Homing in on the social : systems-level influences on overly aggressive treatments at the end of life

Article

DZENG, Elizabeth | DOHAN, Daniel | CURTIS, J. Randall | SMITH, Thomas J. | COLAIANNI, Alessandra | RITCHIE, Christine

CONTEXT: The American medical system is programmed to a default setting of aggressive care for the terminally ill. Institutional norms of decision-making have been shown to promote high intensity care, regardless of consistency with patient preferences. There are myriad factors at a system, clinician, surrogate, and patient level that drive the culture of overly aggressive treatments in American hospitals. OBJECTIVE: To understand physician perspective of the ways systems-level factors influence patient, physician, and surrogate perceptions and consequent behavior. METHODS: Semi-structured in-depth qualitative interviews with 42 internal medicine physicians across three American academic medical centers. This qualitative study was exploratory in nature, intended to enhance conceptual understanding of underlying phenomena that drive physician attitudes and behavior. RESULTS: The interviews revealed many factors that contributed to overly aggressive treatments at the end of life. Systemic factors, which describe underlying cultures (including institutional, professional, or community-based cultures), typical practices of care, or systemic defaults which drive patterns of care, manifested its influence both directly as well as through its impact on patient, surrogate, and physician behaviors and attitudes. CONCLUSION: Institutional cultures, social norms, and systemic defaults influence both normative beliefs regarding standards of care and treatments plans that may not benefit seriously ill patients.

http://dx.doi.org/10.1016/j.jpainsymman.2017.08.019

Voir la revue «JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, 55»

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