Factors affecting physicians' decisions to forgo life-sustaining treatments in terminal care

Abstract

Objectives: Treatment decisions in ethically complex situations are known to depend on a physician's personal characteristics and medical experience. We sought to study variability in decisions to withdraw or withhold specific life-supporting treatments in terminal care and to evaluate the association between decisions and such background factors.Design: Readiness to withdraw or withhold treatment options was studied using a terminal cancer patient scenario with alternatives. Physicians were asked about their attitudes, life values, experience, and training; sociodemographic data were also collected.Setting: Finnish physicians, postal survey.Survey sample: Five hundred general practitioners, 300 surgeons, 300 internists, and 82 oncologists.Results: Treatments most often forgone were blood transfusion (82%) and thrombosis prophylaxis (81%). Least willingly abandoned were intravenous (IV) hydration (29%) and supplementary oxygen (13%). Female doctors were less likely to discontinue thrombosis prophylaxis (p=0.022) and supplementary oxygen (p<0.001), but more readilyxray (p=0.039) and laboratory (p=0.057) examinations. Young doctors were more likely to continue antibiotics (p=0.025), thrombosis prophylaxis (p=0.006), supplementary oxygen (p=0.004) and laboratory tests (p=0.041). Oncologists comprised the specialty most ready to forgo all studied treatments except antibiotics and blood transfusion. The family's wishes (alternative 1) significantly increased treatment activity. Young and female practitioners and oncologists were most influenced by family appeal. Advance directives (alternative 2) made decisions significantly more reserved and uniform. Different factors in the physician's background were found to predict decisions to withdraw antibiotics or IV hydration.Conclusion: The considerable variation observed in doctors' decisions to forgo specific life-sustaining treatments (LST) was seen to depend on their personal background factors. Experience, supervision, and postgraduate education seemed to be associated with more reserved treatment decisions. To increase the objectivity of end of life decisions, training, and research are of prime significance in this ethically complex area of medicine.

Interdisciplinary cooperation of GPs in palliative care at home: A nationwide survey in the Netherlands

“…Physician characteristics, such as age, gender, experience, or education, explain variation in decisions in end-of-life care [16], and these characteristics could also explain some variation in cooperation found in our study. Furthermore, we were unable to measure outcomes, hence we could not analyse any possible relation between quality of care and GP cooperation with other caregivers.…”

Factors Associated with Physician Decision-Making in Starting Tube Feeding

“…The majority of physicians in this survey chose both to withhold tube feeding and to withdraw tube feeding after 3 months without improvement.The confounding influences of patient and family wishes have been noted in previous studies [5][6][7]10,15,24 and physicians often override the advance directives of patients. 7,14 Even patients recognize that their families may not agree with their advance directives, and some prefer for their families' wishes to supersede their own.…”

“…Physicians' end of life treatment preferences have been associated with physician ethnicity, religion, age, and personality style, [5][6][7][8][9][10][11][12][13] while other studies have found associations between treatment decisions and patient or institutional factors. 10,14,15 Physician ethnicity was associated with tube feeding decisions, 16 and patient and institutional factors associated with tube feeding in nursing home patients have been identified in previous observational studies.…”

Avaliação dos óbitos ocorridos no Hospital Universitário da Universidade Federal de Santa Catarina (HU/UFSC)

“…O estudo de McLean et al 25 constatou que a terapêutica mais freqüentemente retirada foi o suporte ventilatório sendo mantidas a sedação e a analgesia. Na Finlândia, Hinkla et al 26 observaram os fatores que afetam os médicos quanto às decisões de recusa ou suspensão de tratamentos em vítimas de doença cancerosa em fase final e constataram que os tratamentos mais recusados foram a transfusão sangüínea e a profilaxia da trombose. Moritz et al 27 , em um estudo que avaliou a atitude dos médicos intensivistas brasileiros diante da RST, mostraram que a sedação e a analgesia foram as intervenções menos recusadas ou suspensas e que os métodos dialíticos constituíram a terapêutica mais comumente recusada ou suspensa.…”