Study: Education Needed To Improve End-Of-Life Care

March 01, 1997

By DAVID WILLIAMSON UNC-CH News Services

CHAPEL HILL -- Intensive education for doctors and special programs within hospitals are more likely to change the kind of care dying people receive than advance care directives, sometimes called "living wills," according to a new University of North Carolina at Chapel Hill and Duke University study.

Altering physicians' behavior, reducing costs and improving both pain control and patient satisfaction should be future goals, authors of the study say.

A report on the findings appears in the March 1 issue of the Annals of Internal Medicine, a medical journal. Authors are Drs. Laura C. Hanson and Marion Danis, assistant professor and associate professor of medicine, respectively, at the UNC-CH School of Medicine, and Dr. James A. Tulsky, assistant professor of medicine at Duke.

"Physicians and nurses have long struggled with decisions about appropriate care for patients who are near death, and during the past 20 years patients and their families have become more likely to participate in these decisions," Hanson said. "Many people now believe that Americans are dying in too much pain, with excessive technology and little human dignity at too great a cost."

More than half of people polled even support physician-assisted suicide as a way to escape the failure of modern health care, she said.

"With increased public awareness has come a demand for new standards of medical care near the end of life, better tailored to the needs of the one who is dying," Hanson said. "Despite intense attention to this problem, an effective solution remains elusive."

For their research, designed to see what efforts work best, the physicians reviewed all academic papers they could find published between 1990 and 1996 describing special, intensive programs to improve end-of-life care. Sixteen studies met the guidelines they established, including eight that tried to give patients more control over treatment, five that attempted to change the way doctors treated dying patients and three that sought to influence both groups" behavior.

"The programs to increase patient control were successful at increasing the use of advance directives or living will," Hanson said. "Unfortunately, when researchers went on to look at the impact of living wills on patient care, they did not change the treatments that patients actually received."

Sophisticated educational techniques were needed to motivate doctors to change their behaviors, and some reduced their use of life-sustaining treatments for dying people following that education, she said. None of the special efforts studied succeeded in cutting the cost of medical care or reducing pain and suffering, however.

"A larger take-home message from this research is that we should not expect simple strategies like living wills to change difficult decisions about how best to care for dying patients," Hanson said.

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Note: Hanson can be reached at (919) 966-2276. Her pager number is (919) 966-4131 and then 4722.

Contact: David Williamson

University of North Carolina at Chapel Hill

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