Margaret A.WinkerMD, Senior EditorIndividualAuthorPhil B.FontanarosaMD, Senior EditorIndividualAuthor
In Reply.—Dr Mendelson and Dr Robinson
raise the possibility that managed care reduces expensive intensive care in
those who die by processes that include better communication between primary
care and hospital-based physicians, a culture of enhanced patient rights,
and a "more holistic and continuous" relationship between patients and physicians.
We hope this is true. However, it is important to point out that there is
no evidence presented in the article by Cher and Lenert1
to indicate that an enhanced patient-physician relationship accounted for
the observed decrease in intensity of end-of-life care. Mendelson accuses
us of trivializing the likelihood that attention to patient preference and
patient-physician communication can reduce the intensity of end-of-life care.
As we point out in our Editorial, we believe that these factors are critically
important in any effort to minimize the intensity of end-of-life care. Our
point is that we must examine these factors explicitly, rather than assume
that a decrease in the intensity of end-of-life care occurred because of enhanced
patient-clinician communication or even that a decrease in intensity of care
is consistent with the wishes of all patients. Since patient preferences for
end-of-life care vary by ethnicity and socioeconomic status,2,3
it is important to consider carefully the full range of ethnic socioeconomic
diversity before assuming that the views of consumer committees are representative
of the diverse populations served by most health plans.
Curtis JR, Rubenfeld GD. Potentially Ineffective Care in Intensive Care—Reply. JAMA. 1998;279(9):651-654. doi:10-1001/pubs.JAMA-ISSN-0098-7484-279-9-jbk0304