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Withhold  or  withdraw  futile  treatment in  intensive  care: arguments supported by physicians and the general public
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Since the 60s and with increasing intensity a discussion have continued about balance between useful and useless/harmful treatment. Different attempts have been done to create sustainable criteria and recommendations to manage the situations of futile treatment near the end of life. Obviously, to be able to withhold (WH) or withdraw (WD) treatment which is no longer appropriate or even harmful and burdensome for the patient, other processes than strict medical (or physiological) assessments are necessary.

Aim. To shed light on the arguments regarding to WH or WD futile treatment we performed two studies of physicians’ and the general populations’ choice and prioritized arguments in the treatment of a 72-year-old woman suffering from a large intra-cerebral bleeding with bad prognosis (Papers I and II) and a new born boy with postpartum anoxic brain damage (Papers III and IV).

Methods. Postal questionnaires based on two cases presented above involving severely ill patients were used. Arguments for and against to WH or WD treatment, and providing treatment that might hasten death were presented. The respondents evaluated and prioritized arguments for and against withholding neurosurgery, withdrawing life-sustaining treatment and providing drugs to alleviate pain and distress. We also asked what would happen to physicians’ own trust if they took the action described, and what the physician estimated would happen to the general publics’ trust in health services (Paper IV).

Results. Approximately 70% of the physicians and 46% of the general public responded in both surveys. The 72-year-old woman: A majority of doctors (82.3%) stated that they would withhold treatment, whereas a minority of the general public (40.2%) would do so; the arguments forwarded and considerations regarding quality of life differed significantly between the two groups. Quality-of-life aspects were stressed as an important argument by the majority of both neurosurgeons and ICU-physicians (76.8% vs. 54.0%); however, significantly more neurosurgeons regarded this argument as the most important. A minority in both groups, although more ICU-physicians, supported a patient’s previously expressed wish of not ending in a persistent vegetative state as the most important argument. As the case clinically progressed, a consensus evolved regarding the arguments for decision making.

The new born child: A majority of both physicians [56 % (CI 50–62)] and the general population [53 % (CI 49–58)] supported arguments for withdrawing ventilator treatment. A large majority in both groups supported arguments for alleviating the patient’s symptoms even if the treatment hastened death, but the two groups display significantly different views on whether or not to provide drugs with the additional intention of hastening death, although the difference disappeared when we compared subgroups of those who were for or against euthanasia-like actions.

Conclusions. There are indeed considerable differences in how physicians and the general public assess and reason in critical care situations, but the more hopelessly ill the patient became the more the groups' assessments tended to converge, although they prioritized different arguments. In order to avoid unnecessary dispute and miscommunication, it is important that health care providers are aware of the public's views, expectations, and preferences. Our hypothesis—physicians’ estimations of others’ opinions are influenced by their own opinions—was corroborated. This might have implications in research as well as in clinical decision-making.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2016. , 95 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1870
Keyword [en]
Withdrawal life-sustaining treatment, Futility, Neonatal intensive care, Intentions, Hastening Death, Value-based medicine, Evidence-based medicine, Decision-making, Personal values
National Category
Medical Ethics Anesthesiology and Intensive Care
Research subject
Anaesthesiology
Identifiers
URN: urn:nbn:se:umu:diva-128863ISBN: 978-91-7601-629-9 (print)OAI: oai:DiVA.org:umu-128863DiVA: diva2:1057210
Public defence
2017-01-20, Sal 933, byggnad 3A, 9tr, Norrlands Universitetssjukhus, Umeå, 13:00 (Swedish)
Opponent
Supervisors
Funder
Vårdal FoundationSwedish Society of Medicine
Available from: 2016-12-21 Created: 2016-12-16 Last updated: 2016-12-21Bibliographically approved
List of papers
1. Decision making in a life-threatening cerebral condition: a comparative study of the ethical reasoning of intensive care unit physicians and neurosurgeons
Open this publication in new window or tab >>Decision making in a life-threatening cerebral condition: a comparative study of the ethical reasoning of intensive care unit physicians and neurosurgeons
2007 (English)In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 51, no 10, 1338-1343 p.Article in journal (Other academic) Published
Abstract [en]

Severe traumatic brain injury (TBI) is one of the major causes of death in younger age groups. In Umea, Sweden, an intracranial pressure (ICP) targeted therapy protocol, the Lund concept, has been used in treatment of severe TBI since 1994. Decompressive craniectomy is used as a protocol-guided treatment step. The primary aim of the investigation was to study the effect of craniectomy on ICP changes over time in patients with severe TBI treated by an ICP-targeted protocol. In this retrospective study, all patients treated for severe TBI during 1998-2001 who fulfilled the following inclusion criteria were studied: GCS <or= 8 at intubation and sedation, first recorded cerebral perfusion pressure (CPP) of >10 mm Hg, arrival within 24 h of trauma, and need of intensive care for >72 h. Craniectomy was performed when the ICP could not be controlled by evacuation of hematomas, sedation, ventriculostomy, or low-dose pentothal infusion. Ninety-three patients met the inclusion criteria. Mean age was 37.6 years. Twenty-one patients underwent craniectomy as a treatment step. We found a significant reduction of the ICP directly after craniectomy, from 36.4 mm Hg (range, 18-80 mm Hg) to 12.6 mm Hg (range, 2-51 mm Hg). During the following 72 h, we observed an increase in ICP during the first 8-12 h after craniectomy, reaching approximately 20 mm Hg, and later levelling out at approximately 25 mm Hg. The reduction of ICP was statistically significant during the 72 h. The outcome as measured by Glasgow Outcome Scale (GOS) did not significantly differ between the craniectomized group (DC) and the non-craniectomized group (NDC). The outcome was favorable (GOS 5-4) in 71% in the craniectomized group, and in 61% in the non-craniectomized group. Craniectomy is a useful tool in achieving a significant reduction of ICP overtime in TBI patients with progressive intracranial hypertension refractory to medical therapy. The procedure seems to have a satisfactory effect on the outcome, as demonstrated by a high rate of favorable outcome and low mortality in the craniectomized group, which did not significantly differ compared with the non-craniectomized group.

Keyword
Brain Injuries/pathology/*surgery, Decision Making, Female, Humans, Intensive Care Units/*ethics, Male, Middle Aged, Neurosurgery/*ethics, Physicians/*ethics
National Category
Medical Ethics Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:umu:diva-10687 (URN)10.1111/j.1399-6576.2007.01452.x (DOI)000250249500010 ()17944637 (PubMedID)
Available from: 2008-10-17 Created: 2008-10-17 Last updated: 2016-12-20Bibliographically approved
2. Withholding and withdrawing life-sustaining treatment: a comparative study of the ethical reasoning of physicians and the general public
Open this publication in new window or tab >>Withholding and withdrawing life-sustaining treatment: a comparative study of the ethical reasoning of physicians and the general public
2008 (English)In: Critical Care, ISSN 1364-8535, E-ISSN 1466-609X, Vol. 12, no 1, R13Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Our objective was to investigate whether a consensus exists between the general public and health care providers regarding the reasoning and values at stake on the subject of life-sustaining treatment. METHODS: A postal questionnaire was sent to a random sample of members of the adult population (n = 989) and to a random sample of intensive care doctors and neurosurgeons (n = 410) practicing in Sweden in 2004. The questionnaire was based on a case involving a severely ill patient and presented arguments for and against withholding and withdrawing treatment, and providing treatment that might hasten death. RESULTS: Approximately 70% of the physicians and 51% of the general public responded. A majority of doctors (82.3%) stated that they would withhold treatment, whereas a minority of the general public (40.2%) would do so; the arguments forwarded (for instance, belief that the first task of health care is to save life) and considerations regarding quality of life differed significantly between the two groups. Most physicians (94.1%) and members of the general public (77.7%) were prepared to withdraw treatment, and most (95.1% of physicians and 82% of members of the general public) agreed that sedation should be provided. CONCLUSION: There are indeed considerable differences in how physicians and the general public assess and reason in critical care situations, but the more hopelessly ill the patient became the more the groups' assessments tended to converge, although they prioritized different arguments. In order to avoid unnecessary dispute and miscommunication, it is important that health care providers be aware of the public's views, expectations, and preferences.

Keyword
*Attitude of Health Personnel, Cerebral Hemorrhage/surgery/therapy, Critical Care/*ethics/*psychology, Female, Humans, Male, Middle Aged, *Public Opinion, Quality of Life, Questionnaires, Sweden, Withholding Treatment/*ethics
National Category
Medical Ethics Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:umu:diva-31395 (URN)10.1186/cc6786 (DOI)000254812500053 ()18279501 (PubMedID)1466-609X (Electronic) (ISBN)
Note

Rydvall, Anders Lynoe, Niels Comparative Study Research Support, Non-U.S. Gov't England Critical care (London, England) Crit Care. 2008;12(1):R13. Epub 2008 Feb 15.

Available from: 2010-02-10 Created: 2010-02-10 Last updated: 2016-12-20Bibliographically approved
3. To treat or not to treat a newborn child with severe brain damage?: A cross-sectional study of physicians' and the general population's perceptions of intentions
Open this publication in new window or tab >>To treat or not to treat a newborn child with severe brain damage?: A cross-sectional study of physicians' and the general population's perceptions of intentions
Show others...
2014 (English)In: Medicine, Health care and Philosophy, ISSN 1386-7423, E-ISSN 1572-8633, Vol. 17, no 1, 81-88 p.Article in journal (Refereed) Published
Abstract [en]

Ethical dilemmas are common in the neonatal intensive care setting. The aim of the present study was to investigate the opinions of Swedish physicians and the general public on treatment decisions regarding a newborn with severe brain damage. We used a vignette-based questionnaire which was sent to a random sample of physicians (n = 628) and the general population (n = 585). Respondents were asked to provide answers as to whether it is acceptable to discontinue ventilator treatment, and when it actually is discontinued whether or not it was acceptable to use drugs which hasten death unintentionally or intentionally. The response rate was 67 % of physicians and 46 % of the general population. A majority of both physicians [56 % (CI 50-62)] and the general population [53 % (CI 49-58)] supported arguments for withdrawing ventilator treatment. A large majority in both groups supported arguments for alleviating the patient's symptoms even if the treatment hastened death, but the two groups display significantly different views on whether or not to provide drugs with the additional intention of hastening death, although the difference disappeared when we compared subgroups of those who were for or against euthanasia-like actions. The study indicated that physicians and the general population have similar opinions regarding discontinuing life-sustaining treatment and providing effective drugs which might unintentionally hasten death but seem to have different views on intentions. The results might be helpful to physicians wanting to examine their own intentions when providing adequate treatment at the end of life.

Keyword
Withdrawal life-sustaining treatment, Neonatal intensive care, Intentions, Hastening, Death, Euthanasia
National Category
Medical Ethics Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:umu:diva-86833 (URN)10.1007/s11019-013-9498-9 (DOI)000330735500010 ()23771411 (PubMedID)
Available from: 2014-03-17 Created: 2014-03-11 Last updated: 2016-12-20Bibliographically approved
4. Are physicians' estimations of future events value-impregnated?: Cross-sectional study of double intentions when providing treatment that shortens a dying patient's life
Open this publication in new window or tab >>Are physicians' estimations of future events value-impregnated?: Cross-sectional study of double intentions when providing treatment that shortens a dying patient's life
2014 (English)In: Medicine, Health care and Philosophy, ISSN 1386-7423, E-ISSN 1572-8633, Vol. 17, no 3, 397-402 p.Article in journal (Refereed) Published
Abstract [en]

The aim of the present study was to corroborate or undermine a previously presented conjecture that physicians' estimations of others' opinions are influenced by their own opinions. We used questionnaire based cross-sectional design and described a situation where an imminently dying patient was provided with alleviating drugs which also shortened life and, additionally, were intended to do so. We asked what would happen to physicians' own trust if they took the action described, and also what the physician estimated would happen to the general publics' trust in health services. Decrease of trust was used as surrogate for an undesirable action. The results are presented as proportions with a 95 % Confidence Interval (CI). Statistical analysis was based on inter-rater agreement (Weighted Kappa)-test as well as chi (2) test and Odds Ratio with 95 % CI. We found a moderate inter-rater agreement (Kappa = 0.552) between what would happen with the physicians' own trust in healthcare and their estimations of what would happen with the general population's trust. We identified a significant difference between being pro et contra the treatment with double intentions and the estimation of the general population's trust (chi(2) = 72, df = 2 and p < 0.001). Focusing on either decreasing or increasing own trust and being pro or contra the action we identified a strong association [OR 79 (CI 25-253)]. Although the inter-rater agreement in the present study was somewhat weaker compared to a study about the explicit use of the term 'physicians assisted suicide' we found that our hypothesis-physicians' estimations of others' opinions are influenced by their own opinions-was corroborated. This might have implications in research as well as in clinical decision-making. We suggest that Merton's ideal of disinterestedness should be highlighted.

Place, publisher, year, edition, pages
Springer Netherlands, 2014
Keyword
Value-based medicine, Evidence-based medicine, Disinterestedness, Decision-making, Personal values
National Category
Medical Ethics Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:umu:diva-91635 (URN)10.1007/s11019-014-9546-0 (DOI)000338833700009 ()24449290 (PubMedID)1572-8633 (Electronic) 1386-7423 (Linking) (ISBN)
Available from: 2014-08-13 Created: 2014-08-13 Last updated: 2016-12-20Bibliographically approved

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