Comparing doctors' legal compliance across three Australian states for decisions whether to withhold or withdraw life-sustaining medical treatment: does different law lead to different decisions?
Ontology highlight
ABSTRACT: Law purports to regulate end-of-life care but its role in decision-making by doctors is not clear. This paper, which is part of a three-year study into the role of law in medical practice at the end of life, investigates whether law affects doctors' decision-making. In particular, it considers whether the fact that the law differs across Australia's three largest states - New South Wales (NSW), Victoria and Queensland - leads to doctors making different decisions about withholding and withdrawing life-sustaining treatment from adults who lack capacity.A cross-sectional postal survey of the seven specialties most likely to be involved in end-of-life care in the acute setting was conducted between 18 July 2012 and 31 January 2013. The sample comprised all medical specialists in emergency medicine, geriatric medicine, intensive care, medical oncology, palliative medicine, renal medicine and respiratory medicine on the AMPCo Direct database in those three Australian states. The survey measured medical specialists' level of legal compliance, and reasons for their decisions, concerning the withholding or withdrawal of life-sustaining treatment. Multivariable logistic regression was used to examine predictors of legal compliance. Linear regression was used to examine associations between the decision about life-sustaining treatment and the relevance of factors involved in making these decisions, as well as state differences in these associations.Response rate was 32% (867/2702). A majority of respondents in each state said that they would provide treatment in a hypothetical scenario, despite an advance directive refusing it: 72% in NSW and Queensland; 63% in Victoria. After applying differences in state law, 72% of Queensland doctors answered in accordance with local law, compared with 37% in Victoria and 28% in NSW (p?CONCLUSIONSLaw appears to play a limited role in medical decision-making at the end of life with doctors prioritising patient-related clinical and ethical considerations. Different legal frameworks in the three states examined did not lead to different decisions about providing treatment. More education is needed about law and its role in this area, particularly where law is inconsistent with traditional practice.
Comparing doctors' legal compliance across three Australian states for decisions whether to withhold or withdraw life-sustaining medical treatment: does different law lead to different decisions?
<h4>Background</h4>Law purports to regulate end-of-life care but its role in decision-making by doctors is not clear. This paper, which is part of a three-year study into the role of law in medical practice at the end of life, investigates whether law affects doctors' decision-making. In particular, it considers whether the fact that the law differs across Australia's three largest states - New South Wales (NSW), Victoria and Queensland - leads to doctors making different decisions about withhol ...[more]
Project description:BackgroundNeonatal deaths are often associated with the complex decision to limit or withdraw life-sustaining interventions (LSIs) rather than therapeutic impasses. Despite the existence of a law, significant disparities in clinical procedures remain. This study aimed to assess deaths occurring in a Neonatal Intensive Care Unit (NICU) and measure the impact of a traceable Limitation or Withdrawal of Active Treatment (LWAT) file on the treatment of these newborns.MethodsIn this monocentric retrospective study, we reviewed all consecutive neonatal deaths occurring during two three-year periods among patients in the NICU at the North Hospital of Marseille: cohort 1 (from 2009 to 2011 without the LWAT file) and cohort 2 (from 2013 to 2015 after introduction of the LWAT file). Newborns included were: gestational age over 22 weeks, birth weight over 500 g, and admission and death in the same NICU. Deaths were categorized according to the classification described by Verhagen et al.: 1) children who died despite cardiopulmonary resuscitation (CPR) (no withholding nor withdrawing of LSIs), (2) children who died while the ventilator, without CPR (no withdrawing of LSIs, but CPR withheld), (3) children who died after LSIs were withdrawn, or (4) LSIs were withheld.Results193 deaths were analyzed: 77 in cohort 1 and 116 in cohort 2. 50% of deaths followed the decision to limit or stop life-sustaining interventions. The mean age at death did not differ between the two cohorts (p = 0.525). An increase in the mortality rate after life-sustaining interventions were withdrawn was observed. The number of multidisciplinary decision meetings was statistically higher in cohort 2 (32.5% versus 55.2% p = 0.002), which were most often prompted due to neurological pathologies, with an increase in parental advice concerning the management of their child (p = 0.026). Even if the introduction of this file did not have an effect on patient age at death, it was significantly associated with a better understanding of end-of-life conditions (p = 0.019), including medication used to sedate and comfort the patient.ConclusionsIntroduction of the LWAT file seems imperative to develop a personalized healthcare strategy for each child and situation.
Project description:Purpose At the end of life, communication is a key factor for good care. However, in clinical practice, it is difficult to adequately discuss end-of-life care. In order to understand and analyze how decision-making related to life-sustaining treatment (LST) is performed, the shared decision-making (SDM) behaviors of physicians were investigated. Methods A questionnaire was designed after reviewing the literature on attitudes toward SDM or decision-making related to LST. A final item was added after consulting experts. The survey was completed by internal medicine residents and hematologists/medical oncologists who treat terminal cancer patients. Results In total, 202 respondents completed the questionnaire, and 88.6% said that the decision to continue or end LST is usually a result of SDM since they believed that sufficient explanation is provided to patients and caregivers, patients and caregivers make their own decisions according to their values, and there is sufficient time for patients and caregivers to make a decision. Expected satisfaction with the decision-making process was the highest for caregivers (57.4%), followed by physicians (49.5%) and patients (41.1%). In total, 38.1% of respondents said that SDM was adequately practiced when making decisions related to LST. The most common reason for inadequate SDM was time pressure (89.6%). Conclusion Although most physicians answered that they practiced SDM when making decisions regarding LST, satisfactory SDM is rarely practiced in the clinical field. A model for the proper implementation of SDM is needed, and additional studies must be conducted to develop an SDM model in collaboration with other academic organizations.
Project description:COVID-19 has challenged people worldwide to comply with strict lock-downs and meticulous healthcare instructions. Can states harness enclave communities to comply with the law in such crucial times, even when compliance conflicts with communal sources of authority? We investigated this question through the case of Israeli ultra-Orthodox schools compliance with COVID-19 regulations. Drawing on semi-structured interviews with school principals, documents and media sources, and a field survey, we found that the state has the capacity to quickly internalize new norms and harness the cooperation of previously suspicious communities. At the same time, we found that communal authorities were able to shield widespread communal defiance from legal enforcement. These findings expose the bidirectionality of legal socialization: As the community uses its defiance power to attenuate the law, it socializes public authorities to accede to their bounded authority. As public authorities come to realize that the community cannot be brought to full compliance, they curtail enforcement efforts and socialize the community to operate outside the law. Our findings animate the reciprocity assumption in legal socialization theory and highlight one of the crucial tasks for the next 50 years of research: to examine the bidirectionality of legal socialization and discover its socio-legal effects.
Project description:ObjectiveTo describe the prevalence and context of decisions to withdraw extracorporeal membrane oxygenation (ECMO), with an ethical analysis of issues raised by this technology.Patients and methodsWe retrospectively reviewed medical records of adults treated with ECMO at Mayo Clinic in Rochester, Minnesota, from January 1, 2010, through December 31, 2014, from whom ECMO was withdrawn and who died within 24 hours of ECMO separation.ResultsOf 235 ECMO-supported patients, we identified 62 (26%) for whom withdrawal of ECMO was requested. Of these 62 patients, the indication for ECMO initiation was bridge to transplant for 8 patients (13%), bridge to mechanical circulatory support for 3 (5%), and bridge to decision for 51 (82%). All the patients were supported with other life-sustaining treatments. No patient had decisional capacity; for all the patients, consensus to withdraw ECMO was jointly reached by clinicians and surrogates. Eighteen patients (29%) had a do-not-resuscitate order at the time of death.ConclusionFor most patients who underwent treatment withdrawal eventually, ECMO had been initiated as a bridge to decision rather than having an established liberation strategy, such as transplant or mechanical circulatory support. It is argued that ethically, withdrawal of treatment is sometimes better after the prognosis becomes clear, rather than withholding treatment under conditions of uncertainty. This rationale provides the best explanation for the behavior observed among clinicians and surrogates of ECMO-supported patients. The role of do-not-resuscitate orders requires clarification for patients receiving continuous resuscitative therapy.
Project description:ProblemCompliance with UK regulations on junior doctors' working hours cannot be achieved by manipulating rotas that maintain existing tiers of cover and work practices. More radical solutions are needed.DesignAudit of change.SettingPaediatric night rota in large children's hospital.Key measures for improvementCompliance with regulations on working hours assessed by diary cards; workload assessed by staff attendance on wards; patient safety assessed through critical incident reports.Strategies for changeDevelopment of new staff roles, followed by change from a partial shift rota comprising 11 doctors and one senior nurse, to a full shift night team comprising three middle grade doctors and two senior nurses.Effects of changeCompliance with regulations on working hours increased from 33% to 77%. Workload changed little and was well within the capacity of the new night team. The effect on patient care and on medical staff requires further evaluation.Lessons learntReduction of junior doctors' working hours requires changes to roles, processes, and practices throughout the organisation.
Project description:BackgroundThis study aimed to gather insights in physicians' considerations for decisions to either refer for- or to withhold additional diagnostic investigations in nursing home patients with a suspicion of venous thromboembolism.MethodsOur study was nested in an observational study on diagnostic strategies for suspected venous thromboembolism in nursing home patients. Patient characteristics, bleeding-complications and mortality were related to the decision to withhold investigations. For a better understanding of the physicians' decisions, 21 individual face-to-face in-depth interviews were performed and analysed using the grounded theory approach.ResultsReferal for additional diagnostic investigations was forgone in 126/322 (39.1%) patients with an indication for diagnostic work-up. 'Blind' anticoagulant treatment was initiated in 95 (75.4%) of these patients. The 3 month mortality rates were higher for patients in whom investigations were withheld than in the referred patients, irrespective of anticoagulant treatment (odds ratio 2.45; 95% confidence interval 1.40 to 4.29) but when adjusted for the probability of being referred (i.e. the propensity score), there was no relation of non-diagnosis decisions to mortality (odds ratio 1.75; 0.98 to 3.11). In their decisions to forgo diagnostic investigations, physicians incorporated the estimated relative impact of the potential disease; the potential net-benefits of diagnostic investigations and whether performing investigations agreed with established management goals in advance care planning.ConclusionReferral for additional diagnostic investigations is withheld in almost 40% of Dutch nursing home patients with suspected venous thromboembolism and an indication for diagnostic work-up. We propose that, given the complexity of these decisions and the uncertainty regarding their indirect effects on patient outcome, more attention should be focused on the decision to either use or withhold additional diagnostic tests.
Project description:Distributive justice concerns how individuals and societies distribute income in a just or equal manner. We aimed to test the roles of social preference in behavioral distributive justice. We thus provide evidence of a causal link between the neural and behavioral results through the application of bilateral transcranial direct current stimulation (tDCS) over the temporoparietal junction (TPJ) of our participants. The participants were found to make fairer distributions within the known position after receiving right anodal/left cathodal tDCS and receiving right cathodal/left anodal tDCS over the TPJ than the participants who received the sham stimulation. Simultaneously, we elicited the participants' advantage inequity aversion and found that the participants who received right anodal/left cathodal tDCS and who received right cathodal/left anodal tDCS over the TPJ were more averse to advantage inequity. Additionally, the participants' distributive proportions to the lowest income stratum within the known position were strongly related to their social preference of advantage inequity aversion. Therefore, the present study demonstrated that the modulation of the excitability of the TPJ using tDCS altered the distributive decisions of the participants within the known position, and this effect might be attributable to a change in the individuals' social preferences.
Project description:Societal norms exert a powerful influence on our decisions. Behaviours motivated by norms, however, do not always concur with the responses mandated by decision relevant information potentially generating a conflict. To probe the interplay between normative and informational influences, we examined how prosocial norms impact on perceptual decisions subjects made in the context of a simultaneous presentation of social information. Participants displayed a bias in their perceptual decisions towards that mandated by social information. However, normative prescriptions modulated this bias bi-directionally depending on whether norms mandated a decision in accord or contrary to the contextual social information. At a neural level, the addition of a norms increased activity in prefrontal cortex and modulated functional connectivity between prefrontal and parietal areas. The bi-directional effect of our norms was captured by differential activations when participants decided against the social information. When norms indicated a decision in line with social information, non-compliance modulated lateral prefrontal cortex activity. By contrast, when norms mandated a decision against social information norm compliance increased activity in the anterior cingulate cortex. Hence, social norms changed the balance between a reliance on perceptual and social information by modulating brain activity in regions associated with response inhibition and conflict monitoring.
Project description:While expert groups often make recommendations on a range of non-controversial as well as controversial issues, little is known about how the level of expert consensus-the level of expert agreement-influences perceptions of the recommendations. This research illustrates that for non-controversial issues expert groups that exhibit high levels of agreement are more persuasive than expert groups that exhibit low levels of agreement. This effect is mediated by the perceived entitativity-the perceived cohesiveness or unification of the group-of the expert group. But for controversial issues, this effect is moderated by the perceivers' implicit assumptions about the group composition. When perceivers are provided no information about a group supporting the Affordable Care Act-a highly controversial piece of U.S. legislation that is divided by political party throughout the country-higher levels of agreement are less persuasive than lower levels of agreement because participants assume there were more democrats and fewer republicans in the group. But when explicitly told that the group was half republicans and half democrats, higher levels of agreement are more persuasive.
