End-of-Life Care Received by Physicians Compared With Nonphysicians | Geriatrics | JAMA Network Open | JAMA Network
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    Original Investigation
    Geriatrics
    July 24, 2019

    End-of-Life Care Received by Physicians Compared With Nonphysicians

    Author Affiliations
    • 1Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
    • 2Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
    • 3Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
    • 4Department of Anesthesiology, Columbia University, New York, New York
    • 5ICES, Toronto, Ontario, Canada
    • 6Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
    • 7Department of Medicine, University of Toronto, Toronto, Ontario, Canada
    • 8Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, Florida
    • 9Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York
    • 10Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
    • 11The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
    JAMA Netw Open. 2019;2(7):e197650. doi:10.1001/jamanetworkopen.2019.7650
    Key Points español 中文 (chinese)

    Question  What are the patterns of care at the end of life for physicians compared with nonphysicians?

    Findings  In this cohort study of 2507 physicians and 7513 nonphysicians who died in Ontario, Canada, physicians were no more likely to die at home than nonphysicians. Overall, they did not consistently opt for less-aggressive care but instead used both intensive and palliative care more than nonphysicians.

    Meaning  These findings highlight a more nuanced perspective of what physicians may perceive to be optimal care at the end of life.

    Abstract

    Importance  The idea that physicians as patients choose less-aggressive care at the end of life for themselves is an often-cited rationale to advocate for less technology-laden end-of-life care.

    Objective  To assess end-of-life care received by physicians compared with nonphysicians in a system with universal health care.

    Design, Setting, and Participants  In this population-level decedent cohort study of data from April 1, 2004, through March 31, 2015 (fiscal years 2004-2014), in Ontario, Canada, 2507 physicians were matched approximately 1:3 to 7513 nonphysicians (ie, individuals who never were registered as a physician with the College of Physicians and Surgeons of Ontario) according to age, sex, income quintile, and location of residence.

    Main Outcomes and Measures  The primary outcome was location of death. Other outcomes included measures of health care use in the last 6 months of life. Differences were assessed using Poisson regression with robust error variances, adjusting for the Charlson Comorbidity Index.

    Results  In total, 2516 physicians and 954 836 nonphysicians died between April 1, 2004, and March 31, 2015, in Ontario; 2247 physicians (89.3%) and 474 182 nonphysicians (49.7%) were men. The median (interquartile range) age at death was 82 (74-87) years for the physicians and 80 (68-87) years for the nonphysicians. After matching, data for 2507 physicians and 7513 nonphysicians were analyzed. For physicians, the risk of death at home was no different from that for nonphysicians (42.8% vs 39.0%; adjusted relative risk [aRR], 1.04; 95% CI, 0.99-1.09), but the risk of death in an intensive care unit was increased (11.9% vs 10.0%; aRR, 1.22; 95% CI, 1.08-1.39). In the prior 6 months, physicians had a decreased risk of an emergency department visit (73.0% vs 78.4%; aRR, 0.96; 95% CI, 0.94-0.98) but increased risks of an intensive care unit admission (20.8% vs 19.1%; aRR, 1.14; 95% CI, 1.05-1.24) and of receipt of palliative care services (52.9% vs 47.4%; aRR, 1.18; 95% CI, 1.13-1.23). Among a subgroup of 457 physicians and 1347 nonphysicians with cancer, the risk of death at home or intensive care unit was increased (37.6% vs 28.6%; aRR, 1.30; 95% CI, 1.13-1.50), as was the risk of receiving chemotherapy in the last 6 months of life.

    Conclusions and Relevance  There was no difference overall for physicians compared with nonphysicians in terms of the likelihood of dying at home; physicians were more likely to die in an intensive care unit and to receive chemotherapy, but also to receive palliative care services. These findings suggest that physicians do not consistently opt for less-aggressive care but instead receive end-of-life care that includes both intensive and palliative care. These findings inform a more nuanced perspective of what physicians may perceive to be optimal care at the end of life.

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