Treatment decision‐making at the end of life: a survey of Australian doctors' attitudes towards patients' wishes and euthanasia

Abstract

ObjectiveTo examine factors that influence medical practitioners' treatment decisions for patients with life‐threatening or terminal illnesses. DesignPostal survey, conducted between September and November 1995, of a self‐administered questionnaire, describing four clinical case scenarios, to a random sample of 2172 Australian doctors in all States and Territories. Respondents were asked to prescribe treatment for the patients described in the scenarios. Patients' characteristics varied in terms of mental competence, illness severity, prognosis, the presence of advance directives, request for assisted death, and sociodemographic factors. The respondents' sociodemographic and medical training characteristics were also obtained. SettingRandom national sample of all active medical practitioners. ParticipantsHospital trainees, general practitioners, physicians, palliative care practitioners and surgeons were surveyed. A response rate of 73% was achieved. Main outcome measuresFrequency of prescription of supportive, acute or intensive treatment for patients in the four clinical scenarios based on respondents' sex, religion, medical training and country of medical degree. ResultsThree main findings were: (i) doctors did not make consistent decisions, but their decisions varied systematically by sociodemographic and medical training factors; (ii) doctors generally adhered to patient and family wishes when these were known; (iii) doctors did not generally adhere to a patient's request for assisted death. ConclusionTreatment provided is significantly determined by the individual characteristics of the doctor and not solely by the nature of the medical problem. Participation in the informed‐consent process and in the preparation of advance health care directives would enable practitioners to be familiar with patient and family wishes and could reduce variations of treatment related to sociodemographic and medical training factors. Stronger empirical data on the way that treatment decisions are made could provide the basis for an informed euthanasia policy.

Decision‐making for older patients by Australian and New Zealand doctors with Advance Care Directives: a vignette‐based study

“…This is in contrast to other vignette‐based ACD studies, which reported that doctors with more experience were more likely to select supportive care as opposed to younger doctors . These studies did not use real‐life ACDs . As real‐life ACDs were used in this study, perhaps senior clinicians were more likely to be cautious in their treatment decisions and offer broader levels of treatment.…”

“…In this study, senior clinicians were more likely to offer full care than junior clinicians in vignettes 1 and 2. This is in contrast to other vignette‐based ACD studies, which reported that doctors with more experience were more likely to select supportive care as opposed to younger doctors . These studies did not use real‐life ACDs .…”

“…Little is known about doctors’ decision‐making patterns when using ACDs, particularly for older patients in Australia and New Zealand. Only three studies have reported on the level of agreement between doctors in their decision‐making for older patients using ACDs with Australian doctors in their sampling …”

Exploring the interface between ‘physician‐assisted death’ and palliative care: cross‐sectional data from Australasian palliative care specialists

“…16,18,21,22 This trend has also been suggested in the Australian context. 23,24 The question of why has not yet been addressed or explored. However, it is often claimed that fear of a subsequent reduction in funding for palliative care services (in the context of reduced need with legalisation of PAD) drives palliative care specialists' opposition to legislative change.…”

Advance care planning in Australia: overdue for improvement

“…22 Even so, Waddell et al have reported that AD do affect practitioners' management choices in favour of patient wishes and reduce the difficulty that practitioners may experience when making them. 23 Notably, many of the issues pertaining to AD that have been investigated overseas have, thus far, largely not been investigated in this country. These issues are discussed below.…”