Continuing, Withdrawing, and Withholding Medical Treatment at the End of Life and Associated Characteristics: a Mortality Follow-back Study

Abstract

BACKGROUND: Studies on forgoing treatment often ignore treatments that are continued until death. OBJECTIVE: To investigate how often specific treatments are withdrawn or withheld before death and to describe the associated patient, physician, and care characteristics. DESIGN: National mortality follow-back study in Switzerland in 2013/2014 using a standardized survey to collect information on the patient's end of life and demographics on the physician. PARTICIPANTS: A random sample of adults who died non-suddenly without an external cause and who had met the physician completing the survey (N = 3051). MAIN MEASURES: Any of nine specific treatments was continued until death, withdrawn, or withheld. KEY RESULTS: In 2242 cases (84%), at least one treatment was either continued until death or withheld or withdrawn. The most common treatment was artificial hydration, which was continued in 23%, withdrawn in 4%, and withheld in 22% of all cases. The other eight treatments were withdrawn or withheld in 70-94% of applicable cases. The impact of physician characteristics was limited, but artificial hydration, antibiotics, artificial nutrition, and ventilator therapy were more likely to be withheld at home and in nursing homes than in the hospitals. CONCLUSIONS: Large differences exist between care settings in whether treatments are continued, withdrawn, or withheld, indicating the different availability of treatment options or different philosophies of care. While certain patient groups are more likely to have treatment withheld rather than attempted, neither patient nor physician characteristics impact the decision to continue or withdraw treatment.

Práticas de cuidado hospitalares no final de vida: revisão integrativa

“…Em relação à caracterização dos estudos, quanto ao desenho metodológico, 38 eram de abordagem quantitativa (Årestedt et al, 2018;Axelsson et al, 2018;Beauverd et al, 2014;Bedell et al, 1986;Camhi et al, 2009;Chang & Brass, 2014;H.-C. Chou et al, 2018;Clarke et al, 2014;Cook et al, 1995;Courtwright et al, 2015;DeMartino et al, 2017;Economos et al, 2019;Farrington et al, 2014;Fu et al, 2018;Gilbar et al, 2019;Hamano et al, 2018;Hiramoto et al, 2019;Koff et al, 2017;Liu et al, 2015;Moffat et al, 2016;Montagnini et al, 2018;Mori et al, 2019;Mroueh et al, 2019;Opstelten et al, 2017;Parpa et al, 2010;Penders et al, 2020;Penrod et al, 2012;Piili et al, 2018;Pugh et al, 2009;Seale, 2010;Steindal et al, 2015;Syed et al, 2017;Taniguchi et al, 2016;Thomas et al, 2014;Tsai et al, 2018;Verhofstede et al, 2017;Wang et al, 2019;Ziegler et al, 2018), 13 qualitativa (Bélanger et al, 2014;W.-Y. S. Chou et al, 2017;De Bal et al, 2006;De W...…”

“…As revistas Palliative Medicine (De Witt Jansen et al, 2017;Pugh et al, 2009;Lenzo Robijn et al, 2018;Robinson et al, 2007;Syed et al, 2017), Journal of Pain and Symptom Management (Axelsson et al, 2018;Hamano et al, 2018;Kruser et al, 2017;Tsai et al, 2018;Verhofstede et al, 2017), Journal of General Internal Medicine (Anderson et al, 2011;Chang & Brass, 2014;Penders et al, 2020;Thomas et al, 2014;Ziegler et al, 2018) e Critical Care Medicine (Barnato et al, 2008;Camhi et al, 2009;Koff et al, 2017;Penrod et al, 2012) e os países Estados Unidos da América (Anderson et al, 2011;Bedell et al, 1986;Camhi et al, 2009;Chang & Brass, 2014;W.-Y. S. Chou et al, 2017;Courtwright et al, 2015;DeMartino et al, 2017;Koff et al, 2017;Kruser et al, 2017;McIlvennan et al, 2017;Montagnini et al, 2018;Penrod et al, 2012;Lenzo Robijn et al, 2018;Thomas et al, 2014;Wagemans et al, 2017) e Inglaterra (Clarke et al, 2014;Farrington et al, 2014;Pugh et al, 2009;Reid et al, 2015;Wang et al, 2019) se destacaram entre os que mais publicam sobre a temática.…”

“…Quanto ao nível de evidência, destaca-se o nível VI, presente em 46 estudos (Anderson et al, 2011;Årestedt et al, 2018;Axelsson et al, 2018;Barnato et al, 2008;Beauverd et al, 2014;Bedell et al, 1986;Bélanger et al, 2014;Chang & Brass, 2014; W.-Y. S. Chou et al, 2017;Clarke et al, 2014;Cook et al, 1995Cook et al, , 1995De Bal et al, 2006;De Witt Jansen et al, 2017;DeMartino et al, 2017;Díez-Manglano et al, 2019;Farrington et al, 2014;Gilbar et al, 2019;Guardia-Mancilla et al, 2017;Hamano et al, 2018;Hiramoto et al, 2019;Kruser et al, 2017;Kryworuchko et al, 2016;Le & Watt, 2010;Liu et al, 2015;McIlvennan et al, 2017;Montagnini et al, 2018;Mori et al, 2019;Parpa et al, 2010;Penders et al, 2020;Philip et al, 2019;Piili et al, 2018;Pugh et al, 2009;Reid et al, 2015;L. Robijn et al, 2017;Lenzo Robijn et al, 2018;Robinson et al, 2007;Scott et al, 2018;Seale, 2010;Sellars et al, 2017;Steindal et al, 2015;Syed et al, 2017;…”

“…A hidratação e a nutrição artificial foram mais propensas a retirada em pacientes oncológicos, idosos, mulheres e naqueles que faleceram no domicílio (Penders et al, 2020;Pugh et al, 2009). Médicos com maior tempo de formação e especialistas possuem maior dificuldade em limitá-las ou retirá-las (Penders et al, 2020).…”

Characteristics of life-sustaining treatment decisions: National data analysis in South Korea

“…An international study used national death statistics on age of death, cause, and contents of forgoing treatment to identify the proportion and characteristics of patients forgoing treatment. [6][7][8] A South Korean study identi ed the types and related factors of life-sustaining treatment (LST) for geriatric patients, attitudes and characteristics of elderly patients to LST, and whether they wrote POLST. [9][10][11] However, these studies mostly considered data shared by a single or several medical institutions; as no data analysis was conducted using National Institute of Statistics data, there was limited information on the system's characteristics.…”