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Published Online: 19 May 2011

Exploring Physician Decisions about End-of-Life Opiate Prescribing: A Qualitative Study

Publication: Journal of Palliative Medicine
Volume 14, Issue Number 5

Abstract

Background: Opiates are commonly used for symptoms at the end of life (EOL). Little is known about the decision-making process physicians go through when deciding to prescribe opiates for their EOL patients. The study's objective was to explore physician factors affecting EOL opiate prescribing.
Methods: Qualitative study of 38 physicians in the Denver area in the specialties of outpatient and inpatient medicine, geriatrics, oncology, and palliative care. Semi-structured qualitative interviews by trained interviewers asked physicians about their knowledge, attitudes, and experiences in prescribing opiates, reasons for prescribing opiates, barriers to prescribing opiates, changes in prescribing habits, and perceived patient factors that influence prescribing. Interviews were analyzed using ATLAS.ti qualitative analysis software and independently coded by two reviewers.
Results: We found a spectrum of beliefs ranging from the viewpoint that opiates are underused at EOL to overused. We found five key themes: practices in when and how to use opiates, barriers to prescribing, personal experiences drive prescribing, social meaning of opiates, and differences in the role of physician. Physicians interviewed described experiences, both personal and professional, that influenced their opiate-prescribing habits. All respondents expressed positive experiences with prescribing opiates in being able to ease patients' suffering at EOL and to improve their functionality and quality of life.
Conclusions: Differences in prescribing habits, attitudes, and experiences of physicians influence opiate prescribing, which may lead to over- and underprescribing. Knowledge, barriers, and fears about EOL opiate prescribing need to be addressed to ensure EOL patients are receiving appropriate symptom relief.

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Appendix

Interview Framework for Opiate Prescribing Study
Thanks for agreeing to talk to us so that we can better understand opiate prescribing decisions at EOL. Your experiences as a physician will help us understand why and how physicians make decisions about opiate prescribing.
As we meet today, I have a range of questions I'd like to ask you and I'll ask you about your personal experiences. If at any time you have questions please ask me, or if you want to stop for any reason please let me know.
First:
What is your specialty?
How long have you been practicing?
How would you define EOL care? (Our study defines it as care within the last 6 months of life.)
How many EOL patients do you typically see in a month?
How often do you think you prescribe opiates for pain management?
1. To get started, could you tell me a story or instance about a patient—it could be a recent patient, or a memorable one—that you took care of at the EOL that you prescribed opiates for pain control.
Probing questions if needed:
Why did you make those decisions?
What factors affected your decisions? Or what influences your decisions?
2. Now tell me a story about a recent patient you took care of at the EOL that you did not prescribe opiates for pain control.
Why did you make those decisions?
What factors affected your decisions? Or what influences your decisions?
3. EXPERIENCE
What do you talk about with your patients about opiates and pain treatment options?
In general, why do you decide to or not to use opiates at EOL?
∘ How do you decide when to start prescribing opiates to a patient?
What influence have families of EOL patients had on your prescribing decisions?
What illnesses do your patients at EOL typically suffer from that you prescribe opiates for?
∘ Have you ever prescribed opiates to an EOL patient who did not have cancer?
∘ -What are the differences between how you think about or use opiates in EOL cancer patients versus noncancer EOL patients?
Have you ever had any patients who refused opiates?
∘ What reasons did they give?
∘ How did you handle that situation?
These next questions refer to your experience overall with opiate prescription, so they are asking about a broader perspective than the stories you just shared.
4. ATTITUDES
Do you think opiates in EOL care need to be used more or less?
What do you think the advantages of using opiates in EOL patients are?
What are the disadvantages?
What fears or concerns do you have when you prescribe opiates?
Do you think opiates are a treatment of last resort in EOL care?
Do you worry about titrating the dose of opiates up or down?
How do you think your practices are different from your colleagues?
How do you think your practices are similar to your colleagues?
5. BARRIERS
Are there any barriers to prescribing opiates in the last 6 months of life?
∘ For example, regulatory or formulary barriers?
Are there patient factors that make you less likely to prescribe opiates for EOL care?
Are there patient factors that make you more likely to prescribe opiates for EOL care?
Have you ever treated an addict/addicted patient (to opiates, alcohol, something else) at the EOL and did that change how you used opiates?
6. KNOWLEDGE:
Have you done anything to increase your knowledge of opiate prescribing at EOL since completing your residency or fellowship training?
Are there areas of EOL opiate prescribing you wish you knew more about?
7. CLOSING:
How have your thoughts about opiate prescribing at the EOL changed over the course of your career?
Are there any particular positive or negative opiate prescribing experiences that have influenced your practice style?
Do you have any thoughts or ideas about why there might be such variation in opiate proscribing rates among physicians?
What if any differences have you seen in the opiate prescribing habits of residents/fellows compared with attending physicians for EOL patients?

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Information & Authors

Information

Published In

cover image Journal of Palliative Medicine
Journal of Palliative Medicine
Volume 14Issue Number 5May 2011
Pages: 567 - 572
PubMed: 21413855

History

Published online: 19 May 2011
Published in print: May 2011
Published ahead of print: 17 March 2011
Accepted: 6 January 2011

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Authors

Affiliations

Judy Zerzan, M.D., M.P.H.
Division of General Internal Medicine, University of Colorado Denver, Aurora, Colorado.
Courtney A. Lee, M.A.
Department of Health and Behavioral Sciences, University of Colorado Denver, Aurora, Colorado.
Leah M. Haverhals, M.A.
U.S. Department of Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado.
Carolyn T. Nowels, MSPH
Division of General Internal Medicine, University of Colorado Denver, Aurora, Colorado.

Notes

Address correspondence to:Judy Zerzan, M.D., M.P.H.General Internal MedicineUniversity of Colorado Denver12631 East 17th Avenue, Mail Stop B180Aurora, CO 80045E-mail: [email protected]

Author Disclosure Statement

No competing financial conflicts of interest exist.

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