Advance Care Planning and the Problem of Overtreatment
Nancy S. Jecker
Health professionals caring for critically ill and dying patients face daunting challenges. Deciding what treatments to recommend is complex for providers, and choosing among the available options can feel overwhelming for the patient and family. Even more challenging is the task of deciding with patients and families when treatments are no longer benefitting the patient and should be stopped. Shifting the focus of care from battling disease and prolonging life to providing palliative and comfort care often represents a pivotal moment in the trajectory of a patient's disease. Yet this pivotal moment is often poorly timed, coming later than it would ideally come. Providers often put off decisions to discuss withdrawing aggressive interventions, continuing to treat patients against their better judgment.
Overtreatment is a major concern among health professionals, and a source of moral distress. In the 1990s, Solomon et al. (1993) first found evidence that the majority of physicians and nurses were concerned about treatments that were overly burdensome, compared with only a small minority worried about undertreating patients. More recent findings show that overtreatment continues to be a major concern among providers (Sirovich, Woloshin, & Schwartz, 2011). Overtreatment often results in moral distress for health care professionals, especially in situations involving prolonging life in dying patients, inflicting harm, and dehumanizing patients (Wilkinson, 1987).
Overtreatment is driven by a variety of factors, including reimbursement incentives that encourage providers to perform more procedures, while offering little or no remuneration for sitting down and talking with patients about advance care planning (ACP) and health care goals. Providers who reported inadequate time to spend with patients also reported increasing their ordering of tests and treatments, which is likely substituting for explanation and reassurance (Grady, 2011). Limited professional experience, especially the experience of supporting a dying patient, may provide an additional reason for overly aggressive treatment (O'Kane, 2011).
One result of failing to spend time discussing health care values and goals with patients is that when patients become incapacitated, ACP has usually not occurred. In such cases, treatment decisions are left by default to family members, who may have little or no clear direction from the patient about treatment preferences. Family members may feel obligated to “do everything possible,” or may think this is the only or best way to demonstrate their love for and devotion to the patient (Schneiderman, Faber- Langendoen, & Jecker, 1994). Under such circumstances, it is easy to see how providers can end up giving patients more treatment than they believe is in the patient's best interest, and continuing with aggressive treatment well past the point of helping the patient. When a well-intentioned family member presses for aggressive interventions, providers often feel reluctant to go against that person's wishes. All of these factors together can conspire to make it more likely that providers find themselves doing more procedures, ordering more tests, and making more referrals than they ideally believe they should (Sirovich et al., 2011).
This chapter addresses the problem of overtreatment by focusing on the importance of ACP as one of many tools needed to improve the care of critically ill patients. I first clarify the definition of overtreatment and why it is a problem for patients, families, and the health care team. Next, I draw attention to two important values that underlie ACP. First, the value of honesty, which supports engaging in critical conversations with patients and families, and coming to terms with the reality of a patient's situation. Second, I consider the fragile thing called hope and explore the relationship between hope and honesty. I argue that, properly understood, hope aligns with honesty, offering the prospect of meaningful closure for patients and families.