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Withholding and withdrawing life-sustaining treatment: a comparative study of the ethical reasoning of physicians and the general public
Department of Surgical and Perioperative Sciences, Anaesthesiology, University Hospital of Northern Sweden, Lasarettsbacken SE-90185 Umeå, Sweden.
Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Berzelius vaeg 3 SE-17177 Stockholm, Sweden.
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.

Place, publisher, year, edition, pages
2008. Vol. 12, no 1, R13
Keyword [en]
*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: urn:nbn:se:umu:diva-31395DOI: 10.1186/cc6786ISI: 000254812500053PubMedID: 18279501ISBN: 1466-609X (Electronic) (print)OAI: oai:DiVA.org:umu-31395DiVA: diva2:292943
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: 2017-12-12Bibliographically approved
In thesis
1. Withhold  or  withdraw  futile  treatment in  intensive  care: arguments supported by physicians and the general public
Open this publication in new window or tab >>Withhold  or  withdraw  futile  treatment in  intensive  care: arguments supported by physicians and the general public
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
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:nbn:se:umu:diva-128863 (URN)978-91-7601-629-9 (ISBN)
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

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