Discontinuation of futile therapy is increasingly discussed in Polish clinical practice. Taking into account the broadly understood well-being of the patient, it is necessary to consider whether all clinical options resulting from medical progress should be used for every patient and on what grounds decisions to limit therapy should be based. Our study aimed to know the opinion of Polish medical staff on the topic discussed. The study was an anonymous survey conducted in paper and electronic versions among doctors of all specialties. An analysis of the collected data was carried out using the methods of descriptive and analytical statistics. The respondents were divided into two groups according to their specialization: intensivists and doctors of other specializations. A total of 323 doctors participated in the study; 93% of participants were aware of the problem of futile therapy in adults (statistically, significantly more often intensivists, p = 0.002); 95% of respondents supported the idea of discontinuing futile therapy, and over 68% of respondents used the therapy discontinuation protocol. Among the most common reasons for undertaking futile therapy, the respondents declared (more than one answer was possible) fear of legal liability for not taking such action (93.5%), as well as fear of being accused of unethical behavior (62.2%), and fear before talking to the patient/patient’s family and their reaction (57.9%). The respondents also indicated what would facilitate making decisions about limiting futile therapy. These were primarily: precise qualification criteria for limiting therapy and education in this area (95.3%), the patient's declaration of will (87.5%), and a clear legal act (81.3%). The vast majority of study participants supported the idea of limiting futile therapy, and this issue is well-known to Polish doctors.
Article
Opinion of Polish doctors on the use of futile therapy
https://doi.org/10.21203/rs.3.rs-3581184/v1
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The Polish discussion on medical limitations was initiated by experts in the field of ethics, medicine, and law at a conference entitled "The limits of medical therapies" in 2008. The tangible result of this scientific meeting was the establishment of the Polish Working Group on End-of-Life Ethical Problems and the development of a definition of futile medical care.1 Based on this definition, recommendations and guidelines for making medical decisions regarding medically futile actions were developed. The first recommendations regarding the cessation of persistent life-sustaining treatment were published for pediatricians (2011),2 then for specialists in anesthesiology and intensive care of adults (2014),3 for neonatologists (2019),4 and specialists in pediatric intensive care (2022).5 Based on the position of the appointed team of experts, the Patient Ombudsman issued a publication on the implementation of the patient's right to a dignified death, containing standards for end-of-life medical therapies (2021).6 The latest Polish document extensively discussing end-of-life medical care is the Position of the Polish Society of Internal Medicine Working Group on Medical Futility at Internal Medicine Units.7
Doctors providing services to seriously ill patients have received useful tools to help them make decisions that are important from an ethical point of view. Taking into account the broadly understood well-being of the patient, it is necessary to consider whether all clinical options resulting from medical progress should be used for every patient and on what grounds decisions to limit therapy should be based. The period of the SarsCoV-2 virus pandemic forced in some cases, also in our country, consideration of triage and reflection on the need to allocate funds.8
A survey was designed to find out the opinion of doctors, nurses, and the young part of society represented by university students on the above-mentioned issues. The results regarding the opinions of Polish nurses have already been analyzed and published.9 In this publication, we present the results of a survey conducted among doctors. The work on public opinion is in progress.
In 2022, a cross-sectional study was conducted using the proprietary questionnaire. The Polish-language questionnaire consisted of two parts with a total of 26 questions. The first part consisted of 8 questions and concerned socio-demographic characteristics such as gender, age, and religion, but also professional work, including practice, workplace, and medical specialization. The second part, which consisted of 18 questions, concerned the main topic, i.e. the respondents' opinions on various aspects of futile therapy (including the reasons for its implementation or the legitimacy of its limitation). The questionnaire was available in two forms, traditional paper and electronic, and contained both open and closed questions (single and multiple choice); the respondents were asked to answer the questions on their own. Electronic access was secured by the professional license number and e-mail. The questions were prepared by the authors of the study after consultation with Polish experts in the discussed field. The questionnaire was validated in a group of 20 randomly selected medical workers, who were surveyed twice a week apart, with the use of the same tool. The percentage compliance of the answers in the test and retest was assessed, and Cohen's kappa for the key questions was determined. The obtained results indicated good or very good repeatability of the questions. Doctors of all specializations employed in hospitals located in the Silesian, Lesser Poland, Subcarpathian, and Greater Poland voivodeships were invited to participate in the study (500 subjects, i.e. approximately 4% of professionally active doctors in the above-mentioned regions). Participation was fully voluntary and anonymous; study participants did not incur additional costs or receive any gratifications. The study design was approved by the Ethics Committee of the Medical University of Silesia (KNW/0022/KB/284/18). I confirm that all methods were performed in accordance with the relevant guidelines and regulations.
Statistical analysis
An analysis of the collected data was carried out using the methods of analytical and descriptive statistics. The respondents were divided into two groups according to their specialization: intensivists and doctors of other specializations. Qualitative variables were presented in the form of frequencies (numerical and percentage values), while differences between groups were assessed with the chi-square test. As quantitative variables deviated from the normal distribution (Shapiro-Wilk test), the median with the interquartile range (IQR) was used to describe these variables, and non-parametric tests (Mann–Whitney U test) were used to analyze differences between groups. When interpreting the results, the criterion of statistical significance p < 0.05 was adopted. Detailed data are presented in the Results section. All calculations were performed using the R statistical environment (v 4.1.0).
Characteristics of the study population
Out of 500 doctors invited to participate, 323 joined the study (participation rate was 64.6%). The paper version was completed by 131 respondents (40.6%), and the online version by 192 participants (59.4%). The median age of the entire study population was 40 years (IQR 33-51), and statistically, intensivists were significantly older than other specialists (42 vs. 37 years, p=0.0172). Women constituted the majority of study participants (N=211, 65.3%). Catholics constituted the majority (70.2%), and only 57% of the respondents declared weekly participation in the church service. Detailed characteristics of the respondents are presented in Table 1.
Work experience and workplace
The median work experience was 14 years (IQR7-25 years), with intensivists working on average three years longer than other respondents, but this difference was not statistically significant. Among non-intensivists, 19.9% of respondents had experience of working in Intensive Care Units (ICUs). It is worth mentioning that the majority of respondents were employed in teaching hospitals with ICUs (57%).
Experience and opinions related to futile therapy
Questions about the experience and opinions of the surveyed doctors on futile therapy were important for the study; detailed results regarding the respondents' declarations are presented in Table 2. Less than half (40%) of the respondents talked to patients' families about discontinuing the therapy (with no difference related to specialization); the question about preparation for such a conversation was answered positively by 117 respondents (41.5% of respondents), significantly more often (p=0.01) by intensivists (82% vs. 35%). However, 30% of respondents did not consider themselves prepared for such a conversation, regardless of their specialization; only 6% of respondents avoided talking to patients' families despite the need to do so. Most respondents who had no experience in talking to patients' families about this topic did not work in a place where such a need existed. An important question concerned the specific nature of professional work in terms of possible contact with a dying patient. More than half of the respondents (60.1%) declared that such an opportunity occurred even several times a month (intensivists predominated). The majority (93%) of the respondents were familiar with the problem of futile therapy in adults (statistically, significantly more often intensivists, p=0.002), while over 73% of the respondents had such experience in pediatric practice (with no difference related to specialization). Over 87% of surveyed intensivists knew the guidelines for discontinuing futile therapy in adults, while only every second one knew such a document used in children. A total of 95% of respondents supported the idea of discontinuing futile therapy, and over 68% of respondents used the therapy discontinuation protocol. Table 3.
Reasons for futile therapy
Among the most common reasons for undertaking futile therapy in adult patients, the respondents declared (more than one answer was possible) fears of legal liability for not taking such actions (93.5%), as well as fears of being accused of unethical behavior (62.2 %) and fears of talking to the patient/family and their reaction (57.9%), while non-intensivists were statistically more likely to be afraid of the opinions of their colleagues and also believed that one must fight heroically for life until the very end. The opinions of the respondents in the context of working with pediatric patients were similar, but the fear of talking to parents and the fear of being accused of unethical behavior prevailed. Almost every second respondent pointed out that the reason for using futile therapy was the recommendation of the Head of Department. Detailed data are summarized in Table 6.
Limitation of futile therapy and related decisions
The vast majority of respondents (94.7%) believed that the idea of limiting futile therapy was right but more than half of them (57.9%) considered its use a medical error; only every fifth respondent had no opinion on this topic. Opinions on the impact of economic considerations on the use or discontinuation of futile therapy were equally divided. Among the reasons for the lack of consent of the patient's family to limit futile therapy, the lack of acceptance of the inevitability of death prevailed (255 respondents, 78.9%). Almost every second family member (157, 48.6%) believed in the supernatural possibilities of medicine. Almost 60% of surveyed doctors believed that the family did not trust them enough, which was why they did not agree to discontinue therapy (Tables 2 and 5).
The respondents also indicated what would facilitate making decisions about limiting futile therapy. These were primarily: precise qualification criteria for limiting therapy and education in this area (95.3%), the patient's declaration of will (87.5%), and a clear legal act (81.3%). However, the majority of respondents indicated all of the above-mentioned medical procedures, the use of which should be limited or discontinued, apart from the use of antibiotics. Anesthetists were statistically more likely to discontinue or not introduce renal replacement therapy (Tables 2 and 4).
An important issue was to indicate the entity responsible for discontinuation of futile therapy. In the case of adult patients, respondents believed that the cessation of futile therapy should be decided by the patient in a declaration of will (94.1%), followed by the doctor (97.2%). Every third respondent mentioned the patient's family, with significantly less frequent responses from intensivists. In controversial cases, almost 40% of respondents indicated the court. When it comes to pediatric patients, the majority of respondents indicated the medical decision (95.7%). Decisions made by parents were indicated by 65.2% of respondents, and every second respondent indicated the court. It is also worth mentioning that the vast majority of doctors, i.e. 300 (92.9%) would agree to withdraw futile treatment if they suffered from an incurable disease. It should be noted that the respondents usually believed (93.1%) that the decision to discontinue futile therapy should be made by the patient in a living will or a declaration of will. Over 90% of respondents would leave this decision to the doctor and approximately 40% to the family; every fourth respondent indicated the court's decision (Table 7).
Differences in the opinion of intensivists
Intensivists who participated in the study had greater knowledge of the discussed topic, relevant recommendations, and guidelines, and also had greater practical experience in contact with dying patients. In addition, intensivists were much less likely to let the patient's family decide on discontinuing the patient's therapy (p=0.004). Intensivists were also less likely to fear the opinions of other doctors and the patient's family about the ethics of their behavior (p<0.001 and 0.005); they did not provide futile treatment due to the heroic obligation of fighting to the end (p=0.007) and more often admitted to passivity in action, i.e. avoiding making decisions (p=0.003); they also considered the use of renal replacement therapy as a component of futile therapy (p<0.001), similarly to pharmacological and mechanical support of the circulatory system (p=0.03).
Our study shows that the issue of futile therapy is widely known in the Polish medical community, and the majority of respondents consider its use to be medical malpractice. Similar results were obtained in a study conducted in Poland in 2011 by Kübler A. et al.10 among doctors working in the ICUs; 93% of respondents did not undertake certain therapeutic activities, and 75% refrained from activities due to their futility. However, there was a significant difference in recording this fact in the medical documentation; in 2011, only 10% of surveyed doctors in Poland documented their decisions. In our study, the vast majority of subjects completed appropriate documents related to the discontinuation of therapy, and only 6% of respondents omitted to document clinical decisions. Although Polish law allows discontinuation of therapy, the matter is still not regulated. In addition to the published Guidelines and the Position of the Patient Ombudsman, a clear legal act would facilitate decision-making for the majority of surveyed doctors. In a study conducted in 2016 among Australian doctors, only one-third of the respondents indicated fear of legal consequences as the reason for conducting futile therapy.11 An interesting global study collecting opinions from 178 hospitals from 31 countries is The Worldwide End-of-Life Practice for Patients in Intensive Care Units (WELPICUS),12 which indicates the individual factors that have the greatest impact on decision-making regarding end-of-life care, including doctor's belief, hospital policy, and regional conditions. However, in this study, approximately 80% of doctors supported the idea of withholding and withdrawing therapeutic procedures due to their futility, regardless of an agreement with the patient's family.
Japanese ethicists have a different opinion; they leave the decision to the family and point out the need for honest information from the medical staff about the futility of therapy.13 The difference in opinions highlights the role of the regional culture but also the fact that the discussion conducted in the humanist community may differ significantly from that in the medical community. Nevertheless, proper communication with the patient's family plays an important role in the process of avoiding futile therapy.14–16 Our respondents indicated the fear of talking to the patient’s family not accepting the inevitability of death or not trusting the doctor, as well as the fear of the family's legal claims, as the basic reasons for continuing futile therapy. In our earlier study regarding nurses' opinions on the discussed topic,9 only 6% of study participants believed that they were sufficiently prepared for such a conversation. This issue requires broadly understood education, workshops, and the acquisition of so-called soft skills, as indicated by over 90% of our survey participants. The mere belief in the validity of the idea of discontinuing therapy is not enough to improve the quality of end-of-life care.
The position of the Polish Society of Internal Medicine Working Group on Medical Futility at Internal Medicine Units emphasizes the need for end-of-life care to provide time (conversation, reflection, maturation of decisions), good communication based on truth and respect, and comprehensive care for patients, focused on their physical, psychosocial, and spiritual needs.7 A declaration of will, i.e. the willingness to decide for oneself, is the most popular proposed solution to controversial situations.17–20 Respecting the patient's will and self-determination regarding the expected therapy would, in the authors' opinion, be an expression of respect for the patient's right to make decisions. However, patients very often have no influence on their end-of-life care.
Children are a special group of patients. The death of a child is a shocking experience that evokes extremely strong emotions.5 However, this does not change the fact that pediatric patients also have the right to a dignified and peaceful death, spared from futile treatment.
Our respondents pointed out the particular difficulty of talking to the child's parents and the need to make every effort to ensure that medical decisions are based on a consensus agreed with the child's family. Most members of the American Academy of Pediatric Section of Critical Care did not clearly support discontinuing therapy against the opinion of the patient's parents, even if they agreed with the idea.21 Perhaps this is due to fear of possible lawsuits, so common in the USA; however, providing professional support to the family in such difficult decisions is a priority, necessary to avoid conflict situations. An objective person, who is not part of the therapeutic team and in whom the patient's family would have full trust, may contribute to resolving controversial situations.
In our study, the majority of respondents were intensivists, who make decisions about end-of-life care. In 2019, a survey conducted among Polish pulmonologists showed that the vast majority of respondents admitted not talking routinely to patients with advanced chronic obstructive pulmonary disease about end-of-life issues such as the need to make decisions about invasive mechanical ventilation, cardiopulmonary resuscitation, or the place of dying.22 It does not seem that Polish intensivists talk to their patients more often, especially in the ICUs. Nevertheless, according to the results of our study, they are deprived of the idealized vision of a miracle-working doctor and find it easier to make decisions about discontinuing therapy. Frequent contact with a dying patient helps to maintain some autonomy from the emotional influences of the patient's family or doctors of other specialties, and, at the same time, it may cause a certain type of burnout characterized by passivity while waiting for someone else to make decisions, as our results can prove.
Our study was limited by the representativeness of the study group for the entire medical community in Poland. Our study group constituted less than 0.5% of all doctors in the country, and the selection of study participants was focused mainly on the southern voivodeships.
The vast majority of doctors participating in the study support the idea of not practicing futile therapy, and this issue is well-known to Polish doctors. Further education and acquiring skills in talking to the patient's family, but also educating society about the declaration of will as an opportunity to influence end-of-life therapy, may contribute to improving medical practice in this area.
Author contributions
M.D.,M.G.,M.K.,E.K-Cz. designed the study and drafted the manuscript. M.D.,Ł.W.,B.R. and E.B-M. collected data. M.G., M.K. conducted the data analysis. M.D. prepared the final version of the manuscript.A.P-L.,B.R. and A.Ś-B. critically reviewed and edited the manuscript. All authors have read and agreed to the published version of the manuscript. The study design was approved by the Ethics Committee of the Medical University of Silesia (KNW/0022/KB/284/18).
Funding
This paper was not funded. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
Data availability
The data generated and analyzed in the current study are available from the corresponding author on reasonable request.
Informed consent
Participation was fully voluntary and anonymous; study participants did not incur additional costs or receive any gratifications. There was not a experiments involving human participant.
Competing interests
The authors declare no competing interests.
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Table 1. General characteristics of the studied population
|
|
Overall n (%) |
Intensivists n (%) |
|||
|
|
n= 323 |
No 140 (43,34%) |
Yes 183 (56,66%) |
p |
|
|
Mode of interview |
Offline |
131 (40.6%) |
53 (37.9%) |
78 (42.6%) |
0.688
|
|
Online |
192 (59.4%) |
87 (62.1%) |
105 (57.4%) |
||
|
Age (years) |
Median [q25-q75] |
40.0 [33.0-51.0] |
37.0 [31.0-48.0] |
42.0 [35.0-53.0] |
0.017
|
|
Missing |
2 (0.6%) |
1 (0.7%) |
1 (0.5%) |
||
|
Gender |
Female |
211 (65.3%) |
101 (72.1%) |
110 (60.1%) |
0.079
|
|
Male |
112 (34.7%) |
39 (27.9%) |
73 (39.9%) |
||
|
Length of employment(years) |
Median [q25-q75] |
14.0 [7.00-25.0] |
12.0 [5.00-23.0] |
15.0 [8.50-26.0] |
0.052 |
|
Work in the intensive care unit |
Yes |
184 (58.4%) |
27 (19.9%) |
157 (87.7%) |
<0.001
|
|
No |
131 (41.6%) |
109 (80.1%) |
22 (12.3%) |
||
|
Missing |
8 (2.5%) |
4 (2.9%) |
4 (2.2%) |
||
|
Place of work - teaching hospital with ICU |
Yes |
184 (57.0%) |
88 (62.9%) |
96 (52.5%) |
0.174
|
|
No |
139 (43.0%) |
52 (37.1%) |
87 (47.5%) |
||
|
Place of work - non-clinical ICU hospital |
Yes |
184 (57.0%) |
88 (62.9%) |
96 (52.5%) |
0.174
|
|
No |
139 (43.0%) |
52 (37.1%) |
87 (47.5%) |
||
|
Place of work - hospital without ICU |
Yes |
184 (57.0%) |
88 (62.9%) |
96 (52.5%) |
0.174
|
|
No |
139 (43.0%) |
52 (37.1%) |
87 (47.5%) |
||
|
Place of work - only a doctor's office |
Yes |
184 (57.0%) |
88 (62.9%) |
96 (52.5%) |
0.174
|
|
No |
139 (43.0%) |
52 (37.1%) |
87 (47.5%) |
||
|
Place of work - other |
Outpatient clinic |
2 (33.3%) |
2 (100%) |
0 (0%) |
0.423
|
|
Hospice |
2 (33.3%) |
0 (0%) |
2 (50.0%) |
||
|
Private hospital |
1 (16.7%) |
0 (0%) |
1 (25.0%) |
||
|
General practice |
1 (16.7%) |
0 (0%) |
1 (25.0%) |
||
|
Missing |
317 (98.1%) |
138 (98.6%) |
179 (97.8%) |
||
|
Confession |
Catholic who attends church every week |
129 (40.1%) |
65 (46.4%) |
64 (35.2%) |
0.173
|
|
Catholic |
97 (30.1%) |
31 (22.1%) |
66 (36.3%) |
||
|
Atheitst |
67 (20.8%) |
33 (23.6%) |
34 (18.7%) |
||
|
Protestant, baptist |
29 (9.0%) |
11 (7.9%) |
18 (9.9%) |
||
|
Missing |
1 (0.3%) |
0 (0%) |
1 (0.5%) |
||
Table 2. Work experience and employees’ views on futile therapy (numbers and percentages in brackets)
|
|
Overall n (%) 323 |
Intensyvists n (%) |
p
|
|||||||||
|
No 140 (43,34%) |
Yes 183 (56,66%) |
|||||||||||
|
Contact with a dying patient |
||||||||||||
|
few cases in recent years |
42 (13.0%) |
37 (26.4%) |
5 (2.7%) |
<0.001 |
||||||||
|
several times a year |
87 (26.9%) |
56 (40.0%) |
31 (16.9%) |
|||||||||
|
several times a month |
194 (60.1%) |
47 (33.6%) |
147 (80.3%) |
|||||||||
|
Witnessing illness and death |
||||||||||||
|
Yes |
238 (73.9%) |
90 (64.7%) |
148 (80.9%) |
0.005 |
||||||||
|
No |
84 (26.1%) |
49 (35.3%) |
35 (19.1%) |
|||||||||
|
Missing |
1 (0.3%) |
1 (0.7%) |
0 (0%) |
|||||||||
|
Knowledge of the futile therapy in adults |
||||||||||||
|
Yes |
297 (93.7%) |
121 (88.3%) |
176 (97.8%) |
0.003 |
||||||||
|
No |
20 (6.3%) |
16 (11.7%) |
4 (2.2%) |
|||||||||
|
Missing |
6 (1.9%) |
3 (2.1%) |
3 (1.6%) |
|||||||||
|
Knowledge of the futile therapy in children |
||||||||||||
|
Yes |
228 (71.3%) |
100 (71.9%) |
128 (70.7%) |
0.972 |
||||||||
|
No |
92 (28.8%) |
39 (28.1%) |
53 (29.3%) |
|||||||||
|
Missing |
3 (0.9%) |
1 (0.7%) |
2 (1.1%) |
|||||||||
|
Knowledge of PTAiIT guidelines for futile therapy |
||||||||||||
|
Yes |
206 (64.4%) |
47 (33.8%) |
159 (87.8%) |
<0.001 |
||||||||
|
No |
114 (35.6%) |
92 (66.2%) |
22 (12.2%) |
|||||||||
|
Missing |
3 (0.9%) |
1 (0.7%) |
2 (1.1%) |
|||||||||
|
Knowledge of the BKEP expert on futile therapy |
||||||||||||
|
Yes |
128 (40.0%) |
37 (26.6%) |
91 (50.3%) |
<0.001 |
||||||||
|
No |
192 (60.0%) |
102 (73.4%) |
90 (49.7%) |
|||||||||
|
Missing |
3 (0.9%) |
1 (0.7%) |
2 (1.1%) |
|||||||||
|
Talking to the patient and/or his family about limiting futile therapy |
||||||||||||
|
Yes |
134 (41,5%) |
61 (43,6%) |
73 (39,9%) |
0.966 |
||||||||
|
No, even though it was necessary |
21 (6,5%) |
8 (5,7%) |
13 (7,1%) |
|||||||||
|
No, due to the type of specialization |
168 (52,0%) |
71 (50,7%) |
97 (53%) |
|||||||||
|
Being prepared for such a conversation with the patient and/or the patient's family |
||||||||||||
|
Yes |
117 (41,5%) |
35 (30.7%) |
82 (48.8%) |
0.014 |
||||||||
|
No opinion |
80 (28,4%) |
44 (38.6%) |
36 (21.4%) |
|||||||||
|
No |
85 (30,1%) |
35 (30.7%) |
50 (29.8%) |
|||||||||
|
Missing |
41 (12,7%) |
26 (18.6%) |
15 (8.2%) |
|||||||||
|
Use of futile therapy is a mistake |
||||||||||||
|
Yes |
187 (57.9%) |
76 (54.3%) |
111 (60.7%) |
0.103 |
||||||||
|
No opinion |
59 (18.3%) |
35 (25.0%) |
24 (13.1%) |
|||||||||
|
No |
77 (23.8%) |
29 (20.7%) |
48 (26.2%) |
|||||||||
|
Idea of limiting futile therapy is right |
||||||||||||
|
Yes |
306 (94.7%) |
132 (94.3%) |
174 (95.1%) |
0.257 |
||||||||
|
No opinion |
10 (3.1%) |
7 (5.0%) |
3 (1.6%) |
|||||||||
|
No |
7 (2.2%) |
1 (0.7%) |
6 (3.3%) |
|||||||||
|
Economic aspects should be decisive in stopping futile therapy |
||||||||||||
|
Yes |
130 (40.2%) |
55 (39.3%) |
75 (41.0%) |
0.957 |
||||||||
|
No opinion |
56 (17.3%) |
27 (19.3%) |
29 (15.8%) |
|||||||||
|
No |
137 (42.4%) |
58 (41.4%) |
79 (43.2%) |
|||||||||
|
What would make the decision to limit futile therapy easier? -unambiguous legal act |
||||||||||||
|
Yes |
260 (81.3%) |
105 (75.0%) |
155 (86.1%) |
0.138 |
||||||||
|
Don’t know |
37 (11.6%) |
23 (16.4%) |
14 (7.8%) |
|||||||||
|
No |
23 (7.2%) |
12 (8.6%) |
11 (6.1%) |
|||||||||
|
Missing |
3 (0.9%) |
0 (0%) |
3 (1.6%) |
|||||||||
|
- precise eligibility criteria for limiting therapy |
||||||||||||
|
Yes |
305 (95.3%) |
133 (96.4%) |
172 (94.5%) |
0.947 |
||||||||
|
Don’t know |
8 (2.5%) |
3 (2.2%) |
5 (2.7%) |
|||||||||
|
No |
7 (2.2%) |
2 (1.4%) |
5 (2.7%) |
|||||||||
|
Missing |
3 (0.9%) |
2 (1.4%) |
1 (0.5%) |
|||||||||
|
- education in this area (practical form of education, e.g., workshops) |
||||||||||||
|
Yes |
307 (95.3%) |
130 (92.9%) |
177 (97.3%) |
0.25 |
||||||||
|
Don’t know |
8 (2.5%) |
4 (2.9%) |
4 (2.2%) |
|||||||||
|
No |
7 (2.2%) |
6 (4.3%) |
1 (0.5%) |
|||||||||
|
Missing |
1 (0.3%) |
0 (0%) |
1 (0.5%) |
|||||||||
|
- patient's declaration of will/living will |
||||||||||||
|
Yes |
279 (87.5%) |
119 (86.2%) |
160 (88.4%) |
0.333 |
||||||||
|
Don’t know |
25 (7.8%) |
15 (10.9%) |
10 (5.5%) |
|||||||||
|
No |
15 (4.7%) |
4 (2.9%) |
11 (6.1%) |
|||||||||
|
Missing |
4 (1.2%) |
2 (1.4%) |
2 (1.1%) |
|||||||||
Table 3. The answer to question - Do you limit futile therapy in your practice?
|
|
Overall n (%) |
Intensyvists n (%) |
p |
||||||||
|
No 140 (43,34%) |
Yes 183 (56,66%) |
||||||||||
|
Yes, but I omit this fact in the documentation |
|||||||||||
|
Yes |
32 (21.6%) |
7 (12.3%) |
25 (27.5%) |
0.092
|
|||||||
|
No |
116 (78.4%) |
50 (87.7%) |
66 (72.5%) |
||||||||
|
Missing |
175 (54.2%) |
83 (59.3%) |
92 (50.3%) |
||||||||
|
Yes, I note it in the documentation |
|||||||||||
|
Yes |
162 (68.1%) |
48 (55.2%) |
114 (75.5%) |
0.005
|
|||||||
|
No |
76 (31.9%) |
39 (44.8%) |
37 (24.5%) |
||||||||
|
Missing |
85 (26.3%) |
53 (37.9%) |
32 (17.5%) |
||||||||
|
No, because I don't want to be responsible for such a decision |
|||||||||||
|
Yes |
8 (6.0%) |
3 (5.6%) |
5 (6.3%) |
0.986
|
|||||||
|
No |
126 (94.0%) |
51 (94.4%) |
75 (93.8%) |
||||||||
|
Missing |
189 (58.5%) |
86 (61.4%) |
103 (56.3%) |
||||||||
|
No, because there is no such practice in my department |
|||||||||||
|
Yes |
42 (28.8%) |
27 (41.5%) |
15 (18.5%) |
0.009
|
|||||||
|
No |
104 (71.2%) |
38 (58.5%) |
66 (81.5%) |
||||||||
|
Missing |
177 (54.8%) |
75 (53.6%) |
102 (55.7%) |
||||||||
|
This issue is not related to my specialization |
|||||||||||
|
Yes |
43 (26.7%) |
41 (49.4%) |
2 (2.6%) |
<0.001
|
|||||||
|
No |
118 (73.3%) |
42 (50.6%) |
76 (97.4%) |
||||||||
|
Missing |
162 (50.2%) |
57 (40.7%) |
105 (57.4%) |
||||||||
|
Other |
|||||||||||
|
Decisions are made by the head of the department together with the team |
25 (80.6%) |
8 (66.7%) |
17 (89.5%) |
-
|
|||||||
|
I don't make that decision |
5 (16.1%) |
4 (33.3%) |
1 (5.3%) |
||||||||
|
There are no such procedures |
1 (3.2%) |
0 (0%) |
1 (5.3%) |
||||||||
|
Yes, after talking to the doctor in charge of the ward |
0 (0%) |
0 (0%) |
0 (0%) |
||||||||
|
Missing |
292 (90.4%) |
128 (91.4%) |
164 (89.6%) |
||||||||
Table 4. Medical procedures which should be limited or discontinued
|
|
Overall n(%) |
Intensivists n(%) |
p |
||||
|
No 140 (43,34%) |
Yes 183 (56,66%) |
||||||
|
Intubation and the use of mechanical ventilation |
|||||||
|
Yes |
239 (75.4%) |
102 (73.4%) |
137 (77.0%) |
0.965 |
|||
|
Don't know |
37 (11.7%) |
18 (12.9%) |
19 (10.7%) |
||||
|
No |
41 (12.9%) |
19 (13.7%) |
22 (12.4%) |
||||
|
Missing |
6 (1.9%) |
1 (0.7%) |
5 (2.7%) |
||||
|
Mechanical and pharmacological cardiovascular support |
|||||||
|
Yes |
271 (85.0%) |
108 (77.7%) |
163 (90.6%) |
0.030 |
|||
|
Don't know |
22 (6.9%) |
13 (9.4%) |
9 (5.0%) |
||||
|
No |
26 (8.2%) |
18 (12.9%) |
8 (4.4%) |
||||
|
Missing |
4 (1.2%) |
1 (0.7%) |
3 (1.6%) |
||||
|
Extracorporeal blood oxygenation (ECMO) |
|||||||
|
Yes |
304 (94.4%) |
127 (91.4%) |
177 (96.7%) |
0.309 |
|||
|
Don't know |
5 (1.6%) |
4 (2.9%) |
1 (0.5%) |
||||
|
No |
13 (4.0%) |
8 (5.8%) |
5 (2.7%) |
||||
|
Missing |
1 (0.3%) |
1 (0.7%) |
0 (0%) |
||||
|
Renal replacement therapy |
|||||||
|
Yes |
273 (85.0%) |
103 (74.6%) |
170 (92.9%) |
<0.001 |
|||
|
Don't know |
23 (7.2%) |
18 (13.0%) |
5 (2.7%) |
||||
|
No |
25 (7.8%) |
17 (12.3%) |
8 (4.4%) |
||||
|
Missing |
2 (0.6%) |
2 (1.4%) |
0 (0%) |
||||
|
Blood transfusion |
|||||||
|
Yes |
237 (75.0%) |
93 (66.9%) |
144 (81.4%) |
0.064 |
|||
|
Don't know |
31 (9.8%) |
19 (13.7%) |
12 (6.8%) |
||||
|
No |
48 (15.2%) |
27 (19.4%) |
21 (11.9%) |
||||
|
Missing |
7 (2.2%) |
1 (0.7%) |
6 (3.3%) |
||||
|
Antibiotic therapy |
|||||||
|
Yes |
125 (39.8%) |
55 (39.9%) |
70 (39.8%) |
1 |
|||
|
Don't know |
63 (20.1%) |
28 (20.3%) |
35 (19.9%) |
||||
|
No |
126 (40.1%) |
55 (39.9%) |
71 (40.3%) |
||||
|
Missing |
9 (2.8%) |
2 (1.4%) |
7 (3.8%) |
||||
Table 5. The main reason for the family’s refusal to limit futile therapy for their relatives
Table 6. Reasons for starting futile therapy in the population of adult and pediatric patients
|
|
Overall n(%) |
Intensivists n(%) |
p |
|||
|
No 140 (43,34%) |
Yes 183 (56,66%) |
|||||
|
The main reason for undertaking/continuing futile therapy in adult patients: |
||||||
|
fear of talking to the patient/patient's family and their reaction |
||||||
|
Yes |
187 (57.9%) |
86 (61.4%) |
101 (55.2%) |
0.531
|
||
|
No |
136 (42.1%) |
54 (38.6%) |
82 (44.8%) |
|||
|
fear of legal liability for withdrawing or withholding treatment |
||||||
|
Yes |
302 (93.5%) |
129 (92.1%) |
173 (94.5%) |
0.688
|
||
|
No |
21 (6.5%) |
11 (7.9%) |
10 (5.5%) |
|||
|
heroic fight for life to the end, because this is the ethical duty of the doctor |
||||||
|
Yes |
82 (25.4%) |
50 (35.7%) |
32 (17.5%) |
<0.001
|
||
|
No |
241 (74.6%) |
90 (64.3%) |
151 (82.5%) |
|||
|
fear of being accused by the patient's family of the lack of professional ethics |
||||||
|
Yes |
65 (20.1%) |
39 (27.9%) |
26 (14.2%) |
0.010
|
||
|
No |
258 (79.9%) |
101 (72.1%) |
157 (85.8%) |
|||
|
fear of being accused by the patient's family of the lack of professional ethics |
||||||
|
Yes |
201 (62.2%) |
97 (69.3%) |
104 (56.8%) |
0.073
|
||
|
No |
122 (37.8%) |
43 (30.7%) |
79 (43.2%) |
|||
|
order/recommendation from the supervisor |
||||||
|
Yes |
126 (39.0%) |
49 (35.0%) |
77 (42.1%) |
0.434
|
||
|
No |
197 (61.0%) |
91 (65.0%) |
106 (57.9%) |
|||
|
passivity in action (colloquial term - laziness) |
||||||
|
Yes |
81 (25.1%) |
22 (15.7%) |
59 (32.2%) |
0.003
|
||
|
No |
242 (74.9%) |
118 (84.3%) |
124 (67.8%) |
|||
|
The main reason for undertaking/continuing futile therapy in newborns/children |
||||||
|
fear of talking to the patient/patient's parents (family) and their reaction |
||||||
|
Yes |
243 (75.2%) |
105 (75.0%) |
138 (75.4%) |
0.996
|
||
|
No |
80 (24.8%) |
35 (25.0%) |
45 (24.6%) |
|||
|
fear of legal liability for withdrawing or withholding treatment |
||||||
|
Yes |
300 (92.9%) |
127 (90.7%) |
173 (94.5%) |
0.417
|
||
|
No |
23 (7.1%) |
13 (9.3%) |
10 (5.5%) |
|||
|
heroic fight for life to the end, because this is the ethical duty of the doctor |
||||||
|
Yes |
171 (52.9%) |
88 (62.9%) |
83 (45.4%) |
0.007
|
||
|
No |
152 (47.1%) |
52 (37.1%) |
100 (54.6%) |
|||
|
fear of being accused by colleagues of a lack of professional ethics |
||||||
|
Yes |
95 (29.4%) |
49 (35.0%) |
46 (25.1%) |
0.156
|
||
|
No |
228 (70.6%) |
91 (65.0%) |
137 (74.9%) |
|||
|
fear of being accused by the patient's family of the lack of professional ethics |
||||||
|
Yes |
218 (67.5%) |
108 (77.1%) |
110 (60.1%) |
0.005
|
||
|
No |
105 (32.5%) |
32 (22.9%) |
73 (39.9%) |
|||
|
order/recommendation from the supervisor |
||||||
|
Yes |
138 (42.7%) |
55 (39.3%) |
83 (45.4%) |
0.55
|
||
|
No |
185 (57.3%) |
85 (60.7%) |
100 (54.6%) |
|||
|
passivity in action (colloquial term - laziness |
||||||
|
Yes |
65 (20.1%) |
22 (15.7%) |
43 (23.5%) |
0.224
|
||
|
No |
258 (79.9%) |
118 (84.3%) |
140 (76.5%) |
|||
Table 7. Who should decide to limit futile therapy in adult and pediatric patients and in relation to the surveyed?
|
|
Overall n(%) 323 |
Intensyvists |
p |
||||
|
No 140 (43,34%) |
Yes 183 (56,66%) |
||||||
|
Who should decide to limit futile therapy in adult patients? |
|||||||
|
patient in a declaration of will/living will (decision expressed in writing before falling ill or in the presence of a witness) |
|||||||
|
Yes |
301 (94.1%) |
131 (94.9%) |
170 (93.4%) |
0.948
|
|||
|
Don't know |
9 (2.8%) |
4 (2.9%) |
5 (2.7%) |
||||
|
No |
10 (3.1%) |
3 (2.2%) |
7 (3.8%) |
||||
|
Missing |
3 (0.9%) |
2 (1.4%) |
1 (0.5%) |
||||
|
doctors |
|||||||
|
Yes |
314 (97.2%) |
133 (95.0%) |
181 (98.9%) |
0.343
|
|||
|
Don't know |
4 (1.2%) |
3 (2.1%) |
1 (0.5%) |
||||
|
No |
5 (1.5%) |
4 (2.9%) |
1 (0.5%) |
||||
|
nurses |
|||||||
|
Yes |
43 (14.4%) |
14 (10.8%) |
29 (17.3%) |
0.239
|
|||
|
Don't know |
68 (22.8%) |
37 (28.5%) |
31 (18.5%) |
||||
|
No |
187 (62.8%) |
79 (60.8%) |
108 (64.3%) |
||||
|
Missing |
25 (7.7%) |
10 (7.1%) |
15 (8.2%) |
||||
|
patient's family |
|||||||
|
Yes |
112 (36.6%) |
62 (45.9%) |
50 (29.2%) |
0.004
|
|||
|
Don't know |
54 (17.6%) |
28 (20.7%) |
26 (15.2%) |
||||
|
No |
140 (45.8%) |
45 (33.3%) |
95 (55.6%) |
||||
|
Missing |
17 (5.3%) |
5 (3.6%) |
12 (6.6%) |
||||
|
court |
|||||||
|
Yes |
118 (38.4%) |
60 (44.4%) |
58 (33.7%) |
0.389
|
|||
|
Don't know |
70 (22.8%) |
30 (22.2%) |
40 (23.3%) |
||||
|
No |
119 (38.8%) |
45 (33.3%) |
74 (43.0%) |
||||
|
Missing |
16 (5.0%) |
5 (3.6%) |
11 (6.0%) |
|
|||
|
Who should decide about limiting futile therapy in the case of a child? |
|||||||
|
doctors |
|||||||
|
Yes |
309 (95.7%) |
132 (94.3%) |
177 (96.7%) |
0.469
|
|||
|
Don't know |
6 (1.9%) |
2 (1.4%) |
4 (2.2%) |
||||
|
No |
8 (2.5%) |
6 (4.3%) |
2 (1.1%) |
||||
|
head physician |
|||||||
|
Yes |
200 (64.7%) |
79 (59.0%) |
121 (69.1%) |
0.474
|
|||
|
Don't know |
41 (13.3%) |
20 (14.9%) |
21 (12.0%) |
||||
|
No |
68 (22.0%) |
35 (26.1%) |
33 (18.9%) |
|
|||
|
Missing |
14 (4.3%) |
6 (4.3%) |
8 (4.4%) |
||||
|
nurses |
|||||||
|
Yes |
41 (13.8%) |
13 (10.0%) |
28 (16.8%) |
0.573
|
|||
|
Don't know |
68 (22.9%) |
30 (23.1%) |
38 (22.8%) |
||||
|
No |
188 (63.3%) |
87 (66.9%) |
101 (60.5%) |
||||
|
Missing |
26 (8.0%) |
10 (7.1%) |
16 (8.7%) |
||||
|
child's parents |
|||||||
|
Yes |
204 (65.2%) |
95 (69.3%) |
109 (61.9%) |
0.253
|
|||
|
Don't know |
35 (11.2%) |
18 (13.1%) |
17 (9.7%) |
||||
|
No |
74 (23.6%) |
24 (17.5%) |
50 (28.4%) |
||||
|
Missing |
10 (3.1%) |
3 (2.1%) |
7 (3.8%) |
||||
|
Guardianship/ Court |
|||||||
|
Yes |
146 (47.9%) |
72 (53.3%) |
74 (43.5%) |
0.503
|
|||
|
Don't know |
63 (20.7%) |
27 (20.0%) |
36 (21.2%) |
||||
|
No |
96 (31.5%) |
36 (26.7%) |
60 (35.3%) |
||||
|
Missing |
18 (5.6%) |
5 (3.6%) |
13 (7.1%) |
||||
|
Missing |
3 (0.9%) |
2 (1.4%) |
1 (0.5%) |
||||
|
Who would decide to limit futile therapy in relation to the surveyed |
|||||||
|
he/she |
|||||||
|
Yes |
295 (93.1%) |
131 (94.9%) |
164 (91.6%) |
0.816
|
|||
|
Don't know |
14 (4.4%) |
5 (3.6%) |
9 (5.0%) |
||||
|
No |
8 (2.5%) |
2 (1.4%) |
6 (3.4%) |
||||
|
Missing |
6 (1.9%) |
2 (1.4%) |
4 (2.2%) |
||||
|
doctors |
|||||||
|
Yes |
294 (92.7%) |
126 (90.6%) |
168 (94.4%) |
0.64
|
|||
|
Don't know |
7 (2.2%) |
5 (3.6%) |
2 (1.1%) |
||||
|
No |
16 (5.0%) |
8 (5.8%) |
8 (4.5%) |
||||
|
Missing |
6 (1.9%) |
1 (0.7%) |
5 (2.7%) |
||||
|
head physician |
|||||||
|
Yes |
154 (50.7%) |
63 (47.4%) |
91 (53.2%) |
0.761
|
|||
|
Don't know |
44 (14.5%) |
18 (13.5%) |
26 (15.2%) |
||||
|
No |
106 (34.9%) |
52 (39.1%) |
54 (31.6%) |
||||
|
Missing |
19 (5.9%) |
7 (5.0%) |
12 (6.6%) |
||||
|
nurses |
|||||||
|
Yes |
35 (11.8%) |
11 (8.4%) |
24 (14.5%) |
0.565
|
|||
|
Don't know |
41 (13.8%) |
17 (13.0%) |
24 (14.5%) |
||||
|
No |
221 (74.4%) |
103 (78.6%) |
118 (71.1%) |
||||
|
Missing |
26 (8.0%) |
9 (6.4%) |
17 (9.3%) |
||||
|
family |
|||||||
|
Yes |
121 (39.7%) |
62 (45.9%) |
59 (34.7%) |
0.288
|
|||
|
Don't know |
36 (11.8%) |
17 (12.6%) |
19 (11.2%) |
||||
|
No |
148 (48.5%) |
56 (41.5%) |
92 (54.1%) |
||||
|
Missing |
18 (5.6%) |
5 (3.6%) |
13 (7.1%) |
||||
|
court |
|||||||
|
Yes |
69 (23.0%) |
36 (27.1%) |
33 (19.8%) |
0.689
|
|||
|
Don't know |
56 (18.7%) |
23 (17.3%) |
33 (19.8%) |
||||
|
No |
175 (58.3%) |
74 (55.6%) |
101 (60.5%) |
||||
|
Missing |
23 (7.1%) |
7 (5.0%) |
16 (8.7%) |
||||
No competing interests reported.