US and Russian physician perspectives regarding end of life care

Author(s): Gerald J Jogerst*, James G Jackson, Yulia Matveeva, Yinghui Xu, and Anna Turusheva Purpose: To compare US and Russian primary care physicians’ attitudes, comfort and experiences providing palliative care. Design: Cross sectional survey. Settings: Iowa, USA and Leningrad Oblast, Russia Participants: Family medicine physicians at University of Iowa and Northwestern State Medical University, St Petersburg, Russia, community practicing family physici ... Abstract View Full Article View DOI: 10.17352/aggr.000014


Introduction
The World Health Organization (WHO) predicts that by 2040 15% of the world population will be age 65 years or older [1]. Primary care physicians will be treating this aging population and by necessity will be exposed to end of life care demands. Culture of the provider, patient, social environment and policies of the health care system will infl uence the delivery of end of life care. WHO classifi es Russia and 73 other countries has having isolated palliative care provisions and 20 countries including the United States as having advanced integration of palliative care [2].
There have been few studies conducted among US physicians [3] and among Russian physicians [4] regarding end of life care. No research to our knowledge addresses differences between US and Russian primary care physicians' attitudes, comfort or experiences regarding end of life care. The purpose of this study is to compare primary care physicians' end of life care attitudes, comfort and experiences when practicing in isolated (Russia) versus integrated (US) palliative care health systems.
State Medical University department of family medicine or in attendance at one of three conferences in St Petersburg or Gatchina, Russia were invited to participate in this anonymous survey. Questionnaires were distributed during the start of each conference and completed questionnaire were collected at the end of the conferences by the principle investigator. Departmental faculty at the University of Iowa and the Northwestern State Medical University were provided the questionnaire by departmental mail and the completed questionnaires were received by the departmental investigator by the same route. No palliative care topics were discussed during the conferences.
A 21 item questionnaire was developed using questions from existing studies [3,5]. Items included were: gender, years in practice, questions related to best settings for care of terminally ill patients, decision making, physicians' personal preferences for end of life care if they had a terminal illness, comfort in managing symptoms and prescribing medications for terminally ill patients and practice experiences with end of life care over the last six months. An open ended question concluded the questionnaire, which asked for obstacles encountered while caring for terminally ill patients. The questionnaire was translated from English to Russian, back translated by a native Russian speaker and reviewed for content validity [6].

Data analysis
Preliminary descriptive analyses were performed for all variables. The responses that used a 5-Likert scale were combined into two categories (always/often, and sometimes/ rarely/never). For those questions with multiple answer selections, each answer was analyzed as a dichotomous variable. Unpaired t-test was used to compare continuous variables between the two cohorts. The Pearson chi-square test or Fisher exact test were used to compare categorical variables between groups (Total US and Russian physician as well as the sub-groups of US and Russian community practicing physicians). Analyses were also completed controlling for gender. All P-values were 2-tailed, and results were considered statistically signifi cant at P-values less than 0.05. All analyses were performed using SAS version 9.4 (SAS Institute Inc. Cary, NC).
Data for the open response question were analyzed using systematic content analysis [7] completed by 3 US investigators. Initially, each of the investigators individually codifi ed these open responses. Total number of themes ranged from 9 to 37. Following individual analysis, the group met for discussion of overarching themes and identifi ed 5 main groups through discussion and consensus. The identifi ed themes were family issues of care, lack of resources, communication, organizational and educational issues.

Results
One hundred and forty-seven physicians completed the questionnaire; 66 of 116 US physicians (response rate 57%) and 81 of 102 Russian physicians (response rate 79%). Signifi cantly more female and community physicians were in the Russian cohort (Table 1). Home was the preferred location for end of life care with larger percentage of Russian physicians also choosing community hospice, weeks to months before death ( Table 2). Controlling for gender, hospital choice for care by family became signifi cant a p=0.036 favoring US physicians. The results for comfort in managing and prescribing for end of life symptoms are showed in Table 4. Comfort in prescribing sedatives is no longer signifi cantly different when controlling for community physicians p=0.055 and gender p=0.077.
Physician practice experiences listed in Table 5 reveal that Russian physicians made more home visits and US physicians were more satisfi ed with the care they provided to terminally ill patients. US physicians disclosed poor prognoses more often. When analyzing variable "patient dies with dignity" using only community based physicians, there was signifi cantly more US 18.0 (11.5) 0.408** * chi-square ** t-test  medicine [8]. Health care providers were incentivized strongly to act in this fashion. Doctors attempted to avoid anxiety in patients, as it was commonly believed that physical and emotional conditions are intimately related. In addition, it was believed that patients are incapable of making decisions and fully understand the consequences of their decisions regarding further treatment [8]. Only doctors could make such decisions, and treatment was performed "irrespective of the outcome", while ignoring potential opposition from the patients [8].
In 2011, The Federal Law of Russian Federation "On the basis of the protection of public health in the Russian Federation" declared that everyone has the right to receive, in an accessible form, information about results of medical examinations, the presence of diseases, the diagnosis and the prognosis for the development of a disease [9]. However, according to statistics produced by the charity "Miloserdie", doctors prefer to fi rst give the news to relatives, and only then decide whether or not to inform the patient of the condition and prognosis.
Nevertheless, a survey conducted by the charity "Live Now" and the website "Miloserdie.ru" found that 80% of patients would like to know their diagnosis fi rst and only 2.6% of the survey participants agreed that their relatives be aware of their illness before them [10].
There were many detected differences in physician reported comfort with medication prescribing and symptom management at the end of life. All Russian respondents answered that they felt most comfortable managing pain, compared to 88% of US respondents. However, US respondents rated signifi cantly higher comfort with prescribing all other listed medication classes compared to the Russian group. After closer analyses of these fi ndings, it was determined that due to the necessary wording of the Russian questionnaire, Russian physicians interpreted the questions about symptom management as which symptom they were "most comfortable" managing. The US physicians were asked to select all symptoms they were comfortable managing. Another reason for the 100% Russian physicians' comfort with pain management may be due to the fact that many of the Russian respondents had recently completed an educational program for the management of pain in palliative care. Therefore these fi ndings must be interpreted The open response question on obstacles to care found that while Russian care providers lament resource issues in end of life care settings, US providers felt that issues with communications were their greatest challenge. One issue raised by US respondents was confl ict in goals of care and advanced

N/R/S O/A N/R/S O/A N/R/S O/A N/R/S O/A N (%) N (%) N (%) N (%) N (%) N (%) N (%) N (%)
Made There were many signifi cant differences in attitudes and practices between the Russian and US primary care physicians in this study. While a handful of other studies comparing practicing groups across settings exist, much more investigation is needed ahead of a growing need for quality end of life care in an aging world. Cultural differences play a key role in end of life care and must be considered by all physicians caring for their dying patients.