In 1998, American Society of Clinical Oncology conducted the first and only large-scale survey of U.S. oncologists about their experiences in providing care to dying patients. The questionnaire consisted of 118 questions about end-of-life care under eight headings (Hilden et al., 2001):

  1. education and training,

  2. current practice,

  3. perceived barriers to the delivery of care,

  4. decisionmaking,

  5. vignettes about the management of patients,

  6. individual experiences with terminal patients,

  7. the role of ASCO in improving care, and

  8. demographics and practice characteristics of the respondents.

All U.S. oncologists who reported that they managed patients at the end of life, and were ASCO members, were eligible for the survey, a total of 6,645 (the small number of ASCO members from England and Canada was also included). About 40 percent (2,645) responded (see table below) (Emanuel, 2000). No information is available to compare the characteristics of those who responded with those who did not.

This survey documented serious shortcomings in the training and current practices of a large proportion of oncologists. Among the key findings are the following:

  • Most oncologists have not had adequate formal training in the key skills needed for them to provide excellent palliative and end-of-life care. Less than one-third reported their formal training “very helpful” in communicating with dying patients, coordinating their care, shifting to palliative care, or beginning hospice care. About 40 percent found their training very helpful in managing dying patients’ symptoms.

  • Slightly more than half (56 percent) reported “trial and error in clinical practice” as one important source of learning about end-of-life care. About 45 percent also ranked role models during fellowships and in practice as important. Traumatic patient experiences ranked higher as a source of learning than did lectures during fellowship, medical school role models, and clinical clerkships.

  • Only 25 percent reported end-of-life care as highly satisfying; about 40 percent thought it intellectually satisfying; and 63 percent, emotionally satisfying. Substantial numbers reported a sense of failure when a patient becomes terminally ill (10 percent), and a similar proportion reported anxiety and strong emotions when faced with follow-up meetings with dying patients and managing difficult symptoms. About twice as many reported anxiety and strong emotions when they had to tell a patient that his or her condition would lead to death.

  • The large majority of oncologists report that they are highly competent in managing patients’ cancer-related end-of-life symptoms, including pain (95 percent report high competency), constipation (91 percent), nausea and vomiting (93 percent), fever, and neutropenia (89 percent); somewhat fewer report high competency in managing shortness of breath (79 percent), anorexia (63 percent), and depression (57 percent).

  • Very few oncologists (6 percent) feel they can arrange for their patients to get

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