Physicians' Experiences and Perceptions About Withholding and Withdrawal Life-sustaining Treatment in Chiang Mai University Hospital: a Cross-sectional Study

Overview

Journal BMC Palliat Care

Publisher Biomed Central

Specialty Critical Care

Date 2024 Aug 13

PMID 39138443

Authors

Nattanit Ketchaikosol

Kanokporn Pinyopornpanish

Chaisiri Angkurawaranon

Nisachol Dejkriengkraikul

Lalita Chutarattanakul

Affiliations

Soon will be listed here.

Abstract

Background: Withholding or withdrawing life-sustaining treatment in end-of-life patients is a challenging ethical issue faced by physicians. Understanding physicians' experiences and factors influencing their decisions can lead to improvement in end-of-life care.

Objectives: To investigate the experiences of Thai physicians when making decisions regarding the withholding or withdrawal of life-sustaining treatments in end-of-life situations. Additionally, the study aims to assess the consensus among physicians regarding the factors that influence these decisions and to explore the influence of families or surrogates on the decision-making process of physicians, utilizing case-based surveys.

Methods: A web-based survey was conducted among physicians practicing in Chiang Mai University Hospital (June - October 2022).

Results: Among 251 physicians (response rate 38.3%), most of the respondents (60.6%) reported that they experienced withholding or withdrawal treatment in end-of-life patients. Factors that influence their decision-making include patient's preferences (100%), prognosis (93.4%), patients' quality of life (92.8%), treatment burden (89.5%), and families' request (87.5%). For a chronic disease with comatose condition, the majority of the physicians (47%) chose to continue treatments, including cardiopulmonary resuscitation (CPR). In contrast, only 2 physicians (0.8%) would do everything, in cases when families or surrogates insisted on stopping the treatment. This increased to 78.1% if the families insisted on continuing treatment.

Conclusion: Withholding and withdrawal of life-sustaining treatments are common in Thailand. The key factors influencing their decision-making process included patient's preferences and medical conditions and families' requests. Effective communication and early engagement in advanced care planning between physicians, patients, and families empower them to align treatment choices with personal values.

References

Keating N, Landrum M, Rogers Jr S, Baum S, Virnig B, Huskamp H . Physician factors associated with discussions about end-of-life care. Cancer. 2010; 116(4):998-1006. PMC: 2819541. DOI: 10.1002/cncr.24761. View

Kim D, Choi M . Life-sustaining treatment and palliative care in patients with liver cirrhosis - legal, ethical, and practical issues. Clin Mol Hepatol. 2017; 23(2):115-122. PMC: 5497670. DOI: 10.3350/cmh.2017.0018. View

Koh M, Choo Hwee P . End-of-life care in the intensive care unit: how Asia differs from the West. JAMA Intern Med. 2015; 175(3):371-2. DOI: 10.1001/jamainternmed.2014.7397. View

Kavalieratos D, Corbelli J, Zhang D, Dionne-Odom J, Ernecoff N, Hanmer J . Association Between Palliative Care and Patient and Caregiver Outcomes: A Systematic Review and Meta-analysis. JAMA. 2016; 316(20):2104-2114. PMC: 5226373. DOI: 10.1001/jama.2016.16840. View

Horn R . "I don't need my patients' opinion to withdraw treatment": patient preferences at the end-of-life and physician attitudes towards advance directives in England and France. Med Health Care Philos. 2014; 17(3):425-35. PMC: 4078234. DOI: 10.1007/s11019-014-9558-9. View

Temel J, Greer J, Muzikansky A, Gallagher E, Admane S, Jackson V . Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010; 363(8):733-42. DOI: 10.1056/NEJMoa1000678. View

Bandrauk N, Downar J, Paunovic B . Withholding and withdrawing life-sustaining treatment: The Canadian Critical Care Society position paper. Can J Anaesth. 2017; 65(1):105-122. DOI: 10.1007/s12630-017-1002-1. View

Aita K, Kai I . Physicians' psychosocial barriers to different modes of withdrawal of life support in critical care: A qualitative study in Japan. Soc Sci Med. 2009; 70(4):616-22. DOI: 10.1016/j.socscimed.2009.10.036. View

Forte D, Vincent J, Velasco I, Park M . Association between education in EOL care and variability in EOL practice: a survey of ICU physicians. Intensive Care Med. 2012; 38(3):404-12. DOI: 10.1007/s00134-011-2400-4. View

10.

Bosslet G, Pope T, Rubenfeld G, Lo B, Truog R, Rushton C . An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units. Am J Respir Crit Care Med. 2015; 191(11):1318-30. DOI: 10.1164/rccm.201505-0924ST. View

11.

Tanaka M, Kodama S, Lee I, Huxtable R, Chung Y . Forgoing life-sustaining treatment - a comparative analysis of regulations in Japan, Korea, Taiwan, and England. BMC Med Ethics. 2020; 21(1):99. PMC: 7563900. DOI: 10.1186/s12910-020-00535-w. View

12.

Guidet B, Vallet H, Flaatten H, Joynt G, Bagshaw S, Leaver S . The trajectory of very old critically ill patients. Intensive Care Med. 2024; 50(2):181-194. DOI: 10.1007/s00134-023-07298-z. View

13.

Garrido M, Prigerson H . The end-of-life experience: modifiable predictors of caregivers' bereavement adjustment. Cancer. 2013; 120(6):918-25. PMC: 3947659. DOI: 10.1002/cncr.28495. View

14.

Alminoja A, Piili R, Hinkka H, Metsanoja R, Hirvonen O, Tyynela-Korhonen K . Does Decision-making in End-of-life Care Differ Between Graduating Medical Students and Experienced Physicians?. In Vivo. 2019; 33(3):903-909. PMC: 6559926. DOI: 10.21873/invivo.11557. View

15.

Piili R, Lehto J, Luukkaala T, Hinkka H, Kellokumpu-Lehtinen P . Does special education in palliative medicine make a difference in end-of-life decision-making?. BMC Palliat Care. 2018; 17(1):94. PMC: 6052558. DOI: 10.1186/s12904-018-0349-6. View

16.

Torke A, Moloney R, Siegler M, Abalos A, Alexander G . Physicians' views on the importance of patient preferences in surrogate decision-making. J Am Geriatr Soc. 2010; 58(3):533-8. PMC: 3513265. DOI: 10.1111/j.1532-5415.2010.02720.x. View

17.

Yamaguchi T, Kuriya M, Morita T, Agar M, Choi Y, Goh C . Palliative care development in the Asia-Pacific region: an international survey from the Asia Pacific Hospice Palliative Care Network (APHN). BMJ Support Palliat Care. 2014; 7(1):23-31. DOI: 10.1136/bmjspcare-2013-000588. View

18.

Phua J, Joynt G, Nishimura M, Deng Y, Myatra S, Chan Y . Withholding and withdrawal of life-sustaining treatments in intensive care units in Asia. JAMA Intern Med. 2015; 175(3):363-71. DOI: 10.1001/jamainternmed.2014.7386. View

19.

Vincent J . Forgoing life support in western European intensive care units: the results of an ethical questionnaire. Crit Care Med. 1999; 27(8):1626-33. DOI: 10.1097/00003246-199908000-00042. View

20.

Curtis J, Vincent J . Ethics and end-of-life care for adults in the intensive care unit. Lancet. 2010; 376(9749):1347-53. DOI: 10.1016/S0140-6736(10)60143-2. View