Causes of futile life-sustaining interventions from the perspective of physicians and nurses in university hospitals in Tehran

doi:10.21203/rs.3.rs-1416677/v1

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Causes of futile life-sustaining interventions from the perspective of physicians and nurses in university hospitals in Tehran

https://doi.org/10.21203/rs.3.rs-1416677/v1

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Background

Providing futile interventions can lead to moral distress for healthcare providers and impose high costs on healthcare systems. Despite this, evidence demonstrates that such interventions still continue in many parts of the world, particularly in Low and Middle Income Countries (LMICs). Therefore, this current study was conducted to investigate reasons for providing futile interventions from the perspective of physicians and nurses working at hospitals affiliated to Tehran University of Medical Sciences (TUMS)

Method

In this cross-sectional (descriptive-analytical) study, 249 participants including 128 physicians and 121 nurses working in hospitals affiliated to TUMS were recruited through convenience sampling. Data was collected using a 25-item questionnaire assessing causes of providing futile medical and life-sustaining interventions, grouped into 3 domains of “demands of patients/relatives”, “personal reasons of the healthcare team” and “organisation/infrastructural” limitations. Data was analysed using SPSS 16 and the extent to which participants agreed with each of the causes of futile interventions was expressed as a percentage. Comparisons between the views of physicians and nurses on individual questionnaire items was performed using the Chi-squared test. A linear regression analysis was used to compare the views of physicians and nurses in each of the 3 domains of the questionnaire, and for intra-group comparisons.

Results

For both physicians and nurses, the most common reasons for futile interventions related to patients and their relatives including demands/insistence on the continuation of treatment and false hope for the patient’s recovery. Compared to physicians, nurses gave greater importance to the domains of patient/relatives’ demands as well as personal reasons of the healthcare team. Physicians expressed strongest agreement with the domain of organisation/infrastructural limitations, including lack of guidelines and palliative care centres.

Conclusion

This study demonstrates that despite awareness of the healthcare team members regarding the futility of some interventions, they are still performed due to the reasons highlighted. Therefore, it clinical guidelines should be developed for appropriate end-of-life care, including restricting the use of futile interventions, increase public and professional awareness and knowledge around futile end-of-life interventions and strengthen palliative care services, thereby leading to greater efficiency and justice in the healthcare system.

Futile treatment

futile intervention

doctor

nurse

ethics

medical ethics

Despite rapid advancement in science and technology leading to an increase in average patient life expectancy, healthcare professionals in everyday practice still witness patient suffering and the provision of interventions in situations that are, in their opinion, futile (Asadi and Shamsabadi 1393; Huynh 2013). The concept of ‘futility’ in medicine dates to ancient times and texts attributed to Hippocrates. These writings indicate that when routine medication and treatment do not benefit the patient whilst in a critical condition, the physician should not deliver futile interventions to the patient (Lascaratos et al, 1999). Merriam-Webster's dictionary defines “futile” as "serving no useful purpose: completely ineffective” (The New Lexicon Webster's Dictionary, 1989). The word “futile” refers to a specific action while “futility” refers to the relationship between an action and a desired goal. Therefore, “futility” in a clinical context is defined as a practice that has no useful purpose in achieving the desired and specific outcome for an individual patient (Kasman, 2004). In other words, “futility” is when preventative, diagnostic or therapeutic interventions would fail to deliver benefit to a patient (Schneiderman et al, 1990; Pellegrino, 2005).

However, defining futility in medicine is made difficult by its multifactorial nature. Current literature differentiates between “futile” and “illogical” treatment. Examples of the latter have been cited to include treatment that is beneficial for a patient but due to high cost or lack of resources, is not offered to the patient, or treatments currently lacking evidence, or those employed simply due to lost hope. Although this aids in explaining illogical interventions, defining and approximating “futile” interventions remains difficult (Burns et al, 2007; Vergano and Renato, 2014; Swetz et al, 2014).

Current literature has considered the concept of “futility” from both a quantitative and qualitative perspective. From a quantitative perspective, “futility” refers to an intervention that has provided no result for its previous 100 cases therefore will almost certainly not deliver a result for the next patient. From a qualitative point of view, “futility” refers to an intervention that fails to provide the patient with an acceptable quality of life (Schneiderman and Care, 2011; Schiavo and Report, 2013; Brody and Halevy, 1995). In this, either the harms of the treatment outweigh the benefits to the patient, or the treatment provides such miniscule improvement in the patient's quality of life that it is still not worth surviving (Geppert, 2015).On the other hand, differing opinions between the patient and the physician also affect the understanding of what constitutes “futile” medical interventions. In such cases, interventions that fail to achieve the physiological goals of the doctor are futile even though such interventions may be in line with the wishes and goals of the patient and relatives (Jecker, 1991).

Delivering futile interventions conflicts with physician autonomy, does not benefit the patient, harms the patient and society and ultimately, the use of healthcare resources for such interventions results in an unjust healthcare system (Pellegrino et al, 2006; Sibbald et al. 2007; Ozden et al, 2013). Other negative consequences of such interventions include high costs for healthcare systems and families, moral distress of service providers and job dissatisfaction (Schneiderman et al, 1994). Despite these unfortunate consequences the evidence shows that futile interventions are still delivered due to cultural, religious, professional, organisational, social and personal, individual reasons (Yeke Fallah et al. 1397; Aghabarary and Nayeri, 2016; Ozden et al., 2013; Niderman 2010).

Naturally, an important question that arises here is why, despite these negative consequences, medically futile interventions are still offered? We postulate that an understanding of the causes and contexts of these interventions could provide the first step in preventing them. This could facilitate policy makers to appropriately prioritise and address the most important causes to control and manage the issue. Given that the concept of futility is dependent on values and empirical evidence, the reasons affecting the provision of futile interventions could differ according to the country and culture. Religious, social, cultural and economic differences could contribute to the presence or absence of an intervention. Thus, with attention to the cultural-religious context and health system characteristics of Iran and the adherence of its constitution and public/social infrastructures to the religion of Islam, appreciating the views of Iranian physicians and nurses regarding futile interventions warrants interest and importance. Furthermore, given that decision-making and actioning interventions is within the remit of both physicians and nurses, it can be expected that there are different reasons governing the opinions of these two groups regarding prescribing and performing these interventions. On the other hand, our current knowledge demonstrates that many studies in this field are qualitative and that no study has been conducted specifically in Iran to assess reasons for futile interventions. Therefore, this study was designed and conducted with the aim of investigating the perspectives of physicians and nurses working in hospitals affiliated to Tehran University of Medical Sciences (TUMS) regarding reasons for delivering medically futile life-saving interventions and also, comparing the perspectives of physicians and nurses in this regard.

This present study is a cross-sectional, descriptive-analytical study that was conducted to investigate the reasons for delivering futile life-saving interventions from the perspective of physicians and nurses working in hospitals affiliated to TUMS in 2018-2019 and to compare their perspectives. The study population was all physicians and nurses working in hospitals affiliated to TUMS, resulting in participation by 128 physicians consisting of new medical graduates, residents, specialists, fellows and subspecialists in the fields of anaesthesia, haematology-oncology, cancer surgery, internal medicine, general surgery and paediatrics, as well as 121 nurses from Intensive Care (ICU), haemato-oncology and cancer surgery departments.

After obtaining research and ethics approval (Code: IR.TUMS.MEDICINE.REC.1397.706), the researcher, in collaboration with ward managers, met with the study participants and after stating the study’s objectives, recruited them into the study. Then, a questionnaire was distributed among eligible participants. Completion of the questionnaire was considered equivalent to consent to the study while those who did not complete the questionnaire were deemed to have declined.

Sampling was via a multi-stage method. First, a list of hospitals affiliated to TUMS was collated. Then, hospitals housing more wards related to end-of-life care such as ICU, haemato-oncology and cancer surgery were selected for the study. Then in these hospitals, wards belonging to ICU, haematology-oncology, cancer surgery, internal medicine, general surgery and paediatrics were selected for sampling. In the next step, convenience sampling was performed among physicians and nurses from each ward according to the inclusion criteria. The inclusion criterion was employment of at least 2 years.

To calculate the sample size, 20% of the data of each group of physicians and nurses were randomly selected and its indicators (as a pilot study) were used to estimate the sample size of the main study. According to the pilot study indicators and the use of the formula below the sample size required for each group (of physicians and nurses) was 65 participants (alpha 5%, beta 20%, mean and standard deviation of physicians 2.45 ± 1.18 and nurses 1.96 + 0.82). To increase the study accuracy more participants (128 physicians and 121 nurses) were recruited.

To collect data a questionnaire was used to assess the causes of delivering futile life-saving treatments and interventions, designed and validated by Aghabarary et al (2017). The original questionnaire consisted of 35 items, of which 25 were chosen as these were most relevant to participants and the objectives of the study. In the study, the reliability of the questionnaire was evaluated and confirmed using Cronbach's alpha method. The coefficient for all three domains [detailed below] and the whole instrument was calculated at 0.75.

The questionnaire consisted of two parts. The first part collated demographic information and the second was related to the reasons for providing futile life-saving treatment and interventions in three domains of patient/family demand (Q1-9), personal reasons of healthcare staff (Q10-12, Q14-16, Q24-25) and, organizational/infrastructural constraints (Q13, Q17-23). Each item was scored by a 5-point Likert scale with options for “strongly agree” (1), “agree” (2), “no opinion” (3), “disagree” (4) and “strongly disagree” (5). The higher the points, the greater the level of disagreement with the statement. The percentage of agreement of participants with each item was calculated by adding the percentage of “completely agree” and “agree” options.

Data were collected in the nurse’s group in person. In the physician’s group, both in-person and in-absentia (via an electronic version of the questionnaire distributed via the Telegram^® platform) methods were utilised to collect data. Data were analysed using the SPSS-16 software. Results were presented in terms of absolute and relative frequencies, mean and standard deviations. Also, data related to participants' agreement with each cause of futile life-saving interventions were expressed as percentages. Comparison between the physician and nurse group was performed using the Chi-Square test. A p-value less than 0.05 was considered to reflect a significant difference.

A regression analysis was used to compare the responses of physicians to nurses within each of the three domains of the questionnaire.as well as test which domain was considered the most significant cause of futile intervention within each group of physicians and nurses. For this, after the scores of each domain were standardised with attention to a normal distribution, a linear regression analysis was performed where the dependent variable was the total score obtained from the questionnaire in that group and the independent variable was the (standardised) score obtained from the domains. Thus, two regression models for physicians and nurses were separately calculated, with R² indicating the percentage change in the total score of each group due to each domain in that group. The standard deviation of R² was calculated with a 95% confidence interval using the formula SD R2 = √ ((1-R2) / (n-2). If the confidence intervals of the other two domains did not overlap the point estimation of the third domain, it was considered a significant difference in the effect of that domain on changes of the total score. Using the same method the effect of [the other two] domains on the total score was analysed.

In this study, all necessary ethical considerations were observed. Physicians and nurses’ participation in the project was voluntary, and necessary information was provided before completing the questionnaire. Returning questionnaires was understood to indicate consent to participate in the study. Questionnaires were completed anonymously, and participants' data was kept strictly confidential.

In this study 361 questionnaires were distributed. Of these, 249 were returned by healthcare team members including 128 physicians and 121 nurses working in hospitals affiliated to TUMS. The response rate was 60.5% in the nurse group and 79.5% in the physician group. The demographic characteristics of the study participants are shown in Table 1.

Table 1

– Demographic Characteristics of Study Participants (n = 249)
Demographic Variables		Group
Demographic Variables		Nurses (n = 121; 49%)		Physicians (n = 128; 51%)
Age in Years (Mean ± SD; [Range])		35.6 ± 2.3 [25–53]		30.5 ± 5.9 [25–50]
Years in Employment (Mean ± SD; [Range])		5 ± 11.7 [2–26]		5.6 ± 2.8 [2–22]
Gender
Female (n, [%])		92 (76%)		62 (48%)
Male (n, [%])		29 (24%)		66 (52%)
Hospital Site
Imam Khomeini Hospital (n, [%])		69 (57%)		32 (25%)
Shariati Hospital (n, [%])		9 (7.4%)		30 (23%)
Sina Hospital (n, [%])		22 (18%)		34 (27%)
Bahrami Hospital (n, [%])		21 (17.4%)		32 (25%)
Working Shift
Fixed Morning (n, [%])		18 (14.9%)		-
Fixed Afternoon (n, [%])		3 (2.5%)
Fixed Night (n, [%])		5 (4.1%)
Fixed Afternoon/Night (n, [%])		21 (17.4%)
In Circulation (n, [%])		74 (61.2%)
Employment Status
Formal		73 (60.2%)		-
Temporary		15 (12.4%)
Temporary Contract		23 (19%)
Committed Service		10 (10.3%)
Level of Education/Training
Nurses (n = 121; 49%)			Physicians (n = 128; 51%)
Bachelor’s Degree (n, [%])	92 (78.5%)		Interns (n, [%])		39 (30.5%)
Master’s Degree (n, [%])	25 (20.7%)		Residents (n, [%])		46 (35.9%)
PhD (n, [%])	1 (0.8%)		Specialists (n, [%])		17 (13.3%)
			Fellows (n, [%])		8 (6.2%)
			Attendant (n, [%])		18 (14.1%)
Ward/Speciality
ICU (n, [%])	49 (40.5%)		ICU (n, [%])		14 (10.9%)
Cancer Surgery (n, [%])	32 (26.4%)		Cancer Surgery (n, [%])		9 (7%)
Haemato-Oncology (n, [%])	40 (33.1%)		Haemato-Oncology (n, [%])		16 (12.5%
			General Surgery (n, [%])		15 (11.7%)
			Internal Medicine (n, [%])		21 (16.4%)
			Paediatrics (n, [%])		16 (12.5%)

The findings of this study showed that from the perspective of physicians and nurses participating in the study, the most common reason for providing futile life-sustaining interventions related to the domain of patient/relatives’ demands. The item “3. Request and insistence of relatives to make all possible efforts to save the patient's life in order to prevent their future guilt" received the most (83.5%) agreement.

From the perspective of nurses in particular, the most common reason for futile interventions was also related to the domain of patient/relatives’ demands, although their most agreed upon cause was “6. Hope of the patient or relatives stemming from their ignorance of the nature of the illness” (87.6%). Interestingly however, physicians paid greater attention to the domain of organisational causes, agreeing equally upon the items: “3. Request and insistence of relatives to make all possible efforts to save the patient's life in order to prevent their future guilt", “20. Lack of operational guidelines and clear instructions regarding the treatment and care processes for patients approaching death” and, “21. Lack of or not enough palliative care centres for timely referral and transfer of patients approaching death from the hospital to these centres” as the most common reasons for these interventions (80.5%) (Table 2).

Table 2

Percentage Agreement of Physicians and Nurses with Each Cause for Futile Life-Saving Interventions, and comparison between both groups
Question no.	Nurses	Physicians	Total	P-Value
1. Request and insistence of the patient or relatives based upon their religious beliefs	77.7	64.8	70.7	0.112
2. Request and insistence of the patient or relatives based upon cultural beliefs, expectations and social custom	77.6	75	76.3	0.618
3. Request and insistence of relatives to make all possible efforts to save the patient's life in order to prevent their future guilt	86.8	80.5	83.5	0.180
4. Inability of relatives to care for the patient at home due to lack of knowledge and insufficient skills	78.5	59.5	68.7	0.004*
5. Impossibility of caring for the patient at home due to the patient's poor physical condition (dependence of the patient on life-support equipment, a ventilator and life-supporting medication)	83.5	78.1	80.7	0.275
6. Hope of the patient or relatives stemming from their ignorance of the nature of the illness	87.6	70.3	78.7	0.001*
7. Denial and non-acceptance of the patient or relatives of the reality of the poor prognosis of the illness and the inevitability of the patient's death	81	64.8	72.8	0.012*
8. Difficulty accepting the death of a loved one due to emotional attachment between the patient and relatives	84.3	76.6	80	0.297
9. Helping relatives to gradually prepare to accept the patient's death	73.6	61.7	67.6	0.148
10. Belief of the healthcare team in the sanctity of life and the need to strive to preserve human life as much as possible as per religious standards.	74.4	62.5	68.3	0.310
11. Personal obligation of the healthcare team to provide life-saving interventions based upon previous experiences of miracle and recovery despite poor prognosis	52.9	34.4	43.4	0.003*
12. Obligation of the healthcare team to provide life-saving interventions and not abandon a patient who is alive and breathing, as a human and moral duty	76	63.3	63.5	0.201
13. Legal obligation to provide life-saving interventions and not abandon a patient who is alive and breathing	86	74.2	73.5	0.069
14. Concern of the healthcare team of being in a similar position for themselves or their other relatives in case of shortcomings in providing life-saving interventions to a patient	68.6	50.8	59.4	0.014*
15. Sympathy of the healthcare team due to the patient’s young age	66.1	50	57.2	0.076
16. Creation of emotional attachment between the patient and healthcare team resulting stemming from long-term interaction during treatment and patient care	61.2	39.1	49.8	0.001*
17. Lack of legal, moral or religious permission and instruction to discontinue life support equipment in patients nearing death (end-of-life stage)	71.9	79.1	75.9	0.414
18. Lack of legal, moral or religious permission and instruction for non-resuscitation in patients nearing death (final stages of life)	72.7	77.3	75.1	0.693
19. Lack of hospital ethics committee (or its inadequacy) for reviewing and deciding on ethically and legally challenging cases	65.3	71.9	68.7	0.041*
20. Lack of operational guidelines and clear instructions regarding the treatment and care processes for patients approaching death	69.4	80.5	75.2	0.001*
21. Lack of or not enough palliative care centres for timely referral and transfer of patients approaching death from the hospital to these centres	73.6	80.5	77.3	0.288
22. Inadequacy of home-care services for timely referral and transfer of patients approaching death from hospital to home	68.9	71.1	70.1	0.745
23. Obligation of hospitals and specialist centres to accept patients approaching death in need of palliative care	79.3	65.6	72.3	0.054
24. Delay in the healthcare team reaching agreement on the patient's diagnostic and treatment processes	63.6	29.7	46.2	0.001*
25. Neglect of physicians and the healthcare team of the patient’s and relatives’ independence and right to choose	57	19.5	37.8	0.001*

Table 3 compares the views of physicians and nurses by corroborating groups of questions into the different domains of the questionnaire. The lower the score, the greater the trend towards agreement with the domain of causation. As demonstrated by the results according to the analysis, in the two domains of “Patient/relatives demands” and “Personal reasons of the healthcare team”, there is a significant difference between the views of physicians and nurses. This meant that nurses gave greater importance to these domains than physicians however, in the third domain of “Organisational/infrastructural” reasons, there was no significant difference. On the other hand, the R² intragroup comparison of physicians in the three domains indicated that physicians gave more importance to the “Organisational/infrastructural” factors domain compared to the other two domains, whereas in the case of nurses this difference was not significant.

Table 3

Comparison of the effect of three domains of causes of futile intervention according to the total score of the groups of participating physicians and nurses, as per Adjusted R² (n = 249).
Group	Domain of Questionnaire Item
Group	Demands of Patients/Relatives	Personal reasons of healthcare team members	Organisational/Infrastructural
Physicians (Mean score ± SD)	20.74 ± 4.80	22.94 ± 4.88	16.96 ± 4.78
Nurses (Mean score ± SD)	17.77 ± 4.79	18.75 ± 4.59	16.60 ± 4.87
Physicians Adjusted R2 (CI95%	0.376 (0.21–0.55)	0.368 (0.20–0.54)	0.555 (0.41–0.70)
Nurses Adjusted R2 (CI95%)	0.581 (0.44–0.69)	0.560 (0.41–0.71)	0.608 (0.47–0.75)

The aim of this study was to determine the causes of futile interventions via participation from 128 physicians and 121 nurses of four different hospitals affiliated to TUMS. Findings of this study showed that from the perspective of participating physicians and nurses, the most common reason for providing futile life-saving interventions was the factor of patient/relatives’ demands.

The family's demand and insistence on making every effort to save the patient's life, the impossibility of caring for the patient at home, and the difficulty of accepting the death of a loved one due to emotional attachment between the patient and relatives were the most common causes for futile intervention as per the view of the healthcare team. The demand and insistence of relatives for continuing futile interventions can have various causes, the most common of which in this study were to prevent their future guilt and, their ignorance of the nature of the illness. Similarly, in the studies of Palda et al. (2005) and Downar et al. (2015), the most common reason reported for providing futile life-saving interventions were the requests of patients/companions and their ignorance of the nature of the illness and its prognosis (Palda et al, 2005; Downar et al, 2015). Bearing in mind that the objective of the healthcare team of caring and treating a human is to pay attention the whole person and not just organs and physiological functions; still they are not inclined to avoid [futile] interventions despite poor prognosis and awareness of the consequences of such interventions (Schneiderman 2011). This however is contrary to the patient's relatives who lack appreciation of the illness’s poor prognosis and may envisage that by consenting to refuse life-sustaining intervention, they would be committing an act against the beliefs or laws of those around them or society, thus suffering from a guilty conscience and desire and insistence to continue treatment. If on the other hand, relatives are given the necessary information about the nature of the illness, types of treatments and its effects on the patient, they may not feel remorse, due to awareness that they did not exhibit shortcomings in relation to the patient‘s care. Perhaps therefore, poor communication of medical staff with the patient's relatives is the cause of their ignorance regarding the prognosis of the illness, their false hope for the patient's recovery and, their subsequent demand for continued treatment. Furthermore, the Iranian cultural-Islamic belief in “shifa” (miraculous curing) of the ill may also influence the on-going insistence from relatives for patient’s to be given the time/chance to recover.

In addition to the family demand factor, physicians participating in the study gave importance to the role of organisational infrastructure in the provision of futile interventions and reported the lack of operational guidelines and clear instructions on treatment and care processes for patients approaching death as the most common reason for these interventions. Currently in Iran, no clear guidelines for continuing or discontinuing futile life-sustaining treatments and interventions have been composed, with only a limited number of guidelines for brain death patients and those in need of cardiopulmonary resuscitation.

In countries where the law is based upon the official religion, the first step should be to clarify the religion's opinion on life-sustaining treatments and interventions and then formulate laws accordingly. Mohiuddin et al show that in many Islamic countries there are no clear and agreed-upon religious edicts regarding life-sustaining interventions in the last stages of life which may be the reason for a lack of clear laws and guidelines (Mohiuddin 2020). Furthermore, Palda et al. (2005) demonstrated that 51% of physicians and 26% of nurses believed that a lack of guidelines on futile interventions affected the delivery of these interventions in Canada, and that 40% considered their guidelines inadequate (Palda et al, 2005). In contrast, findings by Kadoka et al. (2014) in Japan and Wilmott et al. (2016) in Australia gave less importance to the role of hospital medical infrastructural/organisational deficiencies in the delivery of these treatments (Kadooka et al, 2013; Willmott et al. 2016).

Another common reason was the defensive medicine approach which is prominent in Iranian healthcare, with the legal requirement to provide life-sustaining interventions and to not abandon a patient who is alive and breathing. This is due to the inability of current practice/legislature to differentiate between the fact that all life-sustaining treatment is not necessarily “life-saving” and may simply prolong a terminal/dying process. On this, 75% of participants in the study by Palda et al. (2005) reported legal pressures to continue treatment and futile interventions as common reasons for these interventions (Palda et al, 2005). Refusing to provide life-sustaining interventions is highly sensitive, and failure to provide these interventions in the absence of clear laws and guidelines could have serious consequences for physicians or healthcare staff and so, guidelines that are developed on this issue should be completely clear. However, even with the existence of some guidelines, we still witness the provision of these futile interventions. Interestingly, Yun et al. show that despite instructions on futile interventions from the Korean Ministry of Health and Welfare, the law in Korea emphasises continuous pain control, nutritional support and fluid prescriptions in these patients (Yun et al 2018; Ivo et al 2011; Ministry of Health and Welfare of the Republic of Korea 2010). The provision of these interventions due to the excuse of unclear legislation in countries with relatively clear laws in these cases (such as Canada) also confirms this phenomenon (Palda et al, 2005).

Other organisational causes include the lack of or insufficient palliative care centres for timely referral and transfer of patients approaching death from hospital to these centres. Aghabarari and Dehghan Nayeri (2017) also report a lack of palliative care centres and inadequacy of home-care services as a cause futile treatment (Aghabarary and Dehghan Nayeri, 2017). In fact in the present study, much attention has been given to this factor by both physicians and nurses. It appears that in Iran the necessary infrastructure to refer patients from hospitals to home-care services or to hospices/palliative care centres is significantly lacking compared to Western countries.

The findings of the present study showed differing attitudes of physicians and nurses regarding the domains of demands of patients/relatives and personal reasons of healthcare team members, while they equally supported and gave importance to the domain of organisation/infrastructural reasons. This may be attributed to the culture of Iranian society, which sometimes makes the organizational/infrastructrual causes more visible and marginalizes causes related to clients and the service provider itself.

The present study demonstrated a significant difference when comparing the opinions of physicians and nurses on the reasons for providing futile interventions the domains of “patient/relatives’ demands” and “personal reasons of healthcare team members, with nurses giving greater importance to these two domains than physicians. Within physicians, organisational/infrastructural factors were considered more important than the other two domains. This might be explained by the broader role of physicians as decision-makers and their greater responsibility in treatment processes compared to nurses, meaning that they are particularly sensitive to following the hospital's current guidelines and procedures, and sense greater need for help from another authority such as an ethics committee or a comprehensive set of guidelines. In the study of Palda et al., physicians paid particular attention to the shortcomings of hospital ethics committees with 60% considering the establishment and improvement of hospital ethics committees as an important solution to the issue of providing futile interventions (Palda et al, 2005). This is while nurses, who generally have greater communication with patients and their companions, placed more emphasis on the desires of patients and their companions and demonstrated a significant difference in levels of agreement compared to the physician group in this domain. Nurses also considered factors such as neglect by the physician/healthcare team of the patient/relatives’ independence and right to choose and, delay of the healthcare team in reaching consensus on diagnostic and treatment processes, to affect the provision of futile treatment. Belief in ignoring the autonomy of the patient and his companion’s is an issue which has not been investigated much in previous studies and is thus a novel finding of this study compared to previous studies.

The findings of the present study have demonstrated that among three main factors affecting the provision of futile interventions, organisational/infrastructural factors play a prominent role according to the opinion of participants, especially physicians. Thus, it appears that most medical staff are familiar with [futile] interventions though are not keen to provide them, except due to external causes such as requests and insistence of patients/relatives, lack of guidelines for patients approaching death, lack of or insufficient palliative care centres for patient referrals and the inadequacy of home-care services which lead to the use of such interventions. Therefore, it seems that in the first instance developing clinical guidelines as well as improving public awareness around futile, life-sustaining, end-of-life treatment and interventions and, promoting the right attitudes as well as developing clinical guidelines, could reduce the frequency of these interventions and promote greater efficiency and justice in the healthcare system.

Ethics approval

Tehran University of Medical Sciences – Research Ethics Committee Approval granted.

Code: IR.TUMS.MEDICINE.REC.1397.706

We confirm that all methods were carried out in accordance with relevant guidelines and regulations. We also confirm that the experimental protocol was confirmed by the local Research Ethics Committee. Informed consent was obtained from all participants as outlined below under “Consent to participate”.

Consent to participate

The researcher, in collaboration with ward managers, met with the study participants and after stating the study’s objectives, recruited them into the study. Then, a questionnaire was distributed among eligible participants. Completion of the questionnaire was considered equivalent to consent to the study while those who did not complete the questionnaire were deemed to have declined.

Consent for publication

Not applicable, as no identifiable information of participants was revealed in this submission.

Competing/Conflicts of interests

We confirm that all authors have no competing or conflicts of interests.

Funding

This research project and study was not funded.

Authors' contribution

This study was the summation of the thesis of Dr Akbari, who collected the data and wrote the thesis. Professor Parsapoor and Professor Dehghan Nayeri designed the study. Professor Moosavi provided feedback on the methodology and composed the first draft of this paper. Dr Syed provided feedback on the statistical analysis/results/discussion and composed the English-translated draft of this paper. Professor Aghabarary and Professor Dehghan Nayeri provided feedback on the methodology/discussion and also statistics. Professor Shamsi provided feedback on the method/discussion. Professor Parsapoor was the supervisor of the project, with input into the design/methodology/results/discussion and composition of paper drafts.

Acknowledgements

The present article is the result of the findings of a medical doctoral student dissertation. We would like to thank all the physicians and nurses who participated in the study, and Dr Farshad Sharifi for his valuable guidance in the statistical analysis of the study.

Authors' information (optional)

See under title heading on page 1 for authors’ positions and institutional affiliations.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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Causes of futile life-sustaining interventions from the perspective of physicians and nurses in university hospitals in Tehran

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