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March 4, 1998

Potentially Ineffective Care in Intensive Care—Reply

Author Affiliations

Margaret A.WinkerMD, Senior EditorIndividualAuthorPhil B.FontanarosaMD, Senior EditorIndividualAuthor

JAMA. 1998;279(9):651-654. doi:10-1001/pubs.JAMA-ISSN-0098-7484-279-9-jbk0304

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.