CLINICAL ETHICS

Decisions at the end of life: an empirical study on the involvement, legal understanding and ethical views of preregistration house officers

J Schildmann¹, L Doyal², A Cushing³ and J Vollmann⁴

¹ Department of Medicine III, Friedrich-Alexander University, Erlangen Nuremberg, Institute for Medical Ethics and History of Medicine, Ruhr-University Bochum, Germany
² Department of Human Science and Medical Ethics, Queen Mary’s School Of Medicine and Dentistry (Emeritus), London, UK
³ Clinical Communication Learning Skills Unit, Queen Mary’s School of Medicine and Dentistry
⁴ Institute for Medical Ethics and History of Medicine, Ruhr-University Bochum

Correspondence to:
Correspondence to:
J Schildmann
Institut fuer Medizinische Ethik und Geschichte der Medizin, Ruhr-Universitaet Bochum, Markstraße 258a, D-44799 Bochum, Germany; jan.schildmann{at}rub.de

Objectives: To collect information on the involvement, legal understanding and ethical views of preregistration house officers (PRHO) regarding end-of-life decision making in clinical practice.

Design: Structured telephone interviews.

Participants: 104 PRHO who responded.

Main outcome measures: Information on the frequency and quality of involvement of PRHO in end-of-life decision making, their legal understanding and ethical views on do-not-resuscitate (DNR) order and withdrawal of treatment.

Results: Most PRHO participated in team discussions on the withdrawal of treatment (n = 95, 91.3%) or a DNR order (n = 99, 95.2%). Of them, 46 (44.2%) participants had themselves discussed the DNR order with patients. In all, it was agreed by 84 (80.8%) respondents that it would be unethical to make a DNR order on any patient who is competent without consulting her or him. With one exception, it was indicated by the participants that patients who are competent may refuse tube feeding (n = 103, 99.0%) and 101 (97.1%) participants thought that patients may refuse intravenous nutrition. The withdrawal of artificial ventilation in incompetent patients with serious and permanent brain damage was considered to be morally appropriate by 95 (91.3%) and 97 (93.3%) thought so about the withdrawal of antibiotics. The withdrawal of intravenous hydration was considered by 67 (64.4%) to be morally appropriate in this case.

Conclusions: PRHO are often involved with end-of-life decision making. The results on ethical and legal understanding about the limitations of treatment may be interpreted as a positive outcome of the extensive undergraduate teaching on this subject. Future empirical studies, by a qualitative method, may provide valuable information about the arguments underlying the ethical views of doctors on the limitations of different types of medical treatment.

Abbreviations: DNR, do not resuscitate; PRHO, preregistration house officers

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