Does special education in palliative medicine make a difference in end-of-life decision-making?

Abstract

BackgroundCharacteristics of the physician influence the essential decision-making in end-of-life care. However, the effect of special education in palliative medicine on different aspects of decision-making in end-of-life care remains unknown. The aim of this study was to explore the decision-making in end-of-life care among physicians with or without special competency in palliative medicine (cPM).MethodsA questionnaire including an advanced lung cancer patient-scenario with multiple decision options in end-of-life care situation was sent to 1327 Finnish physicians. Decisions to withdraw or withhold ten life-prolonging interventions were asked on a scale from 1 (definitely would not) to 5 (definitely would) – first, without additional information and then after the family’s request for aggressive treatment and the availability of an advance directive. Values from chronological original scenario, family’s appeal and advance directive were clustered by trajectory analysis.ResultsWe received 699 (53%) responses. The mean values of the ten answers in the original scenario were 4.1 in physicians with cPM, 3.4 in general practitioners, 3.4 in surgeons, 3.5 in internists and 3.8 in oncologists (p < 0.05 for physicians with cPM vs. oncologists and p < 0.001 for physicians with cPM vs. others). Younger age and not being an oncologist or not having cPM increased aggressive treatment decisions in multivariable logistic regression analysis. The less aggressive approach of physicians with cPM differed between therapies, being most striking concerning intravenous hydration, nasogastric tube and blood transfusions. The aggressive approach increased by the family’s request (p < 0.001) and decreased by an advance directive (p < 0.001) in all physicians, regardless of special education in palliative medicine.ConclusionPhysicians with special education in palliative medicine make less aggressive decisions in end-of-life care. The impact of specialty on decision-making varies among treatment options. Education in end-of-life care decision-making should be mandatory for young physicians and those in specialty training.Electronic supplementary materialThe online version of this article (10.1186/s12904-018-0349-6) contains supplementary material, which is available to authorized users.

Does Decision-making in End-of-life Care Differ Between Graduating Medical Students and Experienced Physicians?

“…Participants. In autumn 2015, a postal survey with a questionnaire was sent to 500 GPs who were randomly selected from the registry of the Finnish Medical Association [details published earlier by Piili et al (8,13)]. The survey was sent twice to non-respondents.…”

Has there been a change in the end-of-life decision-making over the past 16 years?

“…The influence of gender is also unclear in end-of-life decisionmaking, as some studies have shown that female physicians are more in favour of active treatments and in some studies there is no gender-dependent difference in withholding or withdrawing life-sustaining treatments. [11,17,19,20,28] Only approximately 10% of the respondents in both years considered costs of care to influence their decisions, and the patient's social status was even less influential. Some studies do report that a patient's financial resources influence physicians' decision-making, [29] while our results probably reflect the Finnish health care system, where the cost of care are covered by the society with tax money.…”

“…[9][10][11][12][13][14][15] The specialty of a physician impacts their decision-making, as oncologists have been shown to be more opposed to accepting the risk of hastening death by using high doses of drugs for symptom control compared to other specialties, but they are more willing to withhold or withdraw futile treatments in EOL-care. [12,16,17] Religion is shown to be associated with the unwillingness to withdraw lifesupportive care, [16,18,19] whereas age and gender of the physician are inconsistent factors in the decision-making. [11,17,[19][20][21] Decision-making should be consistent in the same types of clinical situations regardless of the physician who is responsible for the care of the patient.…”

“…[12,16,17] Religion is shown to be associated with the unwillingness to withdraw lifesupportive care, [16,18,19] whereas age and gender of the physician are inconsistent factors in the decision-making. [11,17,[19][20][21] Decision-making should be consistent in the same types of clinical situations regardless of the physician who is responsible for the care of the patient. The surrounding society and atmosphere do change over time, which might also influence the medical decisions.…”

Conhecimento e autoeficácia em cuidados paliativos dos enfermeiros da Atenção Primária à Saúde

“…Ademais, os processos de tomada de decisão de interromper ou suspender terapias na prática clínica são impulsionados principalmente pela educação e a experiência clínica em CP, além das preferências do paciente. (Piili et al, 2018).…”