In July 2022, 84-year-old retired entrepreneur James O’Brien broke his hip following a fall at his home in rural New Mexico (1). Upon being wheeled to the hospital to receive treatment, Mr. O’Brien—who was already dying of heart failure and advanced lung disease—declined to receive surgery for his injury, choosing to “die comfortably” rather than suffer from post-surgical complications. The physicians tasked with caring for Mr. O’Brien, however, attempted to go against his wishes, calling his daughter Jennifer with the expectation that she would convince Mr. O’Brien to accept a hip operation. Ultimately, Jennifer opted to support her father’s decision instead and placed him in a local hospice where he would spend the final months of his life. Although James O’Brien died in the way that he desired, thousands of other end-of-life patients are not given the same liberties; specifically, those who are rendered incapable of making their own medical decisions often become subjected to undergoing invasive treatments that cause them to die painfully rather than peacefully (2). This article analyzes the underlying causes and ethical consequences of the administration of aggressive end-of-life medical care.
Aggressive end-of-life care is defined as any form of medical treatment aimed at prolonging dying patients’ lives rather than improving their quality of life; examples include chemotherapy, invasive surgeries, feeding tubes, and mechanical ventilation (3).
When terminally ill patients who are no longer able to make medical decisions for themselves permit their physicians to choose on their behalf, these patients end up being more likely to endure aggressive or experimental treatments (2). However, previous studies have demonstrated that such invasive modes of intervention lead to increased physical and psychological distress prior to death (4). This evidence thus indicates that patients who opt to allow their physicians to choose their treatments may not be receiving the end-of-life care that they would have desired. Moreover, these individuals are likely not dying in the place that they would have wished; aggressive interventions require prolonged stays in intensive care units or emergency rooms, but 70% of patients have been shown to demonstrate a preference for dying at home rather than in the hospital (5). Evidently, a disconnect exists between the types of care dying patients want and the treatments their physicians actually end up administering.
So why are physicians opting for aggressive end-of-life interventions despite knowing that their patients would likely desire more palliative ones? For starters, medical professionals often believe that the “default” purpose of hospital care is to prolong patients’ lives. Thus, electing to not administer aggressive treatment is perceived by many physicians as a symbol of giving up on their patients. A qualitative study interviewing internal medicine doctors revealed this notion; as one physician put it, patients “came to the hospital to get well” and “were not ready to die,” making it his obligation to utilize whatever means necessary to prevent death from occurring (6). Additionally, discussing the topic of letting patients die is an unpleasant confrontation that medical professionals prefer to avoid, especially when people close to patients such as family members desire aggressive treatment to be continued. Although some individuals—such as in the case of Jennifer O’Brien—opt to permit and accept the deaths of their loved ones, many others choose to interpret grim prognostic information in an overly optimistic light, insisting that their ailing relatives will be able to recover even when told otherwise by medical professionals (7). Evidently, deciding to allow death to happen brings the possibility of legal backlash against physicians and the hospitals they work for; thus, it is no surprise that aggressive treatments are so frequently maintained for end-of-life patients.
Ultimately, the controversy surrounding aggressive end-of-life interventions cannot simply be blamed on the physicians who decide to administer them. Instead, this dilemma is rooted in deeper systemic and social issues that coerce these doctors into making specific medical decisions, even if such choices serve to harm rather than help their patients. Further discussion that aims to improve the ethicality and rationality behind end-of-life care is thus necessary to ensure that patients do not continue to undergo unnecessary suffering in the final moments of their lives.
Reviewed by Kelly Ma
Graphic by Shanzeh Sheikh
References
Span, P. (2023, March 14). Aggressive Medical Care Remains Common at Life’s End. The New York Times. https://www.nytimes.com/2023/03/14/health/end-of-life-care-hospice.html.
Finnegan, J. (2019, June 18). Patients Get More Aggressive End-of-Life Interventions When Physicians Take Over Decision Making, Study Finds. Fierce Healthcare. https://www.fiercehealthcare.com/practices/patients-get-more-aggressive-end-life-treatment-when-physicians-take-over-decision-making.
Gallo, J. J., Abshire, M., Hwang, S., & Nolan, M. T. (2019). Advance Directives, Medical Conditions, and Preferences for End-of-Life Care Among Physicians: 12-year Follow-Up of the Johns Hopkins Precursors Study. Journal of Pain and Symptom Management, 57(3), 556–565. https://doi.org/10.1016/j.jpainsymman.2018.12.328.
Mohammed, A. A., Al-Zahrani, O., Salem, R. A., & Elsayed, F. M. (2019). Aggressive Care at the End of Life; Where Are We?. Indian Journal of Palliative Care, 25(4), 539–543. https://doi.org/10.4103/IJPC.IJPC_59_19.
Where People Want to Die (n.d.). Healthtalk. https://healthtalk.org/experiences/living-dying/where-people-want-to-die/.
Dzeng, E., Dohan, D., Curtis, J. R., Smith, T. J., Colaianni, A., & Ritchie, C. S. (2018). Homing in on the Social: System-Level Influences on Overly Aggressive Treatments at the End of Life. Journal of Pain and Symptom Management, 55(2), 282–289.e1. https://doi.org/10.1016/j.jpainsymman.2017.08.019.
Zier, L. S., Sottile, P. D., Hong, S. Y., Weissfield, L. A., & White, D. B. (2012). Surrogate decision makers' interpretation of prognostic information: a mixed-methods study. Annals of Internal Medicine, 156(5), 360–366. https://doi.org/10.7326/0003-4819-156-5-201203060-00008.