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Communicating End-of-Life Decisions
- Russell S. Phillips, MD;
- Jan C. Hofmann, MD; and
- Neil Wenger, MD
- Beth Israel Deaconess Medical Center; Boston, MA 02215 University of California, Los Angeles, School of Medicine; Los Angeles, CA 90024
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IN RESPONSE:
We appreciate Dr. Reilly's and Dr. Halm's thoughtful comments about our article on patients' preferences for communication near the end of life. We are troubled by the implications of our finding that a majority of patients who have not discussed preferences for cardiopulmonary resuscitation do not want to do so. We believe that this finding should provoke attempts to improve patient–physician communication at the end of life to overcome this barrier to effective communication. Whether we can require patients to discuss difficult end-of-life issues raises serious ethical concerns, as Dr. Halm suggests, but we believe that, in most circumstances, motivated physicians can find ways to approach these important issues with patients without compromising patient autonomy.
Dr. Reilly correctly points out that 44% (707 of 1589) of our patients, overall, had not discussed and did not want to discuss preferences for cardiopulmonary resuscitation. As we made clear several times in our text, abstract, and figures, 58% (707 of 1223) of those patients who had not already discussed their preferences were not interested in doing so. We believe we have summarized our data correctly.
Direct comparisons between our results and those published by Reilly and colleagues are difficult because our methods and patient populations differed. For example, our analytic sample comprised SUPPORT patients who were interviewed before the seventh day after study enrollment, whereas Reilly and colleagues included patients for whom a physician had completed an advance directive document or who had been in the hospital for at least 7 days. The observation that fewer of the patients we studied did not want cardiopulmonary resuscitation (30% compared with 41%) and fewer patients had already discussed preferences for cardiopulmonary resuscitation (23% compared with 47%) is likely to be due, in part, to differences in patient selection. Had we selected patients on the basis of their having an advance directive document completed by the physician, we suspect that a much higher percentage of patients in our study would have discussed cardiopulmonary resuscitation.
We agree with Dr. Reilly that what patients say about their preferences for communication with their physicians about end-of-life care is influenced by who asks the question and how it is asked. Our observation that many patients are not eager to discuss these issues represents a barrier to communication that, if acknowledged, might be overcome by compassionate, sensitive physicians who are comfortable discussing end-of-life issues with their patients.
Russell S. Phillips, MD
Jan C. Hofmann, MD
Beth Israel Deaconess Medical Center; Boston, MA 02215
Neil Wenger, MD
University of California, Los Angeles, School of Medicine; Los Angeles, CA 90024
- Copyright ©2004 by the American College of Physicians
