Factors affecting physicians' decisions an ...

ORIGINAL RESEARCH * NOUVEAUTES EN RECHERCHE

Factors affecting physicians' decisions on caring for an incompetent elderly patient: an international study D. William Molloy,* MB; Gordon H. Guyatt,*t MD; Efrem Alemayehu,*t MD; William Mcnlroy,*t PhD; Andrew Willan,t PhD; Martin Eisemann,4 PhD; Gebrehiwot Abraham,§ MD; Jan Basile,1 MD; Graeme Penington,11 MB, BS; Marion E.T. McMurdo,** MD; Paul Finucane,tt MB; Alice Zelmanowicz4t MD; Michael Hyland,§§ MB Objectives: To determine what treatment decisions physicians will make when faced with a hypothetical incompetent elderly patient with life-threatening gastrointestinal bleeding and to examine the relative importance of physician characteristics and factors (legal and ethical concerns, hospital costs, level of dementia, patient's age, physician's religion, patient's wishes and family's wishes) in making those decisions. Design: Survey. Setting: Family practice, medical and geriatrics rounds in academic medical centres and community hospitals in seven countries. Participants: Physicians who regularly cared for incompetent elderly patients. Main outcome measures: A self-administered questionnaire describing the elderly patient. Respondents were asked to choose one of four levels of care and to identify the level of importance factors had in making that decision. Older physicians, those less concerned about litigation, those for whom the level of dementia was important and those for whom the patient's age was important were expected to give less aggressive care than the other physicians. Main results: Supportive care was chosen by 8. 1% of the respondents, limited therapeutic care by 41.5%, maximum therapeutic care without admission to the intensive care unit (ICU) by 32.2% and maximum care with admission to the ICU by 18.2%. The patient's wishes were reported by 91.0% as being extremely or very important in choosing the treatment. Stepwise logistic regression analysis revealed that the following variables independently predicted the level of treatment: level of dementia, country of residence, duration of practice, legal concerns, patient's age and ethical concerns. These factors were significantly correlated with the physicians' treatment choices (p < 0.05). Conclusions: The importance that the physicians placed on the level of dementia was the strongest predictor of the level of care that would be provided. A societal consensus on the influence of cognitive function on the appropriate level of care as well as training of physicians in ethical issues are required. From the departments of *Medicine and of tClinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.; tthe Department ofPsychiatry, Umea University, Umea, Sweden; §the Department ofPsychiatry, Queen's University, Kingston, Ont.; I/the Department of Medicine, Medical University of South Carolina, Charleston, SC; llthe Rehabilitation Unit, Mount Royal Hospital, Victoria, Australia; **the Department ofMedicine, Ninewells Hospital and Medical School, Dundee, Scotland; ttthe Department of Geriatric Medicine, University of Wales College of Medicine, Cardiff Wales; ttthe Faculty ofMedicine, Federal University, Porto Alegre, Brazil; and §§the Department of Geriatrics, Cork Regional Hospital, Wilton, Ireland

Drs. Molloy and Guyatt are career scientists of the Ontario Ministry of Health.

Reprint requests to: Dr. D. William Molloy, Memory Clinic, Henderson General Division, Hamilton Civic Hospitals, 711 Concession St., Hamilton, ON L8 V I C3 -

For prescribing information see page 1019

CAN MED ASSOC J 1991; 145 (8)

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Objectifs: Determiner les decisions en ce qui concerne le traitement que le medecin devra prendre dans l'hypothese ou il serait en presence d'un malade age et incapable souffrant d'une hemorragie gastro-intestinale qui menace la vie du sujet et examiner l'importance relative des caracteristiques du medecin et des facteurs (problemes juridiques et ethiques, couts d'hospitalisation, degre de demence, age du malade, religion du medecin, volonte du malade et de la famille) qui interviennent dans ces decisions. Conception: Sondage. Contexte: Service de pratique familiale, de medecine et de geriatrie de centres medicaux d'ensiegnement et d'h6pitaux communautaires dans sept pays. Participants: Medecins qui ont traite regulierement des malades ages et incapables. Mesures des resultats: Questionnaire a remplir soi-meme decrivant le malade age. Les repondants devaient choisir un degre de soins sur quatre et identifier le degre d'importance des facteurs intervenus dans leur decision. Chez les medecins plus ages, ceux qui se preoccupaient moins des litiges, ceux pour qui le degre de demence etait important et ceux qui accordaient de l'importance a l'age du malade, on s'attendait a moins d'acharnement therapeutique que chez les autres medecins. Principaux resultats: Des soins d'entretien ont ete choisis par 8,1 % des repondants, on a choisi des soins therapeutiques limites dans une proportion de 41,5 %, des soins therapeutiques maximum sans admission a l'unite des soins intensifs (USI) ont fait l'objet du choix de 32,2 % des repondants et des soins maximum avec admission a l'USI ont ete choisis par 18,2 % d'entre eux. La volonte du malade a ete signalee par 91,0 % des repondants comme etant extremement ou tres importante dans le choix du traitement. Une analyse de regression logistique par degres a revele les variables suivantes qui ont ete prevues independamment du niveau de traitement: le degre de demence, le pays de residence, la duree de pratique, les problemes juridiques, l'age du malade et les problemes ethiques. I1 y avait une correlation significative entre ces facteurs et les choix de traitement des medecins (p < 0,05). Conclusions: L'importance accordee par les medecins au degre de demence etait la variable predictive la plus importante du niveau de soins fournis. Un consensus social est necessaire sur l'influence de la fonction cognitive sur le niveau approprie de soins de meme que la formation des medecins par rapport aux questions d'ethique.

C aring for incompetent elderly patients pre- more, the recent introduction of advance health care sents some of the most difficult medical, directives encourages physicians to discuss treatment ethical and legal problems faced by physi- options with their patients not only at the time of cians.'"6 Recent advances in health care technology their illness but also in advance.'4-16 have enabled physicians to prolong life and postpone A number of factors may be considered in death, often despite severe debilitating illness. The deciding on the level of care a terminally ill patient widespread use of this technology may be problemat- should receive. Physicians have considered the paic, especially in prolonging the life of terminally ill tient's quality of life,'7'8 although these judgeelderly patients. With the increasing proportion of ments reflect the values, preconceptions and biases older adults in society and the escalating health care of the person making the judgement.'9 Only patients costs, the problem is becoming more urgent and have the experience and standards to evalusignificant.7'ate the quality of their life, and in many cases Decision-making by clinicians involves a com- judgements by physicians or families are arbitrary. plex interaction of many factors. Physicians must In a study involving febrile patients in extended care apply medical knowledge, analyse the problems, facilities many factors, including the patient's mental weigh the probabilities and usefulness of various status (coma or stupor), level of pain, degree of outcomes and accept risk. In addition, clinical deci- mobility, marital status and the relationship with the sions are influenced by interactions between the physician, were significantly related to the physiclinician, the patient and the patient's family and by cian's decision to withhold treatment. Variables that the sociocultural setting.'0" Increasing our under- showed no relation to the level of care provided standing of the factors that physicians consider in included the patient's age, sex and race and a making life-prolonging treatment decisions will be diagnosis of dementia.20 Although Roman Cathnecessary to improve the care the incompetent olics are less disposed to passive euthanasia2' elderly receive. Physicians' communication with there was no relation between the physician's relidying patients is increasing, as is support for the gion and the level of care provided.20 Conversely, omission of life-prolonging treatments.'2'3 Further- Sudnow22 reported that physicians' attitudes to948


LE 1 5 OCTOBRE 1991

E--

ward resuscitation differed according to their religious beliefs. The age of the patient and physician have not been consistent factors in treatment decisions. Dialysis was stopped more frequently in older patients and in those living in nursing homes than in younger patients.2324 In a survey of 918 Canadian family physicians concerning various ethical problems their age and sex were not consistently related to the pattern of responses.25 Interactions between the patient's family and the health care team26-28 as well as institutional policies29 may also affect physicians' treatment decisions. In one study patients with fever who had no family were found to be more likely than those with a family to have treatment withheld.20 The physician's level of training, country of practice and social, cultural and religious background may also influence the treatment choice.'0,30,31 Given that physicians' attitudes are changing in this important area and that no studies have compared the attitudes in different countries, this study determined the treatment decisions of physicians from seven countries faced with a hypothetical incompetent elderly patient who had life-threatening gastrointestinal bleeding. In addition, we examined the relative importance the physicians attributed to eight factors. Individual physician characteristics were also examined to establish the impact they had on treatment choices.

Methods

I

the emergency department at 2 am with life-threatening gastrointestinal bleeding. He lives in a nursing home, has urinary and fecal incontinence, needs help washing and dressing and does not recognize his daughter. His blood pressure is 70/40 mm Hg and his heart rate 120 beats/min. The patient cannot communicate, and his family and physician cannot be reached. The nurse's aide who accompanied him to the emergency department is not familiar with the patient. There is no information available about his wishes or those of his family concerning treatment in this situation.

We asked the physicians to choose one of four levels of care: supportive care (SUPP), limited therapeutic care (LIM), maximum therapeutic care without admission to the intensive care unit (ICU) (MAX) and maximum care with admission to the ICU (MICU).30,32 SUPP was the equivalent to palliative care: routine bloodwork, grouping, crossmatching and transfusions would not be done, but analgesics (e.g., morphine) would be given. LIM included blood transfusions and intravenous therapy but excluded surgery, gastroscopy and colonoscopy. MAX incorporated the elements of limited care plus gastroscopy, colonoscopy and emergency surgery if necessary; ventilation, except that needed for surgery, would not be offered. MICU involved all of the possible treatments available in a large modern hospital. At the end of the questionnaire we asked the physicians to provide their age, sex, duration of practice, level of training and specialty as well as the country where their degree was obtained and the country where they were currently practising. We also asked them to rate the importance of eight factors (legal and ethical concerns, hospital costs, level of dementia, patient's age, physician's religion, patient's wishes and family's wishes) on a 5-point scale: 5 not important at all, 4 somewhat important, 3 moderately important, 2 very important and 1 extremely important. Our a priori hypotheses were that older physicians, those less concerned about litigation, those for whom the level of dementia was the most important factor and those for whom the patient's age was the most important factor would give less aggressive care than the other physicians.

The methods of the survey and some results have been previously published.30 From September 1987 to March 1989 we administered a questionnaire to interns, residents, family physicians and specialists attending family practice, medical and geriatric rounds in large teaching hospitals in Australia, Brazil, Canada, Scotland, Sweden, the United States and Wales. We excluded nonclinicians (e.g., pathologists) and physicians whose practice did not include elderly patients (pediatricians and obstetricians). The questionnaire was mailed to the physicians in Australia and distributed at the start of rounds in the remaining countries. The questionnaire was prepared in English and then translated into Portuguese for the survey in Brazil. In addition, changes were made in the termi- Statistical analysis nology for different countries. For example, "resident" was used in Canada and the United States but We examined the distribution of physician "house officer" or "registrar" in Britain. characteristics and responses across the countries. The following case vignette was included in the We used multiple linear regression analysis to deterquestionnaire. mine the extent to which each factor was related to the dependent variable (the treatment decision). An 82-year-old man with a 3-year history of progressive Stepwise regression analysis was used to determine dementia, diagnosed as Alzheimer's disease, is brought to the factors that independently contributed to the OCTOBER 15, 1991


949

1

respondents' decisions. In this analysis we included any variable that explained a statistically significant additional portion of the variance (p < 0.05) in the model. For significant variables we calculated the proportion of variance explained by the variable alone as well as the proportion of additional variance explained in the stepwise regression analysis.

Results The response rate was more than 80%. Table 1 presents the characteristics of the 1160 physicians who responded. SUPP was chosen by 93 (8.1%) of the respondents, LIM by 475 (41.5%), MAX by 368 (32.2%) Table 1: Characteristics of physicians who participated

Characteristic

Country of residence Australia Brazil Canada Scotland Sweden United States Wales Age less than 40 yr Male sex r| practice 20 years or less Level of training Intern or resident Family physician Specialist Other

No. (and %) of physicians

104 90 533 100 101

124 108 733 840

(9.0) (7.8)

(45.9)

(8.6) (8.7) (10.7) (9.3) (64.8) (74.0)

Discussion This study had a number of limitations. The selection of physicians was somewhat haphazard and depended on the circumstances of the investigators in each country. However, to enrol enough physicians the investigators attended a variety of hospital rounds, ensuring heterogeneity in each sample. Al-

710 (78.3)

329 245 400 161

and MICU by 208 (18.2%). The patient's wishes extremely important factor 57.3% of the by physicians, ethical concerns by 43.8%, the family's wishes by 19.1%, the level of dementia by 17.2%, legal concerns by 15.9%, the physician's religion by 5.4%, the patient's age by 2.0% and hospital costs by 1.5% (Table 2). The following variables were independently predictive of the physicians' treatment choices: the level of dementia (the higher the level of importance, the less aggressive the care), the country of residence (from most to least aggressive care: Brazil, the United States, Canada, Sweden, Wales, Scotland and Australia), duration of practice (the more years, the less aggressive the treatment), legal concerns (the higher the level of importance, the more aggressive the treatment), patient's age (the higher the level of importance, the less aggressive the treatment) and ethical concerns (the higher the level of importance, the more aggressive the treatment). The proportions of variance explained by each variable, independently and in the stepwise regression model, are presented in Table 3. The stepwise regression model explained 25.6% of the variance. The variables that did not significantly improve the prediction of the physicians' choices included the physician's religion, the patient's wishes, the family's wishes and the hospital costs. were considered to be an

(29.0) (21.6) (35.2) (1 4.2)

Table 2: Physicians impressions of the importance of various factors ir incompetent elderly patient

decicrQ-:.:

r`- re

.,

Level of importance, no. 'andl 2ph'vs/. `.

Factor Legal concerns

Extremely

very

Moderately

So.rrr,n r eX -

(n- 1149)

183 (15.9)

330 (28.7)

353 (o)'.7t

23a 3 -a 5

502 (43.8)

498 (43.4)

115 (10.0)

17 (1.5)

48 (4.2)

281 (24.4)

398 (34.6)

197 (17.2)

426 (37.2)

349 (30.4)

1 43( 125i

23 (2.0)

141 (12.3)

322 (28.1)

62 (5.4)

116(10.1)

141 (12.3)

388(338) 149 :..

659 (57.3)

387 (33.6)

71 (6.2)

26 f-. 3

219 (1 9.1)

479 (41.7)

304 (26.5)

122 1d 0 61i

Ethical concerns (n 1146) Hospital costs ;n

1150)

Level of dementia (n -- 1 146) Patient's age (n

147)

Physician's religion (n -- 1 146) Patient's wishes

(n 11 50) Family's wishes (n---- 1148) 950


30

300

:-

2L, 6)

406 35 231

v

273 12