Decisions Near the End of Life: Professional Views on Life-Sustaining Treatments

Abstract

A growing number of authorities have articulated ethics guidelines for decisions about the use of life-sustaining medical technologies, in keeping with the basic legal principles articulated by the courts. These guidelines recognize the right of competent patients to forgo treatment, even if refusal may lead to death; they support deference to patients' wishes to withhold or withdraw life support of all kinds, from cardiopulmonary resuscitation and mechanical ventilation to antibiotics; they encourage the use of advance directives to guide treatment once the patient has lost the ability to make decisions; and they call for the provision of adequate pain relief and palliative care. A central tenet is the right of patients to refuse medical treatment they find unduly burdensome.

However, there has been very little research to determine whether clinicians know about these recommendations, agree with them, and find them useful. Nor do we know how health care professionals themselves see the issues. To explore these questions, we surveyed 687 physicians and 759 nurses at five hospitals. The hospitals were located in Massachusetts; Georgia; Washington, DC; and California. They included a city hospital, a Catholic community hospital, and three urban teaching facilities. They ranged in size from 180 to 660 beds. This article reports and analyzes the empirical results.

The data reveal an important gap between the views of practicing clinicians and the prevailing guidelines. They also reveal important differences in the views of attending physicians, house officers, and nurses. Almost half (47%) of all respondents and fully 70% of the house officers reported that they had acted against their conscience in providing care to the terminally ill. Four times as many respondents were concerned about the provision of overly burdensome treatment than about undertreatment. Many physicians and nurses were disturbed by the degree to which technological solutions influence care during the final days of a terminal illness and by the undertreatment of pain.

These survey results suggest that changes in the care of dying patients may not have kept pace with national recommendations, in part because many physicians and nurses appear to disagree with or be unaware of some key recommendations, such as the permissibility of withdrawing treatments.

Keywords: Life-Sustaining Treatment, End-of-Life, Termination of Treatment, Pain Relief, Palliative Care, Death, Dying, Medical Practice, Physicians, Nurses, Attitudes, Empirical Research, Empirical Studies, Bioethics, Health Law