New study suggests race might not influence life-sustaining treatment decisions in end-stage cancer

Sophisticated simulation techniques typically used for medical training could provide a powerful way of examining interactions between physicians and patients to reveal, for example, how race and other factors influence decision-making, said University of Pittsburgh School of Medicine researchers. In a study published in this month’s Critical Care Medicine, they found that hospital-based physicians did not treat black and white mock patients differently in an intensive care scenario, but they overestimated the preference for life-sustaining intervention in both groups and among blacks in particular.

Previous research has shown that compared to white patients, black patients with late-stage cancer are more likely to be admitted to an intensive care unit (ICU) and to receive life-sustaining interventions such as dialysis or breathing support by a ventilator, said lead investigator Amber E. Barnato, M.D., associate professor of medicine.

Also, research suggests that black patients are more likely to prefer aggressive life-sustaining treatment.

“For our study, we examined whether physician decision-making was influenced by patient race to play a role in creating these differences,” she explained. “Unlike previous research efforts in which physicians sat in a booth and asked questions that prompt videotaped patient responses, we used extensively trained actors to portray patients in mock triage setting, which we believe is more likely to capture what happens in the real world.”

Conducted at the Peter M. Winter Institute for Simulation Education and Research (WISER) at Pitt, the scenario mimicked the triage environment and time pressure in which decisions about ICU admission and intubation are typically made. The researchers simulated a scenario in which a black or white patient with either end-stage gastric or pancreatic cancer experienced dangerously low blood pressure or oxygen levels. Then they assessed how doctors dealt with it medically and surveyed them about their perceptions of patient preferences.

Of the 33 physicians who participated, 12 were emergency room doctors, eight were hospitalists and 13 were intensivists. Each participated in an encounter with one black and one white patient, and did not know the study was examining the influence of race on decision-making.

Four black and four white actors playing patients and family caregivers were trained to give certain answers in response to anticipated physician questions about the medical problem: if asked, they would reveal that they knew the tumor to be widespread; the treating oncologist said they were too weak to receive chemotherapy and that death could happen within six months; and they didn’t want to be admitted into an ICU, be on a ventilator or be resuscitated. The patient’s chart provided neither prognostic or treatment information, nor an advance care plan.

The researchers found no treatment decision differences regarding administration of opiate pain killers, a trial of noninvasive mechanical ventilation, elicitation of intubation preferences, chart documentation of preferences, ICU admission, intubation, comfort measures only and palliative care consultation.

Surveys showed that the physician participants believed that a black patient with late-stage pancreatic cancer was more likely than a similar white patient to prefer potentially life-prolonging chemotherapy over palliative care, to want breathing support via a ventilator to extend life by one week, and less likely to want a “do not resuscitate” order if hospitalized.

“These findings could mean that in this setting, physician beliefs about patient preferences did not change their treatment decisions,” Dr. Barnato said. “It’s also possible that there were no differences because this scenario isolated race from other social and cultural variables, such as socioeconomic status, religiosity, trust and level of advanced care planning, that may influence physician behavior.”

Future research will explore the interaction of race and those variables in end-of-life decision-making.

“The challenge is to find a way to use simulation with larger numbers of participants,” Dr. Barnato noted. “If we can do that, we could gain invaluable insight into the dynamic between doctors and patients.”