This study examined the decision-making of non-physician individuals and that of physicians surrounding end-of-life healthcare, particularly relevant to advance directives. I identified the opinions and knowledge of individuals surrounding these topics. A number of factors and the patient-doctor relationship emerged as the biggest barriers in the decision-making process of non-physicians. These factors included the fear of death and readiness to die, religion and belief in the afterlife, financial burdens and family burdens. A primary aim was to address why physicians made relatively more conservative end-of-life decisions than non-physician individuals do. Addressing how and why these differences exist was of principal importance.
Physicians’ views on end-of-life healthcare and on advance directives were heavily swayed by their experiences and knowledge on medicine based on their experiences in the field dealing with patients at the end of life. When assessing their attitudes towards end-of-life care for their patients versus end-of-life care plans for themselves, it was evident that the terms of each significantly differed. The prioritization of patient autonomy in a system where the default of individuals’ treatment plans is for the most heroic and extensive treatments is often times why
this gap remains. This factor, coupled with families having a difficult time letting go of loved ones and people generally being ill-informed regarding advance directives and end-of-life healthcare options are two other factors that contribute to the prolongation of individuals’ lives. Physicians also shared the different factors that seem to most drive decision-making with their patients as well as the factors that drive their personal end-of-life healthcare decision-making. While patients were often times concerned with the external burdens in their lives and allowed this to guide their decision-making, physicians were most focused on functionality when it came to their own end of life. Again, physicians’ background and knowledge on end-of-life care guided them towards more conservative end-of-life healthcare decision-making and was the primary reason for this discrepancy.
Strengths and Limitations
A major strength of this study was that it explores both non-physicians and physicians’ attitudes towards advance directives and the topic of end-of-life decision-making comparatively. Similar surveys and guided interview questions for the two groups allow for the much larger question at hand to be examined on the level of knowledge, opinions and experience for both groups. This approach made it apparent as to where the differences lie in considerations and prioritization of factors that lead physicians to often times be more conservative in their end-of- life healthcare decision-making approach as relevant to their personal lives. Another key strength of this study was that it provides insight into physicians’ opinions and feelings on the current system of advance directives in the United States, along with feedback on their effectiveness and shortcomings. Past research on this topic has led to the same conclusions regarding a more conservative approach taken by physicians, yet it has not sufficiently and thoroughly examined these questions on a deeper level using qualitative methods.
Although this research has its strengths, it also has several limitations that provide room for further research to be conducted on the topic of non-physicians versus physicians’ end-of-life healthcare decision-making. First, this research study was cross-sectional and addressed a sample that was limited in its scope and perhaps not representative of the larger population of non-
physician individuals and physicians living and working in the United States. The majority of research participants in both the non-physician and physician groups have been living and working in North Carolina for many years. The individuals in the group of non-physicians all live in retirement communities, and the physicians primarily work in the Chapel Hill/Durham, North Carolina area. These may be factors of self-selection towards certain trends in responses. More research is needed to understand national trends in responses, especially as they relate to different patient demographics depending on socioeconomic status, race, and other factors. Secondly, both groups of participants were not asked to fill out advance directive forms that were collected or to complete a questionnaire asking specific questions about what end-of-life
measures they would take and/or would not take. This could have provided a more concrete idea of relatively how much more conservative physicians are when it comes to their own end-of-life care decision-making. Due to the small sample size used in this study, the results are not
generalizable. However, participants still provided valuable insight on their outlooks regarding advance directives. Perhaps additional qualitative studies addressing similar questions conducted more widely in the region or in the United States may lead to more generalizable results if similar conclusions are reached.
Based off of the valuable feedback provided in particular in this study, both non- physicians and physicians exposed problems in the current design and implementation of advance directives. These problems, as mentioned, include strains in the patient-doctor
relationship, lack of understanding regarding advance directives and end-of-life healthcare on behalf of non-physicians, obstinate views of individuals, physicians feeling burdened by limited time, the inaccessibility of the system, and the increased fragmentation of healthcare. Taking these issues into account, if further research pinpoints the same troubles, policy-making efforts may be directed towards recreating a more detailed and user-friendly method of making advance directives in the United States for patient use. Further analysis can be done to assess the
preparation of physicians in discussing advance directives, and to see if the education they are receiving on this topic is effective in practice. Lastly, the fragmentation of healthcare and the changed role of primary-care physicians and growing emphasis on the use of hospitalists is another problem in itself within the domestic healthcare system. Although the implications of this fragmentation contribute to the deterioration of trust in the patient-doctor relationship, the scope of this problem lies outside of this analysis on advance directives, but would additionally be worth analyzing.
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