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27 Overdiagnosis and end of life care: structural factors
  1. Ruth Groenhout
  1. University of North Carolina, Charlotte, Charlotte, NC, USA


There are a number of social and cultural mechanisms that contribute to overdiagnosis, particularly in end of life care, which almost inevitably leads to overtreatment at a time when that is very problematic. One of the more significant mechanisms is the tendency to define ‘care’ as the use of technology, pharmaceuticals, or other physical treatments. Medical care, especially during the end of life, needs to begin with time, empathy, and understanding the meaning of patient’s lives. The patient/professional relationship is a professional one, so a relationship of care in this medical context does not involve becoming overly close to patients, but without time spent both explaining and listening, there is little in the way of a caring relationship, and care-givers are unable to respond appropriately to patient needs. This has been supported by numerous sociological studies, and by basic analyses of care in the philosophical bioethics context.

A combination of structural features tilts care in the direction of technology, requiring diagnosis and treatment in every case. One major factor in the US is the structure of insurance responses; insurance companies consider diagnosis and treatment as a payable expenses, while a care-giver’s time spent with patients is not covered. Care-givers, in fact, are often mandated to see large numbers of patients, making time far too short for any adequate connections with patients. At the same time health care administrators, even in non-profit systems, see their primary allegiance to maximizing profits. Over the past several decades this has resulted in a focus on cutting personnel, particularly nursing staff, as they are one of the more expensive aspects of health care. Recognition of patients’ actual care needs is one crucial aspect of avoiding overdiagnosis and addressing both of these subsidiary problems. If treatment, particularly advanced technological treatment, is seen as the only focus of care-givers in end of life care, overdiagnosis becomes almost automatic.

Social structures that enable adequate caring relationships can work to diminish one social structure that leads to overdiagnosis. Supporting adequate time with patients as a required part of insurance coverage, as well as adequate staffing requirements for health care systems are both essential. But the distance between care providers in different fields also contributes to overdiagnosis, indicating that a vital aspect of the time and care needed involves structuring patient care by care teams, rather than by unconnected individual care-givers. If physicians assume their specialized knowledge is the only part of treatment they need to provide, and if nursing staff rarely speak with physicians about their understanding of patient experiences, especially in the context of end of life care, it results in a tendency toward aggressive treatment and the patient’s loss of connections to relationships that support their sense of self.

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