Limiting medical care: physicians' beliefs, physicians' behavior

Reviewing intuitive decision-making and uncertainty: the implications for medical education

CONTEXT

Intuition and uncertainty are inescapable conditions of many instances of clinical decision- making. Under such conditions biases and heuristics may operate, distorting the decision-making process. Physicians and students are generally unaware of these influences.

PURPOSE

To review the extant literature regarding the role of uncertainty and intuition and associated biases on medical decision-making, to highlight the implications this holds for medical education.

CONTENT

Using literature identified via Medline and Bioethicsline searches of the past 3 decades, this paper reviews the sources of uncertainty in clinical practice and the role of intuitive decision-making. A detailed description of associated heuristics and biases is provided, and linked with demonstrable examples from medical decision-making.

CONCLUSIONS

It is argued that although uncertainty can be reduced, it can never be completely eliminated from decision-making. Therefore most decision-making performed in medicine contains an irreducible intuitive element and is thus vulnerable to these biases and heuristics. Given that few medical curricula overtly address the process of medical decision-making, both medical students and physicians remain vulnerable to these effects on their own (and their patients') decision-making. Insight via education appears the major means in which to avoid distorting decision-making processes.

Code status decision-making in a nursing home population: processes and outcomes

OBJECTIVES

To examine the clinical utility of prehospital code status discussions in a nursing home (NH) setting and the health care outcomes of the decisions made. Also to identify patient factors and other variables associated with these decisions.

DESIGN

Retrospective uncontrolled observational study carried out through record review.

SETTING

A single skilled-level teaching NH and its affiliated university hospital.

PATIENTS

All of the 350 individuals who resided at the NH during a 2-year period.

MAIN RESULTS

Code status decisions were routinely sought through discussion involving primary care physician/social worker teams and residents or surrogates of demented patients. Choices were made for 80% of the NH residents, most (73%) by surrogates and most (80%) for do-not-resuscitate (DNR) orders, usually within 10 weeks of NH admission. Neither short-term measures of NH care intensity nor hospital use changed after a DNR decision. Most (80%) hospital transfer records included code status documentation. At the NH, both the likelihood of decisions and their directions were associated with involvement by specific physician/social worker teams. Additionally, a dementia diagnosis, white race, and older age were associated with a nursing home DNR decision. At the hospital, a DNR order was associated with white race, the presence of nursing home DNR documentation in the transfer records, hospital attending care by certain NH physicians, and a terminal hospital stay. Hospital inpatient medical and surgical therapy use, except for intensive care procedures, was similar for DNR and non-DNR inpatients. Residents with DNR orders had a higher mortality rate, yet most survived at least 1 year after the order. In the short term, a DNR order had no impact on measured health care resource consumption, but, for those in the final months of life, in-patient hospital use was less for the DNR group, and most of these died at the nursing home.

CONCLUSIONS

Prehospital code status decisions can be made effectively within the NH setting. Outside of medical intensive care, DNR orders have no impact on NH and hospital care intensity in the short term. In the final 6 months of life, however, hospital use is less for the DNR subgroup.

The limits of proxy decision making: undertreatment

With the passage by virtually every state legislature of healthcare proxy laws, the medical profession increasingly can expect to rely on the participation of surrogates in making decisions on behalf of incompetent patients. Several concerns about the legitimacy of proxy decision making have been discussed in the ethical and general medical literature: the lack of concordance between the views of patients and their surrogates have been documented on multiple occasions, and cases of abuse by proxies or potential conflict of interest have been reported. Another dilemma that deserves discussion arises when proxies demand withdrawal of treatment that physicians and nurses regard as essential to the wellbeing of the patient. The following case highlights this dilemma.

Differences in the treatment of patients with acute myocardial infarction according to patient age

OBJECTIVE

To identify age-related differences in the treatment of patients with acute myocardial infarction.

DESIGN

Retrospective cohort study.

SETTING

Two university-affiliated medical centers with integrated clinical programs.

PATIENTS

329 patients admitted with acute myocardial infarction in 1988-1990 for whom complete medical records were available. Study exclusions included patients transferred from other hospitals specifically to undergo angiography or other cardiac procedures, nursing home residents, patients with metastatic cancer or dementia, and patients in whom "do not resuscitate" orders were written during the first 2 hospital days.

MEASUREMENTS

Medical records were reviewed to determine socio-demographic data, comorbidity, admission severity of illness, medications, the use of specific diagnostic and therapeutic modalities during and after hospitalization, treatment limitations, and patient outcomes.

MAIN RESULTS

Chronological age of patients was related to the use of several diagnostic and therapeutic modalities. Using logistic regression to adjust for comorbidity, severity, infarct size and location, and other covariates, patients 75 years and older were 12 times less likely to receive thrombolytic therapy, 8 times less likely to undergo coronary angiography, and 7 times less likely to undergo coronary angioplasty than patients less than 65 years of age. However, age was not related to the use of other modalities, including echocardiography or gated blood pool scanning, pulmonary artery catheterization, and transvenous pacing. Finally, in a logistic regression model, the risk of in-hospital death was 4 times greater for patients 75 years and older than patients less than 65 years.

CONCLUSIONS

Physicians' management of patients with acute myocardial infarction differed greatly according to patient age for some diagnostic and therapeutic modalities, but not for others. These findings indicate that generalizations about age-related practice variations should not be based on analysis of a single procedure. Moreover, judgments about the appropriateness of age-related differences in management require knowledge of the relative effectiveness of management strategies in older and younger patients.

The physician's decision to use tube feedings: the role of the family, the living will, and the Cruzan decision

OBJECTIVE

To determine the relative importance of factors influencing physicians to use tube feedings in patients lacking decision-making capacity.

DESIGN

Survey.

SETTING AND PARTICIPANTS

Four hundred thirty-nine members of the Missouri Academy of Family Physicians.

MEASUREMENTS

Using a mailed questionnaire, physicians were asked for a decision about feeding tube placement in an 89-year-old man who was unable to swallow or communicate after a stroke. Changing the conditions of the scenario, we then evaluated the influence of patient age, duration of disability, a living will, the Cruzan decision, and family preferences on the physician's decision.

RESULTS

After reading the initial case history, 47% of physicians opposed tube feedings. Physicians who were told that the patient signed a living will specifically excluding tube feedings were more likely to oppose tube feedings than those who were told that he signed only a standard living will (53% vs 42%; P = 0.02). Forty-two percent of physicians who initially suggested a feeding tube changed their recommendation if the family opposed it. Sixty-six percent of physicians who initially opposed a feeding tube changed their recommendation if the family "pushed" for it. Thirty-three percent of physicians who initially opposed tube feedings under the living will scenario would favor tube feedings if the patient had not signed a living will. Twenty-two percent of physicians who initially opposed tube feedings would change to favor them if the issue had arisen before the Cruzan decision.

CONCLUSIONS

Among this group of physicians, there was no consensus on whether tube feedings should be initiated. However, it was found that the family's opinion was the most influential factor affecting the physician's recommendation about tube feedings. Most physicians endorsed family preferences for tube feedings even when this intervention was specifically opposed in the patient's living will.

Ethical constraints on rationing medical care by age

In a statement published in this issue, the Public Policy Committee of the American Geriatrics Society endorses the view that chronological age should not be a criterion for exclusion of individuals from medical care. This article aims to amplify the Committee's position by placing it within a broader context and identifying its justification in ethical argument. The paper is divided into three parts. The first part clarifies the difference between allocation (the distribution of funds between categories) and rationing (the distribution of funds within a single category). It is argued that given the current allocation of funds to medical care, some form of rationing is unavoidable. As others have noted, rationing is already occurring in an informal and piecemeal fashion. However, ethically sound rationing requires publicly debated and defensible policies. The second section of the paper reviews a number of arguments advanced in favor of rationing medical care on the basis of age. Objections to these arguments are carefully set out. The final part of the paper details and defends a series of positive arguments establishing special duties to the elderly. The paper concludes that to the extent that scarcity forces rationing, older persons should not be excluded because they are old.