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J Pain Symptom Manage. 2018 Feb;55(2):282-289.e1. doi: 10.1016/j.jpainsymman.2017.08.019. Epub 2017 Sep 1.

Homing in on the Social: System-Level Influences on Overly Aggressive Treatments at the End of Life.

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Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA. Electronic address:
Institute of Health Policy Studies, University of California San Francisco, San Francisco, California, USA.
Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington, USA.
Department of Oncology and Palliative Care, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
Massachusetts Eye and Ear Institute, Boston, Massachusetts, USA.
Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA.



The American Medical System is programmed to a default setting of aggressive care for the terminally ill. Institutional norms of decision making have been shown to promote high-intensity care, regardless of consistency with patient preferences. There are myriad factors at a system, clinician, surrogate, and patient level that drive the culture of overly aggressive treatments in American hospitals.


The objective of this study was to understand physician perspective of the ways systems-level factors influence patient, physician, and surrogate perceptions and consequent behavior.


Semi-structured in-depth qualitative interviews with 42 internal medicine physicians across three American academic medical centers were conducted. This qualitative study was exploratory in nature, intended to enhance conceptual understanding of underlying phenomena that drive physician attitudes and behavior.


The interviews revealed many factors that contributed to overly aggressive treatments at the end of life. Systemic factors, which describe underlying cultures (including institutional, professional, or community-based cultures), typical practices of care, or systemic defaults that drive patterns of care, manifested its influence both directly and through its impact on patient, surrogate, and physician behaviors and attitudes.


Institutional cultures, social norms, and systemic defaults influence both normative beliefs regarding standards of care and treatments plans that may not benefit seriously ill patients.


Overly aggressive treatments; end-of-life care; medical culture; qualitative research; social science

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