Foregoing Treatment at the End of Life

Foregoing Treatment at the End of Life

Dr Paulina Taboada
Profesor Centro de Bioetica
Pontificia Universidad Catolica de Chile
Alameda 340 Correo Central 1
Santiago, Chile

The April 2002 number of the Journal of Medical Ethics brings an article on the "Factors affecting physician’s decisions to forgo life-sustaining treatments in terminal care" (Hinka, et. al., J Med Ethics 2002; 28: 109 – 114). A questionnaire-based survey was performed in Finland to study the variability in decisions to withdraw or withhold specific life-supporting treatments in terminal care. The study intended to evaluate also possible associations between treatment-decisions and other variables, such as gender, specialty, experience, life values, sociodemographic data, etc.

The hypothetical clinical scenario of a terminally ill cancer patient was presented and physicians (n=1182) were asked about their decision-making regarding treatment as well as about their attitudes to certain ethical values. The results suggest that the treatments most often forgone were blood transfusions (82%) and thrombosis prophylaxis (81%). Least willingly abandoned were intravenous hydration (29%) and supplementary oxygen (13%). Female doctors were less likely to discontinue thrombosis prophylaxis and supplementary oxygen, but more readily X-ray and laboratory examinations. Young doctors were more likely to continue antibiotics, thrombosis prophylaxis, supplementary oxygen and laboratory tests. Oncologists comprised the specialty most ready to forgo all studied treatments except antibiotics and blood transfusions. Other factors in the physician’s background were found to predict decisions to withdraw antibiotics or IV hydration.

The article may be of some interest as a descriptive survey. But it lacks ethical considerations. The conclusion after reading the article is that various factors influence complex decision-making at the end of life. We get some information about some issues that seem to be specially difficult. The authors put a special emphasis on the role of training and experience in decision-making: "Our finding that postgraduate training greatly promotes readiness to forgo IV hydration also supports the idea that knowledge alters attitudes." (p. 112)

Nevertheless, the knowledge they seem to have in mind is exclusively empirical medical knowledge. They do not make any reference to ethical knowledge, except by a very general reference to personal ‘life values’. Thus, the final impression after reading the paper is that among the factors influencing physician’s complex decision-making, the knowledge of fundamental ethical principles does not have a significant place (at least for these authors).

Hence, I would like to complement the article with a reflection on the ethical principles that may help physician’s decisions to forgo treatments at the end of life. Indeed, this shall be the topic of my contribution to the July number of this Newsletter.

Dr. Paulina Taboada, MD, PhD
Palliative Care and Bioethics