Continuous Deep Sedation Until Death-a Swiss Death Certificate Study

Practices of and Perspectives on Palliative Sedation Among Palliative Care Physicians in Ontario, Canada: A Mixed-Methods Study

Background

Palliative sedation (PS) is a therapeutic intervention employed to manage severe and refractory symptoms in terminally ill patients at end of life. Inconsistencies in PS practice guidelines coupled with clinician ambiguity have resulted in confusion about how PS is best integrated into practice. Understanding the perspectives, experiences, and practices relating to this modality will provide insight into its clinical application and challenges within the palliative care landscape.

Objective

The aim is to explore the perspectives of palliative care physicians administering PS, including how practitioners define PS, factors influencing decision making about the use of PS, and possible reasons for changes in practice patterns over time.

Methods

A survey (n = 37) and semistructured interviews (n = 23) were conducted with palliative care physicians throughout Ontario. Codes were determined collaboratively and applied line-by-line by two independent investigators. Survey responses were analyzed alongside interview transcripts and noted to be concordant. Themes were generated through reflexive thematic analysis.

Results

Five key themes were identified: (1) lack of standardization, (2) differing definitions, (3) logistical challenges, (4) perceived "back-up" to Medical Assistance in Dying, and (5) tool of the most responsible physician.

Conclusion

There was significant variability in how participants defined PS and in frequency of use of PS. Physicians described greater ease implementing PS when practicing in palliative care units, with significant barriers faced by individuals providing home-based palliative care or working as consultants on inpatient units. Educational efforts are required about the intent and practice of PS, particularly among inpatient interprofessional teams.

Palliative sedation determinants: systematic review and meta-analysis in palliative medicine

BACKGROUND

The utilisation of palliative sedation is often favoured by patients approaching end of life due to the presence of multiple difficult-to-manage symptoms during the terminal stage. This study aimed to identify the determinants of the use of palliative sedation.

METHODS

To identify pertinent observational studies, a comprehensive search was performed in PubMed, Embase, Cochrane Library, and PsycINFO databases from their inception until March 2022. The methodological quality of the chosen prospective and retrospective cohort studies was assessed using the Newcastle Ottawa Scale, while the Agency for Healthcare Research and Quality was used to evaluate the methodological quality of the selected cross-sectional studies. For each potential determinant of interest, the collected data were synthesised and analysed, and in cases where data could not be combined, a narrative synthesis approach was adopted.

RESULTS

A total of 21 studies were analysed in this research, consisting of 4 prospective cohort studies, 7 retrospective cohort studies, and 10 cross-sectional studies. The findings indicated that several determinants were significantly associated with palliative sedation. These determinants included younger age, male gender, presence of tumours, dyspnoea, pain, delirium, making advanced medical end-of-life decisions, and dying in a hospital setting.

CONCLUSIONS

The findings of our review could help physicians identify patients who may need palliative sedation in advance and implement targeted interventions to reverse refractory symptoms, develop personalized palliative sedation programs, and ultimately improve the quality of palliative care services.

TRIAL REGISTRATION

PROSPERO registration number CRD42022324720.

Possible age-related differences in healthcare professionals' perspectives on younger and older patients' autonomy and decision-making in the context of sedation in specialised palliative care: exploratory secondary qualitative content and linguistic conversation analysis of interviews with healthcare professionals

Background

Chronic illnesses and multi-morbidity can threaten competence and independence, particularly in old age. Autonomy becomes increasingly important in the context of sedation, as in this case medication leads to (further) changes of consciousness. The study aimed to identify possible age-related differences in the perspectives of healthcare professionals on patients’ autonomy, in the context of sedation in specialised palliative care.

Method

Secondary analysis of interviews with healthcare professionals, analysed by qualitative content and linguistic conversation analysis. The interviews analysed span 51 healthcare professionals in specialised palliative care across 17 centres (adult inpatient and specialist palliative home care services) in Germany.

Results

The study shows that the perspectives of healthcare professionals on patients’ autonomy differs according to the age of the patient in the context of sedation in specialised palliative care. The different perspectives may lead to different ways of treating the patients, for example a greater space of autonomy and decision-making for younger patients.

Conclusion

In particular, measures that may restrict consciousness (e.g. sedation) and thus influence patients’ ability to fully exercise their autonomy and fully participate in decision-making require special attention by healthcare professionals with respect to possible influences on treatment, such as different perceptions by healthcare professionals based on the patient’s age or age-related stereotypes.

Trial registration

The study “SedPall” is registered in the German Clinical Trials Register (ID: DRKS00015047).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00963-y.

Sedatives and Sedation at the End of Life in the Hospital

BACKGROUND

Data on sedation at the end of life (eol) in different medical disciplines are scarce and mostly based on subjective reports. We aimed to assess the use of sedatives with continuous effect in the last week of life and associated factors in different hospital departments, with the aid of objectifiable criteria.

METHODS

We conducted a retrospective cohort study based on the medical records of patients who died in one of five clinical departments of German hospitals between January 2015 and December 2017 (hematology/oncology [two different departments], neurology, geriatrics, and gynecology). The use of sedatives that are recommended in guidelines for palliative sedation was analyzed, irrespective of indication and treatment intent, with the aid of published definitions of continuous effect and of at least moderately sedating doses. The analysis consisted of descriptive statistics and multivariate logistic regression analysis.

RESULTS

260/517 (50%) of the patients who died were given sedatives with continuous effect in the last week of life, 53/517 (10%) in at least moderately sedating doses. For 76/260 (29%) patients, no indication was noted. The term "sedation" was used in the medical records of 20/260 (8%) patients. The use of sedatives with continuous effect was significantly associated with the department in which the patient was treated (hematology/oncology II: OR 0.32, 95% CI [0.16: 0.63]; geriatrics: OR 0.23, 95% CI [0.10:0.50]; reference, hematology/oncology I).

CONCLUSION

It was not possible to draw a clear distinction between the use of sedatives for symptom control, without sedating effect or intent to sedate, and intentional sedation to relieve suffering. The observed differences between hospital departments and deviations from recommended practice, e.g. lack of documentation of the indication, warrant further exploration. Moreover, context-specific supportive measures for the use of sedatives and sedation at the end of life should be developed.

Physicians’ Experiences and Perceptions of Environmental Factors Affecting Their Practices of Continuous Deep Sedation until Death: A Secondary Qualitative Analysis of an Interview Study

As previous research has paid little attention to environmental factors affecting the practice of continuous deep sedation until death (CDS), we aimed to explore these using physicians’ experiences and perceptions. We performed an interpretative thematic analysis of primary data from a qualitative interview study conducted from February to May 2019 in Belgium with 47 physicians. Structural factors were identified: the lack of professional and/or technical support in monitoring sedated patients; the use of guidelines in team contexts; the time constraints for treating individual patients and work pressure; the structural knowledge gap in medical education; the legal context for assisted dying; and the lack of a clear legal context for CDS. Cultural factors were identified: the moral reservations of care teams and/or institutions towards CDS; the presence of a palliative care culture within care teams and institutions; the culture of fear of making clinical errors regarding CDS among a group of physicians; the professional stigma of performing assisted dying among some of the physician population; the different understandings of CDS in medical and policy fields; and the societal taboo around suffering at the end of life and natural death. To conclude, improving CDS practice requires a whole-system approach considering environmental factors.

How should health care providers inform about palliative sedation? A qualitative study with palliative care professionals

Objective

In Switzerland, palliative sedation consists of using sedatives to relieve terminally ill patients. It is divided into several steps, with one of them consisting of informing patients and relatives about the procedure. In the current recommendations, there is a lack of orientation about how and when this discussion should take place. Hence, we aim to explore perceptions and experiences of palliative care professionals regarding these questions.

Methods

Qualitative semi‐structured interviews with five physicians and five nurses working in specialised palliative care were conducted. They were then analysed with thematic analysis.

Results

Results showed a uniformity around definition, goals and indications of palliative sedation. However, there was a lack of consistency regarding the process of delivering this information to patients and relatives. Finally, some participants strongly opposed the idea of systematically informing patients in specialised palliative care, while others were more divided on this question.

Conclusion

Despite a common understanding of the concept of palliative sedation, there is no standard practice when informing patients on palliative sedation among palliative care professionals. Therefore, this study demonstrates the need for further guidelines on this question and calls for a better understanding and knowledge of palliative sedation among health professionals outside palliative care.

Defining “Continuous Deep Sedation” Using Treatment Protocol: A Proposal Article

Context: Continuous deep sedation (CDS) is regarded as a far-reaching form of sedative use for symptom control, but there are no established uniform definitions.

Objectives: To propose types of sedative use related to CDS using treatment protocols with three parameters: documented treatment goals, rapidity of dose titration, and planned duration of treatment.

Methods: Opinion article.

Results: We propose four types of sedative use potentially related to CDS: (1) proportional sedation (treatment goal is symptom relief with regular monitoring to maximize patient communication, not a decrease in consciousness; with gradual use of sedatives; there is a chance to cease sedatives), (2) rapid proportional sedation (treatment goal is symptom relief with a rapid loading phase, followed by regular monitoring to maximize patient communication; there is a chance to cease sedatives), (3) deep sedation with a chance of cessation (deep sedation intended initially, followed by regular assessments of appropriateness of treatment goal; there is a chance to cease sedatives), and (4) continuous deep sedation until death (deep sedation indicated from initiation and maintained until death).

Conclusion: This article proposes an idea that the use of treatment protocols that visualize treatment goals, rapidity of dose titration, and planned duration of treatment may help understand the existing variations in sedative use over the world. The use of treatment protocols in the same way when defining a medical treatment in other specialty fields might clear up the current confusion about the use of sedatives.

Physicians' Opinion and Practice With the Continuous Use of Sedatives in the Last Days of Life

CONTEXT

There are few international studies about the continuous use of sedatives (CUS) in the last days of life.

OBJECTIVES

We aim to describe the experiences and opinions regarding CUS of physicians caring for terminally ill patients in seven countries.

METHODS

Questionnaire study about practices and experiences with CUS in the last days of life among physicians caring for terminally ill patients in Belgium (n = 175), Germany (n = 546), Italy (n = 214), Japan (n = 513), the Netherlands (n = 829), United Kingdom (n = 114) and Singapore (n = 21).

RESULTS

The overall response rate was 22%. Of the respondents, 88-99% reported that they had clinical experience of CUS in the last 12 months. More than 90% of respondents indicated that they mostly used midazolam for sedation. The use of sedatives to relieve suffering in the last days of life was considered acceptable in cases of physical suffering (87%-99%). This percentage was lower but still substantial in cases of psycho-existential suffering in the absence of physical symptoms (45%-88%). These percentages were lower when the prognosis was at least several weeks (22%-66% for physical suffering and 5%-42% for psycho-existential suffering). Of the respondents, 10% or less agreed with the statement that CUS is unnecessary because suffering can be alleviated with other measures. A substantial proportion (41%-95%) agreed with the statement that a competent patient with severe suffering has the right to demand the use of sedatives in the last days of life.

CONCLUSION

Many respondents in our study considered CUS acceptable for the relief of physical and psycho-existential suffering in the last days of life. The acceptability was lower regarding CUS for psycho-existential suffering and regarding CUS for patients with a longer life expectancy.

A qualitative study on continuous deep sedation until death as an alternative to assisted suicide in Switzerland

Background

According to the European Association for Palliative Care, decisions regarding palliative sedation should not be made in response to requests for assisted dying, such as euthanasia or assisted suicide. However, several studies show that continuous deep sedation until death (CDSUD) – a particular form of sedation – has been considered as an alternative to these practices in some countries. In Switzerland, where assisted suicide is decriminalized and CDSUD is not legally regulated, no studies have comprehensively investigated their relation. Our study aimed to identify and describe the experience among palliative care physicians of CDSUD as a potential alternative to assisted suicide in the French-speaking part of Switzerland.

Methods

We performed an exploratory multicentre qualitative study based on interviews with palliative care physicians in the French-speaking part of Switzerland and conducted linguistic and thematic analysis of all interview transcripts. The study is described in accordance with COREQ guidelines.

Results

We included 10 interviews conducted in four palliative care units. Our linguistic analysis shows four main types of sedation, which we called ‘rapid CDSUD’, ‘gradual CDSUD’, ‘temporary sedation’ and ‘intermittent sedation’. CDSUD (rapid or gradual) was not considered an alternative to assisted suicide, even if a single situation has been reported. In contrast, ‘temporary’ or ‘intermittent sedation’, although not medically indicated, was sometimes introduced in response to a request for assisted suicide. This was the fact when there were barriers to an assisted suicide at home (e.g., when transfer home was impossible or the patient wished not to burden the family).

Conclusion

These preliminary results can guide clinical, ethical, linguistic and legal reflection in this field and be used to explore this question more deeply at the national and international levels in a comparative, interdisciplinary and multiprofessional approach. They can also be useful to update Swiss clinical guidelines on palliative sedation in order to include specific frameworks on various sedation protocols and sedation as an alternative to assisted suicide. Potential negative impacts of considering palliative sedation as an alternative to assisted suicide should be nuanced by open and honest societal debate.

Barriers in the Decision Making About and Performance of Continuous Sedation Until Death in Nursing Homes

BACKGROUND AND OBJECTIVES

While decision making about and performance of continuous sedation involve many challenges, they appear to be particularly pervasive in nursing homes. This study aims to identify barriers to the decision making and performance of continuous sedation until death in Flemish nursing homes as experienced by the health care professionals involved.

RESEARCH DESIGN AND METHODS

Ten focus groups were held with 71 health care professionals including 16 palliative care physicians, 42 general practitioners, and 13 nursing home staff. Discussions were transcribed verbatim and analyzed using a constant comparative approach.

RESULTS

Perceived barriers concerned factors prior to and during sedation and were classified according to three types: (a) personal barriers related to knowledge and skills including the lack of clarity on what continuous sedation should be used for (linguistic ambiguity) and when and how it should be used (practical ambiguity); (b) relational barriers concerning communication and collaboration both between health care professionals and with family; (c) organizational barriers related to the organization of care in nursing homes where, for example, there is no on-site physician, or where the recommended medication is not always available.

DISCUSSION AND IMPLICATIONS

The findings suggest there are considerable challenges for sound decision making about and performance of continuous sedation until death in nursing homes. There is a need for multicomponent initiatives that provide guidance in the context of the complexity of a resident's medical situation, the family, and the specific organization of care, which would have the potential to facilitate and improve the decision-making process and performance of continuous sedation in nursing homes.

Sedatives and Sedation at the End of Life in Nursing Homes: A Retrospective Multicenter Cohort Study

OBJECTIVES

There is scarce information about sedation in nursing homes at the end of life. We aimed to assess (1) the use of sedatives generally and "sedatives with continuous effect," based on objective operational criteria, within the last week of life in nursing homes and (2) factors associated with this treatment.

DESIGN

Retrospective cohort study, using the nursing homes' medical records.

SETTING AND PARTICIPANTS

Residents who died in 4 German nursing homes from January 2015 to December 2017 and whose medical records were available (n = 512).

METHODS

Sedatives analyzed were those recommended by guidelines for "palliative sedation": benzodiazepines, levomepromazine, haloperidol (≥5 mg/d), and propofol. The definition of "sedatives with continuous effect" and doses judged as at least moderately sedating were consented by palliative care clinicians and pharmacists, based on the literature. Descriptive statistics and multivariate logistic regression analysis were performed (R version 3.6.1).

RESULTS

Overall, 110/512 (21%) deceased residents received a sedative at least once during the last week of life, 46/512 (9%) "sedatives with continuous effect." Oral lorazepam was used most frequently. Eleven of 512 (2%) residents received doses judged as at least moderately sedating. The term sedation was not used. Most frequent indications were agitation (58/110; 53%) and anxiety (35/110; 32%); no indication was noted for 36/110 (33%) residents. The resident's involvement in the decision for sedatives was documented in 3/110 (3%). Multivariate logistic regression analysis showed significant associations between use of sedatives and age (OR = 0.94, P < .001) as well as institution (P < .001).

CONCLUSIONS AND IMPLICATIONS

Our data indicate a lower prevalence of sedation compared to international data and considerable differences regarding prevalence between institutions. These differences, potential setting-specific challenges, and need for support measures for consistent best practice of sedation in nursing homes should be further explored.

Changing Practices in the Use of Continuous Sedation at the End of Life: A Systematic Review of the Literature

CONTEXT

The use of continuous sedation until death (CSD) has been highly debated for many years. It is unknown how the use of CSD evolves over time. Reports suggest that there is an international increase in the use of CSD for terminally ill patients.

OBJECTIVE

To gain insight in developments in the use of CSD in various countries and subpopulations.

METHODS

We performed a search of the literature published between January 2000 and April 2020, in PubMed, Embase, CINAHL, PsycInfo, and the Cochrane Library by using the Preferred reporting items for systematic review and meta-analysis protocols guidelines. The search contained the following terms: continuous sedation, terminal sedation, palliative sedation, deep sedation, end-of-life sedation, sedation practice, and sedation until death.

RESULTS

We found 23 articles on 16 nationwide studies and 38 articles on 37 subpopulation studies. In nationwide studies on frequencies of CSD in deceased persons varied from 3% in Denmark in 2001 to 18% in The Netherlands in 2015. Nationwide studies indicate an increase in the use of CSD. Frequencies of CSD in the different subpopulations varied too widely to observe time trends. Over the years, more studies reported on the use of CSD for nonphysical symptoms including fear, anxiety, and psycho-existential distress. In some studies, there was an increase in requests for sedation of patients from their families.

CONCLUSIONS

The frequency of CSD seems to increase over time, possibly partly because of an extension of indications for sedation, from mainly physical symptoms to also nonphysical symptoms.

Association between continuous deep sedation and survival time in terminally ill cancer patients

PURPOSE

Our study aimed to evaluate the association between CDS and survival time using the likelihood of receiving CDS to select a matched non-CDS group through an accurate measurement of survival time based on initiation of CDS.

METHODS

A retrospective cohort study was performed using an electronic database to collect data regarding terminally ill cancer patients admitted to a specialized palliative care unit from January 2012 to December 2016. We first used a Cox proportional hazard model with receiving CDS as the outcome to identify individuals with the highest plausibility of receiving CDS among the non-CDS group (n = 663). We then performed a multiple regression analysis comparing the CDS group (n = 311) and weighted non-CDS group (n = 311), using initiation of CDS (actual for the CDS group; estimated for the non-CDS group) as the starting time-point for measuring survival time.

RESULTS

Approximately 32% of participants received CDS. The most common indications were delirium or agitation (58.2%), intractable pain (28.9%), and dyspnea (10.6%). Final multiple regression analysis revealed that survival time was longer in the CDS group than in the non-CDS group (Exp(β), 1.41; P < 0.001). Longer survival with CDS was more prominent in females, patients with renal dysfunction, and individuals with low C-reactive protein (CRP) or ferritin, compared with their counterpart subgroup.

CONCLUSIONS

CDS was not associated with shortened survival; instead, it was associated with longer survival in our terminally ill cancer patients. Further studies in other populations are required to confirm or refute these findings.

Physician and Surrogate Agreement with Assisted Dying and Continuous Deep Sedation in Advanced Dementia in Switzerland

BACKGROUND

Assisted dying and continuous deep sedation (CDS) are controversial practices. Little is known about the perceptions of physicians and surrogates about these practices for patients with advanced dementia.

OBJECTIVES

To describe and compare physician and surrogate agreement with the use of assisted dying and CDS in advanced dementia.

DESIGN, SETTING, SUBJECTS

Physicians (n = 64) and surrogates (n = 168) of persons with advanced dementia were recruited as part of a randomized controlled trial in Switzerland that tested decision support tools in this population.

METHODS

At baseline, the participants were asked about their agreement with assisted dying and CDS in advanced dementia using the following response options: "completely agree," "somewhat agree," "somewhat disagree," "completely disagree," and "do not know." Multivariable logistic regressions compared the likelihood that surrogates versus physicians would completely or somewhat agree (vs. completely or somewhat disagree) with these practices.

RESULTS

The physicians and surrogates, respectively, had a mean age (SD) of 50.6 years (9.9) and 57.4 years (14.6); 46.9% (n = 30/64) and 68.9% (n = 115/167) were women. A total of 20.3% (n = 13/64) of the physicians and 47.0% (n = 79/168) of the surrogates agreed with assisted dying in advanced dementia. Surrogates were significantly more likely to agree with this practice than physicians (adjusted odds ratio, 3.87; 95% CI: 1.94, 7.69). With regard to CDS, 51.6% (n = 33/64) of the physicians and 41.9% (n = 70/169) of the surrogates agreed with this practice, which did not differ significantly between the groups.

CONCLUSIONS

The surrogates were more agreeable to considering assisted dying in the setting of advanced dementia than the physicians, and about half of the participants in both groups reported CDS to be an appropriate option for this population.

Using sedative substances until death: A mortality follow-back study on the role of healthcare settings

Background:

In the last decade, the use of sedative substances to keep a patient in deep sedation until death increased fourfold in German-speaking Switzerland, where every third patient admitted to hospital, palliative care unit or hospice died continuously deeply sedated.

Aim:

To investigate sedation practices across healthcare settings and to identify their associations with conventional symptom control.

Design:

National mortality follow-back study in Switzerland between 2013 and 2014. Questionnaires on medical end-of-life decisions were sent to attending physicians of a continuous random sample of all registered deaths aged 1 year or older.

Setting/participants:

Of all sampled deaths, 3678 individuals who died non-suddenly and not through an external cause were included.

Results:

Across settings, continuous deep sedation appeared more likely in patients aged younger than 65 years (odds ratio range: 1.53–2.34) and as part of or after intensified alleviation of pain and symptoms (odds ratio range: 1.90–10.27). In hospitals, sedation was less likely for cancer patients (odds ratio: 0.7, 95% confidence interval: 0.5–1.0, p = 0.022). In nursing homes, sedation was more likely for people who were married (odds ratio: 1.8, 95% confidence interval 1.3–2.5, p = 0.001).

Conclusion:

In all settings, sedated patients have significantly more pain problems compared to patients not receiving sedation. Large differences between settings seem to indicate different patient populations, different levels of professionals’ palliative care experience and different availability of treatment options. Our study suggests that certain patient groups who may be as vulnerable to refractory pain and symptoms as others are less likely to receive continuous deep sedation until death when warranted.

Reflections on palliative sedation

'Palliation sedation' is a widely used term to describe the intentional administration of sedatives to reduce a dying person's consciousness to relieve intolerable suffering from refractory symptoms. Research studies generally focus on either 'continuous sedation until death' or 'continuous deep sedation'. It is not always clear whether instances of secondary sedation (i.e. caused by specific symptom management) have been excluded. Continuous deep sedation is controversial because it ends a person's 'biographical life' (the ability to interact meaningfully with other people) and shortens 'biological life'. Ethically, continuous deep sedation is an exceptional last resort measure. Studies suggest that continuous deep sedation has become 'normalized' in some countries and some palliative care services. Of concern is the dissonance between guidelines and practice. At the extreme, there are reports of continuous deep sedation which are best described as non-voluntary (unrequested) euthanasia. Other major concerns relate to its use for solely non-physical (existential) reasons, the under-diagnosis of delirium and its mistreatment, and not appreciating that unresponsiveness is not the same as unconsciousness (unawareness). Ideally, a multiprofessional palliative care team should be involved before proceeding to continuous deep sedation. Good palliative care greatly reduces the need for continuous deep sedation.

Physician-related determinants of medical end-of-life decisions - A mortality follow-back study in Switzerland

Background

Medical end-of-life decisions (MELD) and shared decision-making are increasingly important issues for a majority of persons at the end of life. Little is known, however, about the impact of physician characteristics on these practices. We aimed at investigating whether MELDs depend on physician characteristics when controlling for patient characteristics and place of death.

Methods and findings

Using a random sample (N = 8,963) of all deaths aged 1 year or older registered in Switzerland between 7 August 2013 and 5 February 2014, questionnaires covering MELD details and physicians' demographics, life stance and medical formation were sent to certifying physicians. The response rate was 59.4% (N = 5,328). Determinants of MELDs were analyzed in binary and multinomial logistic regression models. MELDs discussed with the patient or relatives were a secondary outcome. A total of 3,391 non-sudden nor completely unexpected deaths were used, 83% of which were preceded by forgoing treatment(s) and/or intensified alleviation of pain/symptoms intending or taking into account shortening of life. International medical graduates reported forgoing treatment less often, either alone (RRR = 0.30; 95% CI: 0.21–0.41) or combined with the intensified alleviation of pain and symptoms (RRR = 0.44; 0.34–0.55). The latter was also more prevalent among physicians who graduated in 2000 or later (RRR = 1.60; 1.17–2.19). MELDs were generally less frequent among physicians with a religious affiliation. Shared-decision making was analyzed among 2,542 decedents. MELDs were discussed with patient or relatives less frequently when physicians graduated abroad (OR = 0.65, 95% CI: 0.50–0.87) and more frequently when physicians graduated more recently; physician's sex and religion had no impact.

Conclusions

Physicians' characteristics, including the country of medical education and time since graduation had a significant effect on the likelihood of an MELD and of shared decision-making. These findings call for additional efforts in physicians' education and training concerning end-of-life practices and improved communication skills.