Physician-related determinants of medical end-of-life decisions – A mortality follow-back study in Switzerland

Abstract

BackgroundMedical end-of-life decisions (MELD) and shared decision-making are increasingly important issues for a majority of persons at the end of life. Little is known, however, about the impact of physician characteristics on these practices. We aimed at investigating whether MELDs depend on physician characteristics when controlling for patient characteristics and place of death.Methods and findingsUsing a random sample (N = 8,963) of all deaths aged 1 year or older registered in Switzerland between 7 August 2013 and 5 February 2014, questionnaires covering MELD details and physicians' demographics, life stance and medical formation were sent to certifying physicians. The response rate was 59.4% (N = 5,328). Determinants of MELDs were analyzed in binary and multinomial logistic regression models. MELDs discussed with the patient or relatives were a secondary outcome. A total of 3,391 non-sudden nor completely unexpected deaths were used, 83% of which were preceded by forgoing treatment(s) and/or intensified alleviation of pain/symptoms intending or taking into account shortening of life. International medical graduates reported forgoing treatment less often, either alone (RRR = 0.30; 95% CI: 0.21–0.41) or combined with the intensified alleviation of pain and symptoms (RRR = 0.44; 0.34–0.55). The latter was also more prevalent among physicians who graduated in 2000 or later (RRR = 1.60; 1.17–2.19). MELDs were generally less frequent among physicians with a religious affiliation. Shared-decision making was analyzed among 2,542 decedents. MELDs were discussed with patient or relatives less frequently when physicians graduated abroad (OR = 0.65, 95% CI: 0.50–0.87) and more frequently when physicians graduated more recently; physician's sex and religion had no impact.ConclusionsPhysicians' characteristics, including the country of medical education and time since graduation had a significant effect on the likelihood of an MELD and of shared decision-making. These findings call for additional efforts in physicians' education and training concerning end-of-life practices and improved communication skills.

Swedish intensivists’ experiences and attitudes regarding end‐of‐life decisions

“…Underlying factors that may contribute to variability in the decision‐making process can be summarized as consisting of physician‐related factors, patient‐related factors and circumstance‐related factors. Nearly all of the respondents emphasized that there is a large variability in decision‐making that primarily depends on the intensivist's personality, which is in line with the results of previous studies . Generally, this was not considered a problem by the respondents.…”

“…Nearly all of the respondents emphasized that there is a large variability in decision-making that primarily depends on the intensivist's personality, which is in line with the results of previous studies. 10,12,13,16,26,27 Generally, this was not considered a problem by the respondents. The unquestioned acceptance concerning the recognized impact of personality and preferences of the individual intensivist on EoL decisions found in this study have previously been described as problematic.…”

“…However, a deeper understanding of conceptions and attitudes in the decision‐making process is still, to a large extent, lacking. Patient factors that contribute to variabilities in EoL decisions include the patient's medical condition, the diagnosis, advanced age, poor baseline functional status and female sex …”

“…Patient factors that contribute to variabilities in EoL decisions include the patient's medical condition, the diagnosis, advanced age, poor baseline functional status and female sex. [9][10][11][12][13][14][15][16][17] In Sweden, the Swedish National Board of Health and Welfare stipulates regulations about LST and EoL decisions. Physicians are obliged to (a) respect patient autonomy, (b) consult at least one other health professional with a license to practice, prior to making a decision regarding withholding or withdrawing LST and (c) provide detailed documentation of the reasons for the decision.…”

Das Lebensende in der Schweiz - Individuelle und gesellschaftliche Perspektiven

“…Zu dieser überraschenden Einsicht kommt eine Studie im Rahmen eines Forschungsprojekts, in welchem Entscheidungen am Lebensende und ihr Zustandekommen in der Schweiz näher untersucht wurden. Wer seine medizinische Ausbildung im Ausland erhalten hat, trifft in der Regel nicht nur seltener eine solche Entscheidung als Kolleginnen und Kollegen, die ihre Ausbildung in der Schweiz absolviert haben, sondern bespricht diese, wenn es doch dazu kommt, auch seltener mit Patientinnen und Patienten oder Angehörigen (Bopp, Penders, Hurst, Bosshard & Puhan, 2018). Offensichtlich führen institutionalisierte Weiterbildungsangebote und Qualitätszirkel nicht automatisch zu einer Angleichung der ärztlichen Praktiken.…”