Medical and Nonmedical Determinants of Decision Making about Potentially Life-Prolonging Interventions

Correlates of end-of-life treatment preferences among young adults and older adults

The purpose of this study was to investigate correlates of end-of-life treatment preferences. Young adults (n = 117) and older adults (n = 305) completed an interview survey. Compared to older adults, young adults endorsed a desire for more medical intervention in end-of-life scenarios. After controlling for age cohort and education, a desire for more medical intervention in end-of-life scenarios was associated with higher religiosity, greater death anxiety, and more positive attitudes toward aging but not with physical or mental health. End-of-life treatment preferences may be more closely related to attitudes, beliefs, and practices than health status.

The development of an individual differences end-of-life treatment preferences scale

The purpose of this study was to create an individual differences measure of end-of-life treatment preferences (EOLTPs). Young adults (n = 427) and older adults (n = 333) completed a survey. Results found that hope of recovery was an important factor in whether individuals preferred a given medical intervention. A single factor explained the majority of the variance in EOLTPs, and EOLTPs were distinct from more general attitudes about medical care. Older adults preferred less end-of-life medical intervention compared to younger adults. Overall, the results of the study support the use of an individual differences approach to measuring EOLTPs.

" The best interest of the adolescent " : Exploring doctors ' decision to proceed with treatment of sexual reproductive health without parental consent

INTRODUCTION

Adolescents below the age of majority require parental consent for treatment or else the treating doctor may be liable for trespass and assault. This creates a dilemma for frontline doctors, as involving parents in the discussion could add yet another barrier to the existing barriers for adolescents in terms of access to healthcare services.

AIM

This paper seeks to explore doctors' treatment decisions made without parental consent when managing adolescents presenting with sexual and reproductive health issues.

METHODS

Based on a qualitative approach, in-depth interviews with 25 doctors throughout Malaysia were conducted. All audio-recorded interviews were transcribed verbatim and analyzed using a thematic approach.

RESULTS

Generally, doctors weigh any decision by examining the health risks and benefits involved. While fear of litigation influences treatment decisions, a strong adherence to the ethical duty of 'do no harm' outweighs other considerations. When all options are risky, choosing what is considered 'the lesser of two evils,' i.e., what is perceived to be in the best interest of the adolescent, is adopted.

CONCLUSIONS

The complexity of a medical decision related to adolescent SRH issues is increased further when legal requirements are not in synch with the ethical and personal values of doctors. The laws relating to parental consent should be promulgated with a provision allowing doctors to exercise discretion in terms of treating specific SRH issues without parental consent.

Nurses’ and Physicians’ Opinions on Aggressiveness of Treatment for General Ward Patients

The aim of this study was to evaluate agreement between nurses’ and physicians’ opinions regarding aggressiveness of treatment and to investigate and compare the rationales on which their opinions were based. Structured interviews regarding 714 patients were performed on seven general wards of a university hospital. The data gathered were then subjected to qualitative and quantitative analyses. There was 86% agreement between nurses’ and physicians’ opinions regarding full or limited treatment when the answers given as ‘uncertain’ were excluded. Agreement was less (77%) for patients with a life expectancy of less than one year. Disagreements were not associated with professional status because the physicians considered limiting life-sustaining treatment as often as the nurses. A broad spectrum of rationales was given but the results focus mostly on those for full treatment. The nurses and the physicians had similar bases for their opinions. For the majority of the patients, medical rationales were used, but age and quality of life were also expressed as important determinants. When considering full treatment, nurses used quality-of-life rationales for significantly more patients than the physicians. Respect for patients’ wishes had a minor influence.

Reasons for continuous sedation until death in cancer patients: a qualitative interview study

End-of-life sedation, though increasingly prevalent and widespread, remains a highly debated medical practice in the context of palliative medicine. This qualitative study aims to look more specifically at how health care workers justify their use of continuous sedation until death and which factors they report as playing a part in the decision-making process. In-depth interviews were held with 28 physicians and 22 nurses of 27 cancer patients in Belgium who had received continuous sedation until death in hospitals, palliative care units or at home. Our findings indicate that medical decision-making for continuous sedation is not only based on clinical indications but also related to morally complex issues such as the social context and the personal characteristics and preferences of individual patient and their relatives. The complex role of non-clinical factors in palliative sedation decision-making needs to be further studied to assess which medically or ethically relevant arguments are underlying daily clinical practice. Finally, our findings suggest that in some cases continuous sedation was resorted to as an alternative option at the end of life when euthanasia, a legally regulated option in Belgium, was no longer practically possible.

The labelling and reporting of euthanasia by Belgian physicians: a study of hypothetical cases

BACKGROUND

Belgium legalized euthanasia in 2002. Physicians must report each euthanasia case to the Federal Control and Evaluation Committee. This study examines which end-of-life decisions (ELDs) Belgian physicians label 'euthanasia', which ELDs they think should be reported and the physician characteristics associated with correct labelling of euthanasia cases, the awareness that they should be reported and the reporting of them.

METHODS

Five hypothetical cases of ELDs: intensified pain alleviation, palliative/terminal sedation, euthanasia with neuromuscular relaxants, euthanasia with morphine and life-ending without patient request were presented in a cross-sectional survey of 914 physicians in Belgium in 2009.

RESULTS

About 19% of physicians did not label a euthanasia case with neuromuscular relaxants 'euthanasia', 27% did not know that it should be reported. Most physicians labelled a euthanasia case with morphine 'intensification of pain and symptom treatment' (39%) or 'palliative/terminal sedation' (37%); 21% of physicians labelled this case 'euthanasia'. Cases describing other ELDs were sometimes also labelled 'euthanasia'. Factors associated with a higher likelihood of labelling a euthanasia case correctly were: living in Flanders, being informed about the euthanasia law and having a positive attitude towards societal control over euthanasia. Whether a physician correctly labelled the euthanasia cases strongly determined their reporting knowledge and intentions.

CONCLUSION

There is no consensus among physicians about the labelling of euthanasia and other ELDs, and about which cases must be reported. Mislabelling of ELDs could impede societal control over euthanasia. The provision of better information to physicians appears to be necessary.

Examining guideline-concordant care for acute myocardial infarction (AMI): the case of hospitalized post-acute and long-term care (PAC/LTC) residents

BACKGROUND

Previous studies have examined differences in care for acute myocardial infarction (AMI) according to patient characteristics such as age, gender, or insurance, but little attention has been given to whether admission source is related to guideline adherence.

OBJECTIVE

To investigate: (1) the use of aspirin and reperfusion in the care of post-acute/long-term care (PAC/LTC) patients who are hospitalized for AMI, and (2) 30-day mortality associated with these treatments.

DESIGN

Secondary examination of data from the Cooperative Cardiovascular Project (CCP) national baseline data.

SETTING

A total of 4013 U.S. hospitals.

SUBJECTS

Patients hospitalized with a confirmed AMI admitted from PAC/LTC (n = 8151) or community-dwelling (n = 120,032) settings.

MEASUREMENTS

Early administration of aspirin and reperfusion via either thrombolysis or percutaneous intervention.

RESULTS

PAC/LTC patients were less likely to receive treatment for AMI, even after adjustment for multiple variables associated with treatment choice. Differences persisted with additional econometric adjustment using seemingly-unrelated regression. Multivariable logistic regression results indicated that aspirin was related to improved 30-day survival for both PAC/LTC and community admissions (odds ratio [OR], 0.50; 95% confidence interval [CI], 0.43-0.58 for PAC/LTC, and OR, 0.57; 95% CI, 0.54-0.60 for community). Reperfusion was associated with higher ORs for mortality for eligible patients admitted from community setting (OR, 1.24; 95% CI, 1.13-1.35), but ideally-eligible candidates had lower ORs for mortality (OR, 0.58; 95% CI, 0.35-0.95 for PAC/LTC, and OR, 0.74; 95% CI, 0.68-0.81 for community).

CONCLUSIONS

Patients transferred from PAC/LTC settings were less likely to receive early treatment for AMI than other patients. Future trials should inform which guidelines are applicable to PAC/LTC patients.

Forgoing artificial nutrition or hydration in patients nearing death in six European countries

Whether or not artificial nutrition or hydration (ANH) may be forgone in terminally ill patients has been the subject of medical and ethical discussions. Information about the frequency and background characteristics of making decisions to forgo ANH is generally limited to specific clinical settings. The aim of this study was to compare the practice of forgoing ANH in six European countries: Belgium, Denmark, Italy, The Netherlands, Sweden, and Switzerland. In each country, random samples were drawn from death registries. Subsequently, the reporting physician received a questionnaire about the medical decisions that preceded the patient's death. The total number of deaths studied was 20,480. The percentage of all deaths that were preceded by a decision to forgo ANH varied from 2.6% in Italy to 10.9% in The Netherlands. In most countries, decisions to forgo ANH were more frequently made for female patients, patients aged 80 years or older, and for patients who died of a malignancy or disease of the nervous system (including dementia). Of patients in whom ANH was forgone, 67%-93% were incompetent. Patients in whom ANH was forgone did not receive more potentially life-shortening drugs to relieve symptoms than other patients for whom other end-of-life decisions had been made. Decisions to forgo ANH are made in a substantial percentage of terminally ill patients. Providing all patients who are in the terminal stage of a lethal disease with ANH does not seem to be a widely accepted standard among physicians in Western Europe.

Relationship between English language use and preferences for involvement in medical care among Hispanic women

OBJECTIVE

To assess how English language use by Hispanic women affects their preferences for participating in decision making and information seeking regarding medical care.

METHODS

The study included 235 Hispanic women aged 35-61 years participating in a larger multicenter study, the Ethnicity, Needs, and Decisions of Women (ENDOW) Project. Participants were recruited from community settings and primary care public health clinics. Bilingual (English and Spanish speaking) interviewers asked participants questions about demographic characteristics, health status, reproductive history, menopausal status, access to healthcare, experience with hormone replacement therapy (HRT) and hysterectomy, outcome expectations about HRT and hysterectomy, medical decision making, and social support. Using univariate and multivariate analyses, we assessed the relationships between the participants' preferences for participating in decision making and information seeking, their language use, and other covariates of interest.

RESULTS

Overall, the participants expressed a strong desire for information about and participating in medical decisions. However, they expressed a lower preference for participating in decisions related to use of HRT compared with the desire for engaging in decision involving invasive medical procedures (hysterectomy and cholecystectomy) and high blood pressure management. Increased use of English language was significantly associated with preferences for participating in medical care decision making, in general (p < 0.001), and with information seeking (p = 0.044). Decreased use of English language was associated with a lower desire for participating in medical care decision making.

CONCLUSIONS

Increased use of English language may influence Hispanic women's preferences for participating in medical decisions and their information-seeking behavior.