Barriers to Good End-of-Life Care: A Physician Survey

Reiko Kayashima MPH and Kathryn L. Braun DrPH

Abstract Several physician-related harriers have been identified as well. Surveyed about barndrs to good end-of-life care were 804 Hawaii First, few medical text hooks include information about and poySiclans in specialties most like/v to oare for dying patients, dying, and few medical schools and residency programs offer Resoonses acre received by 867 (46%). The maiority attended distinct courses or provide mentored experiences in caring for dying termihally illpatients within the past year and felt that the phsidian patients. The SUPPORT study’documented serious shortcom should be the first to tell a patient th:at bc/she is dying. Yet 86% identified barriers to talking about end-of-life preferences and 94% ings in communication between physicians and patients, and found identified barriers to providing good end-of-life care. Perceived as that many physicians had no knowledge of patients’ preferences at major barriers were family conflict about the best course of action, the end of 2life, Other studies have found that physicians lack patient/famil/’ discomfort withor fear of death, and cultural/religious knowledge about assessing and controlling death-related symptoms beliefs of the patient or family. Since relatively few respondents such as pain and psychological distress, or supported the concepts of physidian-assisted (32%) Most patients lack knowledge about the realities of’dying and the physician-assisted death (18%), the alternative is for physicians to limitations (as well as the abilities) of technology/ When physi ioin with other concerned entities to help overcome the attitudinal, cians communicate these realities, patients may not realize behavioral, educational, and economic barriers to providing appro cannot 5 priate, humane, an.d compassionate care for the dying. that they are on a short death trajectory or may not suspect the increasing futility of the care being ot’fered, Finally, attitudes and hitroduction practices relative to death and dying are influenced by culture and Improving end-of-life care has been the topic of nationa.l and local religion, and may affect the quality of care physicians provide to interest, Man.y Americans are afraid that they “will receive more dying patients and their families, Previous Hawaii-based studies medical care and less pain relief tha.n tI e want” when they a.re of comumers found cigmifictnt Hhnic diftesencus m willingness to dy’ing”° Thes e fears are not u.nfounded, A.national survey found talk about death, completion of advance directive., desire to die at that 47% of responding physicians acted agai.nstthei.rcon ‘cience in home, and opinions regarding the use of hospice servicesd providn.g. care to the termina.li ill, and were more concerned about There is concern that the public’s support of physician-assisted7 the provision of overly burdensome treatment than about suicide (PAS) and physician-assisted death (PAD) stems from their undert.reatni.ent/ Validating fears of the public, the SUPFOR.T fears about being kept alive after much functioning and intellect are study reported that half of the patients who died in the hospital d.ied gone. dying in pain, and burdening loved ones at the end of 2life/ In in moderate, to severe pain/ fact, consumer support for PAS and PAD appear to he on the Wh.at are harriers to providing good end-of-life care? Unfortu. increase in the United States, although support is lower among nately, there are many. Whereas most A micans want to die at minority Americans than among Caucasian Americans/ A popu home, about 60% die in hospitals and another 17% die in nursing lation-based consumer survey in Hawaii suggested8 that two-thirds homes/° Death in the hospital, however, often is.prolonged due to of adults support PAS and PAD, However, when asked if policy pressures to use heroic and aggressive treatment that, not cornci efforts should he focused on improving end-of-life care, rather than dently,generates morerevenuethandiscussionandpalliativecare/” on legalizing PAfo 52% agreed/From the physician side, a 1996 Hospice care can iT.nprovethe quality of one’s death, but nationally, study found that less than 30% of Hawaii doctors would agree to less than I5% of in-home are attende.dby hospice/In Hawaii, personally perform AS orP.A.Di about 20% of deaths o.ccur under hospice although many of these Dir several years, Hawaii’2 has, been looking at the “living and individuals are referred to h spic.e in the last week s or days before dyingwithdigr..ity”i.ssueand.agovemnor-supportedc.ommiss:i.onhas death..,’ called for improvement. In 1999, a statewide coalition called Kokua Mau, comprised of about 150 agencies and individuals, was funded by the Robert Wood Johnson Foundatioin to continue research, increase access to spiritually and c.ulturaliy acce.ptahle care at the Corresoonder,ceto: ReikoKayashimaMPH end of life, an.dinitiate pu.hlica:ndprofe.ssionai education in.order to John A.BurnsSchoolofMedicine, Improve,care of the dying. The.current survey was developed in part UniversityofHawaii to assest.:physiciar.s’ pe.rceptioi.mof ha.rrie:rsto good e.nd-of-iife care, 1960East-WestRoad,BiornedC-106, Honoiuiu,Hl96822, and it it.’hope.d. that ou.r data can. su.pport the develo.pmen.t of. e-nail kavashimfithawaitedu, interventions which will help overconie these ha.rriers, Methods i.s;lea.nsan.d frequencies were calculated, For the questi.ons on Respondents barriers, we collapsed the Likert.-scaied ratings into two categ.ori.es: We selected respondents 1mm a Hawaii Medical Association data a rating of 4 or 5 svas rec.oded as “agree” and. all other respon.ses base that includes both members of the organization and nonmeni recoded as; “disag.ree,” Differences between subgroups of ph..ysi hers. We excluded retired physicians, trainees, and physicians ci ins 9/ g hs; ,thmutv ichinn md number of tcimin il patients practicing outside of the state. We included physicians in specialties cared ;r i.n pas.;tyear) were testc-d usi..ngchi-sq are. Bivariate most likely to he involved in the care of patients with terminal c.orreiation. tests were us.ed to gaucie the strength. of a.ssociation. illness, such as family practice and internal medicine with all of its between selecte.d variables. subspecialties (e.g.. oncology, cardiology, pulmonology, geriat rics), We excluded physicians in specialties least likely to he Results involved in end-of-life care (e.g.. dermatology, obstetrics/gynecol Respondent Characteristics ogy ps\Lh strv surgca Of the 86 phyii m sant question The characteristic •s of respondents based. on primary spec’ia.Ity,

naires, 18 had retired. 13 had moved out of state orhad no forwardin ethni.city. and religion are provided, in Table 1. The i.najority were address, 26 were participating in an excluded specialty. and 6 from interna.l medicine (72%) or fa.milypractice (23%). To discern returned empty envelopes or blank surveys, Of the remaining 804 place of practice, we asked wi..ere they saw most of their patients.;; physicians, 367 (46%) returned a completed questionnaire. 74h.. reported seeing most of their patients in ti.e.ir private offi.c.es,

14% said 9/f said 1..ospital or long,-te.rmcare facility, and 9% Measures s;aidclinic (1.1res:ponder..tschecked. t’woresponse options). Eth,n.i.— Our 19—itemquestionnaire was based on the 243literature and pilot call, 319/ we.reCaucasian, 26% were.Jr panese., 1$/f.were C.hinese, testing. The survey asked about: respondentcharacteristics (ethnicity, 8% were Filipino an.d6% were .Hawaiia.n. In terms of religion, I09/ religion, specialty, years practicing medicine, place of practice); were Buddh.ist, I9/i. Catholic, 37% other Christian, 4/.f Jewish I 5% number of terminally ill patients cared for in the past year and their other religion.s, an.d 9%. re.ported..n.oformal re.ligious atfjliatjon. place of death; use of hospice; respondent opinion on when to begin I. verage years in practice was 18.4 years (ran.g.,eI to 64 years).

discussions about end-of-life preferences and who should first tell a Nun..he.rof terminally i.i.lpatle.n.tsseen i.nthe.pas;tyear v’aried: 11%

patient about a terminal condition: perceived harriers to talking report.ed se.eir.. non , 27% reported seei.ng, 1 to 4, 459/ reported

about end-of-life preferences; perceived harriers to providing good seeing 5-14, and 179/. reported seeing, 15 or more term n.al.Iyill end-of-life care: training in end-of-life care: knowledge of a new patients. 1999 Hawaii law on advance directives: preferences for receiving medical information: and support of the concepts of physician- Place of Death and Use of Hospice and physician-assisted death. Responses to ques We asked physicians who reported seeinf. terminally ill patients in tions on barriers were given on a five-point Likert scale ranging from the past year to estimate which percentage die.din various setting.s;

I=not much a harrier to 5=very much a harrier. The survey defined averaging responses su.ggeste.dthat 48/i. of patients died in acute physician-assisted suicide as “providing a competent. dying patient care, 34% at home. and 28% in nursing/care homes. Hospice care who requests it with a prescription for medicine for the patient to use is;provided in al.l th..reeof these setting.s, and 21/f of respondents with the primary intention of ending his/herown life” and physician- repo..rtedthat ovei. half of their termi.nally ill patients;;were atten.ded assisted death as “giving a competent dying patient who requests it by h.ospice at death. Correlating years practicing m.edi.ci.neand a lethal injection with the primary intention of ending the patient’s percent of patients; referred. to hospice, we found a sig.nificantly 4life.” negative re.iatonshp between the two variables, suggesting that Following approval by the University of Hawaii Human Subjects more recen tiy graduated physiciar.s were referri.ng .r..orepatients; to Committee, the survey was mailed to the 867 eligible physicians on h .spic.e (r = -.22, p < 0 1). We also Ibund a 5jg’nificLn correlation June 1, 2(00. Reminder postcards were mailed 2 weeks later, between pe.rcent of patients dying at borne and percent of dying foflosved by a second questionnaire mailed to nonrespondents a pa.tients a.tten.dedby h.ospice (r = ,44, p < 01), No association was month after the initial mailing. All responses received before found between us;e of hospice services; and physic.ian religion or August 15,2000 were included in the analysis. The physicians were ethnic it. assured that th.eirresponses would he confi.dential and.anonymous i..nthe cover letter. Nonrespondents were tracked by the use of code. Barriers to Providing and Talking about Endof4,ife Care numbers pre.printed on return e.nveiopes. When each questionnaire Almost all (95,9/) respor.dents stated that physiciam; should he the. was returned, the researcher removed i.tfrom the envelope, lof.g.ed first to tell a patier..tthat he/she is dying (not shown in table), “.“hen in the code number, and then destroyed the envelope. The que..stion asked about the best time to approach patie.nts regard.ing end-ofiife naires.;were then assiened consecu.t.i.veidentifi.cation numbers for th.e. preference.s, 35% of rrn;poiidents cho.se middle age, regardless % purpose of data entry and.analysis, We were not able.to compare the health status. Other opti ns included greate.r than 6).’years of age. characteristics of the respondents an.dnonrespondents, as no demo 1%’ i u gan Ii onos s;s;ith so ious illnss 19/1 l when pafio! t/ graphic data were.ava lahie on non.responde.nts. I irnih su4gcsrt ii II 9/) less 9/ m 6 month piofnl sis 9/c i cnd clearly near death (‘5%’). Statistical Analysis R.e.vp Re.sponses were entered into Epi-info, a public-domain progra.m., were harrie.rs to provid.ing: good end-of-life care and tal.k.in.g,to md suhscquentl eons;rted into SPSS P( for t itisucal mcI isis patients about end-of-life. preferences (Table 2), T’he most fre

Maccc/IL. JOL;RNA,,, L’.. 60. E6;Boc,ccRY 41 Table1—Samplecharacteristics(n=367) Table2—Perceivedbarriersto providingand talkingabout end-of-lifecare n (%)ofrespondents Providing Talking good about Primaryspecialty care Preterences IM 263 (717) n )%) n (2) FP 83 (22.6) OP 14 (3.8) Familyconflictabout 264 (719) 224 (60,4) Other 7 (1,9) best courseofaction

Ethnicity Patient/familydiscomfort 260 (70,8) 216(589) 115 caucasian (31.3) withor fearofdeath chinese 66 (18.0) Filipino 28 (7.5) Cuituralor religious 151(411) Japanese 96 (25.9) beliefsofpatientor family Hawaiian 21 (57) Other 31 (&4) Providertimeconstraint 96 (26.2) 139(37.9) Missingdata 10 (27) Financialbarrier Religion a. Patient 133(36.2) Budcthist 37 (101) b. Provider 75 (20.4) catholic 69 (18.8) Otherchristian 1•35 (36.8) Providerdiscomfort 112(30.5) 91 (24.8) Otherreligion 56 (15.3) withorfearofdeath Noreligion 33 (9.0) Missingdata 37 (101) Languagebarrier 73 (19.9) 74 (20.2)

Averageyears in practice 18.4 (range1-64) Lackofcontinuityof 97 (267) NA care across settings Place of practice clinic 32 (87) Lackofprovider 92 (251) NA Privateottice 272 (741) knowledgeofhospice HMO 48 (137) and palliativecare Acuteor LTCsetting 35 (9.5) Fear oflitigaton 81(22.1) NA # terminallyillpatients cared for in past year None 37 (101) Lackofhospiceand 71(193) NA 14 96 (261) palliativecare services 514 162 (441) 15+ 63 (172) Missingdata 9 (2.4) cians in End-of-Life Care), offered several times a year in Hawaii. The most preferred way to receive information about advances in Meanpercent of deaths in each setting Home medicine and healthcare was through journals (42%). followed by Nursing/carehome 1-hour lunch meetings (33%). seminars (1(1.3%),internet (10.4%), Acutecare and CD-Rom (6%). About two-thirds said they were familiar with Percent of patients whodied under hospice the 1999 changes in Hawaii law concerning advance directives and <25 174 (49.2) healthcare instructions. 2549 61 (17.2) 5O75 50 (141) Table3.—EOLtraining,preferredwayto receiveinformation. >75 24 (6.8( Missingdata 45 (12]) and awareness ofHawaii’snewhealthcaredirectivelaw.

Percent withtraining quently indicated harrier in both categories was family conflict onEOLcare about best course of action, 71% and 60%, respectively. fext were Medicalschool (18.8) patient/family discomfort with or fear of death (71% and 59%, CME (27,5) EPEC (5.4) respectively) and cultural/religious beliefs of patient or family (47% Residency/fellowship (21.5) and 41%, respectively). Number and percent of physicians agreeing with other perceived harriers are provided in Table 2. Preferred way to get medical information Journal Training and Knowledge Questions Ihour lunchmeetings Overall, 57% of respondents i.;tatedthat they had receive.d trair.ing Seminar internet in end—oN.i.fecare•in ine•or more settir.gs, most frequ.entiy through. CDRom Continuing Medical Education hut also throug.h.medical school.or rVsi&ncv/kl lo ship opporlunitics Only 20 (S’ ii cportLd has mg Awareness of Hawaii’s new healthcare ntLnded thL AMA sponsorod progrim FPEC ibduc ihng Phst directive law

V1EDOAL.JOURNAL..VOL EU.FEBRUARYOY”r 42 1. i Support of Phvsician-ssisIed Suicide PS1 and Physician’ Naidonai •i-reid v, tar!—!. is o eonsu t-slerssopo-ortPAt).— ASsiSted Death (PAl)) p Support for the concepts o P.-\S and Pi-\l) are shown tn faNc —4. Oerall ,32 of respondents s porwdP\S pruvidinea or P-\S-i’At) than >- -n,nrnew Eta!.0 consumer roan-ri tent. dying patient who requests it with a prescriptiun icr nterticine for the patient to use s jilt the primars tnteni on o[ end - ov n life and - supported PAD CR inc a npetenr dsine pattern ho requests tin lethal in ectiun ith the pnmars lnnti000scouina the patient s Ilie r-efore a pain .nt -r-a health eri.s!.s., 04ivs.ci.anr-are e\t.!eet.ed to

I [ >

life ea.reas theirdornain, in a.national study otphystcsanr-ar-.soeated Table 4, Supportfortheconceptsofphysician’assistedsuicide with the \-‘eterans Adtrnuistration system. 82ff. felt they should he and physician.assisteddeath, by ethnicity/religion re-.spotssihlefor staoitt dire-ussions about c-nd-of-life-preferencce.Ff sinai in the current >ut-rev. 95))- sif Hawaii physic.ians r.-aidthat the

physician should be the-first to tell a paticn.t he/she i.s-dying. Second, conr.-umers. want their !iltr..:s.icisInsto initiate- this discussion, cud

Overall N=367 preffir to has-c it in t iated when. t.he.yare middle-aged and n.ot e-t c.nitic.allyilid’ I utortut-tately, on.ly 35% 04 our re-r-pondentscon Ethnicity war-tb-c- d,iscusr.rion.s CaucasianIrc=115, curred th.atmiddle ce pre.ferre-dtime to begin

Chinese(n=66t about pre.ferences - Full 15Fl 19It the-yshould wait to dir.-c.ur.-sc-nd Filipino(n=28) of-1.iie-pre.ferc.nc.esun.tilthe atieFl wa-sdoss- to death (6 mon.ths or Hawaiian(n=21) death, another 18Ffword wai.tun.tilthe-pati.ent Japanese (n=96i less) orver near and Other/Mixedtn-fl war. d.iagnoi..-c-.cIifith a serious iflne-sr-, Family conflict was seen as a major harrier to talking ahi-tut Religion pr;.wishn.g care. Howe-ver, Buddhistun=37; references and good end-of-life if catholic tn=69t preference’s are disi-ussed au-nIa su.rrogate-is appointed early (he/nrc Christianin=135l a health crisis oc-curs), perhaps conflict can he avoided o-rdim.its Jewishtnr13) irhed, Hawaii is. 1999 advance d.i.rectivelaw (of which, only 66% of None(n=33t OtherIn=251 our res.x.mdents were aware) iute:li.tdersa -.fineagsti.nstthe pI.sysician woo doe.s not t!!tiOVe i.-.atieu-lt’s i.e pre-sr-e.dwisher.s,re.gardier.ciof a family’ s threatAT There a-ill still Irecases in wl.ich i.nd.ividuais,once Magnitude of support aried, ho\\ e ci. l’s phvstcian cthnicFy and iii, ma’!—’chance their inind.s ahot.tta course of action, hut the new lose religion. Among ethnic croups. Caucasian respondents were the df--rn.-snei-vpt-e-hfrenc-est. >entd smd a nc-ti--on .x-r to he most supportive of PAS ssoh 44 >a\ n “\es and Filipino> -scrc soooi.iteu. Sonse tanii]vc-rntf-iet will slid, occur, 7 least supporti\ e i \s ith onls saStoe ‘re>’’ and this difference significant i y-=25.() I p<.() I Relicious dt terences wece sienifi cant too, as Catholic and other Chrtstian respondents were hikeR to say “no” to P—\.Sthan respondents ith another, or ibrmal. religious affiliation / -=21.2 ps.trn For PAD, ereatest support was seen in Cauaasian and Japanese 21F- to each “s-es” and the least >upport \ as eporred he Hawaiians and Fit tins ionl -I ‘ in irh oot / r- -‘-3 “< I the Joiii-t.(o- iiiimci-0.!!ii- .m We .-\ceredutat;-on oh’ Heaithcnie lndisiduals with no formal religious all jijatton were most a — ice of’ PAD Li’d-- htle (‘athi dies cud other Christian-’ ode e’ast

I 1!!> is- supportive I each = °5. p°-- 5. Nor tatisticai Uilterence iis P1s.vcici 5.tsdj-;.f- F ic Carea ci in support of PAS and P \D a etc detected ‘,- iN (‘tt>icii—_.ire —ici tn!-’, ,i ‘-s,n 1-ia.a-ui--.t The H. Julia A. sears practice, and nuniher at’ terminalis patients cared fit’ the past rear. Discussion

Our l’indings suggest that ouR a minortts ol Hcaaii phs ieicii> a I us >purn >t ;is-’->> support PAS 3,2’-’iand PAD I Sup port among Hawait dence for the ei:±f-cii-v-c- of earle it-uini u in erud’-o.t-i.ifecan-’- it ph’sieians is similar to the national figures, albeit both national]) seas also i-’rati i- ne that po.-viteu- disc-.trnfort w-it-hor fear iff deat.l-i an.d locally, upport earle> be eth.nicity twit.h less support atflon.g was not ncrcei. ye-i to be a Iarise harnie.r: i.--.mly.5f/-: .saw it at- a ha--crier m.nori.t.ies) and religion with less supnort. amonrt Cati..ol.i.cs), Of to t.a.Ik li-ti.!ahoi.h pt-c fe-rences and on.ly 1•19/ ss-rwit as a bstrnieu’to in.terest. however, is the eeneraliy eonsirstent gap he.t.wcen physi provsdsng i-scsod end af- 1-i-if care -

I 0 uaus sod eonsuutLi s n thr it Lit tud o suppOt t tot PTS nd PAl) F 1>.t li n it >. U >.is U>. tO icr. t tr mttreOS> on> occurred, the literature notes that the actual decision making that across the country have found that support for these end-of-life precedes death is more complicated thanjust following documented options associates significantly with physician characteristics preferences. An article presenting a “rethinking” of the SUPPORT (ethnicity, religion, age, specialty) and m4227attitudes. Based on this findings lists four reasons why this is 30so, First, patient preferences finding, many warn that legalization of PAS and PAD will “open the are not stable; rather they evolve as patients confront new situations door to abuses of vulnerable patients on the basis of age, poverty. ‘‘ and new information is received. Second, many decisions get made mental disorders, or lack of resources for palliative 2care.” in the course of patient care, and it is in retrospect, usually. that a Our study was limited by its relatively low response rate (46ff). particular set of decisions is seen as pivotal in precipitating the especially given the efforts taken to follow-up with nonrespondents. unnecessarily painful or prolonged death. Third, for hospital-based Other studies of physician support for PAS/PAD enjoyed response patients, players (patients. families and physicians) tend to go along rates in the range of Similarly to other authors, we with “the program” rather than advocate for less aggressive care, and were unable to test differences between respondents and families tend to feel guilty if they do not ask foreverything to he done nonrespondents. It is likely, however, that respondents to the for the dying person. Finally, the SUPPORT investigators now Hawaii survey were more aware of and interested in doubt their hypothesis that players want to, or are able to, make care approaches than nonrespondents. This is evidenced by the unex decisions based on prognostic estimates and preferences of a spe pectedly high rate in-home death reported by our respondents. cific patient. Rather, it is more likely that role expectations for Specifically, respondents said that, on average, 34% of their patients doctors and families to do everything to save the life of the patient died at home and only 47% of their patients died in the hospital. Data will prevail. reported by the Department of Kealth, in contrast, note that only Thus, the SUPPORT investigators join with other authors to 21% of deaths occur at home and that 63% occur in the hospital. suggest that drastic improvements in end-of-life care may only Itis likely that efforts on several fronts will be required to improve occur with changes to the structure and financing of care. There is care to the dying and, perhaps, reduce consumer support for physi a recognition that the medical culture and the health care environ cian aid in dying. Health professionals need to initiate dialogues ment encourage heroic and aggressive treatment, and that financial with their patients, consumers need to discuss these issues with incentives often motivate hospitals and doctors to provide invasive family members and choose surrogates, and structural changes to interventions to dying patients whether they want them or not, quite health care financing and standards will need to be made. Given that in contrast to the model of palliative care where patients are allowed Hawaii physicians’ top three barriers to improving end-of-life care to die in peace and with 35dignity.”’ were patient/family-related (conflict, discomfort/fear of death, cul Despite this growing recognition of systems barriers to good end- tural/religious beliefs), a good place to start is with dialogue and of-life care, it is interesting that the top three barriers for Hawaii discussion. Educational efforts that facilitate communication must physicians were patient/family-related. The survey queried about be supported. several potential systems barriers. However, only 20% of physi cians felt that lack of reimbursement was a barrier to talking about Acknowledgments end-of-life preferences. In relation to providing good end-of-life Thissurveywas conductedunderthe John A.Hartford/AmericanFederationfor care, only 36% of physicians saw a patient’s financial constraints AgingResearch,MedicalStudentsGeriatricScholarsProgramdirectedbyPatricia L.Blanchette,MD,MPH,ProfessorandDirectoroftheGeriatricMedicineProgram. and only 22% saw fear of litigation as barriers. In the era of managed JohnA.BurnsSchoolofMedicine(JABSOM).Additionalfundingwasprovidedby care, not surprisingly, 38% found time constraints as a barrier to theOfficeofPublicHealthStudies,JABSOM.Acknowledgmentsare tenderedto talking about end-of-life preferences with patients and 26% identi KamalMasaki,MDand VictorValcour,MDof JABSOM’sGeriatricMedicine fied that to be a significant barrier in providing good care. As Programfortheirmentorshipandsupport,to BeckyKendroofthe HawaiiMedical patients with critical illnesses have multiple specialists caring for Associationforaccesstotheirdatabase,andtoCarolMatsumiyaoftheU.H.Center onAgingforadministrativeassistance. Specialthanksto Drs.LenHoward,Carol them, 26% found lack of continuity of care across settings as a Joseph, RichardKasuya,AnthonyLenzer,GlenRediger,DamonSakal,and Seiji barrier. Although the state is serviced by seven hospice organiza Yamadawhoassisted inpretestingthe survey. tions, 19%of respondents felt that lack of hospice and palliative care services was a significant harrier to providing good care. References Returning to the top three barriers, however, Hawaii physicians 5010mmMZ,O’Donnell L,Jennings B,Gu.ilfoyV,WolfSM,NolanK,JacksonR,et al,Decisionsnear the endoflife:professionalviewsonllifesustainingtreatments.Am•JPublicHealth1993:83:423, reported that patient/family discomfort with death and theircultural! 2 Crnoc AF DawsoNVD—bens NAFUkesonWJ GoldmanU Knai.c11Aeta A on cc tra religious beliefs challenged physician ability to talk about and to improvecareforseriouslyillhospitalizedpatients,JAMA1.995:274:1591-8, 3. FieldMJ,Ca,.aelCK,Approachingdeath:improvingcareat the endoflife,Washington,DC:N-atonal provide end-of-life care. In fact, previous surveys of Hawaii AcademyPress, 1997, consumers have noted significant ethnic and religious differences in 4, MelerDE.EmmonsC.WallensteinS. Do-illT,MorrisonRS.CsssaellC.Anationalsurveyofphysician- assistedsuicideandeuthanasiainthe UnitedStates,NEngiJ Med1998:338:193-201, willingness to talk ahout death, completion of advance directives, 5,TolieSW,RosenfeldAG,TildenVP,ParkY,Oregon’slowin-hospitaldeathrates:whstdefermineswhere 09g preference for place of death, desire for hospice care, and support of p’ocledv a o sOwact0’, t de so onplaceofdeWn an n cm M d ‘ 681 5 8. CallahanD,Onceagain,reslitt:nowwheredowego? Ha-stingCentRep1955:25:533-6, PAS and 24PAD. Ethnic and religious differences in support of 7. BrodyH,,Thebestsystemintheworld,HastingCentRep1g95:25:518-21, 9 8,AnnasGJ,Howwelie,H,ssfingsCentRep1995:25:51204, PAS and PAD were seen for physicians as well. Again, the only way ’ 9, BraunKL,OnakaAT,HoriuchiBY,EndoflifepreferencesinHawall,HawMedJ 2000:59:440-6, to reduce these harriers is to learn more about cultural and religious 10, Hill,TP,Treatingthedyingpatient:thechaiiengeformedicsleducation.ArchIntemMed1995;t55:t265- beliefs in general.v through reading and talking with representatives 11, CarrronAT,LynnJ, KeaneyP. End-of-lifecare inmedicaltextbooks,AnnInternMed1929:130:82-6, of those cultures/religions, and to learn more about specific patient! lv ThIellKMCo’—Wtertcc 0 t e dmg stead o or’9s,c,a as, cc suc,oe 0.5 gI Med family beliefs by talking to 27them. The issue of cultural difference t997’.336:54.7, also raises issues for thL legahi mon of PS md PD Studiss trom Continue,s on p. 47

HAWA’ 1v1cooAL JOURNAL. VOL Rc:,FE.R000Ry 200,1 44 Medical Tidbits L.. ReJ/rences, continned from p. 44 Herb Watch The popular herb echinacea (distant cousin of the ragweed) can produce 13.GanziniL.FansDS.LeeMA.HeintzAT,Bloom3D.AttitudesofOregonpsychiatriststowardphysician. a severe allergic reaction. Dr. Raymond Mullins (from Australia) reported assistedsuicide.AmJ Psychuatry1996:153:t469-75, 14. VonRoenriJH.CleelandCS, GownA.HatheldAK.PandyaKJ.Physicianattitudesandpracticein to the American Academy of Allergy, Asthma and Immunology that cancerpainmanagement;a sumeytramthe EasternCooperativeOncologyGroup.AnnInternMed echinacea may he responsible for hives, acute asthma or anaphylaxis. 1993;ttg;121-6, 15. KaufmanSR. Intensivecare. oid age. and the problemof death in America,The Gerontologist Blood Pressure Alert tggs;38;715.25. The National Heart. Lung & Blood Institute (NHLBI) had to stop its study 16.BraunKL,PietschJH,BlanchettePL.(Eda.)Culfuraiissuesinend-of.lifsdecisionmaking.Thousand Oaks.CA;sags Publications.2000. when one of the drugs was significantly less effective in reducing cardio 17.BraunKLCulturalissuesindeathanddying.HawMed3 1g96;55;260-4. vascular disease, CARDURA (the alpha blocker dexazosin) had 25C/ 18.Benson3M.Thepolls.trends;end.of-liteissues,PubOpinion0 lggt:73;273-7, more cardio-vascular events and patients were twice as likely to he hospi 1g.SiamLK&TanSY. HowHawaiIs doctorsfeelaboutphysician-assistedsuicideandeuthanasia;an talized for heart failure... ovenfiew,RawMedJ 19g6;55;2g6’8, NHLBI advises that hypertensive patients on (including 20. Bachman3G.AlcuerKR,Doukas03, LichtenateinAL,CorningAD,BrodyH.Attitudesof Michigan physiciansandthe publictowardlegalizingphysician-ausistedsuicideand voluntaryeuthanasia,N and should see their physicians for alternative drugs... Hy0rin Mj3jpyes) Engi3 MedlggB:334;sos-g, 21.LeeMA,NelsonRD.TildenVP.GanziniL,SchmidtT,TolleSW.Legalizingassistedsuicide;Hewsof Medical Tidbits Il physiciansinOregon,NEngi3 Medlgg6;334;310.5, Acute respiratory distress syndrome usually occurs in pnemonia, hut can 22.CohenJS. FihnSD,BoykoEJ,JonsenAR,WoodRW.Attitudestowardassistedsuicideandeuthanasia amongphysiciansinWashingtonstate, NEngI3 Medlgg4:31;8g-g4, also occur in trauma patients. eg auto accidents and patients who had 23. MarksonL.Clark3, GlanfzL,LambertonV.KernD.StollermanG. Thedoctor’sroleindiscussing complications in major surgery... advancepreferencesforend-of-lifecare;perceptionsofphysicianspracticingintheVA.3AmGeriair

Each year. an estimated 10O,fOOpatients of all ages develop this syn Soc 1gg7:45;3gg-406, drome and about 1/2 die ‘\ new study shows that physicians in ICU may’ 24.BraunKL.DoHawaiiresidentssupportahysician-assiateddeath;a comparsonoffivsethnc groups. he able to save many such patients in ICU by lowering the respirator rate... HawaiiMed3 tgg8;57;529-34, 25.MilesSH,KoeppA,WeberEP.Advanceend-of-lifetreatmentplanning;a researchreview.Archintern ICU at Sinai, however, says. Thomas Stewart. director of Mount “Low Medlgg6:156;1062-8, ering the airway pressure may not he the best treatment forall conditions...” 26. PietachJR. Frequentlyasked questionsland answers)about Hawaii’snew uniformhealthcars decisionsact imodifled).HamMed3. lggg;58;277.81, 27.Kogan5, BianchettePL,MasakiK.Talkingtopatientsaboutdeathanddying;improvingcommunication acrosscultures,In;BraunKL.PietachJR. BlanchettePL.eds. Culturalissuesinend-of-lifedecision making.ThousandOaks,CA;Sage Publications.2000. 28. CauselCK,FoleyKM.Principlesforcareofpatientsattheendoflife;anemergingconsensusamong the specialtiesof medicine, MilbankMemorialFund,19W. 29. Sakai.D.Personaicommunication,September18.2000.

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