Comparing end-of-life practices in different policy contexts: a scoping review

Boivin, Antoine; Marcoux, Isabelle; Garnon, Geneviève; Lehoux, Pascale; Mays, Nicholas; Prémont, Marie-Claude; Chao, Yi-Sheng; Leeuwen, Evert van; Pineault, Raynald

doi:10.1177/1355819614567743

Cited by 14 publications

(15 citation statements)

References 34 publications

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“…A scoping review highlighted the need to take a comprehensive look at international end-of-life practice variations, because existing reviews tended to focus on specific practices or selected countries [ 6 ]. More specifically, trends in patterns of “euthanasia” and “assisted suicide” are most frequently discussed, with less attention being put on treatment withdrawal and the use of drugs for symptom management [ 7 – 11 ].…”

Section: Introductionmentioning

confidence: 99%

International changes in end-of-life practices over time: a systematic review

Chao

Boivin

Marcoux

et al. 2016

BMC Health Serv Res

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BackgroundEnd-of-life policies are hotly debated in many countries, with international evidence frequently used to support or oppose legal reforms. Existing reviews are limited by their focus on specific practices or selected jurisdictions. The objective is to review international time trends in end-of-life practices.MethodsWe conducted a systematic review of empirical studies on medical end-of-life practices, including treatment withdrawal, the use of drugs for symptom management, and the intentional use of lethal drugs. A search strategy was conducted in MEDLINE, EMBASE, Web of Science, Sociological Abstracts, PAIS International, Worldwide Political Science Abstracts, International Bibliography of the Social Sciences and CINAHL. We included studies that described physicians’ actual practices and estimated annual frequency at the jurisdictional level. End-of-life practice frequencies were analyzed for variations over time, using logit regression.ResultsAmong 8183 references, 39 jurisdiction-wide surveys conducted between 1990 and 2010 were identified. Of those, 22 surveys used sufficiently similar research methods to allow further statistical analysis. Significant differences were found across surveys in the frequency of treatment withdrawal, use of opiates or sedatives and the intentional use of lethal drugs (X2 > 1000, p < 0.001 for all). Regression analyses showed increased use of opiates and sedatives over time (p < 0.001), which could reflect more intense symptom management at the end of life, or increase in these drugs to intentionally cause patients’ death.ConclusionThe use of opiates and sedatives appears to have significantly increased over time between 1990 and 2010. Better distinction between practices with different legal status is required to properly interpret the policy significance of these changes. Research on the effects of public policies should take a comprehensive look at trends in end-of-life practice patterns and their associations with policy changes.

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Section: Introductionmentioning

confidence: 99%

International changes in end-of-life practices over time: a systematic review

Chao

Boivin

Marcoux

et al. 2016

BMC Health Serv Res

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“…Although these changes decreased possible comparability with previous studies, [4][5][6][7][8][9][10][11][12][14][15][16][17][18][19] they increased the validity and relevance of our findings for the Canadian context, allowed a more thorough appreciation of end-of-life care trajectories and reduced risks of misclassification. 23 The fact that respondents provided answers consistently throughout the questionnaire, even for Physicians selected to receive survey (stratified random sample) n = 300…”

Section: Structural Changesmentioning

confidence: 99%

“…Second, to achieve conceptual clarity, we adapted questions for distinguishing observable medical end-of-life practices with different legal status according to a descriptive classification developed in a concurrent research study. 23 After comparing the selected questionnaires, 11,15,17 we decided to document not only the last medical practice performed by physicians before a patient's death but also all other medical practices and the underlying decision-making processes. Our aim was to obtain a more thorough overview of patients' trajectories of care and to better assess practices in line with Canadian legislative frameworks and professional recommendations (e.g., respect of patient's consent).…”

Section: Questionnaire Modificationmentioning

confidence: 99%

“…29,30 A scoping review showed that physicians' intention is not always related to the proportionality of drugs used to relieve suffering or to end a patient's life. 23 As this discrepancy could lead to misclassification (overestimation or underestimation) of some medical practices, we modified the questionnaire using a descriptive classification scheme developed in a concurrent study 23 to include questions on both physicians' intention and the adjustment of drugs according to pain and symptom control.…”

Section: Questionnaire Modificationmentioning

confidence: 99%

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Medical end-of-life practices among Canadian physicians: a pilot study

et al. 2016

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“…Non-beneficial treatment at the end of life is widespread in many countries, 29 but its prevalence and definition vary based on many factors, including national 30 – 34 and institutional culture, 35 – 39 which affect clinician decision-making. In the US, a greater degree of aggressive care at the end of life is more often considered appropriate than in the UK.…”

Section: Discussionmentioning

confidence: 99%

Understanding Experiences of Moral Distress in End-of-Life Care Among US and UK Physician Trainees: a Comparative Qualitative Study

et al. 2020

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Background Moral distress is a state in which a clinician cannot act in accordance with their ethical beliefs because of external constraints. Physician trainees, who work within rigid hierarchies and who lack clinical experience, are particularly vulnerable to moral distress. We examined the dynamics of physician trainee moral distress in end-of-life care by comparing experiences in two different national cultures and healthcare systems. Objective We investigated cultural factors in the US and the UK that may produce moral distress within their respective healthcare systems, as well as how these factors shape experiences of moral distress among physician trainees. Design Semi-structured in-depth qualitative interviews about experiences of end-of-life care and moral distress. Participants Sixteen internal medicine residents in the US and fourteen junior doctors in the UK. Approach The work was analyzed using thematic analysis. Key Results Some drivers of moral distress were similar among US and UK trainees, including delivery of potentially inappropriate treatments, a poorly defined care trajectory, and involvement of multiple teams creating different care expectations. For UK trainees, healthcare team hierarchy was common, whereas for US trainees, pressure from families, a lack of guidelines for withholding inappropriate treatments, and distress around physically harming patients were frequently cited. US trainees described how patient autonomy and a fear of lawsuits contributed to moral distress, whereas UK trainees described how societal expectations around resource allocation mitigated it. Conclusion This research highlights how the differing experiences of moral distress among US and UK physician trainees are influenced by their countries’ healthcare cultures. This research illustrates how experiences of moral distress reflect the broader culture in which it occurs and suggests how trainees may be particularly vulnerable to it. Clinicians and healthcare leaders in both countries can learn from each other about policies and practices that might decrease the moral distress trainees experience.

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Comparing end-of-life practices in different policy contexts: a scoping review

Abstract: It is feasible to compare end-of-life practices in different policy contexts. A systematic review of international evidence is needed to inform public deliberations on end-of-life policies and practice.

Cited by 14 publications

References 34 publications

International changes in end-of-life practices over time: a systematic review

International changes in end-of-life practices over time: a systematic review

Medical end-of-life practices among Canadian physicians: a pilot study

Understanding Experiences of Moral Distress in End-of-Life Care Among US and UK Physician Trainees: a Comparative Qualitative Study

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