A total of 70 of the 100 surveyed DOs responded to the questionnaire mailings. Four of these respondents declined participation, citing either retirement or personal reasons. Therefore, 66 returned surveys could be analyzed for the present study. However, there are fewer than 66 responses to many of the items that were evaluated because of missing data for some questions on some questionnaires.
The average (SD) age of the participating DOs was 50 (10) years. There was an average of 16 (9) years since residency training for these DOs. A majority of responding physicians (35 [53%]) were men (
Table 1). Of those who identified their primary specialty (n=58), a majority (35 [60%]) listed family practice. The largest religious group represented (n=64) was Roman Catholic, with 29 DOs (45%) reporting that religious affiliation.
Sixty-four respondents (97%) reported that they had completed an EPEC training program. Responding DOs provided end-of-life care to an average of 18 (36) patients annually (range, 0-200). Thirty-four percent of respondents indicated they had participated in interdisciplinary teams for more than 75% of the patients whom they cared for at the end of life.
Data on the prevalence of advance directives discussions initiated by survey participants are summarized in
Table 2.
Table 3 provides additional data regarding such communications with patients and their families. Twenty-five DOs (39%) indicated they had discussed advance directives with more than 75% of their patient population. Most responding DOs (46 [73%]) were likely to discuss advance directives with patients who were older than 65 years. Most of the physicians (52 [82%]) were also likely to discuss advance directives with patients who had serious illnesses. The vast majority of DOs (58 [92%]) indicated they documented patients' advance directives, while 45 (70%) of the physicians stated that they reviewed and updated this information. Only 3 DOs (5%) reported billing for these services.
Twenty-six DOs (43%) indicated they always followed specific directions for end-of-life care from a patient after that patient loses the capacity to make healthcare decisions. Twenty-eight DOs (46%) reported that they followed these directions most of the time. On a scale of 0 to 10, with 10 as the highest level of comfort, the results of our survey indicate that participating DOs had on average a comfort level of 8.8 in discussing the dying process with their patients.
A series of questions on the survey form addressed interpersonal relationships and end-of-life care.
Table 4 presents the number of DOs who reported encouraging particular behaviors in patients at the end of life. Fifty-five (87%) of the participating DOs “always” or “most of the time” encouraged patients with terminal conditions to complete any unfinished personal business. Fewer DOs said they always or most of the time encouraged dying patients to reconcile interpersonal relationships through forgiveness (33 [52%]) or thankfulness and love (44 [70%]).
Table 5 presents the responses of participating DOs to survey questions about specific uses of osteopathic medical diagnoses and OM techniques for patients at the end of life. Twenty-six DOs (41%) reported that they used their osteopathic diagnostic skills to assess respiratory function, and 31 DOs (49%) said they used OM techniques to improve respiratory function in patients receiving comfort care.
Among survey participants, the OM techniques most frequently used to manage respiratory function in patients at the end of life with were lymphatic pump as well as rib-raising and soft-tissue (myofascial release) techniques.
Of the 31 DOs who reported that they used OM techniques to improve respiratory function, 11 (36%) said they believed these treatments were often effective (
Table 6). Nineteen DOs (61%) said they believed the OM techniques were sometimes effective at improving respiratory function. The remaining physicians believed that these treatments were seldom effective.
Thirty-six responding DOs (57%) reported using osteopathic diagnostic skills to assess pain in patients at the end of life, while 52 (82%) said they used OM techniques to relieve pain in patients receiving comfort care (
Table 5). The most frequently mentioned OM techniques listed by DOs to relieve pain in patients at the end of life were counterstrain, muscle energy, and soft-tissue (indirect) techniques, as well as simple touch or palpation.
Of the 50 DOs who rated the effectiveness of their use of osteopathic manipulative treatment (OMT) to treat patients with pain symptoms at the end of life, 19 (38%) indicated that these treatments were always or often effective at relieving pain (
Table 6). Twenty-nine responding DOs (58%) believed that OM techniques were sometimes effective in treating these patients. The remaining two physicians said that OM techniques were seldom or never effective in relieving pain in dying patients. The comfort level of DOs in carrying out pain management for patients at the end of life averaged 8.4 (on a scale of 0 to 10 [highest level of comfort]).
Thirty-three DOs (52%) said they used OM techniques to improve lymphatic function in patients with terminal conditions (
Table 5). The techniques most frequently used to improve lymphatic function in dying patients were lymphatic, thoracic, or pedal pump (ie, Dalrymple treatment); effleurage; and myofascial release.
Surveyed DOs were asked on a scale of 1 (unimportant) to 5 (very important) to rate the importance of the four core tenets of osteopathic medicine
3 when applied to end-of-life care. More than 90% of participants rated each of the four osteopathic tenets as important (rating of 4 or 5). Fifty-eight DOs (89%) said they believed that the principle philosophies of osteopathic medicine better prepared them for performing end-of-life care. Forty-eight DOs (79%) agreed that the use of their osteopathic diagnostic and treatment skills augmented their ability to provide quality patient care.
At the end of the survey, DOs were asked to provide education topics that they believed would be most useful in developing and expanding their skills when caring for patients with terminal illnesses. The majority of responses were classified into three broad categories: communication, patient management, and regulatory or legal issues. Communication topics included discussing patient care with family members, helping resolve patient-family conflicts, and communicating unpleasant information. Topics of patient management—which were most often related to caring for patients experiencing pain—included the use of specific OM techniques for comfort care, formulating goals of care, developing an interdisciplinary team, withdrawing care from dying patients, and treating patients with dementia and delirium and those who are unresponsive to intervention. Finally, the regulatory or legal issues submitted by participants included maximizing monetary resources for care, financial and estate planning for patients at the end of life, and discussing funeral and burial preferences with patients' families.