Patients with Disabilities: Avoiding Unconscious Bias When Discussing Goals of Care
Am Fam Physician. 2017 Aug 1;96(3):192-195.
A 58-year-old nonspeaking patient with an intellectual disability was admitted to the hospital for cholecystitis. He also had a well-controlled seizure disorder, secondary parkinsonism from medications he was no longer taking, and diabetes insipidus. His surgery was uncomplicated. Because of the patient's underlying disability and need to drink a high volume of water to maintain sodium balance, his recovery proceeded slowly. Six days after surgery, his ability to swallow had partially recovered, but he was still requiring fluids and food through a nasogastric tube.
The hospitalist took the initiative to invite hospice representatives to a team meeting to discuss goals of care. He recommended a transfer to hospice care because of what he called, “The patient's suffering and risk of aspiration.” Hospice was willing to admit him based on the referral, and his family initially agreed. However, when the hospitalist was confronted with questions from the patient's primary care physician about the terminal diagnosis and evidence of suffering, it became clear that the recommendation for hospice was based on the hospitalist's misperception of the patient's quality of life and pressures to advance discharge, rather than on specific medical indications. The patient was back home within a couple of months, eating his favorite foods, and he recovered to his previous baseline function. He has returned to his day program and activities. What could the hospitalist have done better to support and expedite this outcome?
False assumptions about patients' quality of life can affect prognosis, the treatment options that we present, and the types of referrals that we offer. In this case, the physician equated complex disability with terminal illness. This common confusion can result in premature withdrawal of life-preserving care. Disability is not a disease. Persons with physical, mental, and cognitive disabilities can and do live rich, full lives. They are often healthy, even if they need support for basic activities of daily living. If well managed, secondary conditions such as aspiration, pressure sores, and osteoporosis can be prevented or minimized. With appropriate services and accommodations, persons with disabilities can make decisions, have relationships, and contribute to their community. This outcome is more likely when they are welcomed, supported, and valued. Despite a high prevalence of chronic medical conditions, the life expectancy of persons with developmental disabilities approaches that of the general population.1
Physicians may mistakenly extrapolate high rates of significant functional decline observed in older patients after hospitalization to younger patients with complex disabilities. Younger patients with disabilities, however, are often healthier and more resilient than older patients, and their prognosis is often better after an acute illness.
This patient is recovering slowly from an acute, temporary illness. The physician's concern for aspiration, although understandable, hardly warranted transfer to hospice. Aspiration is a preventable secondary condition that can be effectively managed through diet texture, posture, careful supervision, and assistance with feeding. Falsely labeling a person with a disability as terminally ill can create a self-fulfilling prophecy, especially for those who need long-term support to thrive.2
Physicians should be careful to avoid making assumptions about patients' quality of life, especially those who rely on external assistance. They should also avoid reinforcing patient or caregiver fears and misconceptions about living with disability. For example, in one study of hospitalized able patients with serious illnesses, more than one-half of respondents believed that some health states were the same as or worse than death, including incontinence, requiring a breathing tube, relying on a feeding tube, or needing care from others all of the time.3 But many persons with developmental disabilities have required these supports since birth, yet still have meaningful lives.4 After a period of adjustment, those who live with acquired, chronic illness and disability also typically rate their own quality of life significantly higher than their physicians and caregivers do. Self-reported quality of life for persons with disabilities is not significantly different than that of the general population.5–7
Instead of sharing decision making and respecting autonomy, physicians may unconsciously project their own attitudes onto the patients they serve through how they frame informed-consent discussions.8 Table 1 includes examples of common communication pitfalls with alternative phrasing and resources. Being aware of unconscious biases will help physicians better support their patients during stressful times.
The attitudes and beliefs of physicians can interfere with the care patients want or need.9 We can improve access by reassuring patients that no matter what
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7. Goines JB, Ishii LE, Dey JK, et al. Association of facial paralysis-related disability with patient- and observer-perceived quality of life. JAMA Facial Plast Surg. 2016;18(5):363–369.
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9. Lagu T, Iezzoni LI, Lindenauer PK. The axes of access—improving care for patients with disabilities. N Engl J Med. 2014;370(19):1847–1851.
This series is coordinated by Caroline Wellbery, MD, Associate Deputy Editor.
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