious physicians, physicians who reported that religious importance was "not applicable" were less likely to recommend chemotherapy (adjusted odds ratio [OR] 0.39, 95% CI 0.23-0.66) and more likely to recommend hospice (OR 1.90, 95% CI 1.15-3.16) for a patient with cancer. Compared with physicians who ever attended religious services, physicians who never attended were less likely to recommend left ventricular assist device placement for a patient with congestive heart failure (OR 0.57, 95% CI 0.35-0.92). In addition, Asian ethnicity was independently associated with recommending chemotherapy (OR 1.72, 95% CI 1.13-2.61) and being less likely to recommend hospice (OR 0.59, 95% CI 0.40-0.91) for the patient with cancer; and it was associated with recommending antibiotics for the patient with dementia and pneumonia (OR 1.64, 95% CI 1.08-2.50).
Conclusion: This study provides preliminary evidence that patient disposition toward more and less aggressive treatment in advanced illness does not substantially factor into physician recommendations. Non-religious physicians appear less likely to recommend disease-directed medical treatment in the setting of advanced illness, although this finding was not uniform and deserves further research.