Community physicians who provide terminal care

Background: Most dying patients are treated by physicians in community prac tice, yet studies of terminal care rarely include these physicians. Objective: To examine the frequency of life-sustaining treatment use and de scribe what factors influence physicians' treatment decisions in community- based practices. Methods: Family members and treating physicians for decedents 65 years and older who died of cancer, congestive heart failure, chronic lung disease, c irrhosis, or stroke completed interviews about end-of-life care in communit y settings. Results: Eighty percent of eligible family and 68.8% of eligible physicians participated (N = 165). Most physicians were trained in primary care and 8 5.4% were primary care physicians for the decedents. Physicians typically k new the decedent a year or more (68.9%), and 93.3%;, treated them for at le ast 1 month before death. In their last month of life, 2.4% of decedents re ceived cardiopulmonary resuscitation, 5.5% received ventilatory support, an d 34.1% received hospice care. Family recalled a discussion of treatment op tions in 78.2% of deaths. Most discussions (72.1%) took place a month or mo re before death. Place of death, cancer, and having a living will were inde pendent predictors of less aggressive treatment before death. Physicians be lieved that advanced planning and good relationships were the major determi nants of good decision making. Conclusions: Community physicians use few life-sustaining treatments for dy ing patients. Treatment decisions are made in the context of long-term prim ary care relationships, and living wills influence treatment decisions. The choice to remain in community settings with a familiar physician may influ ence the dying experience.