Practice Patterns of Osteopathic Physicians Providing End-of-Life Care: A Survey-Based Study

David C. Mason; Shauna McElrath; Carol Penn-Erskine; Veronika Kramer-Feeley; Sherry C. Pomerantz; Thomas A. Cavalieri

doi:10.7556/jaoa.2008.108.5.240

Abstract

Context: In 1996, the American Medical Association drafted and organized the Education for Physicians on End-of-Life Care (EPEC) curriculum. Leadership in the osteopathic medical profession has similarly recognized the goals of EPEC—resulting in the development of Osteopathic-EPEC, which incorporates the core tenets of osteopathic medicine.

Objective: To assess the impact of EPEC training and the integration of osteopathic principles and practice in end-of-life care provided by osteopathic physicians (DOs).

Methods: Osteopathic physicians who participated in the 2002 and 2003 AOA (American Osteopathic Association) End-of-Life Care—National Osteopathic Workshops were surveyed (N=100) on the use of advance directives and on their application of the tenets of osteopathic medicine, including the use of osteopathic manipulative techniques, for terminally ill patients.

Results: More than 90% of responding DOs (n=66) ranked each of the four core tenets of osteopathic medicine as important. Among completed responses, 58 DOs (89%) said they believed the tenets and philosophy of osteopathic medicine better prepared them to provide end-of-life care. Forty-eight DOs (79%) agreed that the use of osteopathic diagnostic and treatment skills augmented their ability to provide quality care for terminally ill patients.

Conclusion: Osteopathic physicians indicated that the tenets of osteopathic medicine improve their effectiveness in providing quality end-of-life care to patients. However, fewer than half of surveyed DOs who used osteopathic manipulative techniques to relieve pain and manage the physical symptoms associated with the dying process reported that the techniques are often or always effective.

More than 1 million Americans die each year.¹ There is a large discrepancy between how Americans die and how they say they would like to die. Most people say they would like to have a quick, painless death—or to die in their sleep. However, in the United States, fewer than 10% of people die suddenly; more than 90% of people die from chronic illnesses with protracted or complicated courses.¹

Since the mid-1990s, the medical community in the United States has focused on developing education protocols that can be used to ensure physician confidence and competence in providing quality care for terminally ill patients. In 1996, the American Medical Association (AMA), in association with the Robert Wood Johnson Foundation, drafted and organized the Education for Physicians on End-of-Life Care (EPEC) curriculum in an effort to reduce the disparity between patients' wishes and their actual experiences at the end of life.¹

The EPEC serves as a training guide for continuing medical education. It is comprised of various modules that focus on specific aspects of palliative care, including symptom and pain management; improved communication with patients and their families; and identification of such important life issues as interpersonal relationships, expressions of love, and time for closure.¹

The American Osteopathic Association (AOA) has recognized the importance of the EPEC and its objective to provide comprehensive education material to physicians.² Important issues related to the development of the Osteopathic-EPEC² include the use of the osteopathic structural examination for clinical assessment of patients at the end of life; the use of specific osteopathic manipulative (OM) techniques for symptom management; and the application of the four core tenets of osteopathic medicine. These tenets, as summarized in a statement developed by the Kirksville College of Osteopathy and Surgery³ in 1953, are the following:

The body is a unit.
The body possesses self-regulatory mechanisms.
Structure and function are reciprocally interrelated.
Rational therapy is based on an understanding of the body unit, self-regulatory mechanisms, and the interrelationship of structure and function.

In addition to developing the Osteopathic-EPEC, the AOA is committed to ensuring that osteopathic principles and practice (OPP) are applied to end-of-life care. In 2000, the AOA revised and endorsed 13 principles of end-of-life care developed by the Milbank Memorial Fund to ensure patient comfort and quality of life.⁴ These principles include, among others, physical relief of symptoms; management of psychological, social, and spiritual or religious problems; maintenance of dignity and independence for patients and caregivers; and sensitivity to and respect for the wishes of patients and their families.⁴ These aspects of end-of-life care were also addressed in a theme issue of JAOA—The Journal of the American Osteopathic Association (2001;101:585-624), “Focus on End-of-Life Care.”^4-9

End-of-life care is applied to patients of all ages and terminal disease statuses. It is initiated when the objective of care shifts from curative to palliative. Effective management of pain and other symptoms at the end of life can be achieved with the application of the concept of “total-pain management,” which encompasses not only physical noxious stimuli, but also emotional discomfort, interpersonal conflicts, and lack of acceptance for mortality.¹⁰ These components are often interrelated. Many patients at the end of life—often together with their families and friends—may benefit from concentrating on four concepts articulated by Ira Byock, MD¹¹: forgiveness, thankfulness, love, and saying goodbye.

Holistic thinking is a necessity for providing comprehensive end-of-life care.⁵ Ideally, complete end-of-life care involves an interdisciplinary team of physicians, nurses, hospice personnel, social workers, and religious, legal, and ethical advisors. As part of their standard education, osteopathic physicians (DOs) are specially trained to recognize and apply holistic philosophies that emphasize the importance of treating the physical, spiritual, and emotional needs of the patient.¹²

Quality care at the end of life has been part of osteopathic medical philosophy since its origins. Andrew Taylor Still, MD, DO,¹³ the founder of osteopathic medicine, addressed the role of the physician in cases of terminal illness, emphasizing that physicians are to provide emotional support and encouragement to patients with end-stage medical conditions. Dr Still¹³ also emphasized the importance of providing hope to patients while maintaining realistic goals for disease management and patient care.

In consultation with representatives of the AOA End-of-Life Care Advisory Committee (now known as the AOA Council on Palliative Care Issues), the present survey was designed to assess DOs' habits of incorporating OPP into end-of-life care. The survey was also designed to examine DOs' levels of comfort and competency regarding the complex issues presented in providing end-of-life care, as well as to evaluate the applicability of osteopathic tenets and OM techniques in this healthcare setting.

The goal of acquiring this information was to identify education issues that could enhance training programs for DOs who provide end-of-life care.

Methods

One hundred potential respondents were selected from participants at the AOA End-of-Life Care—National Osteopathic Workshop (ELC-NOW) I conference, held in Oak Brook, Ill, in June 2002, and the ELC-NOW II conference, held in Portland, Ore, in June 2003. These DOs, all of whom specialize in end-of-life care, were surveyed by mail. These physicians were also selected based on their additional training in end-of-life care, either through their participation with the AOA End-of-Life Care Advisory Committee or with the EPEC curriculum. The present study was approved by the Institutional Review Board of the University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine in Stratford.

A questionnaire was developed to assess the impact of the core tenets of osteopathic medicine on end-of-life care (Appendix). The survey instrument included questions on demographic information, use of advance directives (eg, living wills) with various patient populations, application of the tenets of osteopathic medicine, and the use of OM techniques in patient assessment and the clinical management of physical symptoms typically experienced at the end of life.

Each of the 100 surveys mailed to potential participants included a cover letter explaining the survey's purpose and a coded return-addressed envelope. Completed surveys and envelopes were separated by students to ensure participant anonymity; responses were entered into computers without identifiers.

After 4 weeks, a second mailing was sent to those physicians who did not respond to the first mailing. After an additional 4 weeks, the remaining nonresponding physicians were contacted by telephone or electronic mail. The list of physician names and corresponding numerical codes was destroyed at the conclusion of the study.

The data collected in the present survey were analyzed by SPSS statistical software (version 12.0; SPSS Inc, Chicago, Ill) for such descriptive statistics as percentage, mean, and standard deviation. The analyzed data were stored in a locked filing cabinet in the Department of Medicine at the University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine.

Results

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.

Table 1

Demographic Characteristics of Osteopathic Physicians Participating in Survey of End-of-Life Care (N=66) *

Characteristic^†	No. (%)
▪ Sex
*□ Men*	*35 (53.0)*
□ Women	31 (47.0)
▪ Religion (n=64)
□ Roman Catholic	29 (45.3)
*□ Protestant*	*19 (29.7)*
□ Other Christian	5 (7.8)
*□ Jewish*	*4 (6.3)*
□ Other	7 (10.9)
▪ Primary Specialty (n=58)
□ Family practice	35 (60.3)
*□ Internal medicine*	*15 (25.9)*
□ Geriatrics	8 (13.8)

*The sample sizes for religion and primary specialty vary from the total sample size, reflecting the number of participating osteopathic physicians who answered the survey questions for those characteristics.

†Other characteristics: age, mean (SD) = 50 (10) y; age, range = 29-72 y; time since residency, mean (SD) = 16 (9) y; time since residency, range = 1-34 y.

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Table 1

Demographic Characteristics of Osteopathic Physicians Participating in Survey of End-of-Life Care (N=66) *

Characteristic^†	No. (%)
▪ Sex
*□ Men*	*35 (53.0)*
□ Women	31 (47.0)
▪ Religion (n=64)
□ Roman Catholic	29 (45.3)
*□ Protestant*	*19 (29.7)*
□ Other Christian	5 (7.8)
*□ Jewish*	*4 (6.3)*
□ Other	7 (10.9)
▪ Primary Specialty (n=58)
□ Family practice	35 (60.3)
*□ Internal medicine*	*15 (25.9)*
□ Geriatrics	8 (13.8)

*The sample sizes for religion and primary specialty vary from the total sample size, reflecting the number of participating osteopathic physicians who answered the survey questions for those characteristics.

†Other characteristics: age, mean (SD) = 50 (10) y; age, range = 29-72 y; time since residency, mean (SD) = 16 (9) y; time since residency, range = 1-34 y.

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.

Table 2

Number of Osteopathic Physicians Who Discussed Advance Directives With Patients, by Proportion of Patient Population (n=65) *

Population Proportion, %	No. (%)
0-25	19 (29.2)
*26-50*	*11 (16.9)*
51-75	10 (15.4)
*76-100*	*25 (38.5)*

*One participant did not answer this survey question.

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Table 2

Number of Osteopathic Physicians Who Discussed Advance Directives With Patients, by Proportion of Patient Population (n=65) *

Population Proportion, %	No. (%)
0-25	19 (29.2)
*26-50*	*11 (16.9)*
51-75	10 (15.4)
*76-100*	*25 (38.5)*

*One participant did not answer this survey question.

Table 3

Number of Osteopathic Physicians Who Discussed Advance Directives With Given Proportion of Their Patient Population (n=63) *

Patients/Families	No. (%)
▪ Patients
*□ New*	*22 (34.9)*
□ Age >65 y	46 (73.0)
*□ With serious illness*	*52 (82.5)*
▪ Patients' Families	30 (47.6)

*The sample size reflects the number of participating osteopathic physicians who answered the survey questions for advance directives.

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Table 3

Number of Osteopathic Physicians Who Discussed Advance Directives With Given Proportion of Their Patient Population (n=63) *

Patients/Families	No. (%)
▪ Patients
*□ New*	*22 (34.9)*
□ Age >65 y	46 (73.0)
*□ With serious illness*	*52 (82.5)*
▪ Patients' Families	30 (47.6)

*The sample size reflects the number of participating osteopathic physicians who answered the survey questions for advance directives.

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 4

Number of Osteopathic Physicians Who Encouraged Particular Behaviors in Patients at End of Life (n=63) *

	Frequency of Encouragement, No. (%)
Patient Behavior	Always	Most of the Time	Sometimes	Never/Rarely
Complete unfinished business	33 (52.4)	22 (34.9)	5 (7.9)	3 (4.8)
*Seek/bestow forgiveness*	*16 (25.4)*	*17 (27.0)*	*18 (28.6)*	*12 (19.0)*
Express thankfulness/love	21 (33.3)	23 (36.5)	12 (19.0)	7 (11.1)

*The sample size reflects the number of participating osteopathic physicians who answered the survey questions for encouragement of patient behaviors.

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Table 4

Number of Osteopathic Physicians Who Encouraged Particular Behaviors in Patients at End of Life (n=63) *

	Frequency of Encouragement, No. (%)
Patient Behavior	Always	Most of the Time	Sometimes	Never/Rarely
Complete unfinished business	33 (52.4)	22 (34.9)	5 (7.9)	3 (4.8)
*Seek/bestow forgiveness*	*16 (25.4)*	*17 (27.0)*	*18 (28.6)*	*12 (19.0)*
Express thankfulness/love	21 (33.3)	23 (36.5)	12 (19.0)	7 (11.1)

*The sample size reflects the number of participating osteopathic physicians who answered the survey questions for encouragement of patient behaviors.

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.

Table 5

Number of Osteopathic Physicians Who Used Osteopathic Diagnostic or Manipulative Techniques, by End-of-Life Pathologic Condition (n=63) *

	No. (%)
Pathologic Condition	Osteopathic Diagnostic Techniques	OM Techniques	Most Common OM Techniques
Lymphatic^†	NA	33 (52.4)	Pedal pump, effleurage, lymphatic pump, myofascial technique, thoracic pump
*Pain*	*36 (57.1)*	*52 (82.5)*	*Counterstrain, muscle energy, soft-tissue (indirect) techniques, simple touch or palpation*
Respiratory	26 (40.6)‡	31 (49.2)	Lymphatic pump, rib raising, soft-tissue (myofascial) techniques

Abbreviation: OM, osteopathic manipulative.

*The sample size reflects the number of participating osteopathic physicians who answered the survey questions for use of osteopathic diagnostic and manipulative techniques.

†Participating osteopathic physicians were not asked to indicate their use of osteopathic diagnostic techniques in assessment of lymphatic conditions.

‡n=64

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Table 5

Number of Osteopathic Physicians Who Used Osteopathic Diagnostic or Manipulative Techniques, by End-of-Life Pathologic Condition (n=63) *

	No. (%)
Pathologic Condition	Osteopathic Diagnostic Techniques	OM Techniques	Most Common OM Techniques
Lymphatic^†	NA	33 (52.4)	Pedal pump, effleurage, lymphatic pump, myofascial technique, thoracic pump
*Pain*	*36 (57.1)*	*52 (82.5)*	*Counterstrain, muscle energy, soft-tissue (indirect) techniques, simple touch or palpation*
Respiratory	26 (40.6)‡	31 (49.2)	Lymphatic pump, rib raising, soft-tissue (myofascial) techniques

Abbreviation: OM, osteopathic manipulative.

*The sample size reflects the number of participating osteopathic physicians who answered the survey questions for use of osteopathic diagnostic and manipulative techniques.

†Participating osteopathic physicians were not asked to indicate their use of osteopathic diagnostic techniques in assessment of lymphatic conditions.

‡n=64

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.

Table 6

Osteopathic Physicians' Ratings of Effectiveness of Osteopathic Manipulative Techniques, by End-of-Life Pathologic Condition

	No. (%)
Pathologic Condition*	Always Effective	Often Effective	Sometimes Effective	Seldom Effective	Never Effective
Pain (n=50)	5 (10.0)	14 (28.0)	29 (58.0)	1 (2.0)	1 (2.0)
*Respiratory (n=31)*	0	*11 (35.5)*	*19 (61.3)*	*1 (3.2)*	0

*Participating osteopathic physicians were not asked to rate the effectiveness of osteopathic manipulative (OM) techniques in improving lymphatic function. Sample sizes reflect the number of participating osteopathic physicians who responded in the survey that they used OM techniques for treating patients with pain or respiratory conditions and who responded to the question about the effectiveness of OM techniques for those conditions.

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Table 6

Osteopathic Physicians' Ratings of Effectiveness of Osteopathic Manipulative Techniques, by End-of-Life Pathologic Condition

	No. (%)
Pathologic Condition*	Always Effective	Often Effective	Sometimes Effective	Seldom Effective	Never Effective
Pain (n=50)	5 (10.0)	14 (28.0)	29 (58.0)	1 (2.0)	1 (2.0)
*Respiratory (n=31)*	0	*11 (35.5)*	*19 (61.3)*	*1 (3.2)*	0

*Participating osteopathic physicians were not asked to rate the effectiveness of osteopathic manipulative (OM) techniques in improving lymphatic function. Sample sizes reflect the number of participating osteopathic physicians who responded in the survey that they used OM techniques for treating patients with pain or respiratory conditions and who responded to the question about the effectiveness of OM techniques for those conditions.

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 medicine³ 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.

Comment

The objective of the present study was to assess the habits of DOs in applying the tenets of osteopathic medicine to terminally ill patients, as well as to evaluate the applicability of OPP and OMT in this healthcare setting. We also sought to identify areas for improvement in the education process of DOs who care for patients in the final stages of life. Our selection of EPEC-trained DOs was meant to concentrate our efforts on those physicians in the osteopathic medical profession who would have adequate experience treating this patient population. We did not intend to evaluate how well DOs trained in the Osteopathic-EPEC curriculum incorporate OPP into their practices. If that had been the intent of the present survey, a “non-EPEC” group of DOs would have been surveyed for comparison.

Ninety-seven percent of the DOs responding to the present survey had participated in an EPEC course. These highly trained physicians were given an opportunity in the survey to list any education topics they thought would be important for the expansion and improvement of future training curricula for end-of-life care. Their responses were broadly categorized into three areas: communication, patient management, and regulatory or legal issues. The latter topic included burial rites, estate planning, and financial resources for patients with limited incomes.

Communication and regulatory or legal issues are complex and challenging topics that can be best addressed by incorporating a variety of individuals and organizations into an interdisciplinary team. The “Focus on End-of-Life Care” theme in the October 2001 issue of JAOA^4-9 is a valuable resource for physicians who wish to familiarize themselves with optimal communication strategies and ethical issues applied to end-of-life care for patients.

Although a majority of the DOs participating in our survey said they document and update patients' advance directives, only 5% of the physicians said they bill for these services. This finding indicates that DOs may offer many cognitive and behavioral services that are beneficial to patients, but they do not seek reimbursement for providing these forms of care. Perhaps many DOs feel ethically challenged to bill for services if they perceive these services to be in-kind or procedural services. Alternatively, perhaps the physicians do not know how to bill and code for these services.

Efficient delivery of medical services will dictate that conscientious physicians accurately bill patients for all services rendered to ensure a steady revenue stream, likewise documenting these services to maintain quality indicators that will become public record. The Osteopathic-EPEC curriculum includes training in billing and coding in order to familiarize physicians with these procedures when applied to providing end-of-life care and advance directives.

Patient treatment with OMT allows for nonpharmacologic management of physical symptoms that occur at the end of life—management that can alleviate suffering and improve quality of life for terminally ill patients. Many DOs reported use of osteopathic diagnostic and treatment skills to relieve symptoms of dyspnea, lymphedema, and pain for their patients at the end of life. Osteopathic manipulative techniques can be used by the primary care provider, offering patients an interpersonal bond at the end of life through therapeutic touch and comforting techniques.

The benefits of OMT offer an excellent opportunity for the osteopathic medical profession to develop a curriculum of OM techniques taught in an algorithmic manner or in a series of learning modules. Such a curriculum would facilitate the incorporation of specific OM techniques into end-of-life care for patients. Furthermore, end-of-life care can serve as an open field for outcomes research designed to identify those OM techniques that would most reduce the need for pharmacologic intervention, resulting in improved quality of life and greater dignity for patients during the dying process.

Approximately half of survey respondents said they believed that osteopathic diagnostic techniques are appropriate to assess pain and physical symptoms in this patient population. Fewer respondents believed that the application of OMT was effective in managing these problems. It is possible that this perceived lack of effectiveness of OMT may be related to the incorrect application of OM techniques rather than to a lack of efficacy for the procedures.

Based on the survey responses of DOs who use OMT, there seems to be a disconnect between osteopathic diagnosis, application of OMT, and reevaluation. For example, 82% of participating DOs stated that they use OMT to treat patients with pain, while only 57% stated that they use osteopathic diagnostic skills to assess pain. This finding is inconsistent with the expectation that the application of OMT should occur only after the accurate diagnosis of somatic dysfunction. Thus, there is a need to provide research-based evidence that various OM techniques, when properly administered, are effective in both assessment of somatic dysfunction and patient treatment.

Conclusion

Osteopathic physicians responding to our survey indicated that the core tenets of osteopathic medicine make them more effective in providing quality end-of-life care for patients. However, fewer than half of the DOs who used OM techniques to relieve pain and manage the physical symptoms associated with the dying process believed that these techniques were often or always effective.

In the past, concerns over maintaining the distinctiveness of the osteopathic medical profession have often focused on either philosophical differences with allopathic medicine or the use of OM techniques in osteopathic medicine. Optimizing the advantages of osteopathic medicine requires that these two issues be viewed as inseparable and integrated as much as possible. End-of-life care presents the opportunity to apply OMT more appropriately in the context of OPP for the more effective treatment of patients.

Appendix

In consultation with representatives of the American Osteopathic Association's End-of-Life Care Advisory Committee (now known as the AOA Council on Palliative Care Issues), the present survey was designed to assess the habits of osteopathic physicians (DOs) in incorporating osteopathic principles and practice into patient care at the end of life. The survey was also designed to collect self-assessment data on DOs' levels of comfort and competency regarding the complex issues of end-of-life care, as well as to evaluate the applicability of osteopathic tenets and osteopathic manipulative techniques in this healthcare setting.

The instrument was sent via mail to 100 potential subjects who were selected from participants at the 2002 AOA End-of-Life Care—National Osteopathic Workshop (ELC-NOW) I conference and the 2003 ELC-NOW II conference.

A total of 70 of the 100 surveyed DOs responded to the questionnaire mailings. Four of these respondents declined participation. Therefore, 66 returned surveys could be analyzed for the present study. However, there are fewer than 66 responses to many of the survey items because of missing data for some questions on some questionnaires.

Survey has been altered for graphic enhancement only. In consultation with representatives of the American Osteopathic Association's End-of-Life Care Advisory Committee (now known as the AOA Council on Palliative Care Issues), the present survey was designed to assess the habits of osteopathic physicians (DOs) in incorporating osteopathic principles and practice into patient care at the end of life. The survey was also designed to collect self-assessment data on DOs' levels of comfort and competency regarding the complex issues of end-of-life care, as well as to evaluate the applicability of osteopathic tenets and osteopathic manipulative techniques in this healthcare setting.

The instrument was sent via mail to 100 potential subjects who were selected from participants at the 2002 AOA End-of-Life Care—National Osteopathic Workshop (ELC-NOW) I conference and the 2003 ELC-NOW II conference.

A total of 70 of the 100 surveyed DOs responded to the questionnaire mailings. Four of these respondents declined participation. Therefore, 66 returned surveys could be analyzed for the present study. However, there are fewer than 66 responses to many of the survey items because of missing data for some questions on some questionnaires.

Survey has been altered for graphic enhancement only. In consultation with representatives of the American Osteopathic Association's End-of-Life Care Advisory Committee (now known as the AOA Council on Palliative Care Issues), the present survey was designed to assess the habits of osteopathic physicians (DOs) in incorporating osteopathic principles and practice into patient care at the end of life. The survey was also designed to collect self-assessment data on DOs' levels of comfort and competency regarding the complex issues of end-of-life care, as well as to evaluate the applicability of osteopathic tenets and osteopathic manipulative techniques in this healthcare setting.

The instrument was sent via mail to 100 potential subjects who were selected from participants at the 2002 AOA End-of-Life Care—National Osteopathic Workshop (ELC-NOW) I conference and the 2003 ELC-NOW II conference.

A total of 70 of the 100 surveyed DOs responded to the questionnaire mailings. Four of these respondents declined participation. Therefore, 66 returned surveys could be analyzed for the present study. However, there are fewer than 66 responses to many of the survey items because of missing data for some questions on some questionnaires.

Survey has been altered for graphic enhancement only.

Funding for this project was provided by the National Institute on Aging (Grant No. AG00925) in Bethesda, Md.

Editor's Note: Readers are encouraged to view the most recent supplement to the JAOA—The Journal of the American Osteopathic Association devoted to end-of-life care. That June 2007 online-only edition includes the AOA's Policy Statement on End-of-Life Care and the AOA's Position Against Use of Placebos for Pain Management in End-of-Life Care, both drafted by the Association's Council on Palliative Care Issues. From DO-Online (https://www.do-online.org/), click Advocacy under the For Physicians tab, then click Publications.

We thank Janice Ciesielski, MS, of the Department of Medicine at the University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine in Stratford. In addition, we thank the AOA's End-of-Life Care Advisory Committee (now known as the AOA Council on Palliative Care Issues) for their assistance with this project.

1

Emanuel LL, von Gunten CF, Ferris FD, eds. The Education for Physicians on End-of-life Care (EPEC) Curriculum. Chicago, Ill: The EPEC Project; 1999.

2

American Osteopathic Association's End-of-Life Care Committee. American Osteopathic Association's policy statement on end-of-life care. J Am Osteopath Assoc. 2005;105(suppl 5):S32-S34. Available at: http://www.jaoa.org/cgi/content/full/105/suppl_5/S32. Accessed June 15, 2007.

3

Special Committee on Osteopathic Principles and Osteopathic Technic [sic], Kirksville College of Osteopathy and Surgery. Interpretation of the osteopathic concept prepared by committee at Kirksville. J Osteopath. October(1953). ;60:7-10.

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Table 1

Demographic Characteristics of Osteopathic Physicians Participating in Survey of End-of-Life Care (N=66) *

Characteristic^†	No. (%)
▪ Sex
*□ Men*	*35 (53.0)*
□ Women	31 (47.0)
▪ Religion (n=64)
□ Roman Catholic	29 (45.3)
*□ Protestant*	*19 (29.7)*
□ Other Christian	5 (7.8)
*□ Jewish*	*4 (6.3)*
□ Other	7 (10.9)
▪ Primary Specialty (n=58)
□ Family practice	35 (60.3)
*□ Internal medicine*	*15 (25.9)*
□ Geriatrics	8 (13.8)

*The sample sizes for religion and primary specialty vary from the total sample size, reflecting the number of participating osteopathic physicians who answered the survey questions for those characteristics.

†Other characteristics: age, mean (SD) = 50 (10) y; age, range = 29-72 y; time since residency, mean (SD) = 16 (9) y; time since residency, range = 1-34 y.

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Table 1

Demographic Characteristics of Osteopathic Physicians Participating in Survey of End-of-Life Care (N=66) *

Characteristic^†	No. (%)
▪ Sex
*□ Men*	*35 (53.0)*
□ Women	31 (47.0)
▪ Religion (n=64)
□ Roman Catholic	29 (45.3)
*□ Protestant*	*19 (29.7)*
□ Other Christian	5 (7.8)
*□ Jewish*	*4 (6.3)*
□ Other	7 (10.9)
▪ Primary Specialty (n=58)
□ Family practice	35 (60.3)
*□ Internal medicine*	*15 (25.9)*
□ Geriatrics	8 (13.8)

*The sample sizes for religion and primary specialty vary from the total sample size, reflecting the number of participating osteopathic physicians who answered the survey questions for those characteristics.

†Other characteristics: age, mean (SD) = 50 (10) y; age, range = 29-72 y; time since residency, mean (SD) = 16 (9) y; time since residency, range = 1-34 y.

Table 2

Number of Osteopathic Physicians Who Discussed Advance Directives With Patients, by Proportion of Patient Population (n=65) *

Population Proportion, %	No. (%)
0-25	19 (29.2)
*26-50*	*11 (16.9)*
51-75	10 (15.4)
*76-100*	*25 (38.5)*

*One participant did not answer this survey question.

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Table 2

Number of Osteopathic Physicians Who Discussed Advance Directives With Patients, by Proportion of Patient Population (n=65) *

Population Proportion, %	No. (%)
0-25	19 (29.2)
*26-50*	*11 (16.9)*
51-75	10 (15.4)
*76-100*	*25 (38.5)*

*One participant did not answer this survey question.

Table 3

Number of Osteopathic Physicians Who Discussed Advance Directives With Given Proportion of Their Patient Population (n=63) *

Patients/Families	No. (%)
▪ Patients
*□ New*	*22 (34.9)*
□ Age >65 y	46 (73.0)
*□ With serious illness*	*52 (82.5)*
▪ Patients' Families	30 (47.6)

*The sample size reflects the number of participating osteopathic physicians who answered the survey questions for advance directives.

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Table 3

Number of Osteopathic Physicians Who Discussed Advance Directives With Given Proportion of Their Patient Population (n=63) *

Patients/Families	No. (%)
▪ Patients
*□ New*	*22 (34.9)*
□ Age >65 y	46 (73.0)
*□ With serious illness*	*52 (82.5)*
▪ Patients' Families	30 (47.6)

*The sample size reflects the number of participating osteopathic physicians who answered the survey questions for advance directives.

Table 4

Number of Osteopathic Physicians Who Encouraged Particular Behaviors in Patients at End of Life (n=63) *

	Frequency of Encouragement, No. (%)
Patient Behavior	Always	Most of the Time	Sometimes	Never/Rarely
Complete unfinished business	33 (52.4)	22 (34.9)	5 (7.9)	3 (4.8)
*Seek/bestow forgiveness*	*16 (25.4)*	*17 (27.0)*	*18 (28.6)*	*12 (19.0)*
Express thankfulness/love	21 (33.3)	23 (36.5)	12 (19.0)	7 (11.1)

*The sample size reflects the number of participating osteopathic physicians who answered the survey questions for encouragement of patient behaviors.

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Table 4

Number of Osteopathic Physicians Who Encouraged Particular Behaviors in Patients at End of Life (n=63) *

	Frequency of Encouragement, No. (%)
Patient Behavior	Always	Most of the Time	Sometimes	Never/Rarely
Complete unfinished business	33 (52.4)	22 (34.9)	5 (7.9)	3 (4.8)
*Seek/bestow forgiveness*	*16 (25.4)*	*17 (27.0)*	*18 (28.6)*	*12 (19.0)*
Express thankfulness/love	21 (33.3)	23 (36.5)	12 (19.0)	7 (11.1)

*The sample size reflects the number of participating osteopathic physicians who answered the survey questions for encouragement of patient behaviors.

Table 5

Number of Osteopathic Physicians Who Used Osteopathic Diagnostic or Manipulative Techniques, by End-of-Life Pathologic Condition (n=63) *

	No. (%)
Pathologic Condition	Osteopathic Diagnostic Techniques	OM Techniques	Most Common OM Techniques
Lymphatic^†	NA	33 (52.4)	Pedal pump, effleurage, lymphatic pump, myofascial technique, thoracic pump
*Pain*	*36 (57.1)*	*52 (82.5)*	*Counterstrain, muscle energy, soft-tissue (indirect) techniques, simple touch or palpation*
Respiratory	26 (40.6)‡	31 (49.2)	Lymphatic pump, rib raising, soft-tissue (myofascial) techniques

Abbreviation: OM, osteopathic manipulative.

*The sample size reflects the number of participating osteopathic physicians who answered the survey questions for use of osteopathic diagnostic and manipulative techniques.

†Participating osteopathic physicians were not asked to indicate their use of osteopathic diagnostic techniques in assessment of lymphatic conditions.

‡n=64

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Table 5

Number of Osteopathic Physicians Who Used Osteopathic Diagnostic or Manipulative Techniques, by End-of-Life Pathologic Condition (n=63) *

	No. (%)
Pathologic Condition	Osteopathic Diagnostic Techniques	OM Techniques	Most Common OM Techniques
Lymphatic^†	NA	33 (52.4)	Pedal pump, effleurage, lymphatic pump, myofascial technique, thoracic pump
*Pain*	*36 (57.1)*	*52 (82.5)*	*Counterstrain, muscle energy, soft-tissue (indirect) techniques, simple touch or palpation*
Respiratory	26 (40.6)‡	31 (49.2)	Lymphatic pump, rib raising, soft-tissue (myofascial) techniques

Abbreviation: OM, osteopathic manipulative.

*The sample size reflects the number of participating osteopathic physicians who answered the survey questions for use of osteopathic diagnostic and manipulative techniques.

†Participating osteopathic physicians were not asked to indicate their use of osteopathic diagnostic techniques in assessment of lymphatic conditions.

‡n=64

Table 6

Osteopathic Physicians' Ratings of Effectiveness of Osteopathic Manipulative Techniques, by End-of-Life Pathologic Condition

	No. (%)
Pathologic Condition*	Always Effective	Often Effective	Sometimes Effective	Seldom Effective	Never Effective
Pain (n=50)	5 (10.0)	14 (28.0)	29 (58.0)	1 (2.0)	1 (2.0)
*Respiratory (n=31)*	0	*11 (35.5)*	*19 (61.3)*	*1 (3.2)*	0

*Participating osteopathic physicians were not asked to rate the effectiveness of osteopathic manipulative (OM) techniques in improving lymphatic function. Sample sizes reflect the number of participating osteopathic physicians who responded in the survey that they used OM techniques for treating patients with pain or respiratory conditions and who responded to the question about the effectiveness of OM techniques for those conditions.

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Table 6

Osteopathic Physicians' Ratings of Effectiveness of Osteopathic Manipulative Techniques, by End-of-Life Pathologic Condition

	No. (%)
Pathologic Condition*	Always Effective	Often Effective	Sometimes Effective	Seldom Effective	Never Effective
Pain (n=50)	5 (10.0)	14 (28.0)	29 (58.0)	1 (2.0)	1 (2.0)
*Respiratory (n=31)*	0	*11 (35.5)*	*19 (61.3)*	*1 (3.2)*	0

*Participating osteopathic physicians were not asked to rate the effectiveness of osteopathic manipulative (OM) techniques in improving lymphatic function. Sample sizes reflect the number of participating osteopathic physicians who responded in the survey that they used OM techniques for treating patients with pain or respiratory conditions and who responded to the question about the effectiveness of OM techniques for those conditions.

Practice Patterns of Osteopathic Physicians Providing End-of-Life Care: A Survey-Based Study

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