End-of-life Decision-making Differs Between a Cancer and a Dementia Patient: Influences of the Physician's Background Factors

BACKGROUND/AIM

Appropriate decision-making is essential for end-of-life (EOL) care without futile therapies. However, these decisions might vary in cases of cancer and other advanced diseases according to physicians' experience, education, and values. This study aimed to compare the decisions in EOL care of advanced cancer and dementia and the factors that influence them in medical students, general practitioners (GPs), and physicians with special competence in palliative medicine (cPM).

PATIENTS AND METHODS

A questionnaire presenting patient scenarios concerning different decisions and ethical aspects of EOL care with additional questions on attitudes and background factors was delivered to 500 Finnish GPs, all Finnish physicians with cPM (n=82), and all graduating medical students (n=639) in 2015-2016. Altogether 601 responses were obtained (53%).

RESULTS

Palliative care was chosen more often for a patient with advanced prostate cancer (83%) than for a patient with advanced dementia (41%) (both patients males, same age). A suspicion of iatrogenic bleeding in the prostate cancer patient decreased the willingness to choose palliative care, especially among the students. Patient benefit was regarded as an important background factor in decision making by all respondent groups, but physicians' legal protection was not considered as important among the physicians with cPM as it was among the other respondent groups.

CONCLUSION

Finnish doctors and students were more likely to choose palliative care options for an advanced prostate cancer patient than for an advanced dementia patient. Decision-making was influenced by respondents' background factors and attitudes. Education on EOL care for different types of advanced and incurable diseases is highly needed.

Physicians' decreased tendency to choose palliative care for patients with advanced dementia between 1999 and 2015

Background

Physicians’ decision-making for seriously ill patients with advanced dementia is of high importance, especially as the prevalence of dementia is rising rapidly, and includes many challenging ethical, medical and juridical aspects. We assessed the change in this decision-making over 16 years (from 1999 to 2015) and several background factors influencing physicians’ decision.

Methods

A postal survey including a hypothetical patient-scenario representing a patient with an advanced dementia and a life-threatening gastrointestinal bleeding was sent to 1182 and 1258 Finnish physicians in 1999 and 2015, respectively. The target groups were general practitioners (GPs), surgeons, internists and oncologists. The respondents were asked to choose between several life-prolonging and palliative care approaches. The influence of physicians’ background factors and attitudes on their decision were assessed.

Results

The response rate was 56%. A palliative care approach was chosen by 57 and 50% of the physicians in 1999 and 2015, respectively (p = 0.01). This change was statistically significant among GPs (50 vs 40%, p = 0.018) and oncologists (77 vs 56%, p = 0.011). GPs chose a palliative care approach less often than other responders in both years (50 vs. 63% in 1999 and 40 vs. 56% in 2015, p < 0.001). In logistic regression analysis, responding in 2015 and being a GP remained explanatory factors for a lower tendency to choose palliative care. The impact of family’s benefit on the decision-making decreased, whereas the influence of the patient’s benefit and ethical values as well as the patient’s or physician’s legal protection increased from 1999 to 2015.

Conclusions

Physicians chose a palliative care approach for a patient with advanced dementia and life-threatening bleeding less often in 2015 than in 1999. Specialty, attitudes and other background factors influenced significantly physician decision-making. Education on the identification and palliative care of the patients with late-stage dementia are needed to make these decisions more consistent.