Variability in physicians' decisions on caring for chronically ill elderly patients: an international study.

OBJECTIVES: To determine what treatment decisions physicians will make when faced with an incompetent elderly patient with life-threatening gastrointestinal bleeding and to identify the factors that affect their decisions. DESIGN: Survey. SETTING: Family practice, medical and geriatrics rounds in academic medical centres and community hospitals in seven countries. PARTICIPANTS: Physicians who regularly cared for incompetent elderly patients. OUTCOME MEASURE: A self-administered questionnaire containing three case vignettes. Each provided the same details on an incompetent elderly patient; however, one gave no information about the wishes of the patient and his family (no directive), the second provided a do-not-resuscitate (DNR) request, and the third included a detailed therapeutic and resuscitative effort chart (DTREC) requesting maximum therapeutic care without admission to the intensive care unit (ICU). The four treatment options were supportive care only, limited therapeutic care, maximum therapeutic care without admission to the ICU and maximum care with admission to the ICU. MAIN RESULTS: Treatment decisions varied and were systematically related to age, level of training and country (p less than 0.001). The older physicians and those in family medicine were less likely than the others to choose aggressive treatment options. Brazilian and US physicians were the most aggressive; Australian physicians were the most conservative. The DNR request resulted in a significant decrease in the number of physicians choosing aggressive options (p less than 0.001). The DTREC resulted in a move toward more aggressive treatment, as outlined in the directive (p less than 0.001). Overall, however, about 40% of the physicians chose a level of care different from what had been requested. Furthermore, over 10% would have tried cardiopulmonary resuscitation despite the DNR request. CONCLUSION: Treatment of incompetent elderly patients with life-threatening illness varies widely within and between countries. Uniform standards should be developed on the basis of societal values and be communicated to physicians.     

Ethical dilemmas of brain failure in the elderly

Doctors caring for patients with senile dementia are faced with the dilemma of making treatment decisions for dying, incompetent persons whose lives can be prolonged but not enhanced by modern medical technology. British physician Robertson explores the idea of encouraging elderly people to sign a written declaration of their treatment preferences if afflicted with an incurable dementia. Such a move could help relieve many elderly of their fears of a prolonged, undignified death; encourage physicians to incorporate patients' expressed wishes into treatment decisions; improve the image of geriatric medicine; and clarify public objectives in medical care of the aged.     

Doctors' authoritarianism in end-of-life treatment decisions. A comparison between Russia, Sweden and Germany

Objectives—The study was performed in order to investigate how end-of-life decisions are influenced by cultural and sociopolitical circumstances and to explore the compliance of doctors with patient wishes Participants and measurement—Five hundred and thirty-five physicians were surveyed in Sweden (Umeå), Germany (Rostock and Neubrandenburg), and in Russia (Arkhangelsk) by a questionnaire. The participants were recruited according to availability and are not representative. The questionnaire is based on the one developed by Molloy and co-workers in Canada which contains three case vignettes about an 82-year-old Alzheimer patient with an acute life-threatening condition; the questionnaire includes different levels of information about his treatment wishes. We have added various questions about attitudes determining doctors'' decision making process (legal and ethical concerns, patient''s and family wishes, hospital costs, patient''s age and level of dementia and physician''s religion). Results—Swedish physicians chose fewer life-prolonging interventions as compared with the Russian and the German doctors. Swedish physicians would perform cardiopulmonary resuscitation (CPR) in the event of a cardiac arrest less frequently, followed by the German doctors. More than half the Russian physicians decided to perform CPR irrespective of the available information about the patient''s wishes. Level of dementia emerged as the most powerful determining attitude-variable for the decision making in all three countries. Conclusions—The lack of compliance with patient wishes among a substantial number of doctors points to the necessity of emphasising ethical aspects both in medical education and clinical practice. The inconsistency in the treatment decisions of doctors from different countries calls for social consensus in this matter. Key Words: End-of-life decision • DNR order • advance directive • physicians • cross-cultural comparison • survey     

Medical decisions concerning the end of life: a discussion with Japanese physicians.

OBJECTIVES: Life-sustaining treatment at the end of life gives rise to many ethical problems in Japan. Recent surveys of Japanese physicians suggested that they tend to treat terminally ill patients aggressively. We studied why Japanese physicians were reluctant to withhold or withdraw life-support from terminally ill patients and what affected their decisions. DESIGN AND PARTICIPANTS: A qualitative study design was employed, using a focus group interview with seven physicians, to gain an in-depth understanding of attitudes and rationales in Japan regarding medical care at the end of life. RESULTS: Analysis revealed that physicians and patients' family members usually make decisions about life-sustaining treatment, while the patients' wishes are unavailable or not taken into account. Both physicians and family members tend to consider withholding or withdrawing life-sustaining treatment as abandonment or even killing. The strongest reason to start cardiopulmonary resuscitation- and to continue it until patients' family members arrive-seems to be the family members' desire to be at the bedside at the time of death. All physicians participating in our study regarded advance directives that provide information as to patients' wishes about life-sustaining treatment desirable. All expressed concern, however, that it would be difficult to forego or discontinue life-support based on a patient's advance directive, particularly when the patient's family opposed the directive. CONCLUSION: Our group interview suggested several possible barriers to death with dignity and the appropriate use of advance directives in Japan. Further qualitative and quantitative research in this regard is needed.     

Bioethics for clinicians: 1. Consent.

Patients are entitled to make decisions about their medical care and to be given relevant information on which to base such decisions. The physicians obligation to obtain the patient's consent to treatment is grounded in the ethical principles of patient autonomy and respect for persons and is affirmed by Canadian law and professional policy. A large body of research supports the view that the process of obtaining consent can improve patient satisfaction and compliance and, ultimately, health outcomes. An exception to the requirement to obtain consent is the emergency treatment of incapable persons, provided there is no reason to believe that the treatment would be contrary to the person's wishes if he or she were capable.     

The Medical Directive. A new comprehensive advance care document

Living wills have been strongly endorsed in principle. Unfortunately, existing living wills are rarely used in clinical practice because they are vague and difficult to apply. To remedy this, we propose a new advance care document: the Medical Directive. The Medical Directive delineates four paradigmatic scenarios, defined by prognosis and disability of incompetent patients. In each scenario, patients are to indicate their preferences regarding specific life-sustaining interventions. The Medical Directive also provides for the designation of a proxy to make decisions in circumstances where the patient's preferences are uncertain. Finally, there is a section for a statement of wishes regarding organ donation. The Medical Directive provides an opportunity for significant improvement in the documentation of patients' preferences regarding life-sustaining care in states of incompetence. As an expression of a patient's wishes, the Medical Directive should be honored by courts and should facilitate physician-patient discussions of critical and terminal care options.     

Professional ethics in health care: an introduction

Discussions about issues in medical ethics are often frustrated by the failure to distinguish other concerns: legal and institutional rules, personal values, and personal moralities. Progress can be made if the medical profession reaches a prior agreement on its core values--what the good physician ought to care about--and a consensus on how these values are to be respected by physicians facing ethical dilemmas.     

Public attitudes toward the right to die.

OBJECTIVE: To determine public attitudes toward the right to die, euthanasia and related end-of-life decisions. DESIGN: Mail survey based on telephone numbers randomly selected by computer. SETTING: Edmonton. PARTICIPANTS: Of 1347 computer-generated, randomly selected telephone numbers called between February and June 1992, 902 individuals were reached, and 500 eligible contacts (55%) agreed to fill out the mailed questionnaire based on 12 vignettes involving end-of-life decisions. A total of 356 usable questionnaires (71%) were subsequently returned. MAIN OUTCOME MEASURES: Attitudes toward end-of-life decisions including withdrawal of life support, euthanasia, chronic suffering and the right to die, living wills and family involvement in decision making for incompetent individuals. Comments and demographic data were also solicited. RESULTS: Of the respondents 84% supported a family's right to withdraw life support from a patient in a persistent coma, and 90% supported a mentally competent patient's right to request that life support be withdrawn. Active euthanasia was supported by 65% for only patients experiencing severe pain and terminal illness. There was marked opposition to euthanasia for patients in other circumstances, such as an elderly disabled person who feels he or she is a burden on relatives (opposed by 65%), a patient with chronic depression resistant to treatment (by 75%) or an elderly person no longer satisfied with life and who has various minor physical ailments (by 83%). In all, 63% of the respondents felt that legalization of euthanasia for terminal illnesses would lead to euthanasia for many other, unsupported reasons, and 34% supported legislation to prohibit euthanasia in all situations. CONCLUSIONS: Public support for the right to die varies depending on the circumstances of the patient. The single most significant factor determining attitudes was the level of religious activity. The family's wishes were an important factor in end-of-life decisions for patients unable to communicate their desires. Both the general public and physicians should be primary participants in determining legislation regarding the right to die.     

Survey of Japanese physicians'' attitudes towards the care of adult patients in persistent vegetative state.

OBJECTIVES: Ethical issues have recently been raised regarding the appropriate care of patients in persistent vegetative state (PVS) in Japan. The purpose of our study is to study the attitudes and beliefs of Japanese physicians who have experience caring for patients in PVS. DESIGN AND SETTING: A postal questionnaire was sent to all 317 representative members of the Japan Society of Apoplexy working at university hospitals or designated teaching hospitals by the Ministry of Health and Welfare. The questionnaire asked subjects what they would recommend for three hypothetical vignettes that varied with respect to a PVS patient's previous wishes and the wishes of the family. RESULTS: The response rate was 65%. In the case of a PVS patient who had no previous expressed wishes and no family, 3% of the respondents would withdraw artificial nutrition and hydration (ANH) when the patient did not require any other life-sustaining treatments, 4% would discontinue ANH, and 30% would withhold antibiotics when the patient developed pneumonia. Significantly more respondents (17%) would withdraw ANH in the case of a PVS patient whose previous wishes and family agreed that all life support be discontinued. Most respondents thought that a patient's written advance directives would influence their decisions. Forty per cent of the respondents would want to have ANH stopped and 31% would not want antibiotics administered if they were in PVS. CONCLUSIONS: Japanese physicians tend not to withdraw ANH from PVS patients. Patients' written advance directives, however, would affect their decisions.     

Determining the validity of advance directives

We examine the ethical principles underpinning advance directives (ADs) and the legal duties of doctors in determining their validity. A physician attending an incompetent patient with an acute life-threatening illness, and an AD refusing treatment, should ensure that the AD is legally valid before making the treatment decision. Treatment against a patient's wishes, as expressed in a valid AD, compromises patient autonomy and may constitute battery. Conversely, withholding treatment in accordance with an AD that is not legally valid risks substantial harm to the patient and may constitute breach of the duty of care and negligence. Legally valid directives should be respected. If an AD is not legally valid, the patient should be treated in his or her best interests. If uncertain, the physician should treat according to the patient's best interests while seeking legal advice.     

Comparison of patients' and health care professionals' attitudes towards advance directives.

OBJECTIVES: This study was designed to identify and compare the attitudes of patients and health care professionals towards advance directives. Advance directives promote recognition of the patient's autonomy, letting the individual exercise a certain measure of control over life-sustaining care and treatment in the eventuality of becoming incompetent. DESIGN: Attitudes to advance directives were evaluated using a 44-item self-reported questionnaire. It yields an overall score as well as five factor scores: autonomy, beneficence, justice, external norms, and the affective dimension. SETTING: Health care institutions in the province of Québec, Canada. Survey sample: The sampling consisted of 921 subjects: 123 patients, 167 physicians, 340 nurses and 291 administrators of health care institutions. RESULTS: Although the general attitude of each population was favourable to the expression of autonomy, multivariate analysis of variance (MANOVA) indicated that physicians attached less importance to this subscale than did other populations (p < .001). Above all, they favoured legal external norms and beneficence. Physicians and administrators also attached less importance to the affective dimension than did patients and nurses. Specifically, physicians' attitudes towards advance directives were shown to be less positive than patients' attitudes. CONCLUSION: More attention should be given to the importance of adequately informing patients about advance directives because they may not represent an adequate means for patients to assert their autonomy.     

Medical intensive care for the elderly. A study of current use, costs, and outcomes

All admissions (2,693) to a medical intensive and coronary care unit (ICU/CCU) during a two-year period were reviewed to compare indications for admission, major interventions, and outcomes for elderly patients with those for younger patients. Once admitted to the ICU/CCU, older patients were more likely to receive major life-support interventions such as mechanical ventilation but less likely to survive. Major interventions were used in 32% of patients aged 75 years or older, in 26% of those 65 to 74 years, and in 22% of those 55 to 64 years. Nonetheless, elderly patients had no longer mean lengths of stay and no greater mean hospital charges. Hospital mortality for the oldest patients was 16%, compared with 14% and 8% for the younger age groups. Cumulative mortality one year after discharge for those older than 75 years was 44%. Elderly hospital survivors returned to their preadmission living situation but did not regain their preadmission activity level.     

Outcomes for dialysis patients with end-stage renal failure admitted to an intensive care unit or high dependency unit

OBJECTIVE: To assess the outcomes for chronic dialysis patients requiring admission to an intensive care unit (ICU) or high dependency unit (HDU). DESIGN: Retrospective audit of prospectively collected data from local and national databases. SETTING: The ICU and HDU at a tertiary referral hospital. PARTICIPANTS: 70 chronic dialysis patients admitted between 2001 and 2006. MAIN OUTCOME MEASURES: Unit and hospital mortality, recurrent admission patterns and median survival after discharge from hospital. RESULTS: For patients' last admissions, mortality in the ICU or HDU was 17% and in hospital was 29%. The 12 deaths in the ICU or HDU occurred a median of 18 hours (range, 3-203 hours) after admission, reflecting the severity of their underlying illness. The independent predictors of death in hospital were age and the number of non-renal organ systems failing. Patients with pulmonary oedema had a lower risk of death than patients admitted for other reasons. Although 21 patients accounted for 55 of 104 admissions (53%), recurrent admissions to the ICU or HDU generally occurred during different hospital admissions. They were not associated with a higher risk of death in hospital. Patients discharged home had a median survival of 2.25 years, and a median survival of 3.5 years from starting dialysis. The median survival for patients on dialysis in Australia in general is 4.5 years (Australia and New Zealand Dialysis and Transplant Registry). CONCLUSION: Dialysis patients discharged home after an ICU or HDU admission have survival similar to that of Australian dialysis patients generally.     

Certainty and mortality prediction in critically ill children

OBJECTIVES: The objective of this study is to investigate the relationship between a physician's subjective mortality prediction and the level of confidence with which that mortality prediction is made. DESIGN AND PARTICIPANTS: The study is a prospective cohort of patients less than 18 years of age admitted to a tertiary Paediatric Intensive Care Unit (ICU) at a University Children's Hospital with a minimum length of ICU stay of 10 h. Paediatric ICU attending physicians and fellows provided mortality risk predictions and the level of confidence associated with these predictions on consecutive patients at the time of multidisciplinary rounds within 24 hours of admission to the paediatric ICU. Median confidence levels were compared across different ranges of mortality risk predictions. RESULTS: Data were collected on 642 of 713 eligible patients (36 deaths, 5.6%). Mortality predictions greater than 5% and less than 95% were made with significantly less confidence than those predictions <5% and >95%. Experience was associated with greater confidence in prognostication. CONCLUSIONS: We conclude that a physician's subjective mortality prediction may be dependent on the level of confidence in the prognosis; that is, a physician less confident in his or her prognosis is more likely to state an intermediate survival prediction. Measuring the level of confidence associated with mortality risk predictions (or any prognostic assessment) may therefore be important because different levels of confidence may translate into differences in a physician's therapeutic plans and their assessment of the patient's future.     

Resuscitation: how do we decide? A prospective study of physicians' preferences and the clinical course of hospitalized patients

Physicians have to address the question of the measures to be employed in the event that a patient's condition deteriorates after admission to the hospital. To identify the information that physicians use in making such decisions, all 604 patients admitted to the medical service during a one-month period were studied. The patient's age and residents' estimates of the patient's long-term prognosis and ability to function were the three primary factors that correlated with intervention preferences. When illness severity, the reason for admission, comorbidity, and poor function were taken into account, mortality and morbidity rates did not differ between patients for whom full vs not-full intervention was favored. Apart from differential rates of admission to critical care units, there were no important differences in the care, course, or mortality of patients for whom less than full intervention was initially favored. Suggestions that physicians should discuss resuscitation with all or most patients who may die are unrealistic. A more prudent strategy is to discuss the issue with patients whose hospital course is marked by a steady deterioration.     

Relationships between various attitudes towards self-determination in health care with special reference to an advance directive

OBJECTIVES: The subject of patient self-determination in health care has gained broad interest because of the increasing number of incompetent patients. In an attempt to solve the problems related to doctors' decision making in such circumstances, advance directives have been developed. The purpose of this study was to examine relationships between public attitudes towards patient autonomy and advance directives. SUBJECTS AND MAIN OUTCOME MEASURES: A stratified random sample of 600 adults in northern Sweden was surveyed by a questionnaire with a response rate of 78.2%. The subjects were asked about their wish for control of their health care, their concerns about health care, their treatment preferences in a life-threatening situation (both reversible and irreversible), and their attitudes towards the application of advance directives. RESULTS: Numerous relationships between various aspects of self-determination in health care (desire for control, fears of over-treatment, and choice of treatment level) in general and advance directives, in particular, were found. Those who wanted to have a say in their health care (about 94%) also mainly supported the use of an advance directive. CONCLUSIONS: The fact that almost 30% of the respondents were undecided concerning their personal use of advance directives points to a lack of knowledge and to the necessity of education of the public on these issues.     

After "Eve": whither proxy decision-making?

One of the most difficult problems facing physicians is how to approach proxy decisions made on behalf of congenitally incompetent patients. The author considers two recent court cases that attempt to provide guidelines: Re Stephen Dawson, which opts for a substituted-judgement approach, and Eve v. Mrs E.) which injoins best-interests considerations. The author explores the impact of Eve v. Mrs. E. as superseding Re Stephen Dawson, considers its ethical implications and attempts to clarify the best-interests criterion by sketching some guidelines for its interpretation. In so doing, he tries to reconcile the two decisions by laying bare their common underlying ethical rationale. The author concludes by pointing out some ethically questionable implications of Eve v. Mrs. E. in the area of allocation of health care resources.     

Effect of nonmedical factors on family physicians' decisions about referral for consultation.

OBJECTIVES: To identify nonmedical factors perceived by family physicians (FPs) and consultants as important influences on decisions about referral for consultation, to determine the relative frequency with which such factors are cited and to identify those factors ranked as most important by the FPs and consultants. DESIGN: Survey with semistructured interview between July 1989 and April 1990. PARTICIPANTS: A total of 41 FPs and 20 consultants who were practising or had practised previously in Nova Scotia. INTERVENTIONS: The questionnaire comprised 10 questions: 4 were nondirective "probes" designed to elicit responses without suggesting possible answers, 2 asked the participants to rank such responses in order of importance, and 4 were "prompts" that asked for comments about a list of factors based on a review of the literature. RESULTS: A total of 4845 discrete items were mentioned as being capable of influencing FPs' decisions about referral for consultation. Aggregation of related items resulted in a list of 35 nonmedical factors, of which 11 were identified by at least half the respondents and 14 by less than half but more than 10. These 25 factors fell into three categories: patient and family factors (e.g., patient's wishes), FP and consultant factors (e.g., FP's capabilities), and other influences (e.g., style of practice). On the basis of both frequency of identification and priority scores "patient's wishes" emerged as the most important factor. Two medical factors that were consistently cited--type of problem and age of patient--were thought to interact with the other factors. CONCLUSION: Certain nonmedical considerations may substantially affect physicians' referral practices.     

Rationing of intensive care unit services. An everyday occurrence

We investigated the extent to which bed availability affects decision making in an intensive care unit (ICU). For 1,151 ICU patients, we determined the number of empty ICU beds available at times of admission and discharge and the outcome for those patients. For a randomly chosen group we assessed severity of illness. Patients admitted during times of bed shortage were, on average, more severely ill than those admitted when many beds were unoccupied. Patients discharged under crowded conditions were sicker and had a shorter stay than patients discharged when more beds were available. The relative risk of discharge was inversely related to empty bed availability, illness severity, and age. Bed availability had no effect on rates of death in the ICU, death after discharge, or readmission to the ICU. We conclude that physicians can effectively ration intensive care beds on a regular basis by altering admission and discharge decision making.