all the services they need. About half report getting their patients “almost all” of what they need, but the rest report that their patients get less. More than half (56 percent) report that a palliative care team is either not available or not easy to access. Smaller but still substantial proportions report lack of availability or difficult access to hospital-based hospice (28 percent), a pain service (18 percent), outpatient case management (17 percent), and psychosocial support services (15 percent).

  • The barriers to providing adequate end-of-life care most often cited are patient and family denial that death is approaching and unrealistic expectations for curative treatment. Other factors (e.g., laws restricting opioid usage) are reported as frequent problems by only 6 percent.

  • Reimbursement practices are reported as frequent barriers to providing good care. Slightly more than one-quarter report insufficient reimbursement for time spent in discussion with patients and families as the “most troublesome” among reimbursement barriers. A much larger group (41 percent) reports lack of coverage for unskilled home health services as the most troublesome aspect. Also troublesome are restrictive referral networks and lack of appropriate coding categories (diagnosis-related groups) for end-of-life and palliative care.

  • In answer to questions about a series of patient vignettes, respondents indicated what course of treatment they favored. As an example, for a patient with locally advanced lung cancer who “failed first line chemotherapy,” 3 percent would recommend hospice and the rest would recommend additional chemotherapy (paclitaxel or a phase I trial); after failing paclitaxel, 19 percent would refer to hospice and the rest to additional chemotherapy; failing the third-line treatment, 80 percent would refer the patient to hospice care, but the remaining 20 percent would consider additional chemotherapy.

Attitudes and practices relating to euthanasia and “physician-assisted suicide” were elicited in various questions, with the following points emerging (Emanuel et al., 2000a):

  • About one-third of the respondents had been asked to perform either euthanasia or “physician-assisted suicide” within the previous year, and nearly two-thirds had had such requests at some time during their career; 4 percent had performed one or both within the previous year, and 13 percent, at some time in their career. Most instances were physician-assisted suicide (11 percent of respondents) rather than euthanasia (4 percent).

  • Concern among oncologists about performing euthanasia and physician-assisted suicide limits their willingness to prescribe adequate doses of opioids to control pain. Oncologists who do not support euthanasia or physician-assisted suicide are less willing than others to increase opioid dosages for severe pain.

  • Better training in end-of-life care and the ability to obtain good palliative care for patients are associated with a lower likelihood of oncologists’ performing euthanasia or physician-assisted suicide.

Response Rate Among Specialties

 

Medical Oncologists

Surgical Oncologists

Radiation Oncologists

Pediatric Oncologists

Eligible

5010

499

703

371

Responders

2129

128

203

172

Response Rate, %

42.5

25.7

28.9

46.4



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