The views among physicians and the general public when it comes to deciding whether to withhold or withdraw treatment of terminally ill patients differ greatly. However, in a hypothetical case study at Umeå University in Sweden of a clearly hopeless medical case, great unanimity among physicians' and the public's assessments could be seen with regards to cancelling treatment or offering relief at the final stages of life.
Anders Rydvall, physician at the University Hospital of Umeå and doctoral student at the Department of Surgical and Perioperative Sciences, has completed two surveys in Sweden that investigate attitudes and what arguments seem most significant. The development of techniques to prolong life support in intensive care, which is a relatively young speciality, has advanced at high speed and the opportunities are hence greater than ever. At the same time, there are limiting factors set by human physiology that can often be difficult to relate to. In turn, this leads to continuous treatment beyond what is reasonable when the patient is beyond rescue.
"This ethical dilemma is something that many, including family members, are aware of. But the difficulties in these types of situations often arise when caregivers are afraid of receiving criticism for not doing everything in their power. Also, there is a perceived discomfort in being the bearer of bad news and being on the receiving end of the reactions, as well as holding differing views on what rules and regulations actually imply," explains Anders Rydvall.
The elderly woman with an unpromising prognosis
In a first survey, the attitudes and arguments for and against active treatment (operation) were compared between neurosurgeons (112 of which 70 per cent responded), anaesthesiologist and intensive care physicians (298 of which 70 per cent responded), and the general public (998 of which 50 per cent responded). The hypothetical patient case concerned an older woman with a severe brain haemorrhage and a poor clinical condition. The results showed that caregivers among themselves generally made the same assessments and prioritised the argument "Quality of Life" as the most important one. But anaesthesiologist and intensive care physicians also pointed particularly at the importance of the patient's previous desires.
A comparison between physicians' and the general public's attitudes to this case showed great variations in opinions for or against operation and also in what arguments were considered most important. Out of the physicians, 82 per cent assessed to refrain from operation while only 40 per cent made the same choice out of the general public. But when the case developed to a more hopeless situation, both groups made more unanimous assessments, albeit prioritising different arguments.
The premature baby with severe brain injury
The second survey posed questions regarding a case with a severely brain-injured newborn baby. The survey was submitted to anaesthesiologist and intensive care physicians (299 of which 63 per cent responded), paediatricians and neonatologists (329 of which 67 per cent responded) as well as the general public (585 of which 46 per cent responded). The study compared arguments for the attitude for or against continued respiratory care. A majority of both physicians and the general public supported arguments to withdraw treatment.
The second survey also included questions on whether it could be considered acceptable to give anaesthetics and pain-relief in a dosage to minimize pain or in a higher dosage aimed at shortening the dying process. A large majority of physicians and the general public supported arguments to soothe and minimize pain, also if it in reality and as a consequence could shorten the dying process. Although, when the intention was to actively bring about the inevitable death, the general public seemed much more inclined to accept such an act than caregivers.
"To avoid misunderstandings and communication problems it is important that caregivers take into consideration and has knowledge of the views, expectations and prioritisations of the family. It's also important that caregivers maintain a setting where information is honest and appropriate and communications open," says Anders Rydvall.
Anders Rydvall comes from Stockholm and moved to Umeå in the 1970s. He works as a chief physician at the Centre of intensive and postoperative care at the University Hospital of Umeå.
Article: Withhold or withdraw futile treatment in intensive care: arguments supported by physicians and the general public, Rydvall, Anders, Umeå universitet, published 21 December 2016.