Psychological Determinants of Physician Variation in End-of-Life Treatment Intensity: A Systematic Review and Meta-Synthesis

• Published in: Journal of general internal medicine : JGIM Vol. 38; no. 6; pp. 1516 - 1525
• Main Authors: George, Login S., Epstein, Ronald M., Akincigil, Ayse, Saraiya, Biren, Trevino, Kelly M., Kuziemski, Alexandra, Pushparaj, Lavanya, Policano, Elizabeth, Prigerson, Holly G., Godwin, Kendra, Duberstein, Paul
• Format: Journal Article
• Language: English
• Published: Cham Springer International Publishing 01.05.2023; Springer Nature B.V
• Subjects: Aversion; Avoidance; Communication; Death; End of life; Environmental factors; Health services; Humans; Identity; Internal Medicine; Life extension; Life span; Medicine; Medicine & Public Health; Palliative care; Patients; Pharmaceutical Preparations; Physicians; Psychological factors; Qualitative research; Synthesis; Systematic Review; Terminal Care; physician behavior; practice variation; physician psychology; aggressive care; care intensity; decision-making; low-value care; physician variation; futile care; end-of-life care
• ISSN: 0884-8734; 1525-1497
• DOI: 10.1007/s11606-022-08011-4

Background Physicians treating similar patients in similar care-delivery contexts vary in the intensity of life-extending care provided to their patients at the end-of-life. Physician psychological propensities are an important potential determinant of this variability, but the pertinent literature has yet to be synthesized. Objective Conduct a review of qualitative studies to explicate whether and how psychological propensities could result in some physicians providing more intensive treatment than others. Methods Systematic searches were conducted in five major electronic databases—MEDLINE ALL (Ovid), Embase (Elsevier), CINAHL (EBSCO), PsycINFO (Ovid), and Cochrane CENTRAL (Wiley)—to identify eligible studies (earliest available date to August 2021). Eligibility criteria included examination of a physician psychological factor as relating to end-of-life care intensity in advanced life-limiting illness. Findings from individual studies were pooled and synthesized using thematic analysis, which identified common, prevalent themes across findings. Results The search identified 5623 references, of which 28 were included in the final synthesis. Seven psychological propensities were identified as influencing physician judgments regarding whether and when to withhold or de-escalate life-extending treatments resulting in higher treatment intensity: (1) professional identity as someone who extends lifespan, (2) mortality aversion, (3) communication avoidance, (4) conflict avoidance, (5) personal values favoring life extension, (6) decisional avoidance, and (7) over-optimism. Conclusions Psychological propensities could influence physician judgments regarding whether and when to de-escalate life-extending treatments. Future work should examine how individual and environmental factors combine to create such propensities, and how addressing these propensities could reduce physician-attributed variation in end-of-life care intensity.