CLINICAL ETHICS

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

H Hinkka¹, E Kosunen², R Metsänoja³, U-K Lammi⁴ and P Kellokumpu-Lehtinen⁵

¹ Kangasala Health Center, Kangasala, and Department of General Practice, Medical School, University of Tampere, Finland
² Department of General Practice, Medical School, University of Tampere, Finland
³ School of Public Health, University of Tampere, Finland
⁴ Department of General Practice, Medical School, University of Tampere, Finland
⁵ Department of Oncology, Medical School, University of Tampere, and Clinic of Oncology, Tampere University Hospital, Finland

Correspondence to:
Correspondence to:
Dr H Hinkka, Tahkatie 53, 36200 Kangasala, Finland;
hhinkka@sci.fi

Revised version received 16 June 2001

Accepted 28 August 2001

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 readily x ray (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.

Keywords: End-of-life decisions; terminal care; medical futility; ethics; withdrawing; withholding

The first 150 words of the full text of this article appear below.

Decision making in terminal care is a demanding and stressful duty for all involved. Frequently, moreover, the situation is ethically complex, and the decisions have been shown to depend not only on patients' preferences or clinical circumstances but also on the personal characteristics of the physician.¹ Our own previous studies have shown physicians' age, gender, specialty, marital status, and experiences of severe disease in their own families to be associated with their decisions between palliative or active treatment in terminal care. Also, attitudes concerning for example withholding life-sustaining treatment (LST) and doctor-assisted suicide, and opinions on a doctors' ability to assess a patient's pain, have proved to be significant predictors of decisions.²

From the ethical and legal standpoint the withdrawal or withholding of treatment in terminal care are on a par.³ Many doctors, however, think that deciding to withdraw treatment once initiated is ethically and legally more often wrong or . . . [Full text of this article]

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